Educational Preparation of Rural Maternity RNs in Canada Jennifer Medves, RN, PhD J. Roger Pitblado, PhD Lela Zimmer, RN, PhD (c) Norma Stewart, RN, PhD Martha MacLeod, RN, PhD

Outline Background Nature of Nursing Practice in Rural and Remote Canada RNDB – methods and results Survey – methods and results Conclusions Next steps

Background Hospital maternity service closures Pending retirement of qualified staff Women traveling further for intrapartum care Less choice, and increasing reliance on Level III institutions Sustainability of rural maternity is key to survival of rural communities Rural hospitals in Canada are increasingly pressured by their ability to provide services to the entire community. Intra-partum maternity services have slowly and steadily been reduced and more Canadian women are required to travel to give birth (Klein, Johnson, Christilaw, & Carty, 2002). In addition there is a crisis in rural maternity practice because of the reduction in physicians, particularly obstetricians (Goodwin, 1999). The degree to which decisions to close maternity units are taken because of a shortage of appropriately qualified maternity RNs is not well described. Descriptions of rural maternity nursing are sparse. The majority of literature focuses on the difficulties experienced to deliver and maintain rural maternity practice (Grzybowski, 1998), outcomes of rural births (Grzybowski, Cadesky, & Hogg, 1991) and physician issues (Goodwin, 1999). Assessing competence of rural nurses (Deaton, Essenpreis, & Simpson, 1998), staffing patterns (Giefer, 1992), and community health nurse providers (Hoffmaster, 1986) in maternity. Australian literature has described retaining rural nurses (Hegney, McCarthy, Rogers-Clark, & Gorman, 2002), obstetric outcomes in aboriginal (Powell & Dugdale, 1999) and rural communities (Cameron, 1998), and antenatal transfer implications (Roberts, Algert, Peat, & Henderson-Smart, 2001). American literature has described rural birth outcomes (Leeman & Leeman, 2002) and emergency transportation in labour (Katz & Hansen, 1990).

Nature of Nursing Practice in Rural and Remote Canada Project Study design on line at http://ruralnursing.unbc.ca a) a sub analysis of the Registered Nurses Database, 2000 (available at the CIHI web site ISBN: 1-894766-49-0) b) a survey of rural nurses c) narrative analysis, and d) a documentary analysis. For the purposes of this paper data is reported from the sub analysis of the RNDB, 2000, the survey, and the narrative analysis. In order to answer the primary question an analysis of the RNDB and the survey revealed the initial formal educational preparation.

Research Questions What is the educational preparation of rural maternity nurses who provide comprehensive care including labour and birth? Do these rural nurses have the added skills they believe adequately prepares them for maternity practice? What are the additional courses rural maternity nurses have to assist in delivery of care?

RNDB - Methods The rural maternity nurses were identified if they responded: primary responsibility was maternal/newborn, their primary position was a staff nurse, and they lived in rural and small town Canada Within the RNDB there were 1,631 RNs who stated that their primary responsibility is maternal/newborn who live in rural and small town Canada No information available on courses taken other than diploma and degree programmes

Survey - Methods 685 RNs were identified in the survey 545 prenatal care, management of labour, management of delivery, and postnatal care 140 management of labour, management of delivery, and postnatal care A national survey of registered nurses working in rural and remote areas has been completed using a mailed questionnaire and follow-up based on Dillman’s tailored design method.17 The 3933 eligible respondents represent all provinces and territories with an overall response rate of 68% after correcting for duplicate registrations, address problems, and ineligibility (e.g., live rural, but work urban). Sampling was done in collaboration with the professional nursing colleges or associations of each province and territory, using the databases of all RNs with active registration while maintaining anonymity and confidentiality. The sampling strategy was two-fold. First, a stratified random sample was selected from RNs with RST addresses in each of the 10 provinces. Second, the questionnaire was mailed to: (1) the total population of Canadian RNs who indicated on their registration forms that their primary workplace was a nursing station or outpost setting, and (2) all RNs registered in the territories, as an attempt to capture “remote” areas. Based on a total population of 229,813 RNs in Canada, with stratification by province and assuming that the ratio of rural/urban nurses was similar to the rural/urban population proportions in the provinces, we determined that 3500 rural nurses would provide estimates that are statistically significant (p <.05) nationally, with a 90% confidence level provincially. The rural maternity nurses from the survey were identified as providing four key aspects of care, antenatal, labour, intrapartum, post partum, and worked in an institution such as a hospital or a nursing station.

Demographics – Age of RN’s RNDB Survey 20 – 29 145 (8.8%) 64 (9.4%) 30 – 39 510 (31.2%) 184 (27.2%) 40 – 49 649 (39.8%) 271 (40.1%) 50 – 59 293 (17.9%) 135 (20%) Over 60 33 (2.3%) 21 (3.1%) Age distribution of both groups is similar, with both groups having the majority of nurses aged over 40 years

Demographics – Highest Nursing Education and Employment status Highest Education in Nursing Diploma in Nursing RNDB 1,421 (87%) Survey 502 (73.4%) Bachelor’s degree in Nursing 206 (12.6%) 172 (25.1%) Masters/PhD 4 (0.4%) 9 (1.5%) Employment status Full time 755 (46.3%) 347 (50.1%) Part time 875 (53.7%) 345 (49.9%) The survey sample had significantly more nurses educated with a bachelor degree compared to the RNDB data (25.1% versus 12.6%). Those with a master’s or PhD degree are too small to compare, except to mention that the number in the RNDB should have been more than the survey! Part time status was reported in half the survey responders, but the RNDB in 2000 reported more part time at 53.7%. This may be because in the last three years there has been an increase in the number of full time jobs across Canada.

Province of Registration (RNDB) Province of Work (Survey) Newfoundland and Labrador 5.9% 6.4% Prince Edward Island 1.5% 0.8% Nova Scotia 8.5% 4.4% New Brunswick 2.2% Quebec 16% 5.1% Ontario 33.5% 7.6% Manitoba 5.8% 3.9% Saskatchewan 3.1% 12.3% Alberta 9% 17.7% British Columbia 9.6% 12.9% Yukon 1.6% 3.4% Northwest territories As above 6.8% Nunavut A comparison of place of work shows as expected an increase in the total percentages of rural maternity nurses in the north. This was expected as nurses who were sampled in the survey who lived or worked in the north were over sampled. However the samples differ significantly. In the RNDB almost 50% of the RNs are registered to work in central Canada, while only 12.7% of the survey responders reported that they worked in central Canada. Also RNs who work in northern nursing stations, employed by the federal government, may not be registered in the territories, as they are only required to be registered in one province or Territory .

Initial Education During initial education the time spent in maternity varies across programmes Students are unlikely to have low risk rural maternity clinical experience Majority of nursing programmes in urban centres Anecdotal evidence from health care professionals and policy makers suggest that rural maternity nursing practice is in jeopardy because nurses are not adequately prepared to provide intrapartum care and have limited opportunities to maintain skills because of low numbers in many rural settings. From the survey: nurses did not believe their four year program prepared them because the emphasis while on community was not specific to rural areas The community health component was good, and BSCN from … university has a high emphasis on community nursing, low emphasis on practical nursing. Overall, this group of nurses wrote they were given the skills set through community development, critical thinking, and problem solving helped but they needed a special skill set learned often on the job to give care in rural settings. Diploma prepared nurses had a different perspective nurses did not believe their four year program prepared them because the emphasis while on community was not specific to rural areas The community health component was good, and BSCN from … university has a high emphasis on community nursing, low emphasis on practical nursing. Overall, this group of nurses wrote they were given the skills set through community development, critical thinking, and problem solving helped but they needed a special skill set learned often on the job to give care in rural settings.

Clinical Experience Prior to Rural Maternity Urban or larger centre experience Clinical experience in other fields such as ICU and emergency Northern nursing courses and midwifery particular valued by survey participants The assumption is that any maternity experience is good maternity experience. Not so. One nurse wrote my education never really prepared me for rural nursing. I trained at a larger hospital where everything was at your fingertips. I had never seen an oxygen tank or had to do my own autoclaving or had to run a code with only two people. Another wrote my education was better suited to urban nursing; primary nursing with back up readily available from many other disciplines i.e., respiratory, code team etc. Doing a short preceptorship in rural facility opened by eyes.

Conclusions Maternity practice is complex Initial education does not prepare nurses for rural work Nurses still value hands on experience Recognition of maternity nursing as part of being multi-specialist At a time when there is a transition to undergraduate education as entry to practice in many jurisdictions in Canada there is a responsibility to ensure that nursing students are adequately prepared as beginning practitioners in a number of settings. Many of nurses in this study did not feel that their initial education prepared them for rural practice let alone maternity practice. The issues are multifaceted. If nursing programmes are going to prepare nurses for rural practice then rural placements are essential during education programmes. However, it then becomes a logistic issue as many settings can only accommodate one or two students at a time and not the traditional clinical group of 8 to 10 to one clinical teacher. Rural experiences therefore rely on rural settings to provide sufficient, qualified preceptors. These issues are not insurmountable but are more easily arranged in programmes with smaller rather than larger numbers of students. Participants in the study readily acknowledged the northern nursing programmes as being invaluable in preparing them for rural and remote nursing. In addition, courses traditionally taught to all health care professionals rather than simply nurses were quoted as examples of continuing education initiatives including ACLS, TNCC, PALS and NRP. Preparation for maternity nursing practice for new employees through a combination of orientation and preceptorship takes at least six weeks full time (Hom, 2003). This however reflects practice in a setting where the new nurse is full time and providing only maternity care. When employees are required to orientate to a number of different areas, such as would be found in a rural hospital, time to feel confident and competent will take much longer. In this study the nurses reported the significance of additional courses to prepare them and did not discuss preceptorship specifically, but they did describe the help and guidance received by experienced rural nurses. Almost all the nurses wrote that the best education was hands on in the setting as being the most valuable. The context of rural practice was so different because of learning to triage, multi task, cope with emergencies not necessarily in a hospital setting can’t be learned in a city or urban setting and not within the confines of an education programme. Many of the nurses identified that previous nursing practice in emergency departments or critical care was extremely valuable although several pointed out that if you come to base your practice on having a number of other health care providers available you have to re-learn how to work without them.

Limitations to the Study RNDB data does not capture additional qualifications RNDB has ‘several clinical areas’ designation Survey question did not ask specifically at major area of responsibility Each year RNs are required to register in the province where they work or are going to work. The data is forwarded by provinces to CIHI and data is aggregated into the RNDB. RNs are asked to identify their primary area of responsibility. One area is maternal/newborn. This was the group that were included in this analysis. However, another category is several clinical areas, and evidence (Medves & Davies, in review; Medves, Davies, & Heino, unpublished manuscript) from many rural RNs demonstrates that they would determine that their primary area of responsibility is several clinical areas as they spend about half or less than half of their time caring for childbearing women in any given year. This means there was an underestimation from the total RNDB of RNs who provide maternity nursing care. In the survey there was not a question asking specifically for primary clinical experience. So, nurses may have answered yes to the four skills and be in one or other of the maternal/newborn or several clinical areas groups.

Next Steps Undergraduate nursing experience should be carefully targeted to ensure rural clinical experiences are included. Study to determine the specific ongoing clinical experiences, continuing education, and primary education required. Collaborative maternity education for practice Many of the respondents in the survey recognized that their initial education and subsequent hands on training is not sufficient today especially as rural birth numbers are dropping. Education requirements for safe maternity practice are drastically different today – NRP, Fetal surveillance, labour support. Pain relief is different epidurals etc. Primary education programmes do not include these requirements. Nurses flounder to become qualified while having minimal clinical experience to anchor the courses in. Nationally need to determine the minimum requirements. Regions and provinces need to determine how to maintain skills of all practitioners not simply those in expensive Level III facilities Collaborative maternity care is under investigation. Need support for collaborative maternity education as well. Happening in MORE OB course but I think we need more, especially to support low risk minimally intervention pregnancy and birth and post partum.