The Nature of Nursing Practice in Rural and Remote Canada

by Martha MacLeod, Judith Kulig | Sep 01, 2004

Key Implications for Decision Makers

Nursing practice in rural and remote Canada is characterized by its variability and complexity and by the need for a wide range of knowledge and skills in situations of minimal support and few resources. This study describes the rural and remote registered nursing workforce and the nature of their practice. It gives voice to the nurses in these regions.

  • Managers and policy makers need to better understand the realities of rural and remote practice. A "rural lens" can assist in developing relevant policies and practices. This may be a useful component of a national rural and remote nursing strategy.
  • In small communities, nurses' personal and professional roles are inseparable. The intertwining of nurses' everyday practice and their personal lives needs to be taken into account in developing policies and services.
  • Because many rural and remote nurses work alone or with little backup in their everyday practice, there are pressing needs for providing professional supports at a distance, both in person and using information technology.
  • Recruitment and retention of nurses can be more successful when done with an understanding of the perceptions of nurses in rural and remote communities and in partnership with the communities themselves.
  • New models of interprofessional practice can be developed that are supportive of the varied strengths and resources in rural and remote communities.
  • Special attention needs to be paid to the recruitment, retention, and support of nurses in Aboriginal communities, as well as to ways in which continuity of care and culturally appropriate care can be provided.
  • There is a pressing need for undergraduate and postgraduate education programs to prepare nurses for the realities of rural and remote nursing practice. Targeted funding is needed for university nursing programs that focus on preparing rural and/or remote nurses to address the additional design and implementation costs.
  • New ways are needed to systematically design and provide relevant continuing education for rural and remote nurses, including providing education on site, supporting nurses to travel for further and continuing education, and using information technology.
  • A larger issue for some rural and remote communities than retirement may be the issue of migration - when nurses leave communities for education or alternate employment and do not return. Counting on overseas recruitment to fill these gaps is not a good option, as only a fraction of foreign-educated nurses work in rural Canada.
  • The distinctiveness of rural and remote settings and rural nursing practice will not be adequately captured until nursing databases are improved through the development of unique personal identifiers and relevant rural/urban indicators.

Executive Summary

Although registered nurses are the key to Canadians in rural and remote areas having sustained access to high-quality healthcare, little research has been done about them and their practice. In order to examine and articulate the nature of registered nursing practice in settings of primary care, acute care, community health, homecare, and long-term care within rural and remote Canada, we conducted research guided by the following four questions. Among registered nurses in rural and remote Canada:

  1. What is the nature of nursing practice?
  2. What are their roles and functions?
  3. What are the commonalities and differences among roles and functions in various practice settings? and
  4. What factors facilitate or hinder nurses' practice and their development of expertise?

Four complementary approaches were undertaken concurrently to answer these research questions. Analysis of the Registered Nurses Database enabled the demographic profile of rural registered nurses to be generated for the first time for Canada, both as a whole and for the individual provinces and territories. Systematic analyses of policy and administrative documents undertaken by the documentary analysis team allowed a critical view of the policy context within which rural and remote nurses practise. A national survey of 3,933 registered nurses collected comprehensive information about rural and remote nurses' work, quality of work-life, perspectives on rurality, and degree of satisfaction with work, communities, and practice supports. Finally, an in-depth examination of 152 rural nurses' experiences through a narrative approach brought to life the interplay of the context and the nurses' practices in a variety of rural settings across the country. Each of the co-principal investigators led one of the four approaches, assisted by a small group of co-investigators, research assistants, and in some instances, members of the advisory team.

As this study has created rich, multi-faceted data, this report touches on only a portion of the emerging results. Analysis is ongoing, as is a series of knowledge translation endeavours with decision makers across Canada. Illustrative findings that have the potential to inform decisions about the accessibility of care, the quality of care, and the sustainability of care are presented here.

Accessibility of Care

In order to provide accessible nursing care in rural and remote areas, there is a need for an appropriate supply of nurses who are suitably educated for the roles they need to assume. We found that 18 percent (41,502) of registered nurses in Canada are providing care to the 22 percent (6.6 million) of Canadians living in rural and small town Canada. This lower nurse-to-population ratio in rural areas decreases from east to west. Although most registered nurses in both urban and rural settings work in acute care hospitals, a larger proportion of rural than urban nurses work in community-based settings, reflecting the importance of this type of workplace in rural Canada.

In most areas of practice, registered nurses in rural and remote Canada have greater demands for an expanded role of practice, in spite of the fact that they have a comparatively lower level of formal education than their urban colleagues. Additionally, they have significantly fewer clinical resource supports, with clinical and administrative leaders often located some distance away. They also have more difficulty obtaining additional clinical and academic qualifications. The lower numbers of rural registered nurses who have acquired further academic qualifications suggest that new ways of working with rural nurses and their employers need to be explored in order to make advanced education opportunities relevant and accessible.

Quality of Care

The complexity of rural and remote nursing practice is vastly underestimated; policy and practice changes are needed to improve the quality of services nurses can provide. The interconnection between rural nurses and their context was most apparent in the narrative portion of the study, where the importance of community in shaping the nurses' work lives and everyday practices was clearly evident. Community demographics make a great deal of difference in what the nurses encounter in their practice and influence the development of their skill sets and knowledge. Predominant in the advice from rural and remote nurses to new nurses, administrators, educators, and policy makers is the need for more understanding - the need to "learn to listen and listen to learn." Through learning and listening, there may be greater understanding of the realities of rural and remote practice, with the potential of developing policies, administrative practices, and education programs that reflect those realities. One means to do this would be the creation of a rural lens, a concise set of questions and processes, which could help managers and policy makers develop relevant policies and practices as well as illuminate the strengths of rural practice.

Sustainability of Care

Through an analysis of survey data, we found 11 statistically significant predictors of intent to leave. Individual variables associated with intent to leave were gender, higher perceived stress, no dependent children or relatives, higher education, and fewer years employed in the primary agency. Individual satisfaction levels also predicted intent to leave. Specifically, lower satisfaction with community and the workplace (in matters of scheduling and autonomy) were related to plans to leave within the next year. Nurses were more likely to plan to leave if they were responsible for advanced decisions or practice, if they were required to be on call, or if they were working in a remote community. Administrators and policy makers can begin to address these issues by better understanding gender differences, identifying stressors from the perspective of the nurses, and initiating in consultation with the registered nurses strategies that promote retention.

Migration patterns of rural and remote nurses also affect sustainability of care. Although more rural than urban nurses work in the province in which they are first registered, some provinces, particularly those in the west, depend on nurses educated in other provinces to provide the necessary registered nurse workforce in rural areas. Recruiting registered nurses from overseas is not an effective option, as an extremely small proportion of foreign-educated nurses work in rural and remote areas of Canada.

In general, the findings of this study suggest that rural and remote nursing practice is more complex and multi-faceted than it is usually thought to be. By better understanding the realities of rural and remote practice, as well as by addressing in a more concerted way issues such as education and workplace supports, the strengths of rural and remote nursing practice can be better mobilized. As a result, Canadians living in rural and remote parts of this country could more readily have appropriate access to high-quality nursing care through a sustained nursing workforce.

More information can be found on the study's web site at