1. Martha MacLeod, PhD, RN Cathy Ulrich, MSc, RN
Nursing Leadership at a Distance: Addressing the Experience of Rural and Remote Nurses
Martha MacLeod, PhD, RN
Cathy Ulrich, MSc, RN
Nursing Leadership Conference, February 15, 2005

2. 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 this year.

3. 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

4. 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)
I am the lead investigator, and one of four Co-Principal Investigators.
Judith is leading the Documentary analysis; Norma the survey, Roger, a geographer, the RNDB, and I am leading the study overall and the narrative component. Marian Knock was our principal decision-maker - who led an advisory team.

5. 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.

6. 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).

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

8. 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.

9. Narrative Approach 152 Nurses (11 Francophone)
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.

10. 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.

11. Experiencing Leadership
What is the experience of leadership for nurses working in rural and remote communities?

12. Leadership - Narrative Sub Analysis
115 nurses told of experiences of leadership
20 analyzed in depth (3 in supervisory roles)
Acute, Long-term Care, Public Health, Home-care, Community, Primary Care
10 provinces and territories
Of the 152 nurses interviewed, 65?? specifically

13. Experiencing Leadership
Setting up possibilities for quality practice
Supporting nurses and their practice
Planning for the realities of practice
Pervasive, is the importance of community in shaping the nurses’ worklives and everyday practices.

14. Setting up Possibilities for Quality Practice
Ensuring resources for professional practice
Setting and supporting the achievement of relevant practice standards

15. Supporting Nurses and Their Practice
Advocating for nurses
Supporting with education and resources
Supporting problem-solving

16. Planning for the Realities of Rural and Remote Practice
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]
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 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.

17. What is Needed from Leaders?
Understanding realities of rural and remote practice, practitioners and communities
Supports that minimize difficulties while maximizing the strengths of rural practice

18. Advice: Listen to Learn-Learn to Listen
It would help to have a manager 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
Predominant among the advice was the need for more understanding – the need to learn to listen and to listen to learn… 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”

19. Meeting Challenges of Distance and Diversity
Recognize the complexity of rural and remote practice
Set up facilitative systems and processes
Create a climate that acknowledges and supports the potential of excellence

20. Leading with a 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

21. Leading at a Distance

22. Contact Information
Overall Project and Narratives:
Tel:
Project Coordinator:
Donna Bentham, RN, BSN
Documentary Analysis:
(403)
Survey:
(306)
RNDB:
(705) ext: 3355