35 What Does It Mean to be a Nurse in Canada’s Northern Territories?

Introduction

The aim of this chapter is to illuminate the experience of nurses in Canada’s northern territories: the Yukon, Northwest Territories (NWT), and Nunavut. The territories are located above the 60th parallel, and comprise 39% (3,496,285 km2) of Canada’s land mass, but less than 1% of Canada’s population (113,604 people). Two communities have more than 10,000 residents: Whitehorse in the Yukon, and Yellowknife in NWT; the remaining 51.8% of the population live in in widely dispersed, small communities. The territories share many features of geography and weather, and are home to a variety of persons speaking a range of languages (Statistics Canada, 2017). Nursing practice is shaped in many ways by the territories’ physical, geographical, social, and cultural contexts.

This chapter is based on findings from a study of nursing practice in rural and remote Canada. The study (RRNII) consisted of an analysis of documents (Kulig, Kilpatrick, Moffitt, & Zimmer, 2013); an analysis of the Nurses’ Database (Place, MacLeod, Moffitt, & Pitblado, September 2014a; Place, MacLeod, Moffitt, & Pitblado, September 2014b); and a nation-wide survey, which included all nurses in the territories (MacLeod et al., 2017). The 27-page mailed survey sought to answer the questions: 1) what is the nature of nursing practice in rural and remote Canada? 2) How can the capacity of nursing services and access to nursing care in rural and remote Canada be enhanced? The survey was distributed in 2014 to all 1913 active practising nurses (nurse practitioners, registered nurses, licensed practical nurses, and registered psychiatric nurses) in the three northern territories. A total of 621 nurses responded, of whom, 365 provided narrative answers to the final question in the survey, “what does it mean to be a nurse in rural and remote Canada?” This chapter draws on their responses to this question, which ranged from a few words to lengthy descriptions of experience. The responses were entered into NVivo 10, and were analyzed thematically in a several-stage iterative process by the co-authors (Nowell, Norris, White, & Moules, 2017).

Findings

Although there were some differences in emphasis among nurse practitioners, registered nurses, licensed practical nurses, and registered psychiatric nurses, there was remarkable consistency in what they wrote. Their responses have been combined in the discussion that follows.

In their responses, the nurses wrote positively of many aspects of working in the territories, including the interconnection of their experiences of nursing practice with their experiences of living in northern communities, the opportunity to enact a broad scope of practice, their ability to use a wide range of skills, and practice with considerable autonomy and responsibility. They also wrote about valuing the opportunity to make a difference in communities where nurses may be the only healthcare providers. The nurses mentioned several challenges related to the complexity of northern nursing, including the challenges related to isolation, geography, and cultural dynamics (see also Martin-Misener et al., 2008). Three themes stood out, however, about what it means to be a nurse in the territories: facing the social determinants of health, being a resilient practitioner, and becoming culturally competent environments.

Facing the Social Determinants of Health

People living in the northern territories experience many health disparities (Canadian Polar Commission, 2014). Nurses wrote about how the determinants of health impacted the people in their communities. As one nurse noted:

Homes that are overcrowded, often without running water, sparsely furnished, inadequately heated. Homes where food supply is scarce, where money is short, where laundry cannot always get done because there is no water or because families cannot afford to pay their utility bills.

Access to services was also identified as a major concern throughout the territories, particularly in reaching higher levels of services, “when sick patients with trauma come in a lot of the time we can’t deal with it so patients are sent to our nearest centre, which is in Alberta (Edmonton).” Nurses across all three territories described the limitations of mental health services and how the lack of services impacted their day to day practice, “Due to a lack of mental health and /or addictions services clients use us as their counselors”.

The nurses’ everyday practice was shaped by their communities’ experiences of the social determinants of health, including the lack of ready access to services.

Being a Resilient Practitioner

Nurses experience a largely generalist practice in most, if not all northern practice settings (Anonymous, 2004; Anonymous, 2008; Tarlier, Johnson, & Whyte, 2003; Vanderspank-Wright & McMillan, 2016; Vukic & Keddy, 2002). Northern practice demands resilience: adaptability, resourcefulness, and creativity. Nurses indicated that, “[northern nursing practice] means being incredibly adaptable because there are no training programs that address all aspects of your responsibilities”. Another noted, “one needs to be resourceful. Every health care professional in an under-serviced community will encounter patients, scenarios and challenges that are outside their scope and comfort level. This variety and autonomy is both exciting and difficult.” Creativity is needed. As one nurse wrote, “staff are creative in dealing with situations where resources, equipment etc. are not readily available”. Another nurse gave an example, “There’s no lift team, no IV team, no respiratory therapists, no wound care nurse, there’s me and my coworkers and we’re up for the challenge.”

Nurses mentioned the importance of working as a team and being aware of one’s own strengths while working with the limitations, “it means making do with fewer resources. It means having great assessment skills. It means trusting your judgment. It means building a strong team and good work relationships.” Importantly, nurses “must know the system well enough to care and advocate for patients”.

Becoming Culturally Competent

Indigenous persons make up 85% of Nunavut, 50.7% of the Northwest Territories, and 22.8% of Yukon’s population (Statistics Canada, 2017). Many northern nurses found it “challenging to work in rural communities and with Indigenous persons. A set of life skills, flexibility, knowledge, independence, and proper decision making is required, as well as being able to understand and work with cultural differences.” Nurses noted a need to understand the communities’ history and how colonization influences the people they care for (Greenwood, de Leeuw, Lindsay, & Reading, 2015), and how not to inadvertently perpetuate colonial practices (Rahaman, Holmes, & Chartrand, 2017).

Some nurses reflected how they learned to understand and respect Indigenous ways of knowing and being. For instance, one nurse described, “I was able to understand their culture and beliefs better when I was able to live in it.” Nurses learned about Indigenous peoples and their culture through taking “every opportunity to get to know the people living in the community” and “participating in community events”.

Nurses commented on the many cultures and languages in some communities, and that “It is vital that nurses are self-aware and promote culturally safe environments for their patients, especially in such a vibrant, multicultural community.” Others indicated how it was too easy to make assumptions, and that they learned to “provide information that actually fit with the reality of the clients I was seeing. It made me a better provider and refocused my care to understanding their world and ‘meeting people where they are at’”.

Conclusion

This chapter highlights what stands out for nurse practitioners, registered nurses, licensed practical nurses, and registered psychiatric nurses in their experiences of living and working in northern communities. Nurses noted that they were faced by the social determinants of health on a daily basis, and in responding, their practice was shaped in new ways. Nurses were required to become resilient practitioners, and they found ways to learn how to become sensitive to the cultural realities of the communities within which they lived and worked. There are many complexities and challenges of nursing in Canada’s northern territories, but there are also great opportunities. Just as Anonymous (2014) note, northern nurses have many opportunities for ensuring that persons’ concerns are heard. They can make considerable contributions in addressing health inequities and improving access to respectful, responsive health care.

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