Help Wanted, Experience Preferred, Stamina a Must: A Narrative Review of the Contextual Factors Influencing Nursing Recruitment and Retention in Rural and Remote Western Canada from the Early Twentieth Century to 2023.

Rural and remote communities of Western Canada have struggled to recruit and retain nursing professionals since the turn of the twentieth century. Existing literature has identified the unique challenges of rural nursing due to the shifting context of rural and remote nursing practice. The objective of this narrative review is to explore the history of rural and remote nursing to better understand the contextual influences shaping rural nursing shortages in Western Canada. This narrative review compared 27 sources of scholarly and historical evidence on the nature of rural nursing practices and recruitment and retention methods following the First World War until 2023. The findings suggest that the complex nature of rural nursing practice is a consistent challenge that has intersected with the long-standing power inequities that are inherent in rural marginalization, political influences, the nursing profession, social structures, and organizational design, to perpetuate rural nursing shortages throughout the past century. Integration and collaboration are needed to reduce systemic marginalization and develop effective and sustainable solutions to reduce nursing shortages in rural and remote areas of Western Canada.

Mental health nursing practice in rural and remote Canada: Insights from a national survey.

Access to and delivery of quality mental health services remains challenging in rural and remote Canada. To improve access, services, and support providers, improved understanding is needed about nurses who identify mental health as an area of practice. The aim of this study is to explore the characteristics and context of practice of registered nurses (RNs), licensed practical nurses (LPNs), and registered psychiatric nurses (RPNs) in rural and remote Canada, who provide care to those experiencing mental health concerns. Data were from a pan-Canadian cross-sectional survey of 3822 regulated nurses in rural and remote areas. Individual and work community characteristics, practice responsibilities, and workplace factors were analysed, along with responses to open-ended questions. Few nurses identified mental health as their sole area of practice, with the majority of those being RPNs employed in mental health or crisis centres, and general or psychiatric hospitals. Nurses who indicated that mental health was only one area of their practice were predominantly employed as generalists, often working in both hospital and primary care settings. Both groups experienced moderate levels of job resources and demands. Over half of the nurses, particularly LPNs, had recently experienced and/or witnessed violence. Persons with mental health concerns in rural and remote Canada often receive care from those for whom mental health nursing is only part of their everyday practice. Practice and education supports tailored for generalist nurses are, therefore, essential, especially to support nurses in smaller communities, those at risk of violence, and those distant from advanced referral centres.

The meaning of nursing practice for nurses who are retired yet continue to work in a rural or remote community.

BACKGROUND: Although much research has focused on nurses' retirement intentions, little is known about nurses who formally retire yet continue to practice, particularly in rural and remote settings where mobilization of all nurses is needed to assure essential health services. To optimize practice and sustain the workforce stretched thin by the COVID-19 pandemic, it is necessary to understand what it means for retired registered nurses (RNs) and licensed practical nurses (LPNs) to work after retirement. This study explored what nursing practice means for RNs and LPNs who have formally retired but continue to practice in rural and remote communities. METHODS: A pan-Canadian cross-sectional survey conducted in 2014-2015 of nurses in rural and remote Canada provided data for analysis. Textual responses from 82 RNs and 19 LPNs who indicated they had retired but were occasionally employed in nursing were interpreted hermeneutically. RESULTS: Retired nurses who continued to practice took on new challenges as well as sought opportunities to continue to learn, grow, and give back. Worklife flexibility was important, including having control over working hours. Nurses' everyday practice was inextricably tied up with their lives in rural and remote communities, with RNs emphasizing serving their communities and LPNs appreciating community recognition and the family-like character of their work settings. CONCLUSIONS: Retired nurses who continue to work in nursing see retirement as the next phase in their profession and a vital way of engaging with their rural and remote communities. This study counters the conventional view of retaining retired nurses only to combat nursing shortages and alleviate a knowledge drain from the workplace. Rural and remote nurses who retire and continue working contribute to their workplaces and communities in important and innovative ways. They can be characterized as dedicated, independent, and resilient. Transitioning to retirement in rural and remote practice can be re-imagined in ways that involve both the community and the workplace. Supporting work flexibility for retired nurses while facilitating their practice, technological acumen, and professional development, can allow retired nurses to contribute their joy of being a nurse along with their extensive knowledge and in-depth experience of nursing and the community.

The importance of organizational commitment in rural nurses' intent to leave.

AIMS: To examine determinants of intention to leave a nursing position in rural and remote areas within the next year, for Registered Nurses or Nurse Practitioners (RNs/NPs) and Licensed Practical Nurses (LPNs). DESIGN: A pan-Canadian cross-sectional survey. METHODS: The Nursing Practice in Rural and Remote Canada II survey (2014-2015) used stratified, systematic sampling and obtained two samples of questionnaire responses on intent to leave from 1,932 RNs/NPs and 1,133 LPNs. Separate logistic regression analyses were conducted for RNs/NPs and LPNs. RESULTS: For RNs/NPs, 19.8% of the variance on intent to leave was explained by 11 variables; and for LPNs, 16.9% of the variance was explained by seven variables. Organizational commitment was the only variable associated with intent to leave for both RNs/NPs and LPNs. CONCLUSIONS: Enhancement of organizational commitment is important in reducing intent to leave and turnover. Since most variables associated with intent to leave differ between RNs/NPs and LPNs, the distinction of nurse type is critical for the development of rural-specific turnover reduction strategies. Comparison of determinants of intent to leave in the current RNs/NPs analysis with the first pan-Canadian study of rural and remote nurses (2001-2002) showed similarity of issues for RNs/NPs over time, suggesting that some issues addressing turnover remain unresolved. IMPACT: The geographic maldistribution of nurses requires focused attention on nurses' intent to leave. This research shows that healthcare organizations would do well to develop policies targeting specific variables associated with intent to leave for each type of nurse in the rural and remote context. Practical strategies could include specific continuing education initiatives, tailored mentoring programs, and the creation of career pathways for nurses in rural and remote settings. They would also include place-based actions designed to enhance nurses' integration with their communities and which would be planned together with communities and nurses themselves.

The Mosaic of Primary Care Nurses in Rural and Remote Canada: Results from a National Survey.

BACKGROUND|OBJECTIVE: Nurses provide essential primary care (PC) in rural and remote Canada. We examined the practice context and responsibilities of this little-known understudied workforce. METHOD: Data from Nursing Practice in Rural and Remote Canada II, a 2014 to 2015 pan-Canadian survey, were analyzed. RESULTS: Of 3,822 respondents, 192 identified that PC was their only practice focus (PC-Only), and for 111, it was one focus among others (PC-Plus). Proportionally more PC-Only than PC-Plus nurses had graduate education, were employed in larger communities and had experienced higher job resources and lower job demands. Proportionally fewer PC-Only than PC-Plus nurses followed protocols/decision support tools, dispensed medications and provided emergency services. Proportionally more PC-Only than PC-Plus nurses ordered advanced diagnostic tests/imaging, and fewer PC-Only than PC-Plus nurses performed and interpreted laboratory tests and diagnostic imaging on site. CONCLUSION: Contributions of the rural and remote nursing workforce to PC are rendered invisible by contemporary characterizations of the PC workplace, limiting evaluation and improvement efforts.

Communication tools and sources of education and information: a national survey of rural and remote nurses.

OBJECTIVE: This study examined accessibility of communication tools in the workplace, use of education to update nursing knowledge, and use of information to make specific decisions in practice among registered nurses (RNs) and licensed practical nurses (LPNs) in rural and remote communities in Canada. METHODS: Data were analyzed from the cross-sectional survey, "Nursing Practice in Rural and Remote Canada II," of regulated nurses practicing in all provinces and territories of Canada. Data were collected from April 2014 to August 2015. RESULTS: The survey was completed by 3,822 of 9,622 nurses (40% response), and the present analysis was conducted with a subsample of 2,827 nurses. High-speed Internet was the most accessible communication tool, and nurses used "online/electronic education" more often than "in-person education" to update their nursing knowledge. Internet searches were used more often than several other online/electronic sources to inform decision making. Compared to LPNs, RNs reported greater workplace access to most communication tools and greater use of online/electronic education as well as information sources in online/electronic and print formats. Compared to nurses in community-based health care and hospital settings, nurses in long-term care settings reported lower access to most communication tools, lower use of online/electronic and in-person education, and lower use of online/electronic information. CONCLUSIONS: Access to continuing education and up-to-date information is important for effective patient care. This study points to a need for further research on the continuing education and information needs of rural and remote RNs and LPNs, and on their capacity to incorporate and apply new knowledge in practice.

Rural and Remote Registered Nurses' Perceptions of Working Beyond Their Legislated Scope of Practice.

Registered nurses (RNs) enact their scope of practice in everyday practice through the influences of client needs, the practice setting, employer requirements and policies and the nurse's own level of competence (Canadian Nurses Association 2015). A scope of practice is "dynamic and responsive to changing health needs, knowledge development and technological advances" (International Council of Nurses 2013). In Canada, RNs' scope of practice is set out through provincial and territorial legislation and provincial regulatory frameworks, which are broadly consistent, but vary across provinces (Schiller 2015). Provincial and territorial regulatory bodies articulate the RN scope through frameworks that include expected standards as well as, in some jurisdictions, limits and conditions upon practice (British Columbia College of Nursing Professionals 2018), and which are commonly referred to as a licensed or registered scope of practice. Rural and remote practice is starting to be explicitly acknowledged within nurses' legislated scopes of practice through the identification of certified practices for RNs in specific rural and remote practice settings, following approved education (British Columbia College of Nursing Professionals 2018).

Rural and Remote Licensed Practical Nurses' Perceptions of Working Below Their Legislated Scope of Practice.

Over the past two decades in Canada, licensed or registered practical nurses (LPNs) have experienced an extension of their educational preparation and scope of practice. Simultaneously, there has been an increase in the number of LPNs employed in rural and remote communities. These changes have influenced the practice environment and LPNs' perceptions of their work. The aim of this article is to examine what factors predict rural and remote LPNs' perceptions of working below their legislated scope of practice and to explore their perceptions of working below scope. The findings arise from a national survey of rural and remote regulated nurses, in which 77.3% and 17.6% of the LPNs reported their practice as within and as below their legislated scope of practice, respectively. Three factors, age, stage of career and job-resources related to autonomy and control, predicted that LPNs would perceive themselves to be working below their scope of practice. These results suggest that new ways to communicate nurses' scope of practice are needed, along with supports to help rural and remote LPNs more consistently practice to their legislated scope of practice. Without such changes, the LPN role cannot be optimized and disharmony within rural and remote settings may be exacerbated.

Development and psychometric evaluation of the Job Demands in Nursing Scale and Job Resources in Nursing Scale: Results from a national study.

AIM: To develop and test the psychometric properties of the Job Resources in Nursing (JRIN) Scale and the Job Demands in Nursing (JDIN) Scale. DESIGN: Cross-sectional survey. METHODS: A three-phase process of instrument development and psychometric evaluation was employed: Phase 1: development of a 42-item JRIN Scale and 60-item JDIN Scale through extensive literature review, expert consultation and an iterative content evaluation; Phase 2: pilot survey of 89 nurses and use of item discrimination analysis to estimate the internal consistency reliability of each subscale and reduce the length of each scale; Phase 3: Modified scales were tested in a nationwide survey of 3,822 rural/remote nurses, including use of exploratory factor analysis. RESULTS: The 24 items related to job resources favoured a six-factor structure, accounting for 63% of the variance, Cronbach's alpha 0.88. The 22 items related to job demands favoured a six-factor structure, accounting for 59% of the variance, Cronbach's alpha 0.84.

Competence and confidence in rural and remote nursing practice: A structural equation modelling analysis of national data.

AIMS AND OBJECTIVES: To empirically test a conceptual model of confidence and competence in rural and remote nursing practice. BACKGROUND: The levels of competence and confidence of nurses practising in rural settings have been highlighted as essential to the quality of health outcomes for rural peoples. However, there is limited research exploring these constructs in the context of rural/remote nursing practice. DESIGN: Structural equation modelling was used to verify the conceptual model with data from the cross-sectional pan-Canadian Nursing Practice in Rural and Remote Canada II Survey. The STROBE guidelines for cross-sectional research were followed in the design/reporting of this analysis. The sample consisted of 2,065 registered nurses and nurse practitioners who were working in direct rural/remote nursing practice. RESULTS: The maximum likelihood ratio χ2  = 0.0822, df = 2, p = 0.959 indicated model fit, with final model estimates explaining 53% of the variance in work confidence and 17% of the variance in work competence. The model also accounted for 40% of the variance in work engagement, 39% of the variance in burnout and 15% of the variance in perceived stress. The complexity of competence and confidence in rural nursing practice was evident, being influenced by nursing experience in rural settings, rural work environment characteristics, community factors and indicators of professional well-being. CONCLUSIONS: The factors influencing nurses' competence and confidence in rural/remote nursing practice are more complex than previously understood. Our model, created and tested using structural equation modelling, merits further research, to extend our understanding of how nurses can be prepared and supported for practice in rural and remote settings. RELEVANCE TO CLINICAL PRACTICE: This study highlights the importance of supporting new nurses' exposure to rural nursing experiences, reducing professional isolation and improving decision-making support for those who are working at a greater distance from colleagues and/or those with fewer opportunities for interprofessional collaboration.

Exploratory factor analysis and reliability of the Primary Health Care Engagement (PHCE) Scale in rural and remote nurses: findings from a national survey.

Aim The study purpose was to provide evidence of validity for the Primary Health Care Engagement (PHCE) Scale, based on exploratory factor analysis and reliability findings from a large national survey of regulated nurses residing and working in rural and remote Canadian communities. BACKGROUND: There are currently no published provider-level instruments to adequately assess delivery of community-based primary health care, relevant to ongoing primary health care (PHC) reform strategies across Canada and elsewhere. The PHCE Scale reflects a contemporary approach that emphasizes community-oriented and community-based elements of PHC delivery. METHODS: Data from the pan-Canadian Nursing Practice in Rural and Remote Canada II (RRNII) survey were used to conduct an exploratory factor analysis and evaluate the internal consistency reliability of the final PHCE Scale. Findings The RRNII survey sample included 1587 registered nurses, nurse practitioners, licensed practical nurses, and registered psychiatric nurses residing and working in rural and remote Canada. Exploratory factor analysis identified an eight-factor structure across 28 items overall, and good internal consistency reliability was indicated by an α estimate of 0.89 for the final scale. The final 28-item PHCE Scale includes three of four elements in a contemporary approach to PHC (accessibility/availability, community participation, and intersectoral team) and most community-oriented/based elements of PHC (interdisciplinary collaboration, person-centred, continuity, population orientation, and quality improvement). We recommend additional psychometric testing in a range of health care providers and settings, as the PHCE Scale shows promise as a tool for health care planners and researchers to test interventions and track progress in primary health care reform.

Development and psychometric evaluation of the Primary Health Care Engagement (PHCE) Scale: a pilot survey of rural and remote nurses.

AIM: To report the development and psychometric evaluation of a scale to measure rural and remote (rural/remote) nurses' perceptions of the engagement of their workplaces in key dimensions of primary health care (PHC). BACKGROUND: Amidst ongoing PHC reforms, a comprehensive instrument is needed to evaluate the degree to which rural/remote health care settings are involved in the key dimensions that characterize PHC delivery, particularly from the perspective of professionals delivering care. METHODS: This study followed a three-phase process of instrument development and psychometric evaluation. A literature review and expert consultation informed instrument development in the first phase, followed by an iterative process of content evaluation in the second phase. In the final phase, a pilot survey was undertaken and item discrimination analysis employed to evaluate the internal consistency reliability of each subscale in the preliminary 60-item Primary Health Care Engagement (PHCE) Scale. The 60-item scale was subsequently refined to a 40-item instrument. FINDINGS: The pilot survey sample included 89 nurses in current practice who had experience in rural/remote practice settings. Participants completed either a web-based or paper survey from September to December, 2013. Following item discrimination analysis, the 60-item instrument was refined to a 40-item PHCE Scale consisting of 10 subscales, each including three to five items. Alpha estimates of the 10 refined subscales ranged from 0.61 to 0.83, with seven of the subscales demonstrating acceptable reliability (α ⩾ 0.70). The refined 40-item instrument exhibited good internal consistency reliability (α=0.91). The 40-item PHCE Scale may be considered for use in future studies regardless of locale, to measure the extent to which health care professionals perceive their workplaces to be engaged in key dimensions of PHC.

The transition experience of rural older persons with advanced cancer and their families: a grounded theory study.

BACKGROUND: Transitions often occur suddenly and can be traumatic to both patients with advanced disease and their families. The purpose of this study was to explore the transition experience of older rural persons with advanced cancer and their families from the perspective of palliative home care patients, bereaved family caregivers, and health care professionals. The specific aims were to: (1) describe the experience of significant transitions experienced by older rural persons who were receiving palliative home care and their families and (2) develop a substantive theory of transitions in this population. METHODS: Using a grounded theory approach, 27 open-ended individual audio-taped interviews were conducted with six older rural persons with advanced cancer and 10 bereaved family caregivers. Four focus group interviews were conducted with 12 palliative care health care professionals. All interviews were transcribed verbatim, coded, and analyzed using Charmaz's constructivist grounded theory approach. RESULTS: Within a rural context of isolation, lack of information and limited accessibility to services, and values of individuality and community connectedness, older rural palliative patients and their families experienced multiple complex transitions in environment, roles/relationships, activities of daily living, and physical and mental health. Transitions disrupted the lives of palliative patients and their caregivers, resulting in distress and uncertainty. Rural palliative patients and their families adapted to transitions through the processes of "Navigating Unknown Waters". This tentative theory includes processes of coming to terms with their situation, connecting, and redefining normal. Timely communication, provision of information and support networks facilitated the processes. CONCLUSION: The emerging theory provides a foundation for future research. Significant transitions identified in this study may serve as a focus for improving delivery of palliative and end of life care in rural areas. Improved understanding of the transitions experienced by advanced cancer palliative care patients and their families, as well as the psychological processes involved in adapting to the transitions, will help health care providers address the unique needs of this vulnerable population.

Evidence-based nursing in clinical practice: implications for nurse educators.

To improve patient outcomes currently and in the future, it is important that an evidence-based approach to nursing care be incorporated into clinical practice settings. Nurse educators and clinical nurse educators have a mandate to model and facilitate evidence-based nursing through learning activities. Unfortunately, issues present within clinical practice settings have made this approach difficult for registered nurses to fully incorporate into practice. This article outlines issues inhibiting evidence-based nursing, such as time factors, access to information and resources, nurses' research knowledge, skills, and learning opportunities, and the current nursing culture. Strategies for change that can be used by clinical nurse educators to enhance the use of evidence-based nursing in clinical practice areas are also described.