Realistic expectations: the changing role of paraprofessional health workers in First Nation communities in Canada.

CONTEXT: First Nation communities in Canada rely on a mix of non-indigenous professionals and large numbers of indigenous paraprofessionals to deliver healthcare. Formerly allowed to perform controlled acts in emergencies, the direct care role of paraprofessionals is now restricted because of concerns about liability and accountability. As such, they are limited to health promotion and prevention activities. OBJECTIVES: Focusing on the largest group of indigenous health workers, viz. Community Health Representatives (CHRs), for illustration purposes, this paper (1) examines the evolving role of First Nation health workers, and (2) discusses the proposed introduction of competency-based standards for their education, certification and regulation. METHODS: The paper is informed by findings from open ended, semi-structured and focus group interviews, as well as qualitative survey data, derived from seven studies done in Ontario, Canada. OUTCOMES: Paraprofessionals face conflicting and sometimes unrealistic expectations. Past practices have accustomed community members to hands-on care; however, professionals will no longer delegate tasks requiring clinical skills to them. Moreover, First Nation leaders are concerned about liability for their paraprofessional employees' actions. The paper discusses issues related to paraprofessional competence, preparation for practice, and continuing health education. It then presents the National Indian and Inuit Community Health Representatives Organization's proposal to establish a scope of practice and set of competencies that can form the basis for national practice and training standards, accreditation and regulation. CONCLUSIONS: In Canada or elsewhere, changing practice environments may require adjustments in the roles played by indigenous health workers. The case of First Nation Community Health Representatives illustrates a strategy for role transformation.

Capacity building in rural health research: a Canadian perspective.

INTRODUCTION: The need to build capacity in rural health research is recognized in Canada. During its formative stage, the Canadian Rural Health Research Society (established in 2002), performed a nation-wide survey of the research teaching and training opportunities available to students interested in rural and remote health issues. Intended as a cross-sectional 'snapshot,' and to provide base-line data, the survey involved a comprehensive list of educational programs in health and science disciplines at all Canadian Universities offering graduate-level programs. The present project report gives an overview of the results, documenting the current strengths, but also the noticeable gaps that exist. METHODS: Data were collected via an Internet survey, developed according to Dillman's email survey design principles. Although multiple contacts are recommended, due to time constraints only two were made. The instrument included both open- and closed-ended questions designed to determine institutional commitments to rural health research training generally, as well as specific information about course offerings, infrastructure supports for students, financial assistance for studying specific topics, and future plans. Health was defined broadly and included a number of disciplines beyond those usually considered under the health rubric. Individuals in administrative positions for 462 programs in 24 distinct disciplines at 56 institutions were sent the survey. Responses were received from 120 programs at 40 universities. Due to budget constraints the instrument was not translated into French. Descriptive statistics were used to analyse the data, combined with a thematic analysis of written comments. Ethical approval was obtained from the Lakehead University before the study was conducted. RESULTS: Despite the fact that one-third of Canadians live in rural, remote and northern areas, there is a paucity of research that addresses rural health issues. Moreover, Canadian universities have very limited rural health offerings in their curricula. There are few formal courses available on rural health topics generally or rural health research specifically. Although students can take rural-related independent studies or reading courses, very few actually take advantage of the option. Of all disciplines, nursing faculty are most likely to pursue rural health research and to offer rural health courses. Moreover, nursing faculty most often indicate an intention to expand their rural health offerings. In the social sciences, geography and environmental science programs, relatively few students choose to study rural health. Similarly, in medicine, the number of students exploring rural health issues is small. There is some specific financial assistance available to students who are interested in rural health research and, as well, they have access to general pools of funding. CONCLUSION: The survey results demonstrate the limitations of current educational programs. However, they also indicate areas of potential growth and show widespread interest in increasing the offerings available at universities across Canada. The article concludes by giving an overview of the mandate and initiatives being taken by the new research society to augment training, and to enhance student participation. In addition, it notes the positive developments linked to a new Strategic Plan by the Canadian Institutes of Health Research (CIHR) to enhance rural health research in Canada.

Knowledgeable, consistent, competent care: meeting the challenges of delivering quality cancer care in remote northern communities.

The Northwestern Ontario Regional Cancer Centre (NWORCC) has created outreach services that provide chemotherapy and supportive care to clients in thirteen small, remote communities. Located 100-600 km from the NWORCC, these satellite oncology services are staffed by local physicians, specially prepared nurses and support staff. The present paper reports selected findings from an evaluation of the service, based on two rounds of site visits, interviews and surveys of providers and clients. Although the consensus was that quality care was being delivered, local hospitals and other organizations had to address a variety of challenges. Those discussed in the paper include: maintaining provider competency, strengthening supportive care networks, and adjusting staffing and other resources to meet increased demands for care.

Strength through sharing: interdisciplinary teamwork in providing health and social services to northern native communities.

The delivery of health and social services in Canada's northern First Nations is undermined by the fact that professionals from outside and para-professionals from the communities often fail to respect one another's capabilities or to understand one another's roles and, consequently, do not work well together. This paper explores the personal, professional, and situational causes, using examples of mental health care in the Sioux Lookout Zone of northwestern Ontario. Arguing that an interdisciplinary team approach is the ideal and, perhaps, the only real way in which essential services can be delivered, the authors suggest ways to achieve more effective collaboration.