Nurses and Nurse Practitioners of BC
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The Challenges of Working in Rural Health, by Michael Sandler, RN

Approximately eighty five percent of British Columbians live and work in a city or within a short distance of a town that has a population of at least 1,000 residents. This has an important impact on healthcare as certain services can only be found in cities and towns with a large population base. If you live in a large or even moderate sized city, and you need to navigate through the healthcare system, you will enjoy relatively easy access to a long list of essential services including walk-in clinics, emergency rooms, specialist consults, physiotherapy, speciality rehabilitation services and many other healthcare essentials. Most of us never really think about the challenges faced by those who live further from the centre of a city, or in the case of B.C., the southwestern corner of the province.

Canadians are proud of our universal health coverage and the tenets that support our vision of health, including equal and equitable access to care (accessibility), portability, universality, comprehensiveness and public administration. What we don’t realise is that these pillars of the Canadian healthcare system are not equally applied. Those of us who live in rural areas often struggle with accessibility, universality and comprehensiveness, issues that are not as prevalent in larger centres.

Rural British Columbians understand why it’s more efficient to locate specialized services in Vancouver, Kelowna or Victoria, where most of the population lives. However, with centralization should come a commitment to ensure that the foundational tenets of the Canadian Health Act are adhered to for those of us who live in rural areas. Services like maternity, which used to be available in most rural and remote communities throughout B.C., are now primarily focused in the larger centres. With centralization, rural community healthcare needs have changed. The need for care has not changed, just the location it is provided in, and the need to ‘move’ patients has increased. Yet despite need, changing how rural patients access services has yet to be developed to a point where our access is equitable.

A second risk to downsizing and centralization, a risk that has so far received little attention, is the ‘reduction’ effect on rural scope of practice. What can be handled in smaller centres has started to shrink, mainly because the human health resources are no longer available. The less rural healthcare providers are exposed to a given clinical situation, the less we know about that clinical situation - and ultimately, the less we can do about it when we are presented with it. This is not a failing, it simply highlights why specialized medical services exist, and why they are concentrated in areas that will see enough clinical situations to maintain competence. There are many examples in many rural communities throughout B.C. where changing services levels have led to changing outcomes in certain clinical situations.

This dichotomy in practice leads to unique challenges for rural clinicians. On the one hand you need to know a lot while understanding that you might not have access to the resources you need. This is a challenging practice environment and not for everyone. For this reason, it can be a struggle to recruit rural focused physicians, nurses and other healthcare providers. This leads to reduced rural services and as a result, rural emergency rooms often end up being the only place to access routine healthcare. With limited access to non-urgent healthcare facilities such as walk-in clinics, NP clinics and health centres, there is downward pressure on small town hospitals and healthcare providers to handle both the urgent acute health needs of their community as well as chronic and routine needs. This leads to high rates of burnout and makes it even more challenging to attract doctors and nurses to work in rural areas.

We should be utilizing existing health human resources to their fullest potential. Nursing must be looked at closely as a solution to bridging the existing health human resource gaps. Nurse Practitioners hold promise in increasing capacity for rural centres to manage chronic conditions of patients closer to home. Rural healthcare clinicians can also look to things such as simulation and distance education to maintain skills related to high-risk low-volume medical interventions, increasing retention of rural staff. Reviving the incentives that were previously offered to individuals willing to work outside of the big centres would help to offset the costs that rural clinicians are presented with to maintain their skills and increase the possibility of recruitment. Telehealth should be looked at closely to bring specialized care to patients where they are located, instead of moving them to the coast or larger centre. Lastly, a robust, evidence-based way to move patients to centralized specialized care, when some of the previous suggestions are not practical, needs to be fostered to prevent a continued decline in rural health outcomes.

Nursing and nurses who work in rural areas would like to have a voice in how local healthcare services are developed and implemented. We know our communities, our families and our practice are affected by our location. Bringing forward solutions-based recommendations will strengthen our practice, which will benefit patients, communities and our profession.

michaelsandlerABOUT MICHAEL SANDLER, RN

Michael has been working in various capacities within healthcare for the past 15 years. He recently moved into a more rural setting away from the hustle of the city and has been working with a group of dedicated professionals at improving how and where we deliver rural care.

2 thoughts on “The Challenges of Working in Rural Health, by Michael Sandler, RN”

  1. Lisa D'Alessandro, OT

    Hi Michael,
    Thank you, Michael, for sharing. It is true that rural health care system is in a poor state, and rural population is deprived of necessary health care. It is the responsibility of the government to plan and manage both supply and demand in rural and remote areas. The government must also work with local and state establishments, the public and private health sectors, and universities for both recruitment and retention of health professionals. It is also their responsibility to bring necessary changes in the design features of the health system and its funding for rural areas. Additional incentives to health professionals working in rural areas will also help in recruitment and retention of the workforce.

  2. Karen MacKinnon PhD RN

    I have been studying rural nurses' work in British Columbia and agree with Michael that there are areas of the province where rural health services are being eroded. Decreasing the availability of local services also impacts our clients in a big way, particulalry older clients who may not be able to drive the significant distances required to visit (care for) their loved ones who are receiving care in a larger center.

    I have also examined rural nurses work of providing maternity care which is considered to be an important part of primary health care services (and often many client's first contact with the health care system). I have learned from rural nurses that the fewer births there are in their local community the more concerned RNs become that they will not have the skills needed to work with physicians and midwives to provide this essential service. A vicious cycle is then created where fewer women and families are encouraged to have their babies in a rural or smaller community hospital.

    And yes, when a rural nurse needs a broader spectrum of skills it seem unfair to shift the burden of responsibility onto the individual nurse for paying for all these requirements. I have noticed that communities and employers vary significantly in their willingness to support ongoing professional development for nurses working with rural, remote and indigenous communities.

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