CLASIFICACIÒN DE LA ENFERMEDAD PERIODONTAL (1) :

This final section focuses on identifying barriers that influence rural nursing work and creative possi- bilities or solutions that may address some of these concerns. A global crisis in health and human resources has once again brought attention to the lack of nurses and other healthcare providers who are willing and able to work in rural and remote settings across Canada (Canadian Women’s Health Network, 2008). Internal migration patterns of Canadian-educated rural RNs have recently been stud- ied (Pitblado, Medves, & Stewart, 2005). Using information from the Registered Nurses Database and a national survey, researchers learned that British Columbia has the highest proportion (40.3%) of rural and remote nurses who received their initial education and training in another province or ter- ritory of Canada. Saskatchewan was identified as the province least able to retain RNs who were edu- cated in the province. These researchers also learned that most RNs who leave their rural community for work or for school do not return home. They concluded that “mobility may be even more impor- tant than retirement with respect to the loss of nursing-care providers. There [in small and vulnera- ble rural communities], the losses consist of not only healthcare providers but also community members who directly contribute to the social and economic well-being and therefore the sustainabil- ity of those communities” (Pitblado, Medves, & Stewart, 2005, p. 119).

Proposed recruitment and retention strategies then, involve investing in local communities and investing in local healthcare providers (Table 2.1). Nurses educated in rural communities or small towns are more likely to stay in their communities (Bushy & Leipert, 2005; Courtney et al., 2002). Another strategy that has been proposed to recruit more rural nurses is providing opportunities to live, learn, and work in a rural community as part of pre-registration professional education programs (Neill & Taylor, 2002; Van Hofwegan, Kirkham, & Harwood, 2005). Several creative interprofessional opportunities for nursing, midwifery, and education have also been developed (Interprofessional Network of B.C., 2008; Queen’s University Patient-Centred Education Direction [QUIPPED], 2008). Communities have rallied around these projects, sometimes providing accommodation and support for students (Fraser Annett, 2008). Because local resources are limited, providing support for rural RNs as preceptors of nursing students has also been identified as essential to ensuring success for rural placements (Yonge, 2007). Creating a consortium that allows nursing students and new graduates to rotate between different rural and remote health services to gain experience has also been recom- mended (Hegney et al., 2002a).

Rural nurses place high value on building and maintaining competency in clinical skills, partic- ularly in being able to perform even rarely used emergency skills (Hegney et al., 2002b). Continuing education opportunities, then, become an important retention strategy for rural and remote nurses. Barriers to continuing education that have been identified include staffing shortages and the result- ant inability to replace rural nurses so that they can attend education sessions (MacKinnon et al., 2007). Other barriers include the lack of employer or administrative support, workplace budget constraints, family responsibilities and limited access to childcare, and time and financial con- straints for tuition and travel (Penz et al., 2007). Kosteniuik et al. (2006) proposed that employers can facilitate access to information and knowledge exchange by providing education, travel support, opportunities for knowledge-sharing, and promoting physical access to peripheral information sources (such as the Internet and journals) during work time. Scholarships and bursaries for both

26 ● NURSES, NURSING, AND THE HEALTHCARE SYSTEM

nursing students and rural and remote nurses have been recommended (MacLeod et al., 2004). Supporting nurses through providing opportunities for continuing professional education in their local communities has been identified as an important retention strategy for rural nurses. Lindsey (2007) conducted interviews and focus groups with rural nurses from across British Columbia to develop an education program that was tailored to the needs and concerns of rural nurses. The rural nursing certificate program was then developed collaboratively with participation from nurse lead- ers, nurse educators, and front-line nurses working in rural and remote communities. This module- based, distance education program uses blended learning technologies to deliver educational opportunities as close to home as possible. (See the University of Northern British Columbia’s Web site for further details.) Kulig (2005) noted that a number of nursing education programs with a rural focus are being developed across Canada. Recruitment and retention of rural nurses has become an important priority for employers, and a variety of recruitment incentives are being pro- posed and used. Specific challenges include physical isolation, heavy workloads, fewer social ameni- ties or opportunities for spousal employment, smaller professional networks, fewer treatment services, and increased costs of living in rural and remote communities (Kosteniuk et al., 2006). These incentives include student loan repayment incentives, housing and northern cost of living allowances, and systems that facilitate relocation of spouses and partners. The local provision of maternity care has been identified as one incentive for the relocation of young nurses to rural com- munities (MacKinnon, 2008). Marketing a rural lifestyle and the advantages of community support might also be an effective recruitment strategy (Hegney et al., 2002). Nurses working as the only healthcare provider warrant special consideration. A recent study of 412 RNs working alone in rural and remote Canada described these nurses and the communities they work in and identified pre- dictors of work satisfaction (Andrews et al., 2005). Barriers to continuing education and emotional stressors associated with high workloads were identified as negatively related to job satisfaction. Face-to-face contact with other healthcare providers (not necessarily RNs) and “decision latitude,”

Table 2.1 Articulating the Challenges and Recognizing the Possibilities for Supporting Rural Nursing Work

CHALLENGES POSSIBILITIES

Lack of recognition for the variability and complexity Listening to the voices of rural nurses who know their

of the work work and their communities

Lack of resources including nursing staff & opportunities Creative recruitment incentives and flexible

for continuing education distance/blended learning opportunities

Urban-centric policies, guidelines, and educational Developing policies and programs that reflect the

programs realities of rural nursing practice

Being visible in the community and feeling responsible Developing creative programs based on knowing their

for needed health services community, knowing how to mobilize resources, and

knowing how to promote intersectoral collaboration Difficulty working together when conflict is experienced Relationship building opportunities, nursing leaders

in interprofessional relationships who support “new” nurses, and opportunities for interprofessional education

Generalist/specialist tensions, particularly in hospitals Building areas of “expertise” within generalist practice over time

or the discretion needed to make decisions, organize their work, and use their skills, were positively related to work satisfaction. Given the importance of continuity of care and relationships in remote communities, this study has important implications for employers who recruit and attempt to retain nurses who work alone. MacLeod et al. (2004, p.3) also identified the need to pay special attention to supporting nurses working with Aboriginal communities “as well as to the ways in which continuity of care and culturally appropriate care can be provided.” Creative models with respite from isolated remote communities may also be required (Aboriginal Nurses Association of Canada, 2000; Minore, Boone, & Hill, 2004). Henderson-Betkus and MacLeod (2003) have also identified strategies for retaining PHNs in rural British Columbia. Nursing regulations and scope of practice documents also influence nursing practice in rural and remote communities. Negotiations around scope of practice and “who can do what” are also political acts that tend to ignore the impact of these decisions on rural and remote communities. PHNs working in northern British Columbia identified a number of barriers (including economic, scope of practice limitations, and power rela- tions) as barriers to their ability to offer health promotion and early risk identification for women living in their communities (Leipert, 1999). These rural PHNs believed that their ability to listen, to respect, and to provide care in a nonjudgmental way meant that they could provide more compre- hensive and holistic women’s health services, including sexual health services and PAP screening. Flexible boundaries and overlapping scopes of practice may be more appropriate for healthcare providers working in rural and remote communities. Interprofessional willingness to embrace new and creative models for collaborative practice may come from carefully listening to the experiences and concerns of all rural healthcare providers. Union and management structures and practices can also be a barrier in rural settings. The disappearance of front-line nursing leaders (a.k.a. head nurses) within hospital administrative structures has made visible the need for front-line leadership for nurses working in rural communities. For example, negotiating a delay in a “routine” induction when skilled nursing staff is not available may be difficult for inexperienced rural nurses who do not have the support of a more experienced nurse available to them (MacKinnon & Yearley, 2007). However, closer relationships between managers, nurses, and other healthcare providers in local rural and remote communities also increase the possibilities for collaborative resistance against cen- trally imposed cutbacks in personnel or health services (MacKinnon, 2008). Within nursing educa- tion there are also competing priorities between community health and acute care nursing and between specialty practice as needed for urban and suburban settings and primary healthcare that may be more appropriate for nursing in rural and remote communities. Nursing education pro- grams that focus on rural and remote health services are being developed in several locations across the country, which may allow more sustained attention to the knowledge needed for rural and remote nursing practice. Along with embracing the full scope of nursing practice, creative programs that provide educational opportunities for advanced practice nurses with specialized skills to address rural health needs, such as Clinical Nurse Specialists (CNSs), and with additional skills in primary healthcare, such as NPs, are also being developed to address health needs in rural and remote communities (Smith Higuchi et al., 2006; Tilleczek, Pong, & Caty, 2005).

SUMMARY

R

ural communities are extremely different from one another (MacLeod et al., 2004a), so it is likely that “one-size-fits-all” solutions will not work for all rural and remote communities across Canada. Learning to listen well to rural nurses, other healthcare providers, and community members and sustaining attention through rural health research should help to ensure that policies and practices that influence health and health services in rural communities are identified. Working collaboratively with health planners and decision makers in partnership with rural communities to provide essential and needed health services as close to home as possible can help ensure that

28 ● NURSES, NURSING, AND THE HEALTHCARE SYSTEM

Canadians living in rural and remote communities across Canada are also recipients of our global attention to “Health for All” (World Health Organization, 2008).

Aboriginal Nurses Association of Canada http://www.anac.on.ca/ Canadian Association for Rural and Remote http://www.carrn.com/ Nurses (CARRN)

Canadian Journal of Rural Medicine http://www.cma.ca/cjrm/index.htm Canadian Rural Health Research Society http://crhrs-scrsr.usask.ca/

Nursing Practice in Rural and Remote Canada http://ruralnursing.unbc.ca/ Online Journal of Rural Nursing http://www.rno.org/journal/ and Healthcare index.php/online-journal

Rural and Remote Health: The International http://www.rrh.org.au/home/defaultnew.asp Electronic Journal of Rural and Remote

Health Research, Education, Practice and Policy.

Add to your knowledge of this issue:

Online

REFLECTIONS on the Chapter...

1 Is rural nursing a specialty? If so, what kinds of education and experience do rural nurses need?

2 What does it mean to practice the “full scope” of nursing in rural and remote commu- nities?

3 How can we make continuing education programs for rural nurses affordable and accessible?

4 What role do/could advanced practice nurses, such as NPs or CNSs, play to address health needs in rural and remote communities?

5 How are advanced practice nursing roles being integrated into the healthcare system in rural and northern communities?

6 How can nurses provide “culturally safe” care when working with First Nations’ communities?

7 How could interprofessional teams of healthcare providers work together to ensure that rural health services are available as close to home as possible for Canadians liv- ing in rural and remote communities?

8 What assumptions are currently being made about women’s family caregiving work in rural and remote communities? How could women and families be better supported?

9 What assumptions are currently being made about rural nursing work and what can we learn from nurses working in rural and remote communities?

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In document Tesis presentada por: ALEJANDRA MARISOL JOACHÍN CARRERA (página 34-41)