37 Nursing Leadership for Northern Health

Introduction

            This chapter discusses the leadership that is often expected of nurses practicing in the north. In the first section of this chapter, the unique roles played by nurses in rural and remote northern settings are described. These roles result in northern nurses being called upon to provide leadership both within the health care settings in which they practice, and in the community. The latter part of the chapter describes a model of critical leadership, which can guide and support nurses in their work of ensuring equitable and accessible health and community services to northern populations.

The Health Care Context in the North

Registered nurses working in the north play a key role in addressing the challenge of quality and accessibility of health services for northerners. Accessibility to health services in the sparsely populated regions of the North is heavily dependent on the availability of health professionals, particularly nurses, who make up the largest category of health providers in these regions (Exner-Pirot & Butler, 2015).

Nurses have unique and varied roles in ensuring the health of rural and remote communities (Coyle, M. et al., 2010; Martin Misener et al., 2008; McLeod et al., 2017a; Riley & Middleton, 2017. Some work in isolated primary health centers, delivering a wide variety of services, ranging from chronic disease management to diagnosis and treatment of common health conditions. Some work in community-based services delivering immunization, and pre and post-natal care, or in small in-patient units providing step down care post-surgery, or palliative care as part of a community-based end of life care program. Some provide service in remote health centers, where their jobs range from resuscitating, stabilizing and transporting acute trauma patients, to taking x-rays, and fixing the clinic computers. Regardless of the service provided, the breadth and depth of what is required of these nurses often differs considerably from the more specialized services delivered in urban centers (Coyle, M. et al., 2010; Martin Misener et al., 2008; McLeod et al., 2017a; Riley & Middleton, 2017).

Unlike their southern counterparts, northern nurses’ roles often do not end at the health center door or at the completion of their scheduled work days. Health care in the north is highly relational. Nurses who live and work in the communities they serve are tightly woven into the fabric of that community, and have close and lasting relationships with patients and families, sometimes spanning several generations (Moules, MacLeod, Thirsk & Hanlon, 2010). Many nurses play multiple roles in small communities in addition to their health care roles—team coach, municipal committee member, campaign chairperson, etc. At its best, the caring that emerges in rural and northern settings is based on the strong, multifaceted, complex interpersonal relationships with clients, families, and their communities (Berry, 2017; Cody Chipp, M. et al., 2010; Crooks 2004). As a result, confidentiality, anonymity, role confusion, and proximity may all prove challenges (Moules et al, 2010; Nelson, 2010). Nurses working in northern communities are compelled to develop and communicate a clear sense of their roles in relation to the boundaries between the personal and professional.

The role of the nurse in a small community has been described as a “generalized specialist” (Berry, 2017; MacLeod, 2008). These practitioners require a broad knowledge base, as they are confronted with health problems that would immediately induce consultation with and referral to specialists or other health providers in the south. However, unlike their southern counterparts, health professionals in remote regions are often not surrounded by a broad variety of other health and social services professionals with assigned managerial functions and continuing education roles to support the front line work of delivering health care, nor is there a designated workforce whose job it is to produce institutional and public policy to support health and health initiatives. In places where these specialized managerial and educational positions are not available, these roles are shared amongst those health professionals present in the community, and are often not assigned to particular positions, but are dependent on the skills of those occupying these positions at the time. Nurses working in northern communities assume a variety of the above roles at varying times and have opportunities to contribute to the planning and delivery of health care in ways that may not present themselves as readily to nurses working in the south.

Most health care teams in the North are small. In many communities, the core members of the team work closely together, sometimes over many years, building strong team relationships (Berry, 2017; McLeod et al., 2017; Moules et al., 2010). In a study of northern Canadian nurses, 58% reported living in the northern community in which they worked (MacLeod et al., 2017). In other situations, health services are supplemented by, or delivered entirely by itinerant nursing staff who come and go, either in short rotations of one to two weeks, or in short contracts (MacLeod et al., 2017b).

Unlike in most health services delivered in the south, northern nurses’ work is often aided by highly valuable individuals from the community working in auxiliary roles, who are familiar with the local language, culture and customs. In communities large enough to have staffed clinics or hospitals, maintenance and clerical staff, as well as personal care aides are frequently from the community and provide a strong link to it for nursing staff. In community health in more remote regions, registered nurses’ work is often aided by community health representatives, who are hired to work in local health care programs to support basic health promotion activities. They arrange or provide transportation to immunization, foot care, and other specialty clinics. They deliver medications that have been dispensed, and encourage community members to utilize health care services. They assist in communicable disease tracing, and explain local cultural practices, community health needs, and issues to health professionals from outside the community (Northwest Territories Health and Social Services Careers, 2011). They have limited training, perhaps provided on the job, and provide an important trusted link to community members for nurses.

In some isolated communities, nurses may be some of the very few members of the community with any post-secondary education. This, in tandem with their trusted role as health care providers in the community, gives them a unique skill set and frequently involves them in community discussions with respect to health and social policy and programming decisions.

There has been much attention paid in the last decade to the importance of interprofessional collaboration in health care in order to effectively meet patient, family, and community needs (Canadian Interprofessional Health Collaborative, 2010). Collaborative practice in the south engages many different health professions: nursing, medicine, dentistry, physical therapy, pharmacy, dietetics, etc. In small communities in the north, when looking for other professionals with whom to share in delivery of health care services, often the only other professionals present in the community are teachers and police officers. Nurses and other health professionals in the North are often supported by telemedicine consultation services provided by health professionals remotely. Health and social policy and programming discussions often involve uniquely diverse groups of professionals and community leaders within the community, and unique and varied mechanisms for communication with professionals outside the community, bringing broad perspectives to the table.

One of the most important aspects of the nursing role in the northern context is that many nurses are working in Indigenous communities. While the importance of the understanding of Indigenous culture and health practices, the impact of colonization, and the importance of cultural safety approaches in the provision of health care are beyond the scope of this chapter, it is important to address the issues of jurisdiction that arise when providing care in the North. In some instances, nurses are working directly for Indigenous communities that have control of their own health services. In other instances, nurses are working directly for governments who provide health care services to Indigenous communities. In some cases, multiple different levels of government services may be involved, as is the case in Canada, where Indigenous people from a community that has control over its own health services may require services from federal or provincial service providers, or both. Nurses are often the health care professionals who are left to make their way through the jurisdictional issues that arise when trying to access timely, funded health care services for their patients, across jurisdictional boundaries. With few other professionals in the community on whom nurses can rely on; multiple and changing jurisdictional services and policies; intense and long term relationships with the community; engagement of auxiliary health care workers to link them closely with the community; and broad, eclectic, ever-changing roles, northern nurses are provided rich opportunities that differ significantly from the roles of their southern counterparts. Northern nurses have unique occasions to provide positive leadership that impacts the health and well-being of their communities. Northern communities look to nurses for information and decision making on all things health-related, and rely on the skills of nurses in identifying and addressing community health challenges, solving problems, and articulating policy solutions. Leadership from nurses is often expected, sought, and relied upon.

Leadership for Health in Northern Communities

Faced with the challenges of providing accessible, equitable, quality care to northern communities, in unique roles and unusual circumstances, and with a deep personal and professional commitment to the people they serve, nurses are frequently called on to provide both formal and informal leadership. The critical leadership model can assist nurses in prioritizing actions and approaches when working in northern communities, or in any situations where issues of equity and social justice arise. Critical leadership has five major components: critique, reflection, education, ethics, and inclusion. This model is based on the historical work of critical adult educators Foster (1989) and Ryan (2003). It was developed as a result of a study looking at the leadership experiences of nurse leaders striving to increase the diversity of the nursing profession (Berry, 2010).

Leadership is Critical

Leadership in the delivery of health care services in the North requires reflection on what and how services are delivered, and whose needs are being met in the way the services are constructed. Are these services organized in ways that meet the needs of the patients, families, and communities in which they are delivered, or in ways that meet the needs of the providers of the care, and the funding agencies that fund it? Nurses must especially understand and critically reflect upon their own role in relation to existing community structures, governance and norms, especially when working cross culturally. Critical leadership requires one to look at who is benefitting from the way that services are delivered, and whether this approach meets the needs of the population served (Berry, 2010; Foster, 1989).

Leadership is Transformative

Northern nurses need to reflect on the possible. They cannot simply accept “what is” and “we don’t do that here”.  What can be done to improve service? What would work better? What does this community believe that it needs? Are those needs being met? Transformative leaders maintain a passion for excellence driven by a commitment to their clients and communities, and what could be. Transformative leaders ask “why” and look at “what if”. They avoid getting bogged down by the day-to-day, but keep their eye squarely on the goal of service (Berry, 2010; Foster, 1989).

Leadership is Educative

A significant part of critical leadership is looking analytically at tradition and “the way we’ve always done things”, and envisioning new ways to move forward. This requires vision, a sense of the possibilities, and the ability to engage others in reflection and envisioning the possibilities. Educative learners are open to learning. They link current activities with the larger picture and transformative goals. Educative leaders are role models and advocates. They create opportunities for others. Educative leaders are engaged and engage others in their vision (Berry, 2010; Foster, 1989).

Leadership is Ethical

As previously noted, the way in which northern nurses’ lives intertwine with northern residents requires that nurses recognize the ethical challenges that arise in the provision of northern health care, including issues of anonymity, confidentiality, proximity, and more. In addition, nurses are challenged by their codes of ethics not only to provide ethical care, but to ensure that the system in which they work is morally purposeful in addressing issues of access and equity. Ethical leadership is positive and authentic (Berry, 2010; Foster, 1989)

Leadership is Inclusive

Northern nurses involved in the planning and implementation of health care need to practice inclusive leadership. Inclusive leadership ensures that the process of planning care is in itself inclusive of those who require and receive the care. In addition to the process being inclusive, so too must be the outcome of the planning process, thereby creating a welcoming, respectful, and accessible service. Thus, the inclusive aspect of critical leadership is both a process, and an outcome (Berry, 2010; Ryan, 2003). The goal of inclusion as both process and outcome is especially important when considering the provision of culturally safe, accessible, high quality services to northern Indigenous communities.

Conclusion

Nurses working in northern communities are leaders by virtue of their roles in health care and in the community. Using an approach to leading that is critical, transformative, educative, ethical and inclusive contributes to the creation and delivery of high quality, equitable, and accessible health services that meets the needs of the northern communities in which nurses work.

References

Berry, L. (2017). Rural and remote health care. In B. Kozier, Erb, A. Berman, S.

Snyder, M. Buck, L. Yiu, & L. Ferguson (Eds.), Fundamentals in Canadian Nursing: Concepts, Process and Practice (pp. 2262-270). Toronto, ON: Person Education Canada.

Berry, L. (2010). Making a diversity difference: Stories of leadership in creating a more inclusive nursing profession (Doctoral dissertation). Retrieved from the University of Saskatchewan Electronic Theses and Dissertations https://ecommons.usask.ca/handle/10388/etd-07262010-084241.

Canadian Interprofessional Health Collaborative. (2010). A National Interprofessional Competency Framework. Retrieved from https://www.cihc.ca/files/CIHC_IPCompetencies_Feb1210.pdf

Cody Chipp, M.S., Dewane, S., Brems, C., Johnson, M., Warner, T., & Roberts, L. (2011). Journal of Rural Health, 27, 122-130.,

Coyle, M., Al-Motlaq, M., Mills, J., Francis, K., Birks, M. (2010). Australian Health Review, 34(2), 239-45.

Crooks, C. (2004). Is rural nursing a speciality?. Online Journal of Rural Nursing and Health Care, 4(1), 1-4.

Exner-Pirot, H. & Butler, L. (2015). Healthy Foundations: Nursing’s Role in Building Strong Aboriginal Communities. Ottawa: Conference Board of Canada.

Foster, W. (1989). Toward a critical practice of leadership. In J. Smyth (Ed.), Critical Perspectives on Educational Leadership. (pp. 39-62) London: The Falmer Press.

MacLeod, M., Martin-Meisner, R., Banks, K., Morton, A.M., Vogt, C., & Bentham, D. (2008).”I’m a different kind of nurse”: Advice from nurses in rural and remote Canada. Nursing Leadership, 21(3), 40-53.

MacLeod, M., Stewart, N.,Kulig, J., Anquish, P., Andrews, M.E. et al. (2017a). Nurses who work in rural and remote communities in Canada: A national survey. Human Resources for Health. 15(34) 1-11.

MacLeod, M., Stewart, N., Kulig, J., Olynick, J., Jonatansdorrir, S., & Kosteniuk, J. (August, 2017b). Registered Nurse National Survey Report: Nursing Practice In Rural and Remote Canada. Prince George, BC: Nursing Practice in Rural and Remote Canada II.

Martin Misener, R., MacLeod, M., Banks, K., Morton, A. M., Vogt, C., & Bentham, D. “There’s rural, and then there’s rural”: Advice from nurses providing primary healthcare in northern remote communities. Nursing Leadership, 21(3), 54-63.

Moules, N., MacLeod, M., Hanlon, N., & Thirsk, L. (2010). “And then you see her in the grocery store”: The working relationships of public health nurses and high-priority families in northern Canadian communities. Journal of Pediatric Nursing, 25, 327-334

Nelson, W. (2010). Health care ethics and rural life: Stigma, privacy, boundary conflicts raise concerns. Health Progress, 91(5), 51-54.

Northwest Territories Health and Social Services Careers. (2011). Community health representative. Retrieved from http://www.practicenorth.ca/index.php?page=community-health-representative.

Riley, K. & Middleton, R. (2017). Supporting rural emergency nurses to provide autonomous and life-saving care during resuscitation. Australian Nursing and Midwifery Journal 25(5), 44.

Ryan, J. (2006). Inclusive Leadership. San Francisco: Jossey-Bass.