CHAPTER

24
Rural and Remote Health
Mary Ellen Labrecque and Kelley Kilpatrick

LEARNING OUTCOMES

After studying this chapter, you

should be able to:
1. Describe the characteristics
of rural and remote
communities in a Canadian
context and the impact of
geographical diversity on
health status.
2. Recognize health inequities
associated with access to
care for residents living in
rural or remote communities
in Canada.
3. Explain the context of
nursing practice and
interrelationship with the
social determinants of
health when caring for
clients in rural and remote
areas.
4. Identify challenges and Sources: Courtesy of Mary Ellen Labrecque/University of Saskatchewan; Erin Wilson/University of Northern British Columbia;
rewards in the development Erin Wilson/University of Northern British Columbia; Martha MacLeod/University of Northern British Columbia
of a nursing role in a rural
or remote community INTRODUCTION
and evidence-informed
strategies that support role This chapter introduces concepts relevant to caring for clients and populations residing in
development. rural and remote areas of Canada. The characteristics of rural and remote are delineated with
an emphasis on cultural diversity, equity in distribution of health services, and the rural and
5. Explore ways in which rural remote community health nurse (CHN) role in addressing historical colonialism and health
and remote community inequities. The aim of the chapter is to assist nursing students to develop an understanding
health nurses have a role in of health and the role of CHNs in rural and remote geographical locations.
addressing health policy. Descriptions of rural and remote nursing practice provided by CHNs in national sur-
veys (MacLeod et al., 2017) include community characteristics, geographical location, health
equity, human and technical resources, and nursing practice characteristics. In the chapter, the
features of rural and remote CHN practice are identified and expanded to include perspectives
on the increasing need for advocacy work by CHNs. Critical-thinking questions will enable
students to explore the differences between rural and remote communities, rural and remote
area CHN practice, health care and community services, and will encourage students to think
upstream about the inequities faced by residents living in rural and remote Canada.
 Chapter 24 RURAL AND REMOTE HEALTH 445

THE CHARACTERISTICS OF designations highlight the importance of access to services and

the types of locally available health services while considering
RURAL AND REMOTE CANADA transportation and communication limitations as important
factors in their differentiation between what isolated is and
Definitions is not. A wide variety of indices of rurality exist, such as the
Canadian General Practice Rurality Index (Leduc, 1997) or
Approximately 95% of Canada’s land mass can be considered
the Rurality Index of Ontario (Kralj, 2001).
rural and remote (Moazzami, 2015). However, longstanding
Social approaches to defining rural refer to the nature
debate exists about the definitions of key terms that describe
of the rural community, including such features as specific
the geographical location of communities as rural, remote,
services that are normally associated with larger population
Northern, and isolated. One of the first comprehensive
sizes (e.g., specific types of stores or restaurants) (Pitblado,
reviews of the literature examining rurality highlighted
2005). Although the social nature of place in defining rural is
that indexes reported differing methods for assessing rural
relevant to health care service delivery, particularly the recruit-
(Minore, Hill, Pugliese, & Gauld, 2008). Some of the indices
ment and retention of health professionals, including RNs,
report on access to health care, population, or number of phy-
there has been limited work done on examination of its specific
sicians as a measure of rurality. Therefore, it is important to
meaning or application. The definition offered by Statistics
note that there are few rurality indices that define rural and
Canada identifies “rural and small town” as “individuals in
remote, and little consensus exists in the literature about the
towns or municipalities outside the commuting zone of larger
definition of remote, with the choice of index dependent on
urban centres” (du Plessis et al., 2001, p. 6). Using this defini-
the focus of research endeavours (Kulig, Kilpatrick, Moffitt,
tion, in 2016, 5 918 771 or approximately 17% of Canadians
& Zimmer, 2015). Pitblado (2005) suggested two main ways
lived in communities with populations of less than 10 000
to define rural: technical and social.
people (Statistics Canada, 2017a). This is the definition of rural
Technical approaches to the definition of rural include
employed in this chapter. It is selected because of its growing
locators or geographic regions, like the location of hospitals,
use in studies of rural and remote issues in Canada, including
roads, or specific political areas (i.e., provinces, counties). For
the determinants of health and the delivery of health care.
example, Statistics Canada (du Plessis, Beshiri, & Bollman, 2001)
examined six possible ways to define rural, each emphasizing dif-
ferent criteria, such as population size, population density, and Diversity of Rural and Remote
settlement or labour market contexts. This definition of “census
rural” refers to “individuals living in the countryside outside cen- Communities
tres of 1000 or more population” (du Plessis et al., 2001, p.!6).
Rural and remote communities in Canada are diverse, and their
The Canadian Institute for Health Information (CIHI) adds
economies vary by the specific geographic features. Tradition-
the notion of distance to, and relationship with, urban areas
ally, rural and remote economies have been dependent on the
(Canadian Institute for Health Information [CIHI], 2013). The
natural resources of the geographic landscape, such as oil and
First Nations and Inuit Health Branch (FNIHB) within Health
gas extraction, forestry, fishing, and agriculture. It is incum-
Canada (2005) defines the degrees of rurality as follows:
bent on CHNs to understand the socioeconomic context in the
7 Non-isolated community includes communities with road community where they work, given the influence of economic
access of less than 90 kilometres to physician services. development on the determinants of health.
7 Semi-isolated community includes communities with road The resource base of a community will influence the
access greater than 90 kilometres to physician services. health status of those who live in it. In rural, remote, and
7 Isolated community refers to communities with good isolated communities where there is a heavy reliance on indus-
telephone service, scheduled air transportation flights, but tries such as oil and gas, logging, mining, fishing, and agricul-
no road access. ture, interrelated injuries and illnesses impact the individuals
7 Remote, isolated community means the communities have no as well as the community at large. For example, in 2015 there
scheduled air flights, minimal telephone or radio access, were 271 935 farm operators across Canada (Statistics Canada,
2017b). Operators on medium-size farms had the highest
and no road access.
incidence of injury because they worked the longest hours
Many of the indices of rurality are old, have held only the- without reliance on hired help in comparison to those on the
oretical value, and have never been put into operation. Almost largest farms (Maltais, 2010). Farm operators are also aging,
all of the indices have been designed with physicians—not possibly contributing to the higher incidence of injury in an
nurses—in mind. In the analysis of the perceptions of rurality industry that continues to have one of the highest fatality
by rural registered nurses (RNs), Kulig et al. (2008) concluded rates. According to statistics from the Association of Work-
that there was no benefit in developing a national numerical ers’ Compensation Boards of Canada (AWCB, 2017), in 2015,
index of rurality based on distance to advanced health care there were 3331 accepted time-loss injuries (i.e., “an injury
services because of the variability of absolute distance (ranging where a worker is compensated for a loss of wages following a
from 20 to 1000 kilometres) and mode of travel (e.g., air or work-related injury”) and 10 fatalities in the agriculture and
ground). In addition, most rurality models focus on deficits related service industry across Canada. The Canadian Agri-
rather than the strengths of rural communities. The FNIHB cultural Injury Reporting system found that annual average
446 Part Three Nursing Care of Selected Populations

number of deaths between 2003 and 2012 was 101, with 70% reported to have a certificate, diploma, or degree, compared
being machine-related and 91% of the fatalities being male to rural (69%) or urban (78%) women. For rural Indigenous
(Canadian Agricultural Injury Reporting, 2016). women, 41% were found to have no certificate, diploma, or
Other natural resource industries also employ a significant degree, compared to 35% of urban-based Indigenous women.
number of individuals and impact rural areas. Individuals who The statistics identified a strong relationship with residing in
work in the oil and gas, logging, and mining industries may an urban area and obtaining a university education and decreas-
experience personal health issues such as respiratory problems ing numbers in rural areas, with the lowest rates on reserves.
from environmental exposure to reduced air and water quality There is also unequal access to post-secondary education in rural
as well as the potential for accidents on the job (Fraser Basin and remote areas, which limits the ability for people to change
Council, 2012). For instance, individuals in the logging industry their income and subsequently impacts the socioeconomic sta-
and specifically sawmill workers are exposed to wood dust, which tus of their communities.
can lead to acute and chronic upper and lower respiratory health
conditions (Demers, 2011). In 2015, there were 1330 accepted
time-loss injuries and 13 deaths in the logging and forestry Being Rural and Remote
industry, and 1705 accepted time-loss injuries and 52 deaths
in the mining, quarrying, and oil well industries across Canada Emphasizing such notions as a “type” of rural or remote person
(AWCB, 2017). Events such as explosions (e.g., the Burns Lake can lead to generalizations and inaccurate descriptions of the
Sawmill in 2012), oil spills, and mining accidents all have the variety of people who live in rural and remote settings. Rural
potential to affect not just those who are directly impacted by and remote residents have been the focus of a very small num-
the event but also family and friends who must deal with pre- ber of studies examining the meaning of health. A recent sys-
mature death or long-term health impacts of community mem- tematic review of literature exploring the definition of health
bers. Also of concern is the potential loss of employment and from the perspective of rural- and remote-living people identi-
ultimately negative long-term changes in the community. fied that there may be a difference in how health is perceived
In some natural-resource-dependent areas, industrial by remote, rural, and urban dwellers (Gessert et al., 2015).
camps are set up for varying periods of time. The local health Findings of this review suggested a definition that included the
regions may be responsible for enforcing environmental and ability to participate in work and community social events, and
public health regulations for camps and for helping to address being independent. One important older study on the health
health issues that may arise (Northern Health, 2012). Potential beliefs of rural Canadians in two western provinces found that
health issues involve impacts of shift work, including obesity, being healthy was defined as having a holistic relationship
emotional distress, and domestic issues, all of which may be among mental, social, physical, and spiritual aspects (Harbison,
interrelated with substance abuse (Northern Health, 2012). Coughlan, Karabanow, & VanderPlaat, 2005). In another study,
Another issue CHNs may need to address is the perception the participants defined sickness as a curable and short-term
among workers that cancer can be attributed to working in condition, whereas illness was perceived as chronic and life-
the oil and gas industry (Fraser Basin Council, 2012); this has threatening (Thomlinson, McDonagh, Baird, Crooks, & Lees,
implications for individual and community health assessments 2004). The limited number of studies exploring the meaning of
in identifying relationships and occupational trends. health for rural and remote residents requires that CHNs need
The socioeconomic status of rural and remote com- to explore this issue. The definition of health is diverse and has
munities is not static. For example, in areas where natural cultural and geographical elements.
resources are depleted, or when global pricing and demand Other research with rural and remote residents has focused
decreases, communities often seek alternate economic ventures, specifically on health status—examining differences in dis-
such as tourism, to sustain their economic and social viability. ease patterns and occurrences. For example, one study found
As the rural and remote populations change, such as commu- that a lower proportion of individuals living in small-town
nities with an increasing percentage of older adults, so too do regions, rural regions, and northern regions rated their health
community health needs. as excellent. Specific conditions such as arthritis are higher
Not all individuals who live rural or remote experience than the national average among rural populations (Barnabe
similar access to employment opportunities. Having access et al., 2017), and residents of northern regions have a higher
to local opportunities to earn a reasonable living wage, purchase prevalence of hypertension (Reading, 2015). Canadian studies
healthier food options, and care for family members corresponds (DesMeules et al., 2006; DesMeules et al., 2012; Lavergne &
to a number of the social determinants of health. For example, Kephart, 2017) that examined health status and health deter-
in rural and remote areas of Canada, employment opportuni- minants among the rural population found variations of preva-
ties are considerably limited, particularly for women. The most lence, incidence, and risk for specific diseases and compared to
recent Statistics Canada (2017a) census data analysis reported urban residents, as explored in the “Health Variations among
that 45.6% of rural and 44.6% of remote women were in the Rural, Remote and Indigenous People” box.
labour force, compared to 47.8% of the urban labour force (Sta- Rural health status and rural-specific determinants of
tus of Women, 2016). Reserve-based First Nation (FN) wom- health point to the importance of disease prevention and
en’s income was lower than non-Indigenous women working health promotion through public health initiatives in rural
on reserves and Indigenous women living in rural or urban set- and remote settings. However, what is less clear is whether
tings. Only 56% of women living in a remote community were conventional strategies, mostly developed by urban program
 Chapter 24 RURAL AND REMOTE HEALTH 447

planners for urban residents, are equally effective in rural and Population Diversity in Rural
remote settings. In addressing rural health concerns, CHNs
can apply the three levels of prevention: primary (reducing and Remote Areas of Canada
risks for a potential problem), secondary (providing screening In addition to unique geographic features that affect the live-
and early detection and treatment), and tertiary (maintaining lihood and everyday life cycle of rural and remote residents,
health). For instance, primary prevention would include pro- there is diversity in the groups of people who live in rural and
viding health education for individuals in rural and remote remote areas. Many of these groups face challenges in being
communities to maintain the lower rates of cause-specific can- unique and living in a rural or remote environment; some may
cers; secondary prevention activities would include developing feel excluded from community life, whereas others who want
and implementing diabetes screening programs for women at to live apart prefer residing where they can co-exist with other
risk for death from diabetes; and tertiary prevention would groups but not be expected to interact. It is part of the role
include monitoring the effectiveness of treatment for circula- for CHNs to assess the rural and remote communities within
tory and respiratory diseases. which they live and work to determine the diversity, strengths,
It is important to note that no amount of health educa- and needs that arise from such diversity. The changing face
tion will change the social determinants of health of individu- of immigration, which includes the influx of temporary for-
als and populations living in rural or remote locations. More eign workers in some rural communities, adds to diversity
often than not, the root causes of adverse health outcomes for in rural community populations (Rice & Webster, 2017) and
a population are the result of policies, inadequate programs, a challenges in the delivery of culturally sensitive health care
lack of infrastructure, high cost of living, and a lack of focus on services.
the specific strengths and needs of individuals who live rurally Identifying diversity in a rural, remote, or isolated com-
or remotely. One population that faces noteworthy barriers to munity population is important for the development and
the social determinants of health is the Indigenous people of implementation of appropriate nursing care that incorpo-
Canada, many of whom are rural and remote and face challenges rates an intersectional approach to the social determinants
related to a number of determinants, including inequities; of health. For example, in some rural areas of Canada, the
chronic diseases; underemployment; high costs of food; housing, existence of unique religious groups, including Amish,
and hydro; and dramatically inequitable access to health care. Hutterites, Mennonites, and Conservative Dutch, means that
some health behaviours, such as immunization (Vandenberg,
HEALTH VARIATIONS AMONG RURAL, 2013), are not commonly accessed. The example highlights
REMOTE, AND INDIGENOUS PEOPLE that it is important for CHNs to conduct community assess-
ments that acknowledge the religious, sociohistorical, and
7 Rural areas reported higher proportions of people with policy contexts within which individuals, families, and
low income and less than secondary education level. groups are located. Rather than focus on describing specific
Completion of high school was reported as highest among groups and practices, the principle of cultural safety that is
non-Indigenous people and lowest among Inuit peoples. reflective of cultural awareness, sensitivity, and competence
7 Health-related factors, such as the prevalence of is the appropriate focus. The five principles of cultural safety
smoking and obesity, were elevated in rural Canada, are protocols (i.e., respect for cultural forms of engagement),
while other health influences, such as dietary practices personal knowledge (i.e., understanding one’s own cultural
and leisure-time physical activity, were lower in rural identity), process (i.e., engaging in mutual learning), posi-
areas. On-reserve FN populations reported higher per- tive purpose (i.e., ensuring the process yields the right
centages of adults with diabetes. outcome for the client), and partnerships (i.e., promoting
collaborative practice) (McCall & Pauly, 2012; Polaschek,
7 Life expectancy at birth was significantly higher in
1998).
urban areas and lower among Indigenous people.
Discussions of cultural safety and CHN in a Canadian
7 Higher overall mortality risks among rural communities context must encompass an understanding of the historical
appear to be driven by higher death rates from such colonial context that informs the basis of our knowledge
causes as circulatory diseases, injuries, and suicide; res- about the development of our nation and the perpetua-
idents of the most rural areas are often at highest risk. tion of colonialism in the social and political context of the
7 Incidence rates of most cause-specific cancers were Canadian health care system. This is especially relevant for
lower in rural areas. CHNs working in Indigenous communities in rural and
7 Respiratory disease mortality risks were, for the most remote areas. Chapter 22 discusses the work of the Truth
part, significantly higher among rural residents. The and Reconciliation Commission of Canada (2015) and the
ratio of cases of tuberculosis is higher among Indig- calls to action, which address social determinants of health
enous than non-Indigenous populations. and the particular inequities stemming from oppressive
7 Women living in the most-rural areas had higher risks anti-Indigenous policies. FN, Inuit, and Métis communities
of dying from diabetes. historically have been deprived of basic resources and rights
Sources: Canadian Institute for Health Information (2006). Adapted for achieving optimal health and wellness. These are impor-
and reproduced with permission from the Minister of Health, 2018. tant elements of the work of CHNs in Indigenous rural and
remote communities.
448 Part Three Nursing Care of Selected Populations

HEALTH INEQUITIES terms of the communication of health prevention and pro-

motion being offered in the language of the community,
EXPERIENCED BY RESIDENTS exploring concepts of health from a traditional knowledge
OF RURAL AND REMOTE perspective, and integrating new health care technologies
COMMUNITIES into culturally appropriate practices that address local health
care priorities.
Although they are known for strength, resilience, and com-
munity cohesion, residents of rural and remote Canadian
communities are challenged by numerous inequities—most Inequity and Technology
often reported in the literature as access to health care ser-
vices, reliable access to technologies, poor water quality, Technology includes services such as internet connectivity,
and food insecurity. health informatics, and telehealth. One large area of inequity
for rural and remote communities is access to reliable inter-
net service. In 2018, the Canadian Radio-television and Tele-
communications Commission announced new funding for
Inequity in Health Care Access broadband projects aimed at improving internet access and
Rural and remote communities by nature have fewer health mobile wireless network access for underserved areas, includ-
care delivery options. Boom-and-bust cycles affect economic ing rural and remote regions of Canada (Canadian Radio-
stability and availability of local services for rural and remote television and Telecommunications Commission, 2017).
residents, and the resulting underemployment leads to pov- Where internet connectivity was intermittent or severely
erty, a significant issue for rural and remote people (Rice & limited, Melvin and colleagues (Melvin, Bunt, Oduor, &
Webster, 2017). In rural and remote communities, poverty is Neustaedter, 2015) found that family communication was
a condition that has been largely “invisible” to urban dwell- hindered and social isolation increased. This may also impact
ers. The rural and remote poor are disadvantaged because reserve-based Indigenous people as well as those living in
they need to travel longer distances for services. Poverty is rural and remote communities.
exacerbated by the declining populations and the subsequent Inequitable access to technology impacts health care
declining employment and economic resource opportunities delivery, including the need for strengthened health infor-
in rural and remote communities. matics. Access to health informatics represents the bringing
Economic resources, employment opportunities, and pov- together of data, information, knowledge, and technologies
erty have impacts on health status in general and in particular to support decision making by patients, consumers, physi-
on mental health services. For example, in communities that cians, nurses, and other stakeholders (Mancuso & Myneni,
are dependent on oil and gas extraction, many single men 2016). Important considerations for nurses to have their
or young families have few supports, which increases levels voices heard are the extent to which different perspectives
of stress and needs for mental health resources. Although are represented in technologies. Such steps can facilitate the
research has demonstrated that rural and remote prevalence accurate measurement and representation of nursing activi-
rates of mental health concerns do not differ from that in ties and patient-centred care (Tai-Seale et al., 2014) as well
urban communities, there is a lack of access to local resources as inform decisions about care quality (Kelley, Brandon, &
in communities. Regionally accessible providers are more apt Docherty, 2011).
to be utilized given the perception of a lack of anonymity in For example, some rural and remote communities have
accessing local mental health services (Smith, Humphreys, & access to technologies such as telehealth. This virtual environ-
Wilson, 2008). Many of the inequities in rural and remote ment allows for health education, such as prenatal teaching or
mental health services impact all rural people; however, online support programs for individuals with chronic illnesses.
effects of colonization, legislation, policy, reserve conditions, Rural- and remote-based CHNs need to become familiar with
resources, and residential schools contribute additional layers using e-health initiatives in order to positively impact their
of concern for Indigenous peoples. clients’ health (Nagel & Penner, 2016) and for their own con-
In remote Indigenous communities, health and edu- tinuing professional education (Kulig et al., 2015).
cation programs and services are primarily served by non-
Indigenous individuals or groups, which affects the level of
cultural sensitivity in the provision of these activities. CHN Inequity, Water Quality, and Food
practice needs to specifically address the historical and politi- Insecurity
cal context of each rural and remote community, particularly
in Indigenous communities. CHNs need to advocate for the The Canadian Nurses Association (CNA) recently updated a
inclusion of Indigenous healers and local knowledge keep- position statement on the role of nurses in addressing indoor
ers in health program design and delivery. Further, one of and outdoor environments as linked to the determinants of
the high priorities for the delivery of health care in Indig- health (CNA, 2017). The CNA supports nurses to assess com-
enous communities is the education of community members munity hazards, advocate for change, engage in interdisciplin-
as nurses and other health care providers (Canadian Nurses ary collaboration to address hazards, decrease exposure, and
Association [CNA], 2014). This is particularly important in reduce harm to people and the environment. One of the most
 Chapter 24 RURAL AND REMOTE HEALTH 449

basic needs for human health is clean drinkable water. How-

ever, near the end of 2015, “there were 138 Drinking Water YES, BUT WHY?
Advisories (DWA) in effect in 94 FN communities across
Canada, excluding British Columbia” (Bradford, Bharadwaj, Pregnancy and the Rural and Remote Family Unit
Okpalauwaekwe, & Waldner, 2016). Although DWAs occur What?
in non-Indigenous communities, they are typically treated as
For decades, federal and provincial health policies have
emergencies and resolved in a matter of days. Conversely, many
required expectant mothers to travel long distances to urban
FN communities have been on DWA for years—sometimes
communities to deliver their babies (Health Canada, 2017).
decades.
The policies support the provision of a high level of special-
Bradford and colleagues (Bradford et al., 2016) con-
ized care and safety for both mother and child during deliv-
ducted a scoping review of the literature surrounding water
ery, as few surgical and anesthesia resources are available
quality and effect on the health status of Indigenous people.
in remote communities to support cesarean births. Given
The research identified concerns related to government poli-
the unpredictable nature of deliveries, all rural and remote
cies and data collection as barriers to addressing safe water
expectant mothers are requested to travel to be near a medi-
resources in Northern and isolated communities. The most
cal centre with obstetrical services at 38 weeks gestation.
often cited health concerns in the literature were gastroin-
In remote areas of the country, prenatal and postnatal
testinal illnesses and skin problems. From the perspective
care is provided by local family physicians, nurse practitio-
of health challenges, researchers need to develop collabora-
ners, midwives, and CHNs. Although the level of care may
tions with health care providers to add to the evidence link-
be comparable to that provided in urban settings, access to
ing water quality and health concerns. Researchers are also
ultrasound and specialty obstetrical services requires travel
encouraged to approach investigations about water quality
to a larger centre. Telehealth technologies are beginning to
from a decolonized view, considering humankind’s relation-
address local access to prenatal and postnatal care, specialist
ship and responsibility to water as more than a physical
consultations, and diagnostic ultrasounds in remote commu-
requirement for health. Traditionally, women are the caretak-
nities, decreasing some of the need for travel.
ers of the water. Tending to this role is inclusive of a spiritual
connection to all life. So What?
Water quality and food insecurity are two inter-related The challenge for rural and remote Indigenous and non-
inequities linked to the health of rural and remote popu- Indigenous people has been the disruption to family caused
lations. A discussion paper by Food Secure Canada (2013) by travel to a large urban centre at the end of a pregnancy for
presents issues for rural and remote communities in secur- delivery. The CIHI (2013) identified that from 2008–2012,
ing local access to nutritious food for health. Of concern 67% of expectant rural mothers delivered their children in
for rural communities is the higher cost of food the farther urban hospitals. The frequency of births in hospitals by rural
communities are located from larger urban centres, where mothers was highest in Nunavut (where there are no large urban
the cost of food includes transportation to the community, care facilities), Saskatchewan, Manitoba, and Newfoundland
and poverty limits food choices to less expensive and often (where there are few northern facilities equipped for obstetrical
less nutritious options. Rural communities may be more care). Of the rural deliveries in hospitals, 65.8% were vaginal
agriculture-based than remote communities, although the births and 25.6% were C-sections, compared to 60.8% and
production of food products from agricultural sources is 28.6% for urban women (CIHI, 2013).
mostly centred in urban areas that can support food produc- There is some evidence that travel of over two hours to
tion and distribution businesses. Isolated communities, par- a rural or urban hospital for delivery has effects on birth out-
ticularly in the North, face food insecurity due to exorbitant comes (CIHI, 2013; Grybowski, Stoll, & Komelsen, 2011).
transportation costs to bring in fresh foods, potentiating a Moreover, these studies reported that increasing travel time
dependence on processed foods known to be obesogenic and had negative emotional and financial consequences related
nutrient-lacking. to time off work, travel expenses, and separation from fam-
In many remote Indigenous communities, hunting and ily (Komelsen, Stoll, & Gyrbowski, 2011). The stress caused
fishing increase the self-sufficiency of access to food (Food by the travel over 100 kilometres was likely to be rated as
Secure Canada, 2013). There has been a movement toward moderate to severe.
the development of food products from traditional fish Policies for expectant Northern and remote Indigenous
and game sources in remote communities, but regulatory mothers changed in 2017 to allow for a medical escort
policies for food packaging and inspection hinder innova- (Health Canada, 2018). Previous to this time, maternal travel
tion and economic development. Further, the lack of cost- to urban centres most often did not include a support person.
effective transportation sources to get Northern packaged In high-risk pregnancies, women are most often transported
foods to market impacts the cost to urban consumers and to large urban communities that are commonly a far distance
affects the sustainability of reciprocal food distribution from from their home community. In low-risk pregnancies, women
remote to rural and urban markets. Until the issues related might be able to deliver in a rural community hospital, pre-
to food costs, transportation, and production are addressed, sumably closer to home. The choice of facility appears reason-
little change will occur related to food security for rural and able given the potential for risk to the woman and her unborn
remote communities.
450 Part Three Nursing Care of Selected Populations

child, and the ability to have a companion for travel should

example, CHNs in northern British Columbia found they
decrease the emotional stress on the expectant mother. The
could be more responsive to high-risk and vulnerable fami-
lack of access to local obstetrical care represents a form of
lies when they focused on creating working relationships with
colonialism and breaches the rights of Indigenous women.
families instead of on “home visiting” protocols, because their
services to families happened in many locations in the commu-
Now What? nity, including the grocery store (Moules, MacLeod, Hanlon, &
Although federal policies pertaining to escorted travel will Thirsk, 2009).
persist, the development of birthing centres in the Canadian Innovations that reflect changes to rural and remote
North holds promise for expectant mothers to share the birth nursing roles, settings, and modes of practice are of particu-
of their children with their significant other and family mem- lar interest as health systems transition toward a primary care
bers. There has been ongoing lobbying for expanding the model of service provision and delivery (Banner, MacLeod, &
development of birthing centres in rural and remote areas, Johnston, 2010). It is important to be aware of successful exam-
which may help to address the stress that happens with travel ples of health care innovation in these settings (Wakerman &
to large urban centres and post-colonial traditions and cel- Humphreys, 2011). For example, recognizing collaboration
ebrations around childbirth and maintaining the family unit. between rural and remote stakeholders supports the spread
The recent change to include escorted travel for an expect- of innovation and represents a step forward in improving the
ant mother is an example of inequitable health policies and health of rural and remote populations (Canadian Foundation
hopefully prompts a review of other health services policies for Healthcare Improvement, 2013).
that effect all people in remote and rural locations across the CHNs in rural and remote settings may practise in acute,
country. chronic, tertiary, mental health, or occupational health care.
Standards of Practice Fulfilled
The CHN role often identified with nursing practice in North-
ern communities blends specialized knowledge for performing
#1 Health Promotion activities related to public health, home care, emergency care,
– Considers the determinants of health, the social and palliative care, and management of episodic and chronic condi-
political context, and systemic structures in collabora- tions. Given the breadth of CHN practice, these nurses have
tion with the client to determine action
the capacity to effectively collaborate and lead interprofessional
#6 Health Equity teams to improve health outcomes for rural and remote popula-
– Advocates for healthy public policy and social justice tions (Canadian Health Services Research Foundation, 2012).
by participating in legislative and policy-making activi- Nursing practice, as part of an interprofessional primary-
ties that influence determinants of health and access
care team, may appear very different from the practice of urban-
to services (Community Health Nurses of Canada
[CHNC], 2019, revised).
based teams. A rural or remote team may include only one or
two CHNs and a community health worker (Mills et al., 2010)
collaborating with a nurse practitioner, physician, or itinerant
specialist (e.g., dentists, pediatricians) via telephone, telehealth,
or other electronic means. In urban settings, all team members
CHNs IN RURAL AND REMOTE typically can interact daily in a face-to-face manner. As such,
COMMUNITIES the scope, autonomy, and tools for practice of rural or remote
CHNs may go beyond that of an urban colleague, depending
As a cornerstone of Canada’s health care system, primary health on the focus of the team and the client’s health concerns.
care is the focus of intensive renewal efforts (Kates et al., 2012). The vast physical distances that can separate team mem-
In rural and remote communities, CHNs provide primary care bers necessitate deliberate consideration for professional and
services or work as part of a team providing primary health collegial communication in order to ensure interprofessional
care. The roles and responsibilities of CHNs in primary collaboration (Bainbridge, Nasmith, Orchard, & Wood, 2010)
health care vary based on the needs and services of the and to provide high-quality comprehensive primary-care ser-
community (MacLeod et al., 2008) as well as the complexity vices. Telehealth is one technology that has been successfully
of the community setting and surrounding area. implemented in some locations and is used to complement
Regardless of practice setting, all rural and remote CHNs primary-care services. In Takla Landing, a remote Indigenous
are faced with addressing issues in clinical practice, leader- community in northern British Columbia, the CHNs are able
ship, and the work environment. Rural and remote nursing to use telehealth to consult with off-site health care providers
practice is shaped by the context of communities, with their (Mah, 2013) supporting patients to optimize management of
limited transportation, communications, and other resources. acute and chronic health conditions without leaving their com-
Within small communities, CHNs provide care to clients munity; this reduces the stress experienced by patients and
who also may be friends and neighbours with a wide range families while also saving patients and the health care system
of conditions. Rural nurses experience practice as being mul- money. Telehealth initiatives currently offer several medical
tifaceted and complex, with considerable decision-making specialties in Takla Landing, including general surgery, infec-
challenges and little backup (MacLeod et al., 2008). Rural tious disease, dermatology, and addictions. CHNs manage and
and remote practice demands significant knowledge and skills support the patient on-site, and patients receive the same spe-
to be responsive to community needs (CARRN, 2008). For cialist care as their urban counterparts.
 Chapter 24 RURAL AND REMOTE HEALTH 451

Technologies such as telehealth are increasingly consid- on call are all activities that a rural- and remote-area nurse
ered as a resource to improve access and comprehensiveness of may be expected to perform in addition to being competent
care (Gibson et al., 2011; Taylor, Stone, & Huijbregts, 2012), in direct patient care, illness prevention, health promotion,
although not yet operationalized in all rural and remote com- and emergency care. The demands of providing primary
munities. Rural and remote CHNs often work in settings of care in rural and remote communities are challenging, and
chronic resource shortages of equipment, other providers, and turnover rates can be high in some circumstances (Tarlier,
services (Forbes & Edge, 2009; Kulig et al., 2008). Given that Johnson, Browne, & Sheps, 2013). A rural or remote CHN’s
CHNs are front-line providers working at significant distances intent to leave a position is influenced by interrelated indi-
from tertiary-care settings, rural and remote nursing practice vidual, workplace, and community factors (Stewart et al.,
requires a broad knowledge base (Jackman, Myrick, & Yonge, 2011). Increasingly, and particularly in remote communi-
2012) and advanced educational preparation (Cant, Birks, ties, primary care is provided by relief nurses who stay only
Porter, Jacob, & Cooper, 2011). In an analysis of responses from short periods of time in the communities (Minore et al.,
a national nursing survey, the most common reason nurses 2005). When primary health care service provision is frag-
reported intent to leave their position was to undertake further mented, continuity of care and health outcomes may worsen
nursing education (Stewart et al., 2011). for populations already enduring significant health dispari-
Rural and remote CHNs working in primary care ties (Tarlier et al., 2013).
assume multiple roles that may not be captured by a for- Rural and remote CHNs are resourceful and innovative.
mal job description (Mitton, Dionne, Masacci, Wong, & Rural health care environments may be open to trying things
Law, 2011). Program planning and evaluation, well-woman differently (CFHI, 2013), and CHNs can enjoy and take pride
clinics and immunization clinics, quality-assurance initia- in accepting the challenge of providing best practices in rural
tives such as practice audits, and extended periods of time and remote communities. Rural and remote CHNs providing

C A S E S T U D Y

T he Gibbons family lives on their family farm 90 kilometres

east of a small city (population 68 000). After completing
high school, Nancy and John were married in the Anglican
her, assist her with feeding, and transfer her to the toilet. She
is also frequently in pain and, due to the muscle weakness,
is at risk for falls. Depression has set in, and Nancy has said
church. Nancy is now 45, and John is 46. Nancy has been an that “life is not worth living.” At the same time, she wants
active mother, raising their three sons while also volunteering to die peacefully at the farm and does not want to be moved
in the community. John and his son Peter work on the farm into the city hospital. John is increasingly upset about his
together, which has been in the family for two generations. wife’s condition and appears overwhelmed and bewildered;
The two older sons, Jack and Ian, live and work in cities that he realizes that he needs support to continue to care for
are three to five hours from the family farm. Both Jack and Nancy in their home.
Ian are married and have children. Their jobs, family life, and It takes some time but John finally agrees to have a
other responsibilities mean that they are not able to visit the home care nurse return, do another assessment, and set up
farm very often. equipment resources such as oxygen and personal care aides
Nancy has had an uneventful health history that in- on a routine basis. The home care nurse also refers the family
cludes regular physical examinations, three normal pregnan- to the palliative care nurse. Peter calls his brothers and asks
cies, and a hysterectomy. From a health perspective, she was that they come home to visit their mother as soon as possible.
expecting to enjoy retirement with her husband and their
sons, daughters-in-law, and grandchildren. About a year ago,
Discussion Questions
Nancy began to feel “unwell.” She was tired, shaky, and hav- 1. What are the challenges that arise for CHNs in addressing
ing difficulties sleeping. Four months ago, tests revealed that the mental health needs and supports for this family?
she had amyotrophic lateral sclerosis (ALS), a terminal con- 2. Identify three factors related to living in a rural setting
dition for which there is no cure. that provide challenges in the delivery of nursing care for
She was referred to home care for assessment, but Nancy Gibbons. Identify how a home care nurse could
John refused to have them in the home and instead has address these factors.
provided all of Nancy’s care. The ALS Society was notified 3. Identify three rural community resources that could pro-
by home care about Nancy’s diagnosis and has called to offer vide assistance to the Gibbons family. Identify how a pal-
visits and assist in any way possible. John would agree only liative care nurse could incorporate these factors into a
after Peter convinced his mother and father that it could care plan for Nancy.
be helpful. While the ALS Society was at the home, John Source: This case study is a modified version from the Nursing
expressed his frustration at his wife’s deteriorating condition Education in Southern Alberta curriculum used by the collabo-
and related he was unsure if he could continue providing rative partners, the University of Lethbridge, and Lethbridge
care by himself. Nancy is now dependent upon John to bathe College.
452 Part Three Nursing Care of Selected Populations

primary care services must be adaptable, perseverant, critical

CANADIAN RESEARCH 24.1
thinkers who are willing to listen and learn (Martin-Misener
et al., 2008). Experiences of Disasters among Rural and Remote Nurses
In the first national study of rural and remote nursing in Canada. (Kulig et al., 2017) Copyright © 2017 by
practice in Canada, almost all nurses identified issues related Elsevier Ltd. Used by permission of Elsevier Ltd. doi:
to nursing leadership (MacLeod et al., 2008). Issues included 10.1016/[Link].2017.04.003.
finding ways of working through conflicting priorities, coping There has been a notable rise in disasters around the
with having leaders at a distance, and creating support net- globe, highlighting the role of rural and remote CHNs in
works. Leadership was more effective when leaders set up possi- disaster mitigation, response, and recovery. This study
bilities for quality practice, even in situations of few resources. explored the experiences of rural- and remote-area nurses
When leaders planned for the realities of rural and remote prac- in responding to disaster events in their communities. The
tice, CHNs felt supported. For nursing leaders, providing the analysis of the data from this study was discussed within
appropriate support at a distance was a challenge; for CHNs, each of the World Health Organization/International Coun-
seeking and accepting that support was equally challenging. cil of Nurses’ disaster nursing competency frameworks
Both nursing managers and CHNs needed to work creatively to emphasize the relevance for rural and remote nurs-
within organizations that did not always understand the reali- ing practice and education. The findings indicated that
ties of their practice. nurses between 50–59 years of age working in a remote
Creating quality work environments in rural and remote community, and having worked in more than four rural or
nursing practice settings is particularly challenging. A cen- remote communities, were more likely to have assisted
tral challenge is that many nurses in rural and remote set- with a disaster in the previous five years. The most com-
tings work alone much of the time (Andrews et al., 2005). A mon types of disasters were reported as floods, wildfires,
strategy for developing quality work environments in rural and other weather events.
or remote CHN practice includes developing consistent Rural and remote nurses’ intimate knowledge of their
expectations and approaches among managers and nurses communities makes them ideal members of disaster plan-
to address practice issues at the site level. This includes ning teams as well as advocates for their rural commu-
relevant rural and remote practice standards; policies and nities during all phases of the disaster. One important
practices that support rural CHNs’ scope of practice; prac- challenge for nurses who work in small communities is
tice-driven, rural- and remote-focused nursing education the provision of care to people who may be known to
programs; rural and remote reality-based preceptorship and them personally, and their personal and professional
mentorship programs; and the development of sustained recovery needs. Preparation of nursing students to act in
processes for direct rural and remote nursing involvement this role and ongoing training for rural and remote nurses
in local and regional planning (Martin-Misener et al., 2008; are essential to assist communities to recover after trau-
Stewart et al., 2011). matic events.

Discussion Questions
RURAL AND REMOTE 1. What initiatives can nursing organizations take to support
nurses who work in rural and remote settings?
COMMUNITY HEALTH NURSING 2. What is the responsibility of health regions in preparing
PRACTICE rural- and remote-area nurses to address disasters?
3. Given the geographic isolation of many rural- and remote-
Analyses of the Nurses Database reveal that there were 28 799
area nurses, what is the best way to ensure ongoing train-
RNs working in rural and remote Canada in 2010 (Pitblado
ing in disaster preparation and recovery?
et al., 2013). Of those rural and remote RNs, 22.9%, worked
in community settings, most were women and working full
time. Nurse-to-population ratios vary by region, but on
average there were half as many nurses per 100 000 people in
rural and remote Canada compared to urban Canada. There is A DAY IN THE LIFE
also an east-to-west trend, with higher nurse-to-population
ratios in eastern Canada. Rural and remote RNs were found Although all graduates of nursing programs in Canada are
to have a lower level of education at entry to practice than prepared for generalist practice, working in rural and remote
their urban counterparts, but there has been a significant communities stretches the meaning of being a generalist nurse.
positive change in the percentage of rural and remote RNs The generalist practice of a rural and remote CHN differs by
with a baccalaureate degree: 32.5% of rural and remote RNs setting and across regions in Canada. The following instances
had achieved a baccalaureate degree as their highest level of of “a day in the life” of CHNs in various settings are meant to
education by 2010, compared to 18.5% in 2003 (Pitblado illustrate the diversity in nursing practice in rural, remote, and
et al., 2013). Despite this improvement, limited access to isolated communities. The descriptions that follow combine
continuing nursing education remains a concern for rural- elements of practice and do not represent a particular CHN in
and remote-living RNs. a specific location.
 Chapter 24 RURAL AND REMOTE HEALTH 453

Rural Isolated
Sandra lives on a farm in rural British Columbia. She is mar- Carol works in the far North. Her practice is much the same as
ried with two school-age children. Her husband manages Daniel’s in her remote setting. Carol may have more technolo-
their mixed-farming operation while Sandra leaves home each gies available to her that help to bridge the gap between her
day and commutes 50 kilometres to the next community, location and the urban health centre that she accesses for client
where she is employed full-time as a home care nurse. For consultations or emergency treatment supports. Canadian com-
Sandra, the only typical part of her day is leaving home and munities that might be considered more isolated include small-
travelling to work. The commute for Sandra to begin her island Northern and Arctic communities where road access is
workday changes depending on weather and road conditions. not available and planes arrive infrequently.
The first 20 kilometres are a gravel road that leads to the A typical day for Carol may involve taking a picture of a
highway, which makes driving a challenge on stormy winter wound and emailing the picture to a dermatologist in the south
mornings. for assessment and treatment advice. She offers a chronic-care
Sandra’s workday begins at her office, planning her route clinic in the afternoon that includes connecting via telehealth
to client homes within and outside of the small town. Like her to a specialist for client follow-up appointments. In the evening
urban colleagues, Sandra provides wound-care and chronic- when a client comes in with a severe traumatic injury, Carol
care services to her clients. Unlike her urban colleagues, she connects with ER physicians over telehealth. They support
knows most of her clients and their families outside the con- Carol, in real time, with assessment and treatment prior to air
text of her job, even though they are in the next community, ambulance personnel arriving and transporting the client to a
as this is where her family also does their shopping and her larger facility.
children go to school. Sandra finds that knowing her clients Although nursing practice in the previous descriptions use
well is sometimes positive. It helps her to focus quickly on the word typical, most CHNs practising in these settings will
what might be affecting their quality of life. It also might be suggest that although there are common elements in their day,
negative when they withhold information because they are little is typical. All CHNs in these settings experience a high
concerned about potential breaches of confidentiality due to demand for ongoing flexibility and openness to changes in rou-
Sandra’s dual role as nurse and neighbour. This embeddedness tine. The attraction to rural practice for CHNs like Sandra,
in the community adds to Sandra’s ethical responsibility for Daniel, and Carol includes the challenging nature of the work
confidentiality. and the chance to live and work in a rural community setting
that is or may become their home.

Remote
CHNs in remote and isolated communities often practise in HEALTH POLICIES AND SUPPORT
clinics, but the distance from other services may expand the FOR CHN PRACTICE
scope of practice. Daniel, a community health nurse practi-
tioner (NP) working in a northern Ontario nursing station, Rural and remote CHNs in Canada have been described
begins his day walking down the hall from his apartment to as a marginalized group within health care and are often
the attached clinic. The close proximity of work and home can excluded from key policy decisions (Jackman et al., 2010).
be a benefit to clients, as they know Daniel is there, and they Most policies in Canada, with health policies being no
feel free to come to the clinic at any time of day for treatment. exception, are based on an urban perspective with little con-
But it can be a challenge for nurses, as there is little separa- sideration of their applicability in rural and remote envi-
tion between work and home life, and it can pose an ethical ronments. To best address the health care needs of rural
issue regarding professional boundaries. Daniel also finds that and remote patients, nurses have argued that they are best
it can be difficult living in accommodations attached to his situated to advocate as they have the greatest contact with
workplace, as he lives and works with his co-workers over a patients (Cole, Wellard, & Mummery, 2014). Although
long period of time. well-intentioned, such perspectives may place nurses in a
The typical day for Daniel, as an NP in a remote com- paternalistic role that compromises patients’ autonomous
munity, includes primary-care and health-promotion activities. abilities to make decisions. Others have argued that there
On this typical day, Daniel finds himself applying primary is a “thin line” between advocacy and paternalism for nurses
prevention through immunizing infants, children, and adults. and other health professionals. A critical analysis of the lit-
Secondary prevention occurs through collecting, ordering, and erature by Kalaitzidis and Jewel (2015) highlighted that
reviewing client laboratory results; assessing and treating com- advocacy was an essential part of the nurse’s professional
mon medical conditions; and monitoring and referring chronic role, but there is limited consensus on how to implement
care and prenatal clients. Tertiary prevention occurs through advocacy. More specifically for nurses working in rural and
caring for wounds and suturing lacerations. In remote com- remote communities, advocacy is informed by adapting
munities, an NP like Daniel might also provide care to clients nurses’ practice to the local contexts, engaging in personal
in emergency situations, such as status epilepticus or trauma and relational actions that ensure safety, and addressing sys-
from a motor vehicle collision. temic health inequities (MacKinnon & Moffitt, 2014).
454 Part Three Nursing Care of Selected Populations

The following key issues need to be addressed to promote Although the integration of technologies into rural, remote,
the CHN’s involvement in rural and remote health policies. and isolated community care practices may increase access
to services, tailoring services to meet the unique context
7 Federal and provincial nursing associations need to ensure
and diversity of communities will require CHNs to become
the profession is meeting responsibilities and acknowledg- involved at local, provincial, and federal policy levels to effect
ing our colonial history, and work to address the Truth and positive changes that will be acceptable to local communities.
Reconciliation Commission’s calls to action.
7 Ongoing research supports for rural remote nursing
research chairs in Canada continue to address the unique KEY TERMS
situations experienced by rural and remote residents, par- access to technologies (p. 448)
ticularly around access to care. employment opportunities (p. 446)
7 Few CHNs are educationally prepared for work in the pol- food insecurity (p. 448)
icy arena, and although nurse educators include informa- isolated (p. 445)
tion about health policy in curriculum, CHNs need to be Northern (p. 445)
encouraged to embrace the strength of their political voice. remote (p. 445)
7 Relevant information about the nature of rural, remote, resource base (p. 445)
and Indigenous communities, including the number and rural (p. 445)
location of residents and their health issues, is not read- social approaches (p. 445)
ily available to inform health policy and health human socioeconomic status (p. 446)
resource decisions. technical approaches (p. 445)
7 The perspectives of rural, remote, and Indigenous residents water quality (p. 446)
and their involvement in setting policy and health service
agendas, even at the local level, need to be acknowledged STUDY QUESTIONS
and respected as a key component of rural and remote com- 1. Identify what CHNs working in remote settings can do to
munity development. generate information about the communities they work in.
2. Identify four concepts that would be discussed in a rural and
remote nursing course.
CONCLUSION 3. Identify four challenges experienced by nurses working in a
This chapter focused on the health of rural and remote popula- Northern community.
tions as well as the unique roles of the rural and remote CHN 4. Maria is a 35-year-old Low German Mennonite woman
in Canada. Many diverse practice settings in rural and remote who has just had her fifth child. She was diagnosed with
regions of Canada offer opportunities for a rewarding nursing gestational diabetes and requires follow-up to monitor her
practice. Rural nurses characterize their work as a wonderful health. How would you apply the principles of cultural
opportunity to affect change by being deeply immersed in the safety in the care of Maria?
community in order to see, feel, and know it. The requisite
5. Timothy has been working as a public health nurse in an
creativity required, as well as the autonomy, ability to enact all
Indigenous community for the past four years. Over a year
skills, and opportunity to work downstream, midstream, and
ago the community experienced the loss of several family
upstream all in the same day, keep rural and remote CHNs in
members in a house fire. Identify the levels of prevention
the field.
and specific strategies that Timothy can address in collabo-
Research with rural and remote CHNs commonly reports
ration with community members to deal with the loss and
high levels of work satisfaction and community engagement.
prevent such tragedies in the future.
Working in rural and remote communities that are diverse
requires the application of principles associated with cultural
safety and reflective practice. It is important for all CHNs INDIVIDUAL CRITICAL-THINKING
to remember that rural and remote residents demonstrate EXERCISES
resilience and connectedness to the land and history of their
communities. These characteristics offset the management of 1. Examine the provincial or territorial nursing standards
unique challenges such as inequitable local access to health related to professional boundaries, and identify three chal-
care services, advanced education, food and water security, and lenges in the provision of care in rural and remote com-
stable local employment. munities. As a professional RN, how would you address
In moving forward to address health care delivery and pro- the challenges without jeopardizing ethical standards and
vision of nursing care, CHNs must critically evaluate, respond professional boundaries?
to, and become involved in research and policy development 2. You work in a public health office in a large agricultural area
about health inequities that present as areas in need of change. that includes established farm families and feedlot opera-
It is important for all CHNs who work in rural, remote, and tors. Over the past few years, there has been an increase
isolated communities to partner with diverse populations and in migrant farm workers from Mexico that has added to
to engage in the delivery of strong, culturally safe health care. the diverse mix of the area, which includes conservative
 Chapter 24 RURAL AND REMOTE HEALTH 455

religious groups who also work in the agricultural indus- 3. You have been a home care nurse working in several east-
try. Locating and communicating with these groups has ern coastal communities for five years. It is a job you love
become increasingly challenging, and ensuring routine mostly because of the people you care for and the diversity
public health programs such as immunizations has become within your everyday work. You are currently mentoring an
even more difficult due to varied beliefs and practices. What undergraduate nursing student from an urban-based nurs-
are three barriers that need to be addressed? Who can you ing program. The student has made it clear that it was not
turn to for guidance and support? What actions on your part her choice to come to a rural area or to do home care. As
might facilitate collaboration? What are short- and long- a group, identify how you will address the student’s issues
term goals in this situation? in a productive manner. Identify ways in which you can
3. You work in collaboration with a long-term care facility that encourage the student to see the benefits of her practicum
has just developed a support group for rural families car- experience in rural communities.
ing for a relative with dementia, which is most commonly
caused by Alzheimer’s disease. After the first six months of
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ABOUT THE AUTHORS

Mary Ellen Labrecque, RN(NP), PhD (University of Hospital Research Centre, and an affiliate faculty member
Saskatchewan), is Assistant Professor in the College of Nurs- with the Canadian Centre for Advanced Practice Nursing
ing, University of Saskatchewan, and director of the Nurse Research. She completed a postdoctoral fellowship at
Practitioner programs. She refers to her nursing experiences McMaster University (2011). She also received junior
as “my adventures in nursing.” Her background includes researcher awards from the Fonds de recherche du Québec-
working in rural and urban acute care settings and in North- Santé (2013–2021). Kelley’s research interests include
ern outpost and mining settings in Manitoba, Saskatchewan, nurse practitioner and clinical nurse specialist roles, bound-
Alberta, NWT, and Nunavut. Research interests include rural ary work activities, perceptions of team effectiveness, acute
and remote nursing, the delivery of primary health care that and primary care, and the effects of health care service
addresses the unique determinants of health for a popula- delivery on patients and families. She is a member of
tion, and the integration of technologies into practice. Mary the study “The Nature of Nursing Practice in Rural and
Ellen is a member of the study “The Nature of Nursing Remote Canada, II.” Kelley has used different approaches,
Practice in Rural and Remote Canada, II.” including mixed methods, case study, surveys, systematic
reviews, and qualitative description, to answer her research
Kelley Kilpatrick, RN, PhD (McGill University), is Assistant
questions.
Professor with the Faculty of Nursing at the Université de
Montréal, a researcher with the Maisonneuve-Rosemont