Negotiating the Terrain:

The Challenges and Rewards of

Rural Nursing

Judith C. Kulig, RN, DNSc

Associate Professor

School of Health Sciences

University of Lethbridge

Thanks to:

The Conference Organizers

Wendy Herbers, School of Health Sciences, U of L

Drs. Ray Bollman,

Valerie du Plessis,

Roland Beshiri - Statistics Canada

Ernie Dal Grande - Health Canada

Increased Interest in “Rural”

What Is Rural?

Geographic Building Blocks

* Census Subdivision (CSD) 5,984 CSD

* Census Division (CD) 288 CD

Predominantly Rural Region -

More than 50% of the population

living in rural communities and

population density <150 person/km2

Beshiri & Bollman (2001)

Rural and Small Town Canada: An Overview

Demography: Population Structure

• 31.4 percent of Canada’s population lives in predominantly rural regions (in 1996)

• “predominantly rural regions” have over 50 percent of their population living in rural communities (A rural community is a census consolidated subdivision with less than 150 persons per square kilometer. Census divisions are used to delineate “regions”, to facilitate comparisons with other OECD countries.)

In 1996, 31.4 percent of Canada's population

lived in predominantly rural regions

0

5

10

15

20

25

30

35

40

45

50

1981 1986 1991 1996

Perc

en

t o

f to

tal p

op

ula

tio

n

Predominantly rural regions

Source: Statistics Canada. Census of Population, 1981 - 1996. A predominantly rural region has over 50 percent of its population living in rural communities. An intermediate region has 15 to

49 percent living rural communities and a predominantly urban region has less than 15 percent of its population living in rural communtieis.

Percent distribution of Canada's predominantly

rural population among the provinces

0 2 4 6 8 10 12 14 16 18 20 22 24

Yukon

Northwest Territories

Prince Edward Island

Newfoundland

Manitoba

Saskatchewan

Nova Scotia

New Brunswick

Alberta

British Columbia

Québec

Ontario

Percent of Canada's predominantly rural population in each province in 1996Source: Statistics Canada. Census of Population, 1996. A predominantly rural region has 50 percent of more of its populatoin living in rural communities.

490 thousand Manitobans

live in predominantly rural regions

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

1981 1986 1991 1996

Po

pu

lati

on

Predominantly rural regions

Predominantly urban

Source: Statistics Canada. Census of Population, 1981 - 1996. A predominantly rural region has over 50 percent of its population living in rural communities. An intermediate region has 15 to

49 percent living rural communities and a predominantly urban region has less than 15 percent of its population living in rural communtieis.

Population growth is smaller

in predominantly rural regions

0

2

4

6

8

10

12

1981 to 1986 1986 to 1991 1991 to 1996

Pe

rce

nt

ch

an

ge

in

po

pu

lati

on

(o

ve

r fi

ve

ye

ars

)

Predominantly urban regions Intermediate regions Predominantly rural regions

Source: Statistics Canada. Census of Population, 1981 - 1996. A predominantly rural region has over 50 percent of its population living in rural communities. An intermediate region has 15 to

49 percent living rural communities and a predominantly urban region has less than 15 percent of its population living in rural communtieis.

Population growth is larger in rural regions

adjacent to metro centres

-2

-1

0

1

2

3

4

5

6

7

8

1981 to 1986 1986 to 1991 1991 to 1996

Pe

rce

nt

ch

an

ge

in

po

pu

lati

on

(o

ve

r fi

ve

ye

ars

)

Rural Metro-Adjacent Regions Rural Non-Metro-Adjacent Regions

Rural North Regions

Source: Statistics Canada. Census of Population, 1981 - 1996.

Rural and Small Town

Outside the commuting zones of

larger urban centres (with

10,000 or more)

duPlessis, Beshiri, & Bollman (2000)

Rural and Small Town Canada: An Overview

Demography: Population Growth

• At the Canada level, the rural and small town population is increasing.

• In Newfoundland and Saskatchewan, the rural and small town population has been decreasing for decades.

• In the other provinces, the rural and small town population is increasing only in areas where individuals can commute to cities or where individuals wish to retire.

Rural and Small Town Population, Canada, 1966 to 1996

0

1

2

3

4

5

6

7

8

9

1966 1971 1976 1981 1986 1991 1996

Population (millions)

Source: Statistics Canada. Census of Population, 1966 to 1996.

Rural and small town refers to the population outside Census Metropolitan Areas (CMAs) and outside Census Agglomerations (Cas).

Rural and Small Town Population,

Manitoba, 1966 to 1996

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50

1966 1971 1976 1981 1986 1991 1996

Population (millions)

Source: Statistics Canada. Census of Population, 1966 to 1996.

Rural and small town refers to the population outside Census Metropolitan Areas (CMAs) and outside Census Agglomerations (CAs).

Population trends:

Rural minority in Manitoba in 1951

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

900,000

1871 1881 1891 1901 1911 1921 1931 1941 1951 1961 1971 1981 1991

Rural (centres under 1,000)

Urban (centres 1,000+)

Source: Statistics Canada. Census of Population, 1851 - 1996.

Old Age Dependency Ratio:

> is highest in rural non-metro-adjacent regions

> is increasing everywhere

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Predominantly

rural regions

Intermediate

regions

Rural metro-

adjacent regions

Rural non-metro-

adjacent regions

Rural northern

regions

Old

ag

e d

ep

en

den

cy r

ati

o(p

op

ula

tio

n 6

5 y

ea

rs a

nd

ov

er

as

pe

rce

nt

of

po

pu

lati

on

15

to

64

)

1981

1986

1991

1996

Source: Statistics Canada. Census of Population, 1981 to 1996. A predominantly rural region has over 50 percent of its population living in rural communities. An

intermediate region has 15 to 49 percent and a predominantly urban region has less than 15 percent.

Child Dependency Ratio:

> is highest in rural northern regions

> is declining everywhere

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Predominantly

rural regions

Intermediate

regions

Rural metro-

adjacent regions

Rural non-metro-

adjacent regions

Rural northern

regions

Ch

ild

de

pe

nd

en

cy r

ati

o

(po

pu

lati

on

un

de

r 1

5 y

ea

rs o

f a

ge

as

pe

rce

nt

of

po

pu

lati

on

15

to

64

)

1981 1986 1991 1996

Source: Statistics Canada. Census of Population, 1981 to 1996. A predominantly rural region has over 50 percent of its population living in rural communities. An

intermediate region has 15 to 49 percent and a predominantly urban region has less than 15 percent.

Health Status of Rural

Canadians

largely ignored

Geographic Setting

- Deterioration of health status

- Impact of place

Employment Patterns

• Lung cancer rates higher in mining areas (Pong, et al., 1999)

• Emphysema & asthma among farmers (Fair, 1992)

• Decline in lung function among swine workers & grain farmers (Kirychuk, S.P., Senthilson, A.,

Dosman, J.A., et al., 1998)

Unique Populations

• First Nations

• Ethnic Groups

• Women

Health Services & Health

Professionals

• Fewer physicians in rural areas

• Rural and remote nursing practice – poorly

studied

The Nature of Nursing Practice in

Rural and Remote Canada

PIs: Dr. M. Macleod, UNBC

Dr. J. Kulig, U of L

Dr. N. Stewart, U of S

Dr. R. Pitblado, Laurentian

http://ruralnursing.unbc.ca

Co-Investigators

* Ruth Martin-Misener Dalhousie University * Ginette Lazure Université Laval

* Jenny Medves Queen's University

* Michel Morton Lakehead University

* Carolyn Vogt U. Manitoba

* Gail Remus U. Saskatchewan

* Debra Morgan U. Saskatchewan

* Dorothy Forbes U. Saskatchewan

* Barbara Smith U. Saskatchewan

* Carl D'Arcy U. Saskatchewan

* Elizabeth Thomlinson U. Calgary

* Kathy Banks UNBC

* Sandra Kioke UNBC

* Lela Zimmer UNBC

Advisory Team Members

•Marian Knock, B.C. MOH, Principal Decision-Maker

•Denise Alcock, U. Ottawa

•Madge Applin, Centre for Nursing Studies, Nfld.

•Donna Brunskill, SRNA

•Elizabeth Cook, Aurora College, Yellowknife, NWT

•Marta Crawford, MARN

•Fran Curran, Yukon Health & Social Services

•Joyce England, ANPEI

•Fjola Hart Wasekeesikaw, Aboriginal Nurses Ass’n

•Adele Vukic, Dalhousie U.

•Cecile Hunt, North Central Health District, SK

•Kathleen MacMillan, Ontario Health and Long-Term Care

•Maria MacNaughton, MSB - Health Canada

•Suzanne Michaud, QHA

•Rachel Munday, Health and Social Services, Nunavut

•Debbie Phillipchuk, AARN

•Francine Anne Roy, CIHI

•Marlene Smadu, Saskatchewan Health

•Roxanne A. Tarjan, NANB

•Cathy Ulrich, Northern Interior Health Region, BC

Funding Partners

• Canadian Health Services Research Foundation

• Canadian Institutes of Health Research

• Nursing Research Fund

• Ontario Ministry of Health and Long-Term Care

• Alberta Heritage Foundation for Medical Research

• Michael Smith Foundation for Health Research

• Nova Scotia Health Research Foundation

• British Columbia Rural and Remote Health Research Institute

• Saskatchewan Economic and Cooperative Development

• Provincial and Territorial Nurses Associations

• Government of Nunavut

• Canadian Institute for Health Information

Rewards of Rural Nursing

Practice

• Provide care to unique populations

• Contribute to rural sustainability

• Pursuit of a specific lifestyle

Challenges of Rural

Nursing Practice

Broader but unclear scope

Misunderstandings and lack of

understanding

Lack of Resources

Recruitment and Retention

* Satisfaction with job and community

Rural Health Research & Training

Lack of Education

n = 14

UNBC University of Manitoba

Athabasca University of Saskatchewan

University of Lethbridge Sask. Indian Federated College

University of Alberta University of Ottawa

University of Calgary University of Toronto

Dalhousie University Univ. of Western Ontario

Univ. of New Brunswick Memorial University

(Minore, Kulig, Stewart, & Mack, 2001)

Less than half offered courses

in rural health

• 64% of the students chose a rural health

focus

• 7 of the programs indicated that their

faculty conducted rural health research

(Minore, Kulig, Stewart, & Mack, 2001)

Inappropriate Policies

The Future of

Rural Nursing Practice

Evidence Based Practice

• Rural nurse researchers

• Use of knowledge

• Preparing future rural nurses

New Models for Health

Care Delivery

Nurse Responder

RN First Call Program

“Nurse Practitioners”

Using Technology

Telecommunications infrastructure

FNIHB Pilot Project

Telehealth

Source: Gary Larson