Critical Discourse Analysis Perspective on Norwegian Public Health Nursing Curriculum in a Time of Transition

Abstract

Discourse analysis is an area of social linguistics, which can advance social theory in the direction of language. Public health nurses are to perform health promotion and disease prevention work on an individual and population level. By identifying how features of different discourses are constructed and maintained, combining linguistics tools and social science perspectives, the purpose was to provide an understanding of the health promotion and disease prevention discourse in the public health nursing curriculum to reveal governmental strategies for public health nursing education in a time of transition. Fairclough’s three‐dimensional model of critical discourse analysis that consists of the analytical dimensions social events, social practices, and social structures was carried out. There is a linguistic‐discursive dialectic between the dimensions. The analysis revealed four discourses in the curriculum text: a contradictory health promotion and disease prevention discourse; a paternalistic meta‐discourse; a hegemonic individual discourse; and a hegemonic discourse for interdisciplinary collaboration. The results indicate a hegemonic disease prevention discourse, while the health promotion discourse being more disguised. The analysis revealed how language functions ideologically, and in line with the sociolinguistics, how the role of the language in the curriculum text can have consequences for the social work of public health nurses.

1. Introduction

Critical discourse analysis (CDA) emphasizes how language can function ideologically and how to identify hidden meanings in a text. Discourse analysis is an area of social linguistics, which can advance social theory in the direction of language. Data from a study where we used CDA on the curriculum of Norwegian public health nursing partly forms the basis for this chapter. The purpose was to reveal the governmental understanding and expectations of how the public health nursing profession should perform their work and to reveal possibly underlying meanings about health promotion and disease prevention discourses in the text [1].

Public health nurses are to perform health promotion and disease prevention work on an individual and population level [2]. The role of public health nurses has changed. Traditionally, public health nurses were experts, with a “top‐down” approach toward their service users. They performed mostly controls, inspections and told the population how to live healthy. This is in line with disease prevention strategies. Now the public health nursing role has changed to a “bottom‐up” approach. It is an empowering role, where the public health nurse and the service users are dialogue partners. Emphasis is on revealing the resources of the service users in line with a health promotion strategy.

There are various forms of performing discourse analysis. The discursive psychology approach maintains that individuals are both products of discourse and produce discourses in social interactions. Laclau and Mouffe’s discourse theory on the other hand assumes that discourses construct the social world in meaning, and this meaning is constantly in change. In CDA, the aspect is that discourse is just one of many facets of social practice [3]. In this case, Fairclough’s methodology and analyzing method of CDA were found suitable. Fairclough has developed a useful concept of tools for analyzing text, which contributed to map the relation between the various microdiscourses in the curriculum text and a wider macrosocial discourse of public health nursing.

Discourse analysis is an area of social linguistics, which can advance social theory in the direction of language. CDA in the present shape asserts that the world is both socially and discursively constructed [4]. Fairclough includes microreadings of text with macro‐social perspectives. It is about analyzing the patterns, the structure of the language, to identify the linguistic‐discursive dimension of social phenomena, and processes of change in society [3].

In critical discourse analysis, we combine analyzing tools from linguistics with theoretical perspectives from social science. Combining linguistics tools and social science perspectives can reveal how language functions ideologically and how the language contributes to maintain power relations in society [5].

The chapter describes the public health nursing field, the methodology of CDA, and presents the results of a study using CDA.

2. Background

Norwegian public health nurses are authorized nurses with one year continuing studies of health promotion and disease prevention on the fields of child health clinics and school health services. Their main target group is children, young people and families. Almost 100% of the families attend the service. They shall particularly focus on health promotion and primary prevention strategies on individual and population level. They work with immunization, weight/ length control and advising about healthy living. In youth health centers, they among other issues prescribe prevention, insertion of contraceptive coil; perform pregnancy tests, and tests for chlamydia. The environmental health is about advising in health issues and immunization when travelling abroad, tuberculosis work, and preventing diseases as HIV and Hepatitis. Health services for refugees can include health consultations and examination, advising in health conditions, psychosocial work and immunization. The Norwegian government has given the PHNs a mandate to work with universal and health promotion strategies [2].

A literature review on research on CDA related to nursing curriculum revealed only a few hits. A CDA study of the syllabus of nursing education had focus on perspectives and underlying ideological principles in the sociological contribution to nursing curricula. The CDA was a good tool to reveal rich source of data. The researchers found that the biggest challenge was to challenge the ideologies that was constructed and embedded in the syllabi [6]. An article using CDA focused on the links between discourse, power, and elements of social processes, in line with Fairclough’s methodology. The researchers studied British national newspaper representations of the academic level of nurse education and found that nurses lack a voice in the national press. They maintained that discourses do not exist in isolation, they are part of broader social discourses, and where nurses have little input into the construction of newspaper discourse [7]. Rogers & Shaenen focused on the use of CDA method when making a critical, integrative review of literacy education. They found the CDA method used in 76 literacy‐focused studies, including curricular design [8]. They reflect on three decades of CDA in literacy studies. What they revealed was that there has been an increase in researchers using CDA in literacy education research. They revealed a diversity of approaches around contexts and that the reviewers were acknowledged their role as researchers in a reflexive way when performing CDA. They found that the participants in the reviewed studies mostly struggled against dominant ideologies, and many articles called for social action, both on microlevel and macrolevel. The researchers maintain this finding reject the understanding of CDA that it has no plan for constructive alternatives and social action [8].

From the research found, related to CDA method, we can sum up that CDA can be a relevant tool in analyzing text critically. Hence, the aim of this chapter is to demonstrate how CDA analysis can reveal underlying meaning in a text. The purpose of the study was not to study the curriculum document in depth, but to analyze possible dominant and disguised discourses in the text, to reveal underlying governmental principles for how public health nurses should promote health and prevent diseases.

3. Critical realism and sociolinguistic theory

Fairclough has his roots in a critical discourse analysis tradition. He has developed his methodology and analyzing method over the years, and his philosophy of science is close to critical realism. Critical realism is not as relativistic as social constructivism. Not all representations of the world are equally good, a critical realism defender would say there are some representations that can constitute better knowledge of the world than others [4].

The movement from which Fairclough is affected is the sociolinguistic direction. Sociolinguistics is the study of the relationship between language and society. The emphasis is on the role of language in communication. Fairclough [4] maintains that critical discourse analysis is part of a broadly conceived social linguistics. In the terms of Fairclough to reveal the truth of a text, one must analyze the dialectic between structure and action.

The attention is on the effect of the society on the language. Fairclough defines discourse as the use of language as a social practice and not only as an individual activity [9]. He makes use of the concept discourse about both orally and written language. This is what the structuralist linguist Saussure name parole or the situational language. In the understanding of Saussure, parole is an individual activity not suitable for being analyzed [10]. Socio linguists have put forward criticism of Saussure and maintain that the language is socially created and not individually [9].

There is an increasing emphasis on language in recent social theory but still a failure in showing in social research how language figures in social life [4]. Hence, a theorization of social language can contribute to a dialectic between social structure and action. We can see critical discourse analysis as a part of a broader developed social linguistics.

Fairclough’s draw on Foucault in the understanding of the subject and object as discursively created. Fairclough’s focus includes a broad approach to language and text. Here, he separates from Foucault who is not engaged in the meaning of the language in the discourse and rejects the need of a text analysis. Rather, he refers to a macro‐sociological analysis [3]. Where Foucault sees the subject almost as a victim of the discourse, the subject in Fairclough’s view is an active participant in the change processes in the language and text interpretation. The active role of the subject brings about possibility for change. A critical attitude and possibilities of influence are fundamental in a critical discourse analysis. A way to understand Fairclough and Foucault is that they both find that the subjects constitute the discourse, but they differ in vital respect. Fairclough denies the structuralist view of Foucault and maintains that Foucault emphasizes the structure at the expense of the actor. A structuralist analytical procedure is about reduction and generalization of the text. Leaning on Foucault the curriculum represents a view within a given time, which will influence and determine the interpretation of the text. Fairclough advocates on his side a greater interaction between discourse and society.

The text embeds the ideology, and it is about identifying what lies behind the immediate “common‐sense” understanding. The hidden ideology relates to the concept of hegemony, which Fairclough links to discursive power structures. Power relations maintain and change through struggles for hegemony between discursive and social practices. Authority and ideology are in the optics of Fairclough associated with struggles for hegemony. The ideological discursive struggles contribute to maintain the dominant relations. His opinion divides from Foucault, who understands power as a creative and productive force that permeates all discourses.

4. Method

Critical discourse analysis as method has suitable tools to develop the analysis and to describe important findings and perspectives to the research. Three dimensions of social life form the analysis: the abstract social structure, the concrete events, and the social practice, which mediates the relationship between the two first dimensions.

4.1. Design

Fairclough has developed his design and analysis of text from a former three‐dimensional conception of discourse that consisted of the analytical dimensions text, discursive practice, and sociocultural practice [9]. Fairclough maintains that one can still use this concept; however, he has developed the analyzing parts and given those new names and partly new content, more in line with critical realism theory [5]. The “new” dimensions are the basis in the present study of the curriculum of Norwegian public health nursing. It can be useful to highlight some main concepts which were fond suitable as tools to describe central approaches and results in the study (Table 1).

Text	The written or spoken language produced in a social event
Genre	Use of language associated with a particular social activity or work, for instance, interview genre
Style	How text figures in the identification of people; ways of being; production of social life
Discourse (abstract noun)	Language use conceived as social practice
Discourse (count noun)	Way of signifying experience from a particular perspective; ways of representing
Order of discourse	Totality of social practices of an institution, and relations between them; a specific configuration of discourses, genres and styles
Intertextuality	A text draws on elements and discourses of other texts; for instance, the influence of history on a text, and a text’s influence on history
Interdiscursivity	Shifting articulations of genres, styles and discourses in specific texts; a form of intertextuality
Ideology	Ways of representing aspects of the world that contribute to establishing or/and maintaining power relations and dominance. Ideology is often in the unsaid and implicit in the text
Power	Power and discourse are different elements in the social process. Power is both dominant and more invisible in the text
Hegemony	Processes for dominance in orders of discourse and social struggles. Ideology is associated with power as hegemony

Table 1.

Definitions based on main concepts in Fairclough’s critical discourse analysis.

Critical discourse analysis sees concrete social events and abstract social structures as part of social reality [4]. As mentioned above, Fairclough distinguishes between three dimensions in his understanding of critical discourse analysis: social events, social practices, and social structures. In the social structures lie the potentialities for action. The social events dimension is where the actual actions take place. The social practice domain controls the performance of different events. This means that there is a dialectic between the three dimensions (Figure 1).

Figure 1.

Model inspired of Fairclough’s linguistic‐discursive dialectic dimensions for analysis of social reality.

4.2. Sample

The national curriculum for public health nursing educations in Norway [11] was the field of study. Regulation for public health nursing education was not part of the analysis. The authority and directing perspectives of the government form the basis for the curriculum text. The Ministry of Education and Research produced the curriculum in 1998 and slightly revised it in 2005. It consists of a general section with a historical perspective and an argumentation for the need of a national curriculum, and a section, which describes the claims and expectations concerning the social task and knowledge basis for public health nursing profession. The curriculum defines the public health nursing field to nearby professions.

4.3. Data analysis

4.3.1. Social events—social action—text

The dimension of social events is about social actions on the microlevel, the concrete level [4]. Emphasis is on analyzing the linguistic‐discoursal elements of a text, the verbal interactions. The way the language is used can unveil which institution produced the text. In the present case, we have a governmental document, the educational curriculum.

To unveil the “hidden” meaning in the document, the first step was a linguistic approach to language and text analysis. The attention was both on form and on meaning, through symbols as words or longer text sequences, which per Fairclough is socially motivated and can illustrate a political agenda. The text analysis included four areas or levels: choice of word/ vocabulary, grammar, cohesion, and text structure. To explain how the curriculum constructs different types of discourses can visualize ideological struggles. Focus was here also on strength of the statements, coherence, and intertextuality [9]. The social institutions determine the social actions, and this dimension is the social practice dimension of the analysis.

4.3.2. Social practices—social institution—order of discourse

The dimension of social practice relates to social institutions. An institution includes both ideological norms and discursive orders. Faircolough maintains a discourse is just one among many aspects of any social practice [3]. Hence, the institution constructs subjects ideologically and discoursally, and the institution itself is a sort of ideological community and speech community [4]. To analyze the institutional dimension, one must reveal the linguistic‐discoursal element of orders of discourse (level of practices). Orders of discourse are the totality of social practices of an institution and relations between them, and they are relatively stable. In the present case, the analysis is of an educational order of discourse, and the focus is on a specific configuration of genres, styles, and discourses in the curriculum text. Fairclough maintains that there is a textual moment in any social practice that includes the categories of genre, style, and discourse (as a count noun). The genre of a text reveals how the text produces and reproduces for instance a social activity that constitutes different forms of social relations at work. The style can identify people and their ways of being. The question of discourses is about how people have ways of representing the world. Different discourses are different representations. Social practice is organized into networks based on different forms of social relations, identifications as different representations, and these common practices, for instance, an educational practice is networked into a common field. The category of intertextuality refers to textual aspects of the articulatory character of social practice [4]. The production process of the curriculum occurs in a particular way inside established limits, and we can make a de‐construction of the text to different positions.

4.3.3. Social structures—social formation—semiotic systems

The social structure dimension is about investigating the semiotic systems, the linguistic‐discoursal element of language, which is the language use (codes, norms) in the text. It is about how language interaction is determined by and has effect on social structures. The highest level of social structure is social formation, which is on the macrolevel. The social formations determine the institution. However, in the institution, there is a dialectic relation to the actions and the formation, where the micro and macrolevel (actions and formation) influence on the practice. In line with Fairclough, the institutional dimension manifests the social formation and the social actions [4]. The analysis of the curriculum is about revealing the ideology basis of the text, and what discourses have hegemony, which is a social struggle for dominance. Hegemony is here also connected to a meta‐discourse, where different forms of hegemony structure the meaning of words and the relation between words [4]. A critical text analysis can reveal power dimensions in the curriculum text, which can have influence on the understanding of the public health nursing education.

5. Results

Analysis of the curriculum revealed four features of discourses related to the research question: a contradictory health promotion and disease prevention discourse, a paternalistic meta‐discourse, a hegemonic individual discourse, and a hegemonic discourse for interdisciplinary collaboration.

The analysis started with a language analysis to get a deeper understanding of the text and reveal underlying structures. The writing style was factual prose, and metaphors and value‐laden words were almost absent. The language was precise, with little conflicts regarding the interpretation. The grammar or sentence structure had great statement force and use of present tense. The consequence was a reinforcement of request and requirements of form and content in the curriculum: “The public health nursing education shall help students acquire relevant knowledge of the work to improve public health” [11, p. 5]. The curriculum had a formal and confirming expression in a third‐person perspective: “…is it decided…”. The authors hold an authoritarian position, which was enhanced by the use of professional terminology:”…acquire skills in planning, implementing and evaluating measures…” [11, p. 5]. The use of modal auxiliary as “shall,” “must,” “should,” “may” in the text has significance for the strengthening of the statements. There was an extensive use of “shall” in the first part, regarding the rationale for the curriculum. An outline of the four discourses follows.

5.1. A contradictory health promotion and disease prevention discourse

Contradictory discourses here refer to a contradiction in visibility between the health promotion and disease prevention discourse in the text. The education should place “special emphasize” on “knowledge about and understanding of children and adolescents growth and development, and factors that are beneficial to their health.” Simultaneously students should consider “risk of disease and injuries.” The analysis indicated that health promotion and disease prevention strategies had equal status in the text. On the other hand, the result showed a dominant disease prevention discourse when analyzing a list of seven central themes for public health nursing work that followed. Three themes dealt with both health promotion and disease prevention: “main strategies, challenges and dilemmas in health promotion and disease prevention work,” and four were biomedical areas to prevent disease: “disease perspective,” “prevention strategies,” “information,””nutrition,””epidemiology,” “environmental hygiene, accident and injury prevention” [11, p. 6–7]. A separate chapter named health promotion and disease prevention work of public health nursing could be expected to highlight both working strategies. Nevertheless, emphasize was on disease prevention work, and underlined problem solving priorities: “psychosocial problems, repetitive strain injuries, injury/ accidents, asthma/ allergic, cardiovascular diseases, cancer and infectious disease” [11, p. 4].

The curriculum pointed out that different historical and cultural meanings of the health concept should be emphasized [11, p. 6], but the health concept was not further defined. One can distinguish between a narrowly health concept, understood as “absence of disease,” and an extended health concept, based on WHO’s definition from 1948:”a state of complete physical, mental and social well‐being and not merely the absence of disease” [12]. We can link the first to biomedical knowledge and the latter to social scientific knowledge. The result indicated that the narrow and the wider health concept had equal status in the curriculum.

The students were to acquire evidence‐based knowledge: “shall know current research” [11, p. 7] and “interpret and apply research results” [11. p. 9]. The nurses’ ethical guidelines emphasize that nursing shall be knowledge based [13]. Nevertheless, the curriculum also described the need for practical knowledge and experience, and that students should develop their ability to work in line with a health promotion and disease prevention perspective. The description of priorities in health promotion and disease prevention work emphasized “problem,” “suffering,” and “disease” [11. p. 4]. This harmonizes with a disease prevention discourse. The health promotion discourse was almost absent.

It was apparently a dominant health promotion discourse when it came to the description of the public health nursing field of work, but the prevention discourse showed through. This is confirmed by the fact that the biomedical knowledge was highlighted, in that disease prevention strategies got substantially more space when the areas under each main topic was explained. The critical text analysis revealed that the more invisible disease prevention discourse had a power position in the text and hegemony over the health promotion discourse.

5.2. A paternalistic meta‐discourse

A paternalistic discourse here refers to the identification of a discourse in the curriculum text associated with the traditional expert role of public health nurses. To use the term meta‐discourse means a summing up of the discourses in the text, to examine the purpose of the discourses. What are we to understand by for instance the participation discourse that follows below?

The health promotion strategy that emphasizes service user participation has gradually increased in public health. Political documents highlight collaboration, participation, and to reveal recourses of service users [14]. This shift from a medical discourse linked to disease prevention and paternalistic ideology, to a health promotion discourse and a coping perspective, was hardly noticeable in the curriculum. The curriculum stated:”the study shall emphasize service user and community participation” [11, p. 6]. To use the concept “participation” could indicate that public health nurses should work with health promotion strategies toward the community. However, participation on a population level was mainly touched upon related to “identification of risk‐factors” in the environment and “participate in the problem‐solving work” [11, p. 5]. The analyzing result indicated the public health nursing tasks related to community, and population level was mainly limited to environmental health and expressed in disease prevention strategies.

A service user perspective linked to participation was constructed in the text, where the students should”stimulate the service users attention on and manage to protect own health”…”strengthen the initiative of the population” [11, p. 5]. Concepts as “dialog” and “participation” [11, p. 8] pointed out the significance of a service user perspective and could have contributed to generate a dominant discourse of participation. However, emphasis on concepts like recourse thinking, coping strategies and empowerment‐ideology was absent. Analyzing the service user participation in the text revealed instead an expert discourse: “It shall be emphasized that the students develop an understanding of the power and control‐aspects associated with the helper‐role…” [11, p. 8]. The use of “helper‐role” increases a dependence relation. We here identify a meta‐discourse linked to a paternalistic expert ideology, which appeared to be a dominant discourse in the curriculum text.

5.3. A hegemonic individual discourse

The hegemonic individual discourse refers to a dominant discourse in the text that emphasized an individual perspective and not a population perspective in the description of public health nursing work.

The result indicated public health nurses was to interact on an individual and family basis: “It is thus increased demands on ability to collaboration and interaction on and together with children, young people and their families” [11, p. 5]. The cohesion or coherence between the sentences, for instance, the use of conjunctions (“thus”, “and”) showed an argumentative structure in the text, and it hardly opened for argumentation. Use of the concept “demand” gave an association to power and order, which indicated a discourse of power in the text. The curriculum text opened for collaboration with the service uses but revealed no further emphasis on health promotion strategies related to quality of life on a population basis. The result suggested that the individual discourses in the text were about health promotion and disease prevention, whereas the population discourses related to health promotion strategies were absent in the curriculum. We could have expected that the thoughts from the Ottawa Charter [12], advocating local communities as arenas for health promotion had been more visible in the text.

5.4. A hegemonic discourse for interdisciplinary collaboration

We can identify a discourse of collaboration in the curriculum, enhanced by:”…the necessity that tasks are solved across sector boundaries shall be emphasized” [11, p. 7]. This is in line with guiding principles for the health and social sector, that is, to develop the interdisciplinary collaboration [15]. The use of “shall” emphasized a strong statement force and a hegemonic use of power. The public health nurse was earlier, together with the doctor, the only professional working with health aspects in child health clinics and school health services. Now the service engages new groups as physiotherapists, midwives, child welfare officers, and other professionals. The curriculum stated, “The work demands interdisciplinary and intersectoral collaboration” [11, p. 5]. The text had an argumentative form: “Today’s health problems and social challenges…need for innovation and multi‐disciplinarily…” [11, p. 3]. It referred to the increased emphasize on health promotion and disease prevention in governmental documents, and that the health promotion—and disease prevention work gradually has entered many public and private sectors.

6. Discussion

A text is both socially structuring and socially structured [4]. Fairclough points out that we cannot automatically reproduce a discourse. However, the curriculum is a specific social practice open for change and which can need a reformulation to new positions if health and social political goals and development in society indicate this [11]. In line with the sociolinguistic theory, Fairclough [4] advocates a greater interaction between discourse and society. Transferred to the public health nursing field, this is in line with the goals of World Health Organization, who is claiming for nursing educational programs to act as agents for change in a constant changing health care [16].

The analysis has explored how governmental strategies for the public health nursing profession can come to expression in the curriculum, and produce ideological statements and guidelines for public health nursing educations. The curriculum points out the specific public health nursing work and knowledge basis, which will be of importance in maintaining the professional borders of public health nursing. A profession is characterized by a particular knowledge field, and Abbott [17] relates the boundary drawn around one’s own profession to a power strategy. The curriculum represents the content, which marks the boundaries for public health nursing profession. The results indicate that a discourse about health promotion is constructed and maintained in the curriculum; however, the empowerment and coping perspective were absent. This weakens the power of the health promotion discourse. Following Fairclough, power and ideology have a link to hegemonic struggles [9]. The result revealed a disease prevention discourse and indicated this to be a hegemonic power discourse.

The result identified service users in a helper role, positioned as a weak group. They are in need of help from an expert nurse in a power position. Foucault is concerned about the relation between power and knowledge, where knowledge is internal the power relation. According to Foucault, the power is everywhere, more, or less hidden, and it is about social control and disciplining the dissidents [18]. Public health nurses can appear as disciplining agents seeking to control the life of the service users by telling them how to live their lives. This position can bring about ethical dilemmas related to contradictions between the empowering and expert role of nurses [19]. Fairclough maintains that changes in power relations between discursive practices can be elucidated through new ways of articulating the concept of knowledge and content [4]. The traditional relation between public health nurses, and the service users has in many ways entered a new language or a new mode, disguising the traditional direction. The discursive position as disciplining‐agent harmonizes with the “top‐down” paternalistic discourse especially recognizable from the early days of public health nursing work. Public health nurses are required to follow the official recommendations for the service, which then must reflect the actual practice. This dominant position disclaims core values and can lead to professional and societal resistance discourses [20].

We can argue that the disease prevention perspective has hegemony in the curriculum, and that public health nursing educations must be aware of this in order to challenge it.

Since the 1980s, there has been a gradually change from a biomedical discourse, associated with disease prevention strategy, to a health promotion recourse perspective in Norwegian governmental documents. The public health nursing work has changed with social change from emphasis on epidemiological and pathogenic factors to recourse thinking and salutogenic factors. The salutogenic theory relates to the individual level and is about how to stay healthy by strengthening positive factors [21]. Primary prevention strategies and not health promotion strategies were highlighted in the text. This is not in line with the Norwegian public health nurses’ community mission, stating that public health nurses are to practice both health promotion and primary prevention work [22]. Resource thinking was almost absent in the text, in spite of a revision of the curriculum as late as in 2005, when these were common concepts in Norwegian governmental documents [15]. This is informed already by the Ottawa Charter of 1986 [12] assuming health as a resource for everyday life. This result is enhanced by the fact that the Ottawa Charter was not referred to in the text. When the notions of empowerment and resource thinking are absent, and the population perspective is hardly touched upon, this causes limitations to the health promotion discourse in the curriculum. This study indicates that we need to highlight health promotion in public health nursing, being an agent for quality of life.

The analysis has pointed out a power position in the curriculum illuminating inter‐professional collaboration. A defined knowledge basis of the nurses’ constructs the boundaries toward collaborators. At the same time, when public health nurses know and feel secure in their role, this creates possibilities for interprofessional and interdisciplinary collaboratin. In line with governmental expectations, we can maintain that primary prevention and health promotion should be the strategies of public health nursing work. Secondary and tertiary prevention has a problem focus, and nurses should detect and refer deviations from normality to more specialized services. Public health nurses could then contribute to improve and extend quality of life on a broad public health arena.

Consequently, this study indicates a need for clarity of public health nursing educational basis. To meet the challenges and needs that come with social change, the curriculum has to be examined [23]. When clarifying the health promotion and disease prevention strategies in public health nursing and by questioning and debating other guiding documents for public health nursing, this can develop a joint understanding of the content of the education. Further, this can provide a qualified work force in public health to meet the requirements of the society.

6.1. Limitations

This critical text analysis is just one of the several readings. In CDA, one discourse is not more valuable than another, where the analysis seeks to identify discourses and their effects [24]. It is a cultural production, where we bring our preunderstanding of the field into the CDA analysis [8]. Being a public health nurse myself, working in the public health nursing education can be both a strength and a limitation in the analyzing process. Strength in the way that I have knowledge of the content of the public health nursing education. Limitation in the way that this knowledge can make me blind for variations in the curriculum text. Fairclough maintains that one has to be sensitive to what position and resources one has oneself to do analysis [25]. To acknowledge this position as a researcher, and by using the analyzing tools of the CDA, can contribute to make the necessary distance and critical entrance to the text.

7. Conclusion

The purpose of this study is to illuminate how critical discourse analysis can be a purposeful method in revealing possible dominating discourses and underlying meaning in a text. The example from the analysis of the curriculum text revealed different features of discourses related to health promotion and disease prevention strategies in public health nursing. The analysis is different representations of orders of discourses in the curriculum, and present four contrasting features of discursive practices. The study suggests how analysis of curriculum discourses can illuminate shifting perspectives in public health. The analysis emphasizes a display of social and educational practices in the curriculum. The results indicate that the disease prevention discourse had hegemony, both on an individual and a population level. The health promotion discourse is more disguised and on an individual level. The analysis indicates that the role of the language in the curriculum text can have consequences for the social work of public health nurses. From a sociolinguistic perspective, we can maintain that a revision of the curriculum is needed, to clarify how public health nurses are to work and meet the population for the purpose of promoting health and preventing disease. It is a need for further research on public health nursing practice.