University of Northern British Columbia, Prince George, BC Support of Advanced Practice: Issues for Nurses in Rural and Remote Canada Donna Bentham, BSN RN & Martha MacLeod, PhD RN University of Northern British Columbia, Prince George, BC

12/31/2018 Introduction Literature review of support for Primary Health Care Nurse Practitioners in rural and remote Canada Today’s presentation is based on a literature review for my thesis for a Master’s in Community Health. I am interested in learning what the experience of support is for nurse practitioners in rural and remote Communities in Canada. I grew up in a small town in northern BC and began my nursing career in the hospital there where I learned first hand of some of the creativity that occurs in small hospitals ( we didn’t have fancy incentive spirometers to help with deep breathing, we used children’s pinwheel toys). My latest work experience as a nurse clinician on a medical and palliative care unit highlighted the importance of mentorship and cohesive team work in supporting nurses in the current work situation. My interest in nurse practitioners comes from my work as the Research Coordinator for the Nature of Nursing Practice in Rural and Remote Canada study, and as a research assistant for the narrative portion of the study where I get to listen to incredible stories from nurses across Canada.

The Nature of Nursing Practice In Rural and Remote Canada Study 12/31/2018 The Nature of Nursing Practice In Rural and Remote Canada Study Survey Registered Nurses Data Base (RNDB) Documentary Analysis Narrative Study Aim of this 3 year study, of which we are in the middle of the 2nd year is to examine and articulate the nature of registered nursing practice within rural and remote Canada in practice settings such as primary care, acute care, community health, continuing care (home care) and long term care settings. Several methods are being used to accomplish this: A survey of 6500 nurses regarding their rural and remote nursing practice Analysis of the Canadian Institute of Health Information Registered Nurses Database (RNDB) to provide statistical and demographic profiles of rural and remote nurses An analysis of documents, such as those describing standards and policies of nursing practice And The analysis of narratives from nurses who describe their rural and remote nursing practice

Principal Investigators and Decision-maker 12/31/2018 Principal Investigators and Decision-maker Martha MacLeod University of Northern British Columbia Judith Kulig University of Lethbridge Marian Knock B.C. Ministry of Health Planning Norma Stewart University of Saskatchewan Roger Pitblado Laurentian University Marian Knock from the BC Ministry of Health Planning is the Principal Decision Maker for the study and the Co Principal Investigators are Martha MacLeod, from UNBC Judith Kulig, from University of Lethbridge Norma Stewart, from the University of Saskatchewan And Roger Pitblado from Laurentian University 2

Co-Investigators Dorothy Forbes U. Saskatchewan Barbara Smith 12/31/2018 Co-Investigators Dorothy Forbes U. Saskatchewan Barbara Smith Carl D'Arcy Elizabeth Thomlinson U. Calgary Kathy Banks UNBC Lela Zimmer 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 The Co-Investigators as you can see are also from a number of provinces as well the Advisory team of 21 members includes representation from each province and territory in Canada which adds a wonderful richness to the research team. The study is funded by CHSRF and a number of funding partners, including the Nova Scotia Health Services Research Foundation. 3

Why Primary Health Care Nurse Practitioners? 12/31/2018 Why Primary Health Care Nurse Practitioners? Why rural? Why support? So today, in looking at the issues of support for nurses in advanced practice roles in rural and remote Canada, this presentation will outline the reason for focusing on primary health care practitioners in rural communities and why the concept of support is important to explore for this group of health care providers.

Primary Health Care Nurse Practitioners- who are they? 12/31/2018 Primary Health Care Nurse Practitioners- who are they? Advanced Practice Nurse Clinical Nurse Specialist Nurse Practitioner: Acute Care Nurse Practitioner Primary Health Care Nurse Practitioner Primary Health Care Nurse Practitioners- who are they? While Registered Nurses in Canada have title protection, it is not the same for those in advanced practice roles. (Haines, 1993) This means that different organizations may have different expectations of roles, levels of education, and expertise for nurses with the same job title. So we have two issues to deal with: what are advanced practice nurses being called, and what preparation for the role do they have. Title confusion is not unique to Canada, the US also struggles with clearly defining the roles of nurse practitioners and clinical nurse specialists as noted by Sellard & Mills (1995) and others (Fenton & Brykczynski, 1993). There are differing opinions in the literature as to whether in Canada the nurse practitioner role is clear or continues to be confused with the clinical nurse specialist.( DeGrasse & Nicklin, 2001; Alcock, 1996; Pinelli, 1997) Even with attempting to define the differences between clinical nurse specialists and nurse practitioners, the lines become blurred, mostly in the acute care setting. C.N.A. (1993) defines clinical nurse specialists as “ a registered nurse with a master’s or doctoral degree in nursing with expertise in a clinical nursing specialty who provides direct care, education and consultation with clients as well as consultation and education for the health team.” While the educational preparation is not addressed, C.N.A. states that a nurse practitioner has ‘advanced knowledge and decision-making skills in assessment, diagnosis and health care management.” Like a clinical nurse specialist, nurse practitioners can be based in acute care settings where the nurse practitioner focuses on the management of illness by using advanced practice skills in the nursing and medical domains, mostly within a specific area of practice. On the other hand, primary health care nurse practitioners are community based and have a different focus of practice. The most comprehensive description of this nurse practitioner’s practice comes from the Nurse Practitioner Association of Ontario: a primary health care nurse practitioner provides individuals, families, groups and communities with health services in health promotion, disease and injury prevention, cure, rehabilitation and support. (website, 2002)

Why Primary Health Care Nurse Practitioners? 12/31/2018 Why Primary Health Care Nurse Practitioners? RNDB, 2000: 12.7% of all nurses in rural communities work in community health/health centres. Largest increase in place of work (up 3.5% from 1994) RNDB, 2000: 1% of nurses work in nursing stations So why focus on primary health care nurse practitioners? One portion of our national study was reported in the Supply and Distribution of Registered Nurses in Rural and Small Town Canada (CIHI 2002) spearheaded by Roger Pitblado. Specific information on nurse practitioners was not collected in this study, but some of the results that may reflect on nurses working as nurse practitioners in rural and remote communities were an eye opener for me. On a percentage distribution, the largest increase in area of practice for rural nurses was community health centres and health centres, with almost 13% of the nursing population in rural communities now working in this area in the year 2000. At the same time as this information came out, I was doing interviews for the narrative portion of the study and hearing from nurses in very small communities who were undergoing organizational changes. With that their work site name changed, from outpost, nursing station, clinic to health centre or community health centre.Same job, new name but since the percentage of those working in nursing stations remained stable at 1%, there must also be an increase in providing health care within the concept of a health centre. What really amazed me were the number of communities with only one, single solitary RN providing care.

12/31/2018 Table 6.Frequency Distribution of Canadian Rural and Urban Communities by Age Groupings for Communities with only 1 RN, 2000 Age Category Rural Communities Count Percent Urban Communities Count Percent <30 30-39 40-49 50-59 60+ 54 0.1 103 23.1 127 74.8 93 2.0 22 5.5 2 6.9 10 34.5 5 17.2 6 20.7 Total 399 100.0 29 100.0 Source: RNDB 2000/CIHI From: Pitblado, R., Medves, J., MacLeod, M., Stewart, N., & Kulig, J. (2002). Supply and distribution of registered nurses in rural and small town Canada, 2000. Ottawa: CIHI. I was surprised at the number of communities that have only one RN, and what is just as interesting is the ages of those nurses. In particular, look at the number of nurses under the age of 30…54 brave souls. Almost 400 nurses that are completely alone in their practice in a rural community. Where do they get support for their practice? Although this table does not show what area of practice these nurses are in, many of them may be in a primary health care nurse practitioner type of role. As I am interviewing nurses, I am hearing different needs for support from nurses of different ages and different community sizes. The shortage of human resources in the health care system is providing new opportunities for nursing practice. Primary health care nurse practitioners are not just in northern rural communities any more. Support isn’t just a northern issue anymore, is a national rural issue. There are brand new graduate nurse practitioners out there working in roles that are totally new to the community. Canadian studies on nurse practitioners have been limited and most have focused on acute care and primary health care nurse practitioner in the urban setting. What has not been studied in depth is the role of the primary health care nurse practitioner in rural and remote settings.

Why Rural? Limited Research 12/31/2018 Why Rural? Limited Research RNDB: Rural communities growing but number of nurses decreasing RNDB: Rural communities: 21.7% of total population of Canada, only 17.9% of total number of nurses in Canada As most of you likely know already, rural research in Canada has been very limited. The vast majority of health research in Canada has been on acute care practices in urban settings. Macleod, Kulig and others note that while research on rural nursing is on the rise internationally, with much of the literature coming from Australia and the US, in Canada research in this area is just beginning. Rural communities are different than urban, and they are growing. Yet their health resources are declining.In the last 10 years the nurse to population ratio has dropped to 75.6 nurses/10,000 in Canada. In rural communities that number is 62.3.

2002 Report of the Canadian Nursing Advisory Committee 12/31/2018 Why Support? 2002 Report of the Canadian Nursing Advisory Committee * Recommendations to improve quality of nurse’s work life * Based on Canadian research * Supportive work environments for all nurses are vital Commitment and Care:The benefits of a healthy workplace for nurses, their patients and the system ( Baumann et al, 2001) * Synthesis of research literature * Focus on the supportive work environment & identifies other dimensions of support Two recent significant documents emphasize the importance of support for nurses in their workplace. The 2002 report of the Canadian Nursing Advisory Committee recommended policy changes that would improve the quality of nursing work life in all settings of practice. The report, based on current research, speaks very clearly and simply of the important role of nurses in maintaining health care. It also advocates systemic changes that need to occur to ensure sustainable health care delivery. Supportive work environments for all nurses are vital.   The second document, Commitment and Care by Baumann et al, 2001, is a synthesis of research literature that focuses on the supportive work environment as well.Among other issues such as safety, predictability and matching of resources to the person, the report identifies the need for social support in the workplace. Social support is identified as support from managers and colleagues, as well as education and professional development. Notably, the concept of support is discussed in relation to the work setting only, and in terms of cognitive and emotional support. Both documents recognize the influence of nursing leadership positions in the organization as important supports for nurses and how the organizational restructuring of the health care system in recent years has limited, and in some cases eliminated, these positions. Both documents acknowledge research that report decreased mortality, increased quality of care and patient satisfaction, is directly related to nursing job satisfaction and healthy work environments. In looking at the development of healthy work environments based on these two documents, many of the recommendations take for granted the presence of organizational and human resources in order to implement changes because the research information is predominantly from urban acute care settings. What is not clear is how these recommendations will translate to rural and remote communities, particularly with those nurses working in advanced practice roles like the nurse practitioner.

Support in Rural Context 12/31/2018 Support in Rural Context MacPhee & Scott (2002) 10 rural hospitals in Colorado *Satisfaction with support *Social Support-structural & functional *Findings: younger nurses-peer support, older nurses-management support MacLeod (1998) 3 rural hospitals in northern BC “We’re It” study * Understanding of everyday nursing practice leads to understanding how to support nursing practice The concept of support has not been studied directly in a rural context until recently. MacPhee and Scott (2002) used the Social Network Questionnaire to determine what aspects of social support were found in 10 rural hospitals in Colorado.They looked at both structural and functional support, as well as satisfaction with support. While generalizing the results is difficult because of the very specific sampling from one rural region in Colorado, the article does highlight two main sources of support for nurses. The study found that younger nurses rely more on peer support while older nurses looked to management for support. What is unique about this study is that it is one of the few that specifically looks at a number of ways that support is given as it describes types of support, like feedback on clinical performance and who is providing the support, such as management or peers.  Closer to home, MacLeod in her 1998 study “We’re It” looked at the everyday practice of nurses in three rural hospitals in northern BC. The concept of support is described in relation to the development of rural nursing practice and strategies for the development of knowledge and system supports for practice.

Support-Nurse Practitioner 12/31/2018 Support-Nurse Practitioner International work Limited application Canadian studies NPs in urban settings Limited exploration of support Research on support in nursing, particularly nurse practitioners, has been done in other countries such as the United States, England, Australia and South Africa. The differences in health care systems, legislation governing nurses, and the educational preparation for nurses in each country can make it difficult and sometimes inappropriate to extrapolate the findings to the Canadian health care scenario. Authors such as Sidani et al, 2000; Haines, 1993 say that we should be cautious in using this information as we look at the Canadian setting.   A current study in British Columbia by Schreiber et al ( CHSRF funded) is looking at what is necessary to initiate and support advanced practice roles in BC. Among the factors raised by nurse practitioner participants was the need for supports for their practice, such as: understanding of the role, supportive working relationship with colleagues, infrastructure supports, continuing education opportunities and clearly defined policy, guidelines and standards. Canadian studies of nurse practitioners have focused for the most part on the acute care nurse practitioner and on the primary health care nurse practitioner in urban settings. What needs further in-depth study is the role of the primary health care nurse practitioner in rural and remote settings, and what counts as support to these care providers.

Framework for looking at Support 12/31/2018 Framework for looking at Support Administration Colleagues Family Community So as in many things in life, we take what we can find and work with it. Support of nurse practitioners is looked at from a general point of view in many articles but not in a complete way nor in sufficient depth. In the context of rural primary health care nurse practitioners, a preliminary framework of support that looks at different domains important to nursing practice includes support from administration, colleagues, community and family.

Administration Support 12/31/2018 Administration Support Clarification of nurse practitioner role Infrastructure Continuing education Guidelines, policies, standards Mentorship and preceptorship programs Administrative support is often discussed in the literature as a hindrance or help to nursing practice. The general statement that administration needs to support nurse practitioners in their practice only brings attention to the issue, when what is needed is a clearer understanding of the ways that administration can support the role. Many Canadian and American studies have commented that within the organization, role definition needs to begin with clear practice guidelines and expectations of the position. Management can also support nurse practitioners by assisting other health care team members to understand the role and scope of practice. A few issues have been identified in the current Schreiber et al (2002) study mentioned earlier, that interestingly, have not been examined widely in the nurse practitioner research literature. Such as- Infrastructure supports… computers, space, secretarial staff, etc. Access to continuing education that is appropriate and relevant to the nurse practitioner.This is something that I have been hearing from nurse practitioners in the interviews-nursing education doesn’t cover the full scope of their practice, and physician education doesn’t have a rural enough focus and can be way over their scope of practice. Although the administrative support of guidelines, policies and standards has been discussed in research literature (e.g. Irvine et al 2000), there is very little specific to rural Canadian nurse practitioner practice. Administration has a role in supporting the development and implementation of preceptorship and mentorship programs for new nurse practitioners. In the Illinois study of the transition to first position as a nurse practitioner by Kelly & Mathews ( 2001), new graduate nurse practitioners viewed the presence of a mentor as critical to role development and job satisfaction. While specific programs are not outlined, many research articles in the past decade document the importance of preceptor/mentorship programs in improving job satisfaction, retention and advancement of the role of nurse practitioner. Even though the importance of mentorship and preceptorship of nurse practitioners has been advocated for many years, implementation of these programs is limited. For example, the recent study of primary care nurse practitioners in Ontario by Irvine et al (2000) doesn’t mention such a program even though the length of time in the acute care nurse practitioner role for the 57 participants ranged from one month to 12 years with a mean of 2.5 years. One could say the system is not practicing what the research preaches. In relation to primary health care nurse practitioners in rural and remote communities, management is rarely in the same community and contact may be limited. Exploring the effects of distance on the ability to provide support would be beneficial.

Colleague Support Registered Nurses Nurse Practitioners Physicians 12/31/2018 Colleague Support Registered Nurses Nurse Practitioners Physicians Support from colleagues can occur in ways other than mentorship. A key factor to colleague support is the understanding of the role of the nurse practitioner. The lack of understanding by nurses other than fellow nurse practitioners, is well documented in the literature as an impediment to the practice of nurse practitioners.(Kelly & Mathews, 2001; Brown & Olshansky, 1998; Alcock,1996; Hupcey, 1993) Because of the direct working relationship in hospitals, the literature focuses on the practice of acute care nurse practitioners. Staff nurses undermine the credibility and respect of the nurse practitioner when they reject care plans and even direct orders from acute care nurse practitioners. In hospitals where the work of the acute care nurse practitioner depends on referrals from other health care providers, not understanding the extent of the scope of practice for nurse practitioners has the potential to limit the health care provided to clients, possibly even extending hospitalization. So while the lack of understanding has significant implications for nurse practitioners who are in work settings with other health care professionals, the importance of nurse colleague support will be different for the primary health care nurse practitioner, working alone in a community or only with other nurse practitioners who understand the role. For those primary health care nurse practitioners working in rural and remote communities, the relationship and support from physician colleagues can take on a greater importance as physicians are usually the first contact for clinical support and decision-making. The nature of practice for these nurses relies heavily on the acceptance and understanding of the role by physicians. MacDonald & Katz (2002), explored the perceptions of some Winnipeg physicians involved in the nurse practitioner education program. While the sample size was limited, the results are consistent with issues raised in other research such as Irvine et al in Canada and Hupcey in the US. What is interesting about the MacDonald & Katz study is the marked difference in perceptions of the nurse practitioner role between the faculty physicians and the residents. Faculty physicians were much more accepting of the role of primary health care nurse practitioners and had a clearer understanding of the scope of practice. The residents, whose own practice experience was not mentioned, were more negative about working with nurse practitioners in a collaborative fashion, stating that primary health care nurse practitioner roles should be limited to rural and remote communities where physicians were not willing to practice. What is gained from this study, is a Canadian perspective that supports previous studies on the need for physician support of the nurse practitioner role. It also underlines the need for further exploration of nurse practitioner’s experience of physician support in rural and remote areas.   Many articles such as Brown and Olshansky (1998) and Dunn & Nicklin(1995) note that as physicians become more familiar with the role of the nurse practitioner and the quality of care they can provide, their support for the role increases. From an American perspective, Hupcey notes that despite the role of the nurse practitioner existing for more than a decade, resistance from physicians is still present and hinders the practice of nurse practitioners. We haven’t learned how to work together very well. If nurse practitioners find collaborative working relationships to be important to their practice, then what can facilitate support from physician colleagues? (Schreiber et al 2002).

Family Support Mostly ignored in the literature 12/31/2018 Family Support Mostly ignored in the literature Brown & Olshansky (1998) when colleague support lacking, newly graduated NPs turned to family and friends for support Finally, two domains of support that are for the most part ignored in the literature are the community where practice occurs, and support from the family of the nurse practitioner. These are two areas that I am beginning to hear in the interviews I am doing for the narrative study. I believe that due to the nature of the work in small communities, and the absence of administration and colleagues, these two areas may be of great importance in relation to primary health care nurse practitioners in rural and remote communities.   In their 1998 study of the first year of practice for 35 primary care nurse practitioners in the US, Brown & Olshansky briefly mention the support of family and friends. New graduates seek out support from family and friends only when they are unable to attain support from colleagues or the work environment in general. Again, this is an area I am hearing mentioned by nurses in the study.

Community Support Mostly ignored in the literature 12/31/2018 Community Support Mostly ignored in the literature Nursing role blurs into the community role Confidentiality, isolation Understanding and acceptance of the NP role As for community support, Kelly and Mathews ( 2001) studied the transition of nurses into their first position as nurse practitioners. Although the size of the communities was not extrapolated from the data, the researches noted that the most nurse practitioners were practicing in small town Illinois. This study can be related to the experience of Canadian nurses working in rural and remote communities in relation to role definition, issues of privacy in a small community as well as issues of confidentiality and isolation. These issues relate to how the community understands the role of the nurse practitioner and supports the acceptance of the role in the community. In the 1998 study “We’re It” by MacLeod, nurses talk about how their role as a nurse and their role as a community member often blur together. Being a part of the community seems to have a greater impact for nurses in smaller communities and this relationship needs to be explored in future research.

12/31/2018 Next Steps My Thesis: The experience of support for primary health care nurse practitioners in rural and remote communities in Canada Although no doubt, the issue of support will be explored in the overall Nature of Nursing Practice in Rural and Remote Canada Study, in my thesis I will be drawing on what I have learned from the literature to undertake an interpretive qualitative study of the experience of support for primary health care nurse practitioners in rural and remote communities in Canada. As you have heard, the research field for exploring support for this group of health care providers has significant gaps. One of the things about the research I have talked about today, is that it is all focused on nurse practitioners with formal education. As in many areas of nursing practice, there are nurse practitioners that have learned on the job.In interviews I have heard the philosophy of “see one, do one, teach one.” Some nurses working in the role may or may not have certificates relating specifically to the nurse practitioner role. These individuals are not even mentioned in the literature. In my study, I expect to be examining the experience of support for individuals with varying levels of preparation for the primary health care nurse practitioner role. Does the cultural background of the community influence the experience of support? What is it like for a new graduate nurse practitioner working as the first nurse practitioner in that community? Although I may not be able to address all these questions in my research, they are important ones as we examine the experience of primary health care nurse practitioners in rural and remote Canada.  

12/31/2018 Contact Information Overall Project and Narratives: Martha MacLeod e-mail: macleod@unbc.ca Donna Bentham Research Coordinator Email: rrn@unbc.ca Tel: 1-866-960-6409 http://ruralnursing.unbc.ca Documentary Analysis: Judith Kulig (403) 382-7119 e-mail: kulig@uleth.ca Survey: Norma Stewart (306) 966-6260 e-mail: stewart@sask.usask.ca RNDB: Roger Pitblado (705) 675-1151 ext: 3355 e-mail: rpitblado@nickel.laurentian.ca Thank you very much for your time this afternoon. I would be pleased to answer questions at this time.

12/31/2018 The Nature of Nursing Practice in Rural and Remote Canada Study: 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 Foundatin for Health Research Michael Smith Foundation for Health Research Nova Scotia Health Research Foundation B.C. Rural and Remote Health Research Institute Saskatchewan Economic and Cooperative Development Canadian Institute for Health Information Provincial and Territorial Nurses Associations Government of Nunavut 1