Prepared by Louise Hanvey for the Canadian Nurses Association September, 2005 Draft 3

Transcription

1 Rural Nursing Practice in Canada: A Discussion Paper Prepared by Louise Hanvey for the Canadian Nurses Association September, 2005 Draft 3

2 Introduction While Canada has become an increasingly urbanized nation in the past 50 years, there is still a significant proportion of the Canadian population that lives in rural and remote communities. Nurses have practiced in rural and remote Canada throughout our history. They have always faced challenges. These challenges are now changing, in the context of an aging Canadian population, shortages of nursing personnel overall, changes in technology and restructuring of the health care system. The purpose of this discussion paper is to illuminate the issues regarding rural and remote nursing practice in Canada today. It is not intended to be an exhaustive review of all of the literature on the topic rather it is meant to raise critical issues and share examples of potential approaches. This paper is based on a review of selected literature and interviews with Canadian leaders in rural nursing practice. The dilemma of defining rural The definition of rural is not universally agreed upon. There are no universally accepted methodologies for determining whether a community is rural or remote, or for determining relative degrees of rurality between communities. No standard definition of rural is used in research, policy or planning (Adams et. al., 2003 MacLeod, 1999). MacLeod speculates that this is partly due to the differing needs for and uses of definitions. The most common approach is that all territory not classified as urban is considered rural. How rural is defined is important because each definition produces different numbers, classifies different people as rural and identifies different characteristics of rural populations. For example, based on the 2001 Census data, Statistics Canada s rural and small town definition classified 21 percent of the Canadian population as rural, while the Organization for Economic Cooperation and Development (OECD) predominantly rural regions definition classified 30 percent of the Canadian population as rural. These differences in definition in turn affect decisions on policies, programs, funding and service delivery (Ministerial Advisory Council on Rural Health, 2002). To reflect the unique diversity of communities commonly referred to as rural; a recent Canadian Ministerial Advisory Council on Rural Health used the terminology rural, remote and northern. MacLeod, Browne and Leipert (1998) report that the nursing and medical literature define rural and remote practice based on the skills and expertise needed by practitioners who work in areas where distance, weather, limited resources and little backup shape the character of their lives and professional practice. Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 1

3 It is not the mandate of this discussion paper to make recommendations on the definition of rural. The paper will use the terminology rural and remote to refer to rural, remote, northern and non-urban Aboriginal communities. The specific definition of rural will depend on the literature being cited. What does rural and remote Canada look like? Rural and remote communities have diverse social, geographic and economic characteristics. If we consider rural Canada as being all the territory outside of major urban centres it makes up 95% of the country s land mass. Canada s north occupies half of that land mass. Rural geography and weather is diverse. Rural economies are diverse, ranging from mixed-economy communities to single-industry communities that depend solely on agriculture, forestry, fishing, hunting and trapping, oil and gas, mining or tourism. In terms of economic status, there are prosperous communities located near urban centres and small, remote communities with high unemployment levels and few prospects for economic growth (Ministerial Advisory Council on Rural Health, 2002). The people in rural and remote communities People who live in rural and remote communities are tied to the land by historical and cultural traditions, by long-term economic investments and by their preference for living in small communities, closer to nature. Depending on which definition of rural is used, between 21 and 30 percent of the Canadian population lived in rural communities in Ontario and British Columbia have the lowest percentage of rural residents, whereas the territories and the Atlantic provinces have the highest. Almost half the population of Atlantic Canada lives in rural areas (Ministerial Advisory Council on Rural Health, 2002). More than half of Canada s 1.4 million Aboriginal people First Nations, Inuit and Métis people live in rural, remote and northern communities and they comprise approximately 30% of the population of northern Canada. In absolute numbers, the rural population is growing, but because it is growing more slowly than in urban areas, the actual proportion of the Canadian population living in rural areas is declining in relative terms. The exceptions to this decline are Aboriginal communities, communities close to cities and communities in recreational areas that are rapidly expanding (Ministerial Advisory Council on Rural Health, 2002). Most rural communities have a high dependency ratio, that is large populations of older people and children, with relatively small populations of people of working age (those between 20 and 50 years old). This age distribution is a result of the aging of the rural population, the tendency of retirees to move to Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 2

4 rural areas, and the migration of rural youth to urban centres. The exception to this is Aboriginal communities, which tend to be younger. The cultural and linguistic make-up of rural Canada includes official language minority communities and a small immigrant population. In 1996, rural Canada had the lowest proportion of immigrants, including recent immigrants and visible minorities (Ministerial Advisory Council on Rural Health, 2002). The health of people in rural and remote communities Generally, the health of people living in rural, remote, northern and Aboriginal communities is poorer than that of their urban counterparts indeed, health status declines with distance from urban centres. Compared with urban residents, people living in rural communities have shorter life expectancies, higher death rates and higher infant mortality rates. The difference in life expectancy between urban and rural populations is about a year, life expectancy between regions varies by as much as 16 years. In 1996, infant mortality rates in rural areas were 30% higher than the national average, while death rates from all causes were 9% higher than the national average (Ministerial Advisory Council on Rural Health, 2002). The Ministerial Advisory Council found through its work that the poor health status in rural areas is linked to a broad range of personal, social, economic and environmental factors and conditions that influence health, such as income, employment and working conditions, education, personal health practices and the environment. Income and social status are the most important determinants of health, and in 1995, most people in rural areas had personal incomes well below the national average. Rural Canada also received a high proportion of government transfer income (e.g., old-age pensions, unemployment insurance benefits, child tax benefits, and goods and services tax credits), which is another indicator of lower annual income (Statistics Canada and CIHI, 2002). Employment status is another important health determinant, and most rural areas have higher unemployment rates than urban areas. As well, rural workplace conditions often pose serious health hazards for rural workers, especially farmers, fishers, foresters and miners (Statistics Canada, 2001). Finally, health status tends to improve as educational level increases. In the majority of rural communities, people have fewer years of formal education than those living in urban centres (Statistics Canada and CIHI, 2002). Aboriginal people tend to have the poorest health status. The gap in life expectancy between Aboriginal people and the general Canadian population varies from 6 to14 years. Moreover, the infant mortality rate for Aboriginal people is double that of the Canadian population overall. Aboriginal communities have a high prevalence of all major chronic diseases and high rates of suicide, fatal injuries, smoking and alcohol consumption. Low incomes, low levels of education, chronic unemployment, inadequate housing, exposure to environmental contaminants and the legacy of the residential school era have a Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 3

5 strong influence on the health status of Aboriginal people (Ministerial Advisory Council on Rural Health, 2002). Access to health services in rural and remote communities Through their research, the Ministerial Advisory Council on Rural Health, the Romanow Commission the Future of Health Care in Canada and the Standing Senate Committee on Social Affairs, Science and Technology (The Kirby Report) all found the same thing rural realities and rural health needs are different than those in urban areas. Furthermore, they all reported that people throughout rural Canada have expressed serious concerns about their inability to obtain the health services they need in a timely fashion and closer to home (Romanow, 2002; The Standing Senate Committee on Social Affairs, Science and Technology, 2002; Ministerial Advisory Council on Rural Health, 2002). Browne reports that distance is a major problem in rural and remote communities. There are fewer health care facilities and they are more widely dispersed. She contends that more than two-thirds of residents in northern and remote regions live more than 100 kilometres from health services; and that in the Arctic, people may have to travel by plane for many hours to hospital services. Severe weather can make travel dangerous or not possible (Browne, no date). Health promotion and health education services are underdeveloped in most rural communities. Preventive services are also lacking in most rural communities for example, mammography screening for breast cancer is used significantly less in the far northern regions and Atlantic Canada than it is in Canada as a whole (Jennissen, 1992). Most people living in rural, remote and northern communities have limited or no access to a range of health care services commonly provided in urban centres. These services include rehabilitation, palliative care, home care, counseling, respite and long-term care (Ministerial Advisory Council on Rural Health, 2002). Restructuring and health care reform in the provinces and territories have resulted in increasing centralization of services, downsizing and closures of rural hospitals and long-term care facilities. This restructuring has often occurred without enhancing community-based primary care services and has made it more difficult for people who live in rural areas to access services. Moreover, hospital closures have had a negative economic impact on rural communities, since hospitals are not only majority employers; they generate other economic spin-offs (Hutten Czapski, 1998; Weatherill and Coulson, 1999). Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 4

6 Who are the nurses working in rural and remote communities in Canada? According to a study by the Canadian Institute of Health Information (CIHI, 2002) there are 41,500 registered nurses located in rural and small town Canada. CIHI indicates that 18% of all RNs employed in nursing in Canada work in rural areas. Fewer than 5% of all RNs in rural Canada are male as is the situation in urban Canada. MacLeod, Browne and Leipert (1998) describe that nurses in rural and remote communities work in a variety of settings that reflect the resource-based economics of rural Canada. They state that many nurses work in small rural hospitals, others work in community health clinics, outpost nursing stations or long-term care facilities. They work as public health nurses, community mental health nurses and continuing care nurses. They frequently have responsibilities that span large areas and several communities. An increasing number of nurses are working in positions that link hospital and community practice and provide a combination of acute care, health promotion and prevention services. According to CIHI (2002) the majority 54% of rural RNs work in hospitals. However, increasingly higher proportions of rural RNs are employed in long-term care and home care compared with RNs in urban areas of Canada. CIHI (2002) reported that in 2000, 50% of RNs in rural and small town Canada were employed full time compared to 56% in urban Canada. Almost 17% (16.8%) of RNs in rural areas were employed on a casual basis compared to 15% of their counterparts in urban Canada. In rural areas, 70% of male RNs were employed full-time compared to only 49% of female RNs. Younger RNs, especially in rural Canada, were more likely to be employed casually and part time. Nurses in rural and small town areas of Canada were likely to have more than one employer particularly if they were young and male. Between1994 and 2000 the average age of RNs who lived in rural and small town Canada increased from 40.6 to 42.9 years (CIHI, 2002). Some communities had younger, inexperienced nurses whereas others had older nurses. There were almost 100 communities in Canada where the average age of RNs was greater than 50 years. Twenty-two rural communities in Canada were each served by one RN aged 60 years or older. Another 93 rural communities were each serviced by a sole RN aged 50 to 59 years. At the other end of the age spectrum, 54 rural communities were each served by one RN under the age of 30 (CIHI, 2002). According to MacLeod, Browne and Leipert (1998), nurses are the primary healthcare providers in remote and isolated First Nations and Inuit communities. They report that in the 1960s and 1970s there was an increase in the number of outpost nursing stations and health centres, where nurses function Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 5

7 independently in community health and expanded practice roles to provide a full range of health services. What does the practice of nurses working in rural and remote communities look like? There are inadequate numbers of nurses to provide care There is a discrepancy between the health care needs of people living in rural Canada and the availability of health care providers and health services. According to the Canadian Institute of Health Information (CIHI), in 2000, 18% of registered nurses practised in rural, remote and northern communities, where 22% of Canadians lived. To further complicate the issues, other professionals are in short supply as well. For example, only 17% of family physicians and four percent of specialists practiced in these communities. In reality, nurses, physicians and other health care providers are concentrated in urban centres, where the healthiest people in the country live. CIHI reports that in recent years, the absolute number of RNs working in rural Canada has decreased while the absolute numbers of people living in rural and small town Canada has increased. This impacts on the workloads of rural nurses and has the potential of influencing access even more. There are 62.3 nurses per 10,000 (rural) population in rural Canada and 78.0 nurses per 10,000 (urban) population in urban Canada. However, these ratios are not directly comparable, as they do not take into consideration the differences in nursing services provided in those areas. They also fail to recognize the geographical problems (e.g., distance, isolation that rural nurses must cope with and the problems of health care access that rural populations face); as well as various practice patterns and the context within which nurses work (e.g., the proximity of physicians and other health care providers). They are influenced by geography Geography has an obvious influence on nursing practice in rural and remote communities. Traveling great distances to see clients can be the norm. Inclement weather and treacherous roads create difficult working conditions. MacLeod, Browne and Leipert (1998) report that in northern areas, it is not unusual for nurses to drive for eight hours during a day to visit small villages and settlements. Furthermore, MacLeod, Browne and Leipert have identified that this is further complicated because many rural and remote communities are under-resourced. Therefore, nurses are hard pressed to provide what they call effective and efficient services. They carry a tremendous amount of responsibility In rural and remote communities, the practice of nursing is particularly defined by the responsibility that nurses assume. In a study of the nature of nursing practice in small rural and remote hospitals, the nurses described the central theme Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 6

8 through the phrase, We re it (MacLeod, 1998). The descriptions in this report are compelling. They described the frequent scenario where the hospital is the only facility in town to which people can turn for help 7 days a week, 24 hours a day and they observed that in many small rural communities there are less than three nurses in a hospital shift at any one time ( MacLeod, Browne, Liepert, 1998). There may be physicians are available on an on-call basis but they are likely in a neighbouring community that could be 100 km or more away. During situations in which there are several trauma victims, a complicated birth or competing demands for assistance, nurses find themselves without the depth of medical, nursing or material resources available elsewhere and find themselves mobilizing the resources at hand, including family, visitors, volunteers and the RCMP (MacLeod, 1998). In rural and remote communities the numbers of staff are often lower, and as previously noted, the communities are often under-resourced. Shellian (2002) observes that residents, medical students and ancillary technicians are often not available. Since there are fewer numbers of other health care providers for example, physicians in rural communities, nurses are often expected to be primary care givers. Historically, their specialty area of practice is being an expert generalist. They must have a broad knowledge base to care for clients with a variety of health conditions across the life span and they are expected to function more autonomously in expanded nursing roles. Bushy (2002) describes them as having a rich heritage of resilience, resourcefulness, adaptability and creativity. Their greatest attribute is knowing about formal and informal community resources and how to access these for client systems (p. 109). Shellian has stated that: The nurse in a rural setting needs to be a generalist in the true sense of the word. You may feel more comfortable in one clinical area but you will be required to practice in areas where you may not have the same comfort level. It is not uncommon for the rural nurse to begin the shift in the ER, assist in a delivery at noon and then perhaps end the shift providing oneto-one nursing care for a child with a severe asthmatic episode. The expectation held by patients that you are current in certification in several specialties can contribute to your stress levels. Besides having a strong clinical knowledge, the nurse in the rural setting also needs to have an understanding of community capacity, community assets, politics and intersectoral collaboration (Shellian, 2002). Health care restructuring has had a further impact on rural and remote nursing practice. Amalgamated services, downsizing and shortened hospital stays have all resulted in nurses in rural and remote communities having to care for patients with more and more complex problems. This has resulted in an increased burden of responsibility (MacLeod, Browne and Leipert, 1998). Furthermore, since the health status of rural residents is often lower than that of other Canadians, they often work with a clientele that requires more service and care. Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 7

9 The challenges facing nurses working in rural and remote communities The literature reviewed for this paper, and the discussions with key informants, identified a number of challenges facing nurses working in rural and remote communities. They can be described in the following categories: o Recruitment and retention; o Education; o Being the nurse in a rural or remote community; o Recognition and/or attention; and o Particular challenges for Aboriginal nurses and communities. Recruitment and retention Recruitment and retention of nurses is a problem across the board in Canada. This has been identified by all major reviews, task forces and commissions held in recent years. These include the Canadian Nurses Association and all Provincial/Territorial Associations; the Advisory Committee on Health Delivery and Human Resources Working Group on Nursing Resources and Unregulated Health Care Workers, in their Nursing Strategy for Canada; the Romanow Commission; and the Standing Senate Committee on Social Affairs, Science and Technology (The Kirby Report). In fact, many countries in the world, including Canada, are facing a shortage of nurses among other health human resources. The challenges are particularly acute in rural and remote communities. As was seen above, nurses practicing in rural and remote communities are disproportional compared to the numbers of Canadians they serve and their health status. Kulig et. al, 2003 predict that the current and projected nursing shortage will have a potentially dramatic effect in rural regions as the present cohort of nurses retires. According to a 2001 survey of almost 1,750 registered and licensed practical nurses working in rural and remote communities across Canada, only one-fifth (21%) felt that their communities were successful in recruiting nurses and virtually the same proportion (22%) reported success in retaining nurses in their communities (Adams et. al., 2003). Recruitment and retention is faced with a number of challenges. Professional demands are considerable and complex. Working and living in remote northern communities creates personal as well as professional challenges. MacLeod, Browne and Leipert (1998) point out that personal isolation is compounded by professional isolation, harsh environmental conditions, limited or expensive means of traveling away from the community and isolation from friends or family who frequently live in the south. Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 8

10 The Northern Development Ministers Forum (2002) identified many factors contributing to recruitment and retention difficulties. These are characterized as: financial/economic; education/training; professional development; quality of life; quality of work life and demographic changes. The Forum notes that the root causes of recruitment and retention problems across under-serviced areas in Canada are consistent across jurisdictions. Bushy (2002) reporting on research in Canada, the US and Australia, identified common themes in terms of recruiting and retaining nurses in rural and remote communities. The nurses who are most likely to work in rural areas will have a rural background or family connections to the community. Successful retention rates are associated with recruitment strategies that address the fit of the nurse s personality, needs and expectations with those of the rural community. Most of the creative recruitment models mandate community involvement in the education and recruitment process, as opposed to simply having a recruitment agency find someone willing to work in a small town hospital. Hegney et. al. (2002) conducted research in Australia to determine why nurses are attracted to rural and remote practice. They found that previous exposure to rural or remote life (e.g., the participants grew up in a country area) or previous work experience in the country were the most compelling reasons for nurses to choose rural and remote area employment. The second set of reasons was also linked to their previous exposure to a rural and remote lifestyle for example, strong social networks. They were likely to seek employment in areas in close proximity to family and friends. A sense of belonging to the community and the availability of a social support network ranked high on their list of factors influencing their choice of rural and remote practice. The third set of reasons involved professional issues for example, the fact that employment was available in the area. This was directly related to how easy it was for nurses to secure at least entry level jobs outside urban centres, because of the problems rural and remote communities face when filling vacancies. The Northern Development Ministers Forum (2002) has recommended a number of strategies for new and expanded recruitment initiatives for northern communities in Canada consistent with addressing many of the issues identified above including: o Home grown recruits more access and local training programs; o Increased participation by Aboriginal groups and devolution of service delivery; o Northern hiring policies; o More job fairs and career symposiums in the north; o Increased use of communication and information technology; o Early career planning through more communication at secondary education level; o Expansion of successful initiatives to more northern communities Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 9

11 o Continuation/implementation of partnerships between government, industry, educators and Aboriginal communities. Education MacLeod, Brown and Leipert (1998) have identified that nurses who practice in rural and remote areas enjoy a high level of autonomy and creativity. This goes along with a high demand for knowledge. Frequently, because nurses operate without the benefit of backup or on-the-spot consultation, there is a need for a great diversity and depth of knowledge (MacLeod, Brown and Leipert, 1998). However, this demand for knowledge is often found in a context of professional isolation where access to relevant education is lacking (MacLeod, 1999). What is the basic education of nurses working in rural and remote Canada? Increasingly, nurses are entering the profession with a bachelor s degree in nursing in rural Canada, 9.2% in 2000 compared with 6.4% in However the proportion of rural nurses with baccalaureate preparation is lower than that in urban Canada those figures were 12.3% in 2000 and 8.8% in In rural areas of Canada in 2000, 18% of RNs had attained a bachelor s degree in nursing as their highest education in nursing compared with 13% in This compared with 24% in 2000 and 18% in 1994 among urban nurses (CIHI, 2002). The lower numbers of rural RNs who have acquired additional academic qualifications suggests that new ways of working with rural RNs and their employers need to be explored to make advance educational opportunities relevant and accessible. There is an apparent contradiction between the expanded role of practice demanded of RNs in rural areas and the comparatively lower level of their formal education. According to a 2001 survey of almost 1,750 registered and licensed practical nurses working in rural and remote communities across Canada, nurses express low levels of satisfaction with opportunities for professional development (39%) and consultations/advice provided by other health care professions (38%). Only one-in-four nurses (26%) stated that they were satisfied with opportunities for career advancement (Adams et. al., 2003). Hegney s survey of Australian nurses (2002) also found that the inability to progress beyond lower level jobs due to a lower turnover of higher-level staff was a difficulty inherent in working in rural and remote communities. Canadian nurses (and other health care professionals) also report that access to telehealth services is not extensive. According to the 2001 survey, 30% of respondents (nurses, pharmacists and physicians) indicated that continuous professional development was a telehealth service that was available in their community, with an additional 8% indicating that it is available but not utilized. Those indicating the availability of telehealth for other purposes were fairly low. Only 14% reported having telehealth available for assessment and triage, and 16% reported the ability to perform diagnostic imaging. Uptake was higher for health information and advice of the consumer (29%), patient treatment and Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 10

12 management (23%) and counseling services (21%). For all these services, there was an additional 3% to 4% that said the service was available but not utilized. Educational preparation of nurses for rural and remote areas of Canada has not been the focus of Canadian documents which address rural health. Kulig et. al., (2003) found, after an extensive study of government, educational institutions, and nursing association documents and web sites, that while there are several universities that prepare students for rural and remote settings, no published documents could be found that address the evaluation of such programs. Furthermore, Bushy has stated that what constitutes core nursing content to prepare graduates to effectively practice in a rural setting has not been clearly defined (Bushy, 2002). She has identified, however, that there is consensus (within Canada, the US and Australia), that nurses in rural practice must have excellent generalist skills, along with the ability to provide emergency care for trauma injuries, cardiopulmonary conditions and sometimes obstetric-neonatal care. Kulig et. al. (2003) recommended that what is critical is an integrated, collaborative effort between governments, regional health authorities, nursing associations/colleges, and educational institutions to prepare nurses for practice in rural and remote settings. They reported, after their extensive document review, that little literature was found regarding the education of RNs to work in rural and remote regions of the country. They reported that the majority of the literature that did address education for remote practice focused on advanced nurse practice and First Nations and Inuit health care needs and preparation. Recognition and Attention MacLeod (1999) reports that a lack of awareness on the part of urban practitioners and policy-makers about the realities of rural health are common. She cites examples where rural nurses identify the difficulties they experience when transferring patients to larger facilities ranging from a lack of appreciation of local weather patterns to negative comments about rural and remote nurses ability to assess patients before transfer by urban nurses (p.168). She states that when realities of rural practices settings are not acknowledges by those outside the settings, rural practitioners can feel undervalued and unsupported. Furthermore, the policies and standards written for urban situations are often unsuitable in rural and remote settings (MacLeod, 1999, p. 168). MacLeod reports that there is little research in this country on rural professional nursing practice and this has rendered the character of rural and remote nursing invisible (MacLeod, 1999, p. 168). In preparation for her study of nursing practice in very small rural and remote hospitals in Northern British Columbia, MacLeod reviewed ten years of Canadian nursing research literature on rural nursing and found only one published study that looked directly at rural or remote nursing itself a study of occupational stressors of northern outpost Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 11

13 nurses (MacLeod, 1999). She reported that unpublished research is more common. She states that more common yet, although still few in number, are descriptions of patient care, nursing situations, or case studies of practice and that most of these are of outpost nursing, practice in First Nations communities and historical studies. She found only one article that described a Canadian rural situation. Crooks (2004) contends that historically, rural nurses believed that they were not doing anything important. Because of this she suggests that they did not tend to analyze or write about their practice. This, she states, is in the broader context of society s lack of value on nursing practice; the seemingly recent organization of rural nurses as a group; and the focus on the soft or relational aspects of practice that embody rural nursing. All of this has resulted in rural nursing not gaining (to date) the recognition as a specialty that she believes it deserves. Being the nurse in a rural or remote community After examining research in Canada, Australia and the US, Bushy (2002) reported that in rural communities, informal social structures often predominate, the pace of life seems to be less hectic, and there tends to be a connectedness between people. She states that since the populations are smaller, people are more likely to know each other and this results in different social dynamics than those found in urban areas. As reported earlier, this is often an enticement for working in rural communities. However, this is also a double-edged sword. Bushy (2002) found that along with informal social structures, nurses usually have high public visibility in small communities and the informal networks can present challenges in maintaining individual anonymity and confidentiality within a small community. MacLeod, Browne and Leipert (1998) add further to this dialogue by observing that in rural and remote communities nurses are visible and as a result, they are often accessed by clients in their off hours, at community get-togethers and in public places (p.75). While some nurses view this lack of anonymity as a disadvantage, others enjoy these informal contacts, seeing them as ways in which to build trust, monitor follow-up and foster health promotion (MacLeod, Browne and Leipert, 1998). Shellian (2002) states that rural areas value and embrace their nurses the personal connection is much more evident in these communities. Furthermore, Shellian (2002) proposes that when looking after people they know as is often the case in rural and remote communities nurses have a strong sense of accountability. This often results in the situation where they are always a nurse in their community. Furthermore, confidentiality has a very strong focus in small communities, where nurses know many personal and confidential things about community members. Particular challenges for Aboriginal nurses and Aboriginal Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 12

14 communities Through their extensive review of policy documents, Kulig et. al. (2003) concluded that a major component of nursing practice in rural and remote Canada is nursing and health care delivery in Aboriginal communities and this has been the case since the turn of the century. They report that in Aboriginal communities, nurses work collaboratively with community members. They are often the only health care providers within the community. These researchers concluded that nursing practice in Aboriginal communities is influenced by the current and predicted nursing shortage, as is rural and remote practice throughout the country. It is also, however, influenced by the education of Aboriginal nurses; the introduction and integration of traditional healing methods; and the transfer of health care delivery to tribal councils or local bands (Kulig et. al., 2003). Many years ago the Royal Commission on Aboriginal Peoples identified a significant shortage of Aboriginal health care providers including nurses. The Commission recommended that federal, provincial and territorial governments commit themselves to providing the necessary funding, consistent with their jurisdictional responsibilities to implement a co-coordinated and comprehensive human resources development strategy; and to train 10,000 Aboriginal professionals over a 10-year period in health and social services. Aboriginal people are not proportionately represented in health and social service sectors, and where they are, they are often trained at a lower level (Royal Commission on Aboriginal Peoples, 1996). In 2002, the First Nations and Inuit Health Branch (FNIHB) of Health Canada funded a National Task Force on recruitment and retention strategies for Aboriginal nurses. The Task Force was co-chaired by Dr. David Gregory, Dean of the Faculty of Nursing, University of Manitoba, and Professor Fjola Hart- Wasekeesikaw, President of the Aboriginal Nurses Association of Canada (ANAC). Their report, Against the Odds: Aboriginal Nursing, identified recommendations for support to Aboriginal students through the phases of preparation, recruitment, admission, nursing access and bridging programs, progression, and post-grad recruitment and retention. The report recommended that: o There is an urgent need to ensure that Aboriginal youth complete their high school education. In addition, students must include math, science, and English in their programs of studies. They need encouragement and guidance to consider nursing as an achievable career option. o Successful recruitment of Aboriginal people into nursing depends on concerted and targeted recruitment efforts, visible role models, community development, and ongoing partnerships among government, Schools of Nursing and Aboriginal communities. o Affirmative action around the admission of Aboriginal students into nursing programs is critically important. Programs demonstrating success or which have the potential to foster success include Nursing Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 13

15 Access Programs and bridging programs for Licensed Practical Nurses (LPNs) and Registered Practical Nurses (RPNs). o The progression of Aboriginal students through nursing programs is enhanced when Schools of Nursing offer flexible programming and curricula that are relevant to the world views and life experiences of these students. Community-based programs have eliminated some of the barriers that students face when pursuing post-secondary education. The presence of personal and academic supports also enhances progression. Adequate funding is central to the successful completion of nursing programs. o Targeted mentoring programs, further development of nurse managers, and capacity enhancement of Community Health Representatives (CHRs) hold potential for supporting new graduates and/or new employees. Designated field teaching units may have a positive impact on retention rates as well as foster partnerships among the government, Schools of Nursing and Aboriginal communities (Gregory et. al., 2002). Band transfers of health services in Aboriginal communities are more and more common. Kulig et. al. (2003) reported that by 1999, 41% of the eligible First Nations and Inuit communities had signed transfer agreements. The Aboriginal Nurses Association of Canada (ANAC, 1995) identified issues in the transfer process that are faced by nurses which ultimately influence recruitment and retention. These are: the acceptance of the nurse within the community; the recognition that the nurse is a professional meeting standards of competency; ethical practice guidelines; and clear regulations for practice. ANAC reported that often nurses have not been involved in the transfer process although they are required to implement the resultant changes. After an extensive policy document review, Kulig et. al. (2003) identified that there are a variety of reasons that band transfers have a significant impact on nursing practice. They include: o The increased number of nurses who will work as band-employed health personnel; o The need for an understanding by the band and community about the meaning of transferring health services to their jurisdiction; o The need for an understanding by the band and the nurse about the contract within which the nurse will be hired and work; o The need for a clear set of competencies and educational preparation to ensure the appropriate level of care is provided at the community level; and o The need for provincial nursing licensure to ensure competencies and liability insurance coverage are met (Kulig et. al., 2003). These complexities often translate into difficult realities for community health nurses, primary care nurses and home care nurses who are currently working in Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 14

16 First Nations Communities. They have staffing problems competing with other agencies to recruit nurses and a lack of resources to retain them. Salaries and benefits are sometimes below the levels that nurses could attain in other communities. They may work in environments where there is a lack of understanding about the role of nurses. They also the difficulties of continuing education opportunities faced in other rural and remote communities. They may work with a shortage of resources both human and material. They are often caught in between jurisdictions not being able to access programs/resources that may be available. Kulig et al., (2003) note that the Aboriginal Nurses Association of Canada has recognized these concerns and is addressing them through a series of workshops and through continuous political advocacy. Examples of Canadian and international initiatives National policy and practice initiatives There have been a number of national initiatives undertaken in Canada in recent years that are attempting to address issues faced by nurses working in rural and remote communities. Some of these address rural health and health care overall; some address nursing human resources issues overall; and some address nursing issues in rural and remote communities. Here are some examples. National Rural Health Initiatives The Government of Canada created a national rural health strategy in The result was a plan that prioritized the major issues, and proposed ways for the Government of Canada and rural communities to work together to solve them. It also demonstrated the need for national leadership to: address the shortage of rural health practitioners and improve rural health infrastructure. In order to address issues in rural health and health care, the Government of Canada has created a Ministerial Advisory Council on Rural Health. The Council s purpose is to identify and champion current and emerging issues in rural health and to ensure that they are appropriately referred for action. The Council provides independent advice to the federal Minister of Health on how the federal government can maintain and improve the health of people who live in rural, remote, northern and Aboriginal communities. In 2002, the Advisory Council issued a report with the Council s advice to the federal Minister of Health on a variety of issues affecting the health and well-being of people living in rural Canada. They made a number of recommendations grounded in a health determinants approach that recognized that economic, social and environmental factors have a significant collective influence on health. National Nursing Initiatives Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 15

17 Recognizing the serious situation regarding nursing human resources in Canada that there were not enough nurses in the system to meet current requirements, and too few to meet future requirements the Conference of Deputy Ministers of Health, in 2000, requested a strategy for nurses for Canada. Following consultation with key stakeholders throughout the country, and with the active participation of many parties including nurses, The Nursing Strategy for Canada was created. The goal was to achieve and maintain an adequate supply of nursing personnel who are appropriately educated, distributed throughout Canada, and deployed in order to meet the needs of the Canadian population. Eleven strategies for change address four issues unified action; improved data, research and human resource planning; appropriate education; and improved deployment and retention. The Canadian Nursing Advisory Committee was created as a recommendation of the Strategy, and has released its first report Our Health, Our Future, Creating Quality Workplaces for Canadian Nurses. The report contains recommendations intended to resolve workforce management issues and maximize the use of available resources; create professional practice environments that will attract people into the profession and encourage nurses to stay in the profession; and to monitor activities and disseminate information to support, attract and retain the nursing workforce (Advisory Committee Health Delivery and Human Resources, 2003). A federal government funded project, Building the Future: An Integrated Strategy for Nursing Human Resources in Canada is underway. The goal is to create an informed, long-term strategy to ensure that there is an adequate supply of skilled and knowledgeable nurses to meet the evolving health care needs of all Canadians. Through surveys, interviews, literature reviews, and other research, Building the Future intends to provide a comprehensive report on the state of nursing human resources in Canada. While the focus is broader than rural and remote nursing the findings and implications of the study will include a focus on these issues. The first report of the study has been released The International Nursing Labour Market Report. The report identifies that the contemporary nursing labour market internationally is characterized by a shortage in all but a few countries. Many countries have implemented recruitment strategies to increase their supply of nurses and many recruit abroad. Some are developing action plans for retention better deployment of the nursing workforce, including better cooperation among providers, better education for nurses, and development of guidelines for safe staffing, few have implemented these plans. Rural Nurses and Nursing Practice As has been seen, there is a paucity of Canadian research in the area of rural and remote nursing. Last year, researchers from across Canada launched a three-year study of nursing in rural and remote Canada. The Nature of Nursing Practice in Rural and Remote Canada is led by Martha MacLeod (University of Northern BC); Judith Kulig (University of Lethbridge): Norma Stewart (University of Saskatchewan); and Roger Pitblado (Laurentian University). The study is Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 16

18 funded by the Canadian Health Services Research Foundation in collaboration with provincial and territorial nursing associations, and various governments and health research organizations. The study consists of four parts: an analysis of CIHI s Registered Nurses Database, providing a statistical and demographic profile of rural and remote nurses (published); a document analysis of policy statements, technical reports, nursing practice regulations and reports relating to nursing education in rural and remote settings (published); a narrative analysis that offers nurses across the country a chance to describe their everyday work experiences; and a survey of 3,933 registered nurses who practise in rural and remote settings. Canadian nurses who are leaders in rural nursing practice have created the Canadian Association for Rural and Remote Nursing. The Association will link to the newly formed International Federation for Rural and Remote Nurses. The Association is an emerging CNA Associate Group, which is a new group whose objectives and potential membership are such that they could become a Canadian Nurses Association Associate Member. The group held its inaugural meeting at the CNA meeting in June, As a result of the recognition that much of the research and initiatives in Canada to address rural health human resource issues have been regional and profession-specific, and lacking in cohesion at both the national and multiprofessional levels, the Canadian Medical Association, Canadian Nurses Association, the Society of Rural Physicians of Canada and the Canadian Pharmacists Association formed a partnership to develop a national healthcare planning tool. The result was a national, Multistakeholder Framework/Index of Rurality a tool that could be used for healthcare planning purposes as well as a means for recruiting and retaining health care providers to rural and remote communities. In an effort to promote and conduct research focusing on health related issues of Canadians living in rural and remote areas, the Rural and Remote Health Research Group (RRHRG) was established at the Faculty of Nursing, University of Calgary in May The members of the RRHRG are: Elizabeth Thomlinson, Marlene Reimer, Meg McDonagh and Dana Edge. A research study, Rural Health: An Alberta Perspective is currently underway in southern Alberta with a Dean s Research Award funding. This study is being undertaken with the participation of Kathryn Baird-Crooks of Medicine Hat College and Marg Lees of Keewatin College, The Pas, Manitoba. In addition, interviews have been completed in a second study, Rural and Northern Health: A Manitoba Perspective. Funding support is from a University Starter Grant. Initiatives in rural nursing education MacLeod, Browne and Leipert (1998) report that nursing education programs to prepare nurses to work in rural and remote areas are changing. Basic nursing diploma and degree programs have been developed to prepare nurses for Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 17

19 practice in rural and remote communities, and basic nursing education initiatives are being developed for students who live in remote communities. There are some nursing education programs that have integrated student practicums in rural and remote communities, where students are preceptored by nurses who work in rural programs/institutions. Most often, these clinical placements are by choice and are not required of the program. Minore et. al. (2001) reported, following a survey of nursing education programs in Canada, that less than half (43%) offered courses pertaining specifically to rural health although the majority (79%) offered courses with at least some rural health content. They found that in most nursing programs students would be able to take a rural health related reading or independent study course or chose a rural health focus within the courses offered, however, very few of the programs reported that students actually took these courses. On the other hand, nearly two-thirds reported having had students chose a rural health focus within the courses offered. The majority of the programs indicated that they had plans to expand the rural health education that they offered as well as increase the amount of rural health research conducted in their department. Half of the nursing programs indicated that they had faculty members who have conducted rural health research (Minore et. al., 2001). Following an extensive web-based search, Kulig et. al. (2003) identified some examples of Canadian nursing education initiatives: o A Bachelor of Science in Nursing Program at Aurora College in the NWT. Students are involved in rural practice throughout the program and can graduate with a diploma after three years. The program has a high percentage of Aboriginal students. o A 16-month certificate Primary Health Care Nurse Practitioner program, also at Aurora College, available through an arrangement with the Centre for Nursing Studies in St. John s Newfoundland. Students have experiences throughout the territories and are eligible for registration with the NWT Registered Nurses Association when they graduate. o A rural nursing clinical option in the post-bachelor of Science in Nursing program at the University of Saskatchewan, within which students practice in a rural site. o A four-year nursing program based on the University of Saskatchewan curriculum offered by the Saskatchewan Indian Federated College (SIFC) in Prince Albert, giving preference to Aboriginal students. The clinical settings are primarily rural. o A rural nursing/rural health care focus within the four-year curriculum at the University of Manitoba, Brandon site. o A number of programs in Alberta: o Clinical practicums in rural settings in the baccalaureate nursing programs at Lethbridge, Red Deer, Grand Prairie, Edmonton, Calgary and Medicine Hat; Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 18

20 o Elective clinical placements in rural settings in the senior year at the University of Calgary; o A mandatory rural nursing course with clinical practice in rural settings at University of Calgary at Medicine Hat; and o A mandatory rural nursing course with rural clinical placements at the University of Lethbridge. Other educational programs include: o The focus of all programs at the University of Northern British Columbia is rural, northern and First Nations nursing. In the BSN program, virtually all students have a rural practicum experience. o The Northern Collaborative Baccalaureate Nursing Program is a 4- year BSN program offered by UNBC and the College of New Caledonia. While graduates are well grounded in current nursing practice, there is an emphasis on acute care nursing, rural nursing, community health, or First Nations health. o The Post-Diploma BSN is a two year program that grounds the graduates in community health and enables them to be aware of First Nations culture. They are able to focus on an area of nursing including Community Health, Rural, and First Nations Health. o The Certificate in Rural and Northern Nursing (with an option of BSN completion) provides the opportunity for experienced RN s to pursue post-diploma Undergraduate studies through a concentrated program of courses in rural and northern nursing. o The Masters of Science in Community Health (Nursing Stream) is an interdisciplinary program that focuses on health issues in northern, remote, and First Nations communities (University of Northern British Columbia, 2004). o A rural incentive program at Memorial University of Newfoundland and Labrador. This program enables the placement of up to 50 bachelor of nursing students in rural locations throughout Newfoundland and Labrador for a one month practicum in Community Heath Nursing in the final semester of their program (Minore et. al., 2001). o Nursing in Rural Environments course in the undergraduate program at the University of Manitoba emphasizing the health needs of residents in rural environments and the nature of nursing and issues encountered in rural settings, both in health care institutions and community health nursing practice. A clinical practicum is an integral part of the course (University of Manitoba, 2004). o A Bachelor of Science in Nursing at Nunavut Arctic College in partnership with Dalhousie University. The curriculum emphasizes awareness and respect for Inuit culture and prepares nurses to be leaders in Nunavut health care or the Canadian health care system. Students may exit after three years with a Diploma in Nursing from Nunavut Arctic College and will be prepared to provide hospital based Rural and Remote Nursing Practice: A Discussion Paper: Draft 3 Page 19