The Nature of Nursing Practice in Rural and Remote Canada Judith Kulig, DNSc, RN University of Lethbridge Presentation to ARNNL January 25, 2005

Aim of the Study to examine and articulate the nature of registered nursing practice in primary care, acute care, community health, continuing care (home care) and long term care settings within rural and remote Canada In the context of this, and the need to find out more about rural and remote nurses, we undertook a study - designed to examine and articulate the nature of registered nursing practice in rural and remote Canada Started in 2001 and is winding up over the next year.

The Study Components Survey Registered Nurses Data Base (RNDB) Narrative Study Documentary Analysis The study has three components: A survey of of almost 4000 nurses across rural and remote Canada The analysis of the registered nurses database - what we complete when we are registered each year An analysis of in depth interviews with 152 registered nurses conducted by telephone An analysis of the policy and practice documents used to shape nursing practice

Principal Investigators and Decision-maker Martha MacLeod University of Northern British Columbia Judith Kulig University of Lethbridge Norma Stewart University of Saskatchewan Roger Pitblado Laurentian University Marian Knock B.C. Ministry of Health Planning (to 2003)

Co-Investigators Ruth Martin-Misener Dalhousie University Ginette Lazure Université Laval Jenny Medves Queen's University Michel Morton Lakehead University Carolyn Vogt U. Manitoba Gail Remus U. Saskatchewan Debra Morgan Dorothy Forbes U. Saskatchewan Barbara Smith Carl D'Arcy Kathy Banks BC Women’s Hospital Elizabeth Thomlinson (to 2004) Lela Zimmer UNBC As part of the overall group, we had 13 co-investigators, each of whom are working on one of the study approaches.

Advisory Team Members Cathy Ulrich, BC Anne Ardiel, BC Debbie Phillipchuk, AB Cecile Hunt, SK Donna Brunskill, SK Marlene Smadu, SK Marta Crawford, MB Sue Matthews, ON Suzanne Michaud, QC Roxanne A. Tarjan, NB Adele Vukic, NS Barb Oke, NS Elizabeth Lundrigan, NF Joyce England, PEI Barbara Harvey, NU Madge Applin, NWT Elizabeth Cook, NWT Fran Curran, YT Jan Horton, YT Francine Anne Roy, CIHI Kathleen MacMillan, FNIHB – Health Canada Maria MacNaughton, FNIHB - Health Canada Lisa Dutcher, Aboriginal Nurses Ass’n Lisa Little, CNA We have an Advisory Team from provinces and federal organizations. We are drawing on their expertise to examine the data and present findings to federal, provincial and territorial bodies for health human resource planning - and for more in-depth information for planning about nursing practice and its possibilities (e.g. prevalence of primary health care activities among nurses in all rural nursing settings).

You can see here that our advisors and investigators come from communities across the country.

Funding Partners Canadian Health Services Research Foundation Canadian Institutes of Health Research Nursing Research Fund Ontario Ministry of Health and Long-Term Care Alberta Heritage Foundation for Medical Research Michael Smith Foundation for Health Research Nova Scotia Health Services Research Foundation British Columbia Rural and Remote Health Research Institute Saskatchewan Industries and Resources Provincial and Territorial Nurses Associations Government of Nunavut Canadian Institute for Health Information The study is being funded over three years by the Canadian Health Services Research Foundation and over 20 funding partners.

Rural and Remote Nursing Access to Care Quality of Care Sustainability of Care We are still in the process of analyzing and writing up findings. I will give you a sampling today of what we are finding. These three issues: ensuring access to care, ensuring the quality of care and the sustainability of that care are issues that federal and provincial decision-makers are looking to our study for assistance. We have found as well, that these categories can be useful ways to focus our results. It would help today if you cold let me know if they also make sense for nursing leaders/managers

Supply and Distribution of Nurses Access to Care Supply and Distribution of Nurses Education of Nurses Today, I will highlight, in the context of how can we ensure accessibility to care, what we have learned about the supply and distribution of registered nurses, as well as the education of nurses necessary to achieve appropriate access to care for residents of rural and remote Canada. I’ll focus specially on how this relates to Newfoundland.

How many Registered Nurses are there in rural and remote Canada? The first part of the study completed was the analysis of the Registered Nurses Database. It was published in 2002, and answered a question that hadn’t been able to be answered before, How many registered nurses are there in rural and remote Canada?

This shows you some of the methodology of the RNDB This shows you some of the methodology of the RNDB. Beginning on the left: Nurses in Canada are registered with the provincial nursing colleges or associations. They provide the information to the Canadian Institute for Health Information (CIHI). CIHI worked with Roger through their nursing consultant, to enable the RNDB to be analyzed. The RNDB provided the sampling frame for the survey, and gave us some information about communities that was useful to ask questions in the narratives. For instance, it was found that there are 169 communities in Canada in which there is only one RN living. Roger named these as Sole RN communities. We are now doing further analysis to identify what it means for a nurse to live and work alone in a community.

Rural (RST) % of total Canadian/ Year Number of rural (RST) RNs % of all Rural (RST) % of total Canadian/ NL population 1994 42,303 1544 18.0 29.8 22.3 56.1 2000 41,502 1700 17.9 31.5 21.7 54.3 2002 40,648 17.6 20.6 You can see here that the number of rural and small town (RST) RNs nationally has decreased over the past 8 years in numbers, in proportion of all RNs. This is at a time too, when the proportion of people in living in rural and small town Canada has dropped. Newfoundland has gone slightly in the opposite direction with an increase in the percentage of rural RNs while the rural population has decreased slightly. 2002 – based on CIHI figure generated without Quebec data

In this map, you can see that the nurse to population ratio differs across Canada, with more nurses per population in the eastern and southern parts of the country than the west and the north. Currently the overall nurse-to-population ratio in urban Canada is 78 nurses per 10,000. In Rural Canada that ratio is 62 per 10,000

.. an aging workforce Rural RNs -Canada/NL 1994 average age: 40.6 years/36.0 2000 average age: 42.9 years/38.8 Urban RNs 1994 average age: 41.6 years/38.4 2000 average age: 43.5 years/40.2 All RNs 1994 average age: 41.5 years/37.7 1998 average age: 42.6 years 2000 average age: 43.4 years/39.8 2002 average age: 44.2 years The nursing workforce in Canada is aging, but the average age in rural areas is slightly lower. Newfoundland is below the national averages for both urban and rural having younger nurses overall.

Access to Care Education of Nurses In addition to considering the number of nurses that we might have in the country, the second component of ensuring access to nursing care is to ensure that we have nurses who are educated for rural and remote practice. This is what we are finding about education, primarily at this point, from the analysis of documents.

Documentary Analysis Methods conducted to achieve a contextual understanding of the policy and practice environment systematic collection and analysis of relevant documents according to the policy cycle: policy formulation, policy implementation and policy accountability (Rist, 1994) using this cycle, developed a guide to examine the materials located 200+ documents with input from advisory board - over 150 analyzed The Documentary Analysis team located over 200 policy and practice documents in relation to rural nursing practice from governments, health boards, and professional associations across Canada. They analyzed over 150 of them in depth through a process of qualitative analysis related to the policy cycle identified by Rist. The goal of the analyses was to understand the policy and practice environment for rural nursing. They created a guide on the web, using Web CT, and undertook an analysis, and wrote up a report which is available at the study website.

Education Level of RNs in Rural Canada/NL, 2000 (Source: RNDB) Diploma 81.4% 83.4% Bachelor’s 18% 16% Master’s/Doctorate 0.6% 0.3% Nurses in rural Canada are predominantly prepared at a diploma level. In most provinces the entry to practice is now a bachelor’s degree. But the proportion of nurses with bachelors or masters education remains much less than in rural areas of the country. In Newfoundland Highest level of Nursing Education comparison: Diploma rural: 83.4% Urban: 77.3% BSN rural: 16% Urban: 20.7% Masters rural:2.1% Urban: suppressed to ensure confidentiality Doctorate rural: 0% Urban: suppressed to ensure confidentiality In Sum, there’s about a 20/80 split BSN to Diploma in the cities, and a 15/85 split in the rural areas of Newfoundland. There are far fewer nurses with graduate degrees in rural communities.

Educational Preparation of RNs in Rural and Remote Areas Little information in available reports No government documents located that discuss the need to provide educational opportunities for students in rural sites Little information available in government, education or nursing association documents regarding preparation of RNs for rural and remote areas of Canada

Entry-level competencies focus on generic requirements Most nursing associations equate rural with accessibility issues regarding education Entry-level competencies focus on generic requirements Most nursing association documents include rural under other issues such as accessibility. For example, College of Nurses of Ontario discusses the need for nursing education programs to reduce barriers due to geographic location. Entry-level competencies have been developed for provincial and territorial nursing associations based upon generic requirements without specific comments regarding rural or remote nursing practice settings.

Education for remote practice links it with First Nations health issues Education documents discuss programs with rural focus at locations such as UNBC, University of Saskatchewan, First Nations University of Canada The majority of the literature that addresses education for remote practice focuses on advanced nursing practice and First Nations and Inuit health needs. Some programs are automatically rural-focused due to their physical location. Examples include: Aurora College in the NWT offers a BScN program and all students engage in rural practice for their clinical placements The First Nations University of Canada offers the University of Saskatchewan curriculum at the Prince Albert site and hence the students automatically engage in rural clinical placements The University of Saskatchewan offer a rural nursing clinical option in the post BSN program UNBC has rural-focused options as does the University of Lethbridge, University of Calgary, and Laurentian University. No government documents were located addressing the need to provide educational opportunities and assistance for students in rural sites.

No indication of any telehealth education occurring within nursing programs Nursing programs prepare graduates to be computer-literate but technology not always available or feasible in rural and remote settings No indication that any nursing programs are including telehealth in their curriculum. Nursing programs prepare graduates to be computer literate but the availability of such technology in rural areas varies by jurisdiction and by feasibility (I.e. in some remote areas technology remains unreliable)

Extended mentoring or orientation programs need consideration (documentary analysis) but do not replace basic education with employment mentoring (narrative) Consideration needs to be given to extended mentoring or orientation programs for new graduates who choose to work in rural or remote areas.

Sources of New Information on Nursing Practice The three information sources used most frequently by rural and remote nurses (than any other suggested source) are nursing colleagues, inservice, and newsletters. Nurses are 32% more likely to use newsletters than the library to inform their practice, and 21% more likely to use inservice than continuing education to obtain new information on nursing practice. This slide is from an analysis of the Survey - by Julie Kosteniuk The three information sources used most frequently by rural and remote nurses (than any other suggested source) are nursing colleagues, inservice, and newsletters. Nurses are 32% more likely to use newsletters than the library to inform their practice, and 21% more likely to use inservice than continuing education to obtain new information on nursing practice. The message is how can we maximize the amount and quality of evidence-based information coming to nurses through their colleagues, inservices and newsletters?

Advice for Educators (Source: Narratives) Need for reality-based education Part of curriculum offered in rural settings Educators who are specialized and experienced in rural practice

General Comments from Rural Nurses (Source: Narratives) Most basic education does not prepare new grads for rural and remote practice Rural health nursing needs to part of all basic nursing programs

Quality of Care Community as Shaping Practice Practice Components Working on the Edges of Practice In order for the quality of care to be maintained and enhanced, it is critical that nurses working in rural and remote settings are supported in ways that suit them and the contexts within which they work. Rural and remote nurses have told us that the complexity of their practice is vastly underestimated, and that policy and practice changes are needed to improve the quality of services that they can provide. The interconnection between rural nurses and the contexts of their everyday practices was most evident in the narrative portion of the study, where the importance of community in shaping the nurses’ worklives and everyday practices was clearly evident. The importance is not only for nurses in community roles, such as public health, home care and primary care (nursing station, outpost, nurse practitioner, etc.) but also for nurses practising in acute care and long-term care facilities.

Narrative Approach 152 Nurses (11 Francophone) NL- 10;Atlantic-36 Areas of Practice: Acute, Long-term Care, Public Health, Home-care, Community, Primary Care Telephone Interviews Analysis: interpretative phenomenology & thematic analysis We recruited 152 nurses, 10 of whom were from Quebec, to the study through advertisements in the Canadian Nurse, provincial association newsletters, and word of mouth. They are from all provinces and territories, and from the full range of rural, remote and northern practice, with at least two nurses from of each kind of practice in each province and territory We conducted interviews by telephone, which took an average of 70 minutes each (a range of 45 minutes to 3 hours), about questions such as, Tell me about a situation in which you made a difference in patient/client outcome; a situation that is typical and ordinary. We also asked nurses to tell us what advice they would have for new nurses coming into their situation, educators, administrators and policy-makers. We transcribed the interviews, and are currently undergoing analysis from the perspective of interpretive phenomenology. The advice questions are being analyzed descriptively for themes. The analysis is still underway, but a few central themes are beginning to emerge.

You can see that the nurses who responded to our questions came from across Canada. The nurses from Quebec are not on this slide, but are mostly from northern Quebec and islands in the St. Lawrence.

Community Shaping Practice Size, distance, demographics Expectations of communities Knowing the client in the context of community; the community in the context of the client Pervasive, is the importance of community in shaping the nurses’ work lives and everyday practices. Today, I’ll give just a glimpse into what the nurses said about the meaning of community, and how it figures into the advice they have for new nurses, policy makers, administrators and educators. When analyzed the community’s size, distance from other centres, and the demographics of its people influenced both the focus of the nurses’ attention and their work. The variations in community life, particularly seasonal variations, played a significant role, as did the expectations of the community for health care and for nurses’ work and demeanor. The ways in which the nurses know the clients in the context of community and the community in the context of the clients is key.

Size, Distance, Demographics As I stepped off the ski plane I stepped into a foreign world. My role as a nurse was changed completely and my personal life soon became unfamiliar to me in my unfamiliar surroundings   We do get a lot of moms with children with various things, but mostly with kids, you know, it’s the head colds, bad ear, sore throat, bit of abdo pain. […] Our kids are basically a healthy population. I remember being up in this same community and working 36 hours straight, no sleep, no break, nothing Although not all of the nurses experienced what this northern nurse experienced, the size, distance and demographics of the communities within which they live and work dramatically affect their work and lives. Even for those nurses who have returned to home communities, they return in different roles.   The demographics make a great deal of difference in what the nurses encounter in their practice, and shapes their skills sets and knowledge. In communities, As in this quote of a nurse talking about moms with children.. They become very skilled however, in assessing nuances of well child care. If nurses want to change their skill sets, they cannot change workplaces and remain in the community, they frequently have to move out of the community. One of the key challenges is finding ways of helping nurses to enhance their skills and keep up to date. The small size of the communities affect the on-call of nurses. Many nurses work by themselves, even though they may not be the only nurse in he community. It creates a great strain. I remember being up in this same community and working 36 hours straight, no sleep, no break, nothing.” 8 “ Many remote and rural communities experience great fluctuations of populations. Commonly they are resource dependent, tourist towns, mining communities, oil and gas communities – and communities where a good proportion of the community travels or hunts in the summer –. Seldom do the nurses experience staffing changes to accommodate these fluctuations, but their practices change from season to season. While urban areas are concerned about migration and the effect on health care workers, the effect on small communities and their nurses of significant proportions of their communities changing each year is overlooked.

Expectations of Communities I always say it's a double edged sword because they hold you to high respect because you're their own.[…] . And because of that you can't be the normal person that you are. You have to always be this person that everybody looks up to. And the clinic is situated on the top of a hill, so that I can look down at all the [community] around me. And most times I feel that way, that people think it's like that. That I'm the person on the hill looking down on everybody else. And there's a lot of pressure to be the perfect person when you're the nurse. The expectations of communities shape the work of the nurse in very practical ways. [Read quote]. The relationships of the communities and the nurses varied widely, along a number of dimensions. In this quote, we hear a hint of the separation from the community a nurse who is on contract for a limited time, but who has been in the community for a number of years. All rural and remote communities have expectations of the nurses who work in them. Sometimes these expectations are explicitly negotiated, sometimes they are implicit and evolve over time. Sometimes practices emerge from political actions of a community. One tiny coastal community bought a defibrillator, But this community saw that as important and so they bought their own. So that was an expectation for the nurse that got hired, that he or she would be prepared to defibrillate. So this is very much a community run clinic The practices of the nurses are shaped by the communities and their expectations In other situations, the practice is more directive: Well, he had said […] we were here to care for this community and this was what we had to do, and he made no bones about it that if we didn’t do it then they were going to ban us from the community. The community expectations shape practices in very direct ways. The supports that nurses need are not only practice supports but also community supports

Knowing the Client: Knowing the Community We are very responsive in our community because we see those people in our churches and in our grocery stores. And so you know we try and be all things to all people, maybe that is kind of bad. But in the end we are the one who see these people outside of our work life too. The direct relationship of rural and remote nurses to their communities brings with it a responsiveness to the communities and their needs. [read quote] The priorities that she sets for her work need to be very closely alinged with the community’s - as she is held personally accountable, in the mall, at the post office, and the grocery store - for being responsive, for maintaining confidentiality, and for achieving high quality practice in often less than ideal work situations. This can set up disjunctures between rural nurses and their managers - both need to work carefully together to achieve quality care. It takes nurses with extensive knowledge and skills to be able to work successfully over long periods of time in such settings. The ways in which the nurses know the clients in the context of community, and the community in the context of the clients, is centrally important. Quality nursing practice is enabled by the development and maintenance of trusting working relationships between nurses and clients, and nurses and their communities. Nurses noted the challenges, particularly in Aboriginal communities, and in communities where there is high nursing turnover coupled with the difference of culture.

Advice: Listen to Learn-Learn to Listen Number one, do a lot of listening initially, and very little talking Listen to your nurses! Listen to them and respect their opinions and have an open dialogue Teach them how to use resources – how to find the answers. Don’t give it to them.., don’t feed it to them…. There was a synergy within the advice provided by the rural and remote nurses to new nurses, to administrators and policy-makers and to educators. Predominant among the advice was the need for more understanding – the need to learn to listen and to listen to learn… To new nurses, the advice was “Number one, do a lot of listening initially, and very little talking” Take time to observe and learn about the community, culture and workplace. Take time to get to know the community and for the community to know you. Realize that there will be a steep learning curve, even for experienced nurses, and that work routines and processes will be different than what you may be accustomed to in urban settings. To administrators and policy-makers “It would help to have a manager supervisor who would check in every once in a while and say how are you doing, what are the issues, what support do you need ― that type of thing. I feel that I am left out here” “Listen to your nurses! Listen to them and respect their opinions and have an open dialogue” And educators – there needs to be greater emphasis on ways of learning that will help nurses learn to listen: “Teach them how to…how to use resources ― how to find the answers. Don’t give it to them, don’t feed it to them. Guide them, but, because when you’re in the remote areas you’re on your own, you’ve got to develop your own motivation and your own way of getting information.”   In sum, a systematic analysis and interpretation of the stories and experiences of the 152 nurses is enabling us to begin to articulate the taken-for-granted aspects of rural nursing practice, and to reveal its complexity and challenges. All of these areas of advice point towards the challenges of rural and remote nursing practice, and the kinds of supports needed to achieve quality of care.

Quality of Care Practice Components One of the areas we analyzed were the components of nurses practice. We have variously called this scope of practice or advanced practice.

(Dillman’s Tailored Design Method) Survey Method Mailed questionnaire with persistent follow-up (Dillman’s Tailored Design Method) Sample (N=3933)(NL=333; Atlantic= 1120) 1) random sample of registered nurses (RNs) living in rural areas in all Canadian provinces 2) total population of RNs who work in outpost settings or the northern territories The questionnaire was developed in consultation with content experts, was tested and administered in either French or English. It included questions about demographics, employment issues, community context, roles, satisfaction, health, work environment, community context, practice supports and career plans. The sampling strategy, which was done in collaboration with the professional nursing colleges or associations in each province and territory was two fold. First, we selected a random sample of RNs living in rural areas of all Canadian provinces. Second we sent questionnaires to all RNs registered in the territories (Yukon, North West Territories and Nunavut), and to all those in the provinces who indicated on their registration forms that their primary workplace was a nursing station or outpost setting.

Sample Response Rates by Province and Territory (N=3933) Based on a total population of 229,813 RNs in Canada, we determined that 3500 rural nurses would provide estimates that are statistically significant (p<.05) nationally, with a 90% confidence level provincially. The overall return rate is 68% With over 3900, our confidence levels nationally are closer to 95%

Primary Care as Main Practice National – 8.3% Territories Nunavut – 20% Yukon – 15.6% NWT – 11.5% Provinces British Columbia - 10% Manitoba – 11.4% Ontario – 13.5% Saskatchewan – 8.4% Newfoundland – 6.1% New Brunswick – 6.1% Alberta – 5.7% Nova Scotia – 4.9% Quebec – 4.6% PEI – 0% Rank ordered from high to low. Sampling aimed to capture full population of RNs who worked in outpost areas in provinces and who worked anywhere in the territories. As you look at the next few slides I’d like you to remember that 10% of those nurses whose practice is in primary care (as opposed to long term care, acute care, community health, home care etc.)

Main Area of Nursing Practice NL and All of Canada (n = 3493*) Practice Area NL (%) All of Canada (%) Acute Care 49.3 44.4 Long term Care 18.9 17.7 Community Health 16.1 Home Care 4.1 8.7 Primary Care 6.1 8.3 Other 2.7 4.8 Total n 296 3493 Survey question: “In which of the above practice areas do you spend most of your time?” *Excluded here – education, administration, research

Advanced Decision-Making or Practice Total – 39.1% Territories – 47.8% Provinces Ontario – 50% BC/AB - 42.7% SK/MB – 38.7% Atlantic – 32.6% Quebec – 31.0% Survey question E.4 “Are there nursing practice and decision-making skills that you perform on an advanced level in your area of practice? If yes, please explain.

Health Promotion in Community Total – 48.6% Territories – 56.3% Provinces BC/AB – 54.7% Ontario – 52.7% SK/MB – 49.3% Atlantic – 44.9% Quebec – 36.6%

NL and All of Canada (n = 3493) Scope of Practice NL (%) All of Canada (%) Advanced nursing practice and decision-making 39.7 39.9 Facilitation of community health promotion activities 549.5 47.8 Nothing in my day is routine 62.5 63.3 I am required to take on other roles depending on demand 58.8 58.2 I use protocols specific to ANP 36.5 36.9 Total n 296 3493

Maternity Care NL and All of Canada (n = 3493) Components of Practice NL (%) All of Canada (%) Pre-natal Care 40.5 35.1 Management of labor 17.2 22.8 Management of delivery 16.6 20.8 Post-natal care 40.2 Total n 296 3493

General Diagnostic Tests NL and All of Canada (n = 3493) Components of Practice NL (%) All of Canada (%) Ordering diagnostic tests 27.7 28.5 Performing diagnostic tests 24.0 32.5 Interpreting diagnostic tests 25.3 35.0 Total n 296 3493

Medication and Referrals NL and All of Canada (n = 3493) Scope of Practice NL (%) All of Canada (%) Prescribing medication 10.1 17.8 Dispensing (not administrating) medication 37.8 46.7 Direct referral to an allied health professional 62.8 49.3 Direct referral to a medical specialist 30.4 21.9 Total n 296 3493

Emergency/Acute Care NL and All of Canada (n = 3493) Scope of Practice NL (%) All of Canada (%) Suturing 15.5 20.2 Taking X-rays 1.0 8.2 Casting/Splinting 27.0 25.4 Evacuating patients 37.5 37.0 Pronouncing death 21.6 41.8 Total n 296 3493

Specific Diagnostic Tests NL and All of Canada (n = 3493) Scope of Practice NL (%) All of Canada (%) Performing pap smears 14.5 15.9 Audiometry 14.2 12.6 Refraction 3.0 3.8 Pulmonary function testing 4.4 12.4 Total n 296 3493

Quality of Care Working on the edges of your practice The nurses in primary care roles talked matter of factly about prescribing or dispensing medications, taking x-rays, and making referrals. The theme of working on the edges of your practice became most evident when they talked about the challenges in their practice. There was a fine line of appropriate assessment, appropriate intervention and timely intervention. Enacting a scope is about practising appropriately and competently. For the nurses in our study, this enactment is in situations where there is little backup, a huge range of demands, and often - infrequently experienced conditions - such as dealing with pediatric head injuries.

“Something just didn’t feel right “Something just didn’t feel right. I called the doctor but I couldn’t articulate my concerns and she was kind of cranky on the phone, she said, call me when you know what you’re talking about …..when you know. And this was one of the nights that I was on for 17 hours straight with hardly a break. And we’d had a really, really busy time… we were all extremely exhausted …. I don’t remember ever being so exhausted. And I asked one of the nurses who was still up, I sort of ran it over with her, and she said, ….oh, I can’t, I’m too tired, I can’t really talk to you about this … And I was exhausted so I just kind of thought okay, maybe he’ll be okay. He’ll make it to the morning, the nurse will see him then and if he needs to go out he can go out. Upon examination, education experience and clinical supports figured highly. A highly experienced nurse with extensive clinical and academic education spoke of the level of responsibility and the fear of not being able to articulate and communicate - not being clear enough, awake enough or having the right kind of clinical supports at the time. Because of the lack of depth of clinicians and resources, even experienced nurses practice on the edge.

The hardest thing I find is deciding not to do anything with a patient The hardest thing I find is deciding not to do anything with a patient. Deciding that everything is okay. Like if somebody is acutely ill, you can start IVs and give them antibiotics and do chest x-rays. That’s easy. But it is having the confidence to say no I don’t think this is something really serious, and they can go home and come back and see us again in the morning. A less experienced nurse talked about how the hardest part was not doing anything. The hardest thing I find is deciding not to do anything with a patient. Deciding that everything is okay. Like if somebody is acutely ill and you can start IVs and give them antibiotics and do chest ex-rays that easy. But it is kind of having the confidence to say no I think this person is okay and they can go home [hmm]. I find that to be the most difficult. . . Or I don’t think this is something really serious and they can go home and come back and see us again in the morning or something. Another, more experienced nurse said, …..I think just worrying that I wouldn’t be able to do …..being competent, if there needed to be more intervention There is the presumption that if one has a scope of practice that there is the necessary framework of support to do things like decide on your own if the suicidal teen is safe to go home. Nurses’ experiences show us more. Practising on the edge shows us that it is not only what you do, but how competent and confident you are within ever-changing situations, and what supports there are for you to practice. Many nurses talk about luck, and having a good doctor on the end of the line, having the ability to talk to colleagues and others at the right time.

Sustainability of Care Predictors of Intent To Leave Migration of Nurses

Sustainability of Care Predictors of Intent To Leave

Predictors of Intent To Leave Variables Individual Sociodemographic & professional Satisfaction with work & community Worklife Community In our survey, we asked RNs about intent to leave: “Do you plan to leave your present position?” Yes was taken to mean that the RN intended to leave their present position within the next 12 months and ‘no’ to mean no plans to leave within the next year. Overall, 17% of RNs planned to leave their present position in rural and/or remote Canada in the next year. We also asked numerous questions that could be related to their intent to leave. In the statistical analysis, we selected 41 variables from the 30 page questionnaire that met our initial criteria for an association with the outcome of the intent to leave in the next year. Conceptually, these variables all fit within one of three categories: the perspective of the individual, the work place or the community. Individual variables were either specific attributes (sociodemographic, health, professional) or variables under the RNs control, such as perceptions of satisfaction with work or community. The workplace variables were defined as under the control of the employer, and the community variables were defined by community characteristics.

Predictors of Intent To Leave Registered Nurses were more likely to intend to leave their present nursing position within the next 12 months if they: Were male Reported higher perceived stress Did not have dependent children or relatives Had higher education Were employed by their primary agency for a shorter time Had lower community satisfaction Had greater dissatisfaction with job scheduling Had lower job satisfaction re: autonomy Were required to be on call Performed advanced decisions or practice Worked in a remote setting Our aim in this analysis was to help understand the reasons why some RNs planned to leave and others planned to stay. We found 11 statistically significant predictors of intent to leave. In essence, men were twice as likely to plan to leave as women. Other individual variables associated with intent to leave were: higher perceived stress, no dependent children or relatives, higher education and fewer years employed in the primary agency. Individual satisfaction levels predicted intent to leave; specifically, lower satisfaction with community and the workplace (in matters of scheduling and autonomy) were related to plans to leave within the next year. RNs were more likely to plan to leave if they were responsible for advanced decisions on practice, if they were required to be on call, or if they were in a remote community. Implications of these findings are that policy-makers and administrators need to: understand gender differences in work life - especially in remote settings Identify stressors from the perspective of the RNs and develop strategies to decrease these stressors in collaboration with nursing staff Consult with staff about job scheduling and being on call Attend to the needs (e.g. flexibility) of nurses with dependent children and relatives Recognize nursing staff who have been longstanding employees Understand that RNs in advanced practice and remote settings in Canada have somewhat higher education than other rural nurses. Some of these nurses may leave to continue their education.

Sustainability of Care Migration of Nurses In the context of health human resources planning, and especially in the examination of the supply and distribution of RNs in rural and remote Canada, migration patters have not been examined as much as they might be. Much of the difficulties in this area is in obtaining appropriate data. In this study we examined migration patterns, particularly inter-provincial/territorial moves, using data from the RNDB as well as from our own national survey.

International Nursing Graduates In 2000 14,177 international nursing graduates were registered and employed in nursing in Canada 5.7% of international nursing graduates worked in rural Canada But this represented only 1.9% of rural RNs Therefore, our analyses focus on INTERNAL MIGRATION of Canadian-educated, rural RNs * Newfoundland specific data is not available at this time. Both numerically and proportionally, few foreign-educated RNs work in rural and remote Canada. It is unlikely that recruiting nurses from overseas would substantially decrease nursing shortages in these parts of the country. Our findings do not give us firm data on whether foreign educated nurses would be adequately prepared for the realities of rural and remote practice. In BC, the 232 international nursing graduates are from: USA and Bermuda - 67 Asia - 18 Europe - 132 Oceania - 36

For Canadian-educated nurses, the majority of RNs practise in the province in which they were first educated. If they do migrate, it is most likely that they will move to an immediately neighbouring province, or to a province with a large population, notably, Ontario, Alberta or British Columbia. Newfoundland and Labrador is the province least likely to attract nurses from other provinces; BC relies heavily on other provinces (40.3%) of its rural RN workforce is made up of RNs whose initial nursing education was received elsewhere in Canada. Once an RN moves, it is less likely that they will return.

Correlates of Migration % Migrants Odds Ratio Gender Male Female 7.2 12.0 1.00 1.31* Highest Nursing Education Diploma Baccalaureate Graduate Degree (MA/PhD) 11.0 14.9 24.0 0.90 1.55* Full-Time/Part-Time Employment Part-Time Full-Time 10.8 12.7 1.07* You can see here that the correlates of migration are very similar to the Predictors of intent to leave. With female being the norm at 1.00 - you can see by the asterisks where the significant correlates were found: Male, with a graduate degree in full time employment….

Correlates of Migration (Continued) % Migrants Odds Ratio Place of Work Hospital Nursing Station Nursing Home/Long-Term Care Home Care/Community Health Centre Education/Association/Government Other 10.6 34.4 10.4 14.1 17.8 12.8 1.00 2.40* 0.69* 0.86* 1.10 0.96 Primary Responsibility Direct Care Administration Teaching/Education Research 11.9 10.8 18.2 11.1 0.68* 1.41* 1.18 …. Who worked in a nursing station or with primary responsibility for education or teaching…

Correlates of Migration (Continued) % Migrants Odds Ratio Position Manager Staff/Community Nurse Other 14.5 11.7 10.1 1.00 1.07* 0.72* Metropolitan Influenced Zone Strong MIZ Moderate MIZ Weak MIZ No MIZ 8.4 15.4 16.5 0.84* 1.31* 1.32* … and who was in a community or staff nurse position in a more highly rural area - that is not close to metropolitan areas.

Internal Migration: Items to Consider RNDB “internal migration” = 11.8% Survey “internal migration” = 26.7% By 2006, Canada is projected to lose the equivalent of 13% of the 2001 RN workforce through retirement and death (O’Brien-Pallas et al., 2003) For many rural communities, MIGRATION of RNs may be equally or more significant! In the RNDB, migration between provinces was noted at almost 12%, but in the survey, when more detailed questions were asked about movement between positions and for school, the migration rate is close to 27%. Recalling the study cited earlier, where it is predicted that 13% of the RN workforce will be lost to retirement and death; with overall migration rates within Canada at the 10-30% range, mobility may be even more important than retirement with respect to the loss of nursing care providers.This is particularly so in the small and more vulnerable rural communities of some areas of Canada. These communities are losing people who are not only health care providers but also direct contributors to the social and economic well-being, and therefore the sustainability of those communities.

Nature of Nursing Practice Recognizing nurses and the complexity of rural and remote practice Access to Care Quality of Care Sustainability of Care In sum, nursing practice in rural and remote Canada is characterized by its variability, and complexity and by the need for a wide range of knowledge and skills in situations of minimal support and few resources.

Implications Create a “rural lens” Understand and support the fact of the inseparability of nurses’ professional and personal roles Provide supports at a distance - in-person and via technology Partner with nurses and communities in recruiting and retaining nurses -Rural nursing practice is unique and differs from urban practice, although the language used to describe it is often similar. Needed is a concise set of questions and processes to consider during the formation of policies and practices. Such a “rural lens” will help managers and policy-makers to “get beneath” the language and issues to appreciate the realities of rural practice, and will assist in creating relevant policies and practices. A rural lens can also illuminate the strengths of rural practice, which may inform approaches in urban settings to address similar problems. Through the use of a rural lens within a coordinated national strategy, the practice realities of rural and remote nurses in all provinces and territories can receive more consistent and concerted attention. In small communities, nurses’ personal and professional roles are inseparable. The intertwining of nurses’ everyday practice and their personal lives needs to be taken into account in developing policies and services, as well as in recruiting and retaining nurse Because many nurses in rural and remote settings work alone or with little backup in their everyday practice, there are pressing needs for developing ways of providing ongoing professional supports at a distance, both in person and using info technology. Recruitment and retention of nurses can be more successful when undertaken with an understanding of the perceptions of nurses in rural and remote communities and in partnership with the communities themselves.

Implications Develop new models of interprofessional practice Attend to the needs of Aboriginal communities Develop undergraduate and post-graduate education for rural nursing Nurses in rural and remote communities interact with many other professionals, often at a distance. Unique solutions are needed for the unique needs that this presents. New models of interprofessional practice can be developed that are supportive of the varied strengths of and resources available to rural and remote communities. - Special attention needs to be paid to the recruitment, recruitment and support of nurses in Aboriginal communities, as well as to ways in which continuity of care and culturally appropriate care can be provided. -There is a pressing need for undergraduate and postgraduate education programs to prepare nurses for the realities of rural and remote nursing practice. A key way is to ensure that clinical practica are offered in rural and/or remote settings and supervised by teachers who are experienced practitioners in the area. University nursing programs that focus on preparing rural and/or remote practitioners need funding levels that recognize the additional costs of designing and providing education to students and working with teachers and/or preceptors in rural or remote settings.

Implications Develop and design relevant continuing education Do not rely on recruiting nurses from overseas Improve nursing databases and rural indicators New ways are needed to systematically design and provide relevant continuing education for rural and remote nurses, including providing education on site, sufficiently supporting nurses to travel for further education, and using information technology. This last mode may require sufficient investment in relevant communication systems and hardware. - Although the phenomenon of an aging nursing workforce is being faced in both urban and rural settings, a larger problem for some rural and remote communities than retirement is the issue of migration – where nurses leave communities for education or alternate employment and do not return. Counting on overseas recruitment to fill these gaps is not a good option as only an extremely small proportion of foreign-educated nurses work in rural Canada. - The distinctiveness of rural and remote settings and nursing practice will not be adequately captured until nursing databases are improved through the development of unique personal identifiers, as well as rural/urban indicators that are of relevance to rural and remote nurses.

Contact Information Overall Project and Narratives: Tel: 1-866-960-6409 e-mail: rrn@unbc.ca macleod@unbc.ca http://ruralnursing.unbc.ca Project Coordinator: Donna Bentham, RN, BSN Documentary Analysis: (403) 382-7119 e-mail: kulig@uleth.ca Survey: (306) 966-6260 e-mail: stewart@sask.usask.ca RNDB: (705) 675-1151 ext: 3355 e-mail: rpitblado@laurentian.ca

Rural Nursing Lens A tool to help train the attention and perception of those who develop policies, programs and services Spotlights the needs and realities of rural nursing Helps to ensure that policies, programs and service changes will be sensitive to rural realities and implemented appropriately

Discussion Questions What would you like to see happen differently in 5 years in rural nursing in your area of practice? What would be one key policy or practice change that could address it?

Discussion Questions Cont’d What would need to be communicated to those who do not live the day-to-day reality of rural practice in order to create this policy or practice change (in an appropriate or implementable way)?

Discussion Questions Cont’d What are the things that REALLY, REALLY matter?