Mental health nursing practice in rural and remote Canada: Insights from a national survey

Introduction

While mental illness is a significant cause of morbidity globally (Steel et al. 2014), rural and remote communities are disproportionately impacted by mental health concerns and face unique barriers to accessing timely mental health services (Beks et al. 2018; Canadian Institute for Health Information [CIHI] 2019; Happell et al. 2012; Mental Health Commission of Canada 2020). Internationally, mental healthcare in rural areas is described as disjointed and inconsistently funded, sporadic, and prioritizes acute management (Perkins et al. 2019). In Canada, people in rural and remote areas often need to travel great distances to access the healthcare they need, with some having to rely on ice roads, seasonal ferries, or roads that are impassable in winter and spring. Indigenous peoples face unique needs for mental health services due to complex intergenerational trauma created by Canada’s colonialist history and ongoing oppressive policies and discrimination (Mental Health Commission of Canada 2020).

The need for mental health services has intensified during the COVID-19 pandemic given the increased likelihood of individuals with long-term conditions manifesting mental health symptoms (Buneviciene et al. 2021) along with reduced access to mental health services due to system strains (Warfield et al. 2020) and geographical limitations in rural and remote areas (Lyne et al. 2020; Moffitt et al. 2020; Summers-Gabr 2020). The COVID-19 pandemic has also strained the resources available to rural and urban mental health providers, as well as increased occupational demands related to workload and service adaptations, leading to an increased risk of burnout and turnover (Sklar et al. 2021).

Mental health services and supports in rural and remote communities are shaped by the availability of generalist and specialized health human resources, as well as a complex interplay of factors including cultural inequities, socio-economic conditions, and stigma associated with mental illness and seeking psychological help (Beks et al. 2018; Caxaj 2016; Crowther & Ragusa 2011; Happell et al. 2012; Hirsch & Cukrowicz 2014). Nurses are central providers of healthcare services in these settings, including mental health illness prevention, treatment of mental health disorders, and mental health promotion (Beks et al. 2018; Happell et al. 2012; Huy et al. 2018; Kidd et al. 2012). Although access to mental health services (CIHI 2019) and information about nurses who specialize in mental wellness are increasing (CIHI 2019; Sutarsa et al. 2021), the nursing workforce who provides mental health services throughout rural and remote Canada is not well understood.

Aim

The aim of this study is to explore the characteristics and context of practice of the regulated nurse workforce in rural and remote areas of Canada, who provide care to those experiencing mental health concerns.

In Canada, the delineation of rural and remote is still in flux, unlike Australia, for example, where urban, rural, and remote areas are classified in terms of accessibility (Subedi et al. 2020). Among Canadian nurses, the term, ‘rural and remote’, is seen to be more encompassing than rural alone (Kulig et al. 2008). In this study, rural and remote refer to all rural settings, defined as being outside the commuting zones of communities with a population of 10 000 (du Plessis et al. 2001) and all settings in the three northern territories (Yukon, Northwest Territories, and Nunavut).

Background

The nursing workforce providing care for those with mental health concerns varies across the world. For example, in Australia approximately 7% of registered and enrolled nurses provide mental health services, working principally as mental health nurses and of those, over 85% are registered nurses (Australian Institute of Health & Welfare [AIHW] 2021). In Canada, registered nurses (RNs), nurse practitioners (NPs), and licensed practical nurses (LPNs) provide mental healthcare in all 10 provinces and 3 northern territories. Registered psychiatric nurses (RPNs) are regulated nurses in the four western provinces (Manitoba, Saskatchewan, Alberta, British Columbia) and one northern territory (Yukon).

Education for mental health nursing varies internationally, with some countries, such as Australia and the United Kingdom, providing undergraduate registered nurse programmes with a specialization in mental health nursing. In Canada, nurse education is generalist in nature, with the RPN programme offered only in the four western provinces. Entry to practice for RPNs in Canada is a 2-year diploma with both diploma and baccalaureate programmes available (CIHI 2020).

In 2019, in Canada, 6.6% of regulated nurses (2.6% of NPs, 5.5% of RNs, 4.8% of LPNs, 100% of RPNs) specialized in mental health or worked in mental health facilities (CIHI 2020). In both Australia and Canada, countries with highly dispersed populations, a lower proportion of nurses work in mental health in more rural and remote areas (AIHW 2021; CIHI 2019; Sutarsa et al. 2021).

In rural and remote areas, nurses assume critical roles in the delivery of healthcare services and practice across many settings, from dedicated acute care facilities to geographically isolated community clinics and outposts (Berry 2018; Jansson & Graneheim 2018). Rural and remote nurses provide care to varied patient populations, often practising in relative isolation, with limited access to specialized resources, professional supports, and training (Beks et al. 2018; Kidd et al. 2012; Moore et al. 2010; Skinner & Phillip 2010).

Ready access to a range of appropriately resourced and trained mental health professionals in rural and remote communities is often absent (Beks et al. 2018; Caxaj 2016). As a result, nurses in rural general acute care are considered the ‘front line’ providers (Beks et al. 2018) for patients presenting with acute or long-term mental health concerns (Kidd et al. 2012; Reed & Fitzgerald 2005). Many rural and remote nurses report having limited resources and a lack of confidence in their skills to help people seeking mental health support (Beks et al. 2018; Happell et al. 2012; Huy et al. 2018; Jansson & Graneheim 2018; Link et al. 2019). They report personal and professional challenges in providing psychosocial care overall (Kenny & Allenby 2013), often feeling isolated, unprepared, and unsupported when delivering care to persons living with a mental health concern (Crowther & Ragusa 2011).

A continuing and increasing problem expressed by rural and remote nurses and those caring for persons with mental health issues, is their experience of violence and aggression (Havaei et al. 2020), including ongoing concerns about personal safety (Jahner et al. 2020; Lenthall et al. 2018; Wressell et al. 2018) and when transporting patients from isolated settings (Beks et al. 2018; Jansson & Graneheim 2018; Soomaroo et al. 2014). Nurses consistently identify the need for concrete practice supports, along with continuing education on how to assess and manage patients with diverse mental health needs (Beks et al. 2018; Jahner et al. 2020; Lenthall et al. 2018; MacLeod et al. 2008; Moffitt et al. 2020; Perkins et al. 2019; Skinner & Philip 2010).

Despite a growing body of literature exploring the rural and remote nursing workforce and related practice issues, little is known about the nurses who provide care to persons living with mental health concerns and their practice settings. Without this knowledge it will be challenging to appropriately tailor supports for nurses in both specialized and generalized settings, as well as plan for a sustainable mental health workforce in rural and remote communities. To make advances on this knowledge gap, this study explored the characteristics and context of practice of rural and remote RNs, LPNs, and RPNs in Canada who provide care to those experiencing mental health concerns.

Methods Research design

The data in these analyses were accessed from the Nursing Practice in Rural and Remote Canada (RRNII) pan-Canadian cross-sectional survey of regulated nurses residing in rural and remote communities (MacLeod et al. 2017). Full details on the RRNII method, survey questionnaire development, and sampling frame are available in MacLeod et al. (2017). Ethics approvals were gained from six universities and three territorial organizations. Each participant provided informed consent. The STROBE Checklist was used as the reporting guideline for the study.

Study setting and participants

From a systematically stratified target sample of 10 072 nurses, 9622 nurses were eligible to participate (450 were ineligible due to incorrect address or working urban), with a total of 3822 completed surveys returned for a statistically significant response rate of 40% (3822/9622) from all provinces and territories. The sample was comprised of RNs, LPNs, and RPNs in rural and remote communities in all 10 provinces, all NPs in rural and remote communities, and all regulated nurses in the 3 northern territories. The sampling frame was designed to achieve statistically significant (confidence level of 95% and a margin of error of 0.05) results provincially, territorially, and nationally.

Respondents worked in the full range of practice settings including primary care, acute care, community health, home care, mental health and addictions, and long-term care. The subsample (N = 3457) for the present analysis consisted of rural and remote RNs (n = 1937), LPNs (n = 1313), and RPNs (n = 207) employed as staff nurses, managers, and clinical nurse specialists who indicated that mental health was an area of current practice. Due to small sample sizes, NPs and nurses who were retired and occasionally employed in nursing were excluded from this analysis.

Data collection

The survey was mailed with the assistance of the provincial and territorial nursing regulatory bodies between June 2014 and August 2015. The Dillman method was adopted, including repeated follow-up (Dillman et al. 2014), with both paper and online survey formats available in English and French.

The comprehensive (91 item) survey questionnaire of the RRNII study (MacLeod et al. 2017) was informed by a previous national survey (Stewart et al. 2005) and was developed by the 16-member research team and a 19-member advisory group of nurse leaders in rural and remote practice and policy from all provinces and territories. Areas examined in this analysis were individual (demographic and professional), work community characteristics, practice responsibilities, and workplace factors. The selection of the study variables was informed by our previous analysis (MacLeod et al. 2017), as well as insights garnered from the advisory group and contemporary literature. Variables chosen were individual variables (nurse type, age, gender, current primary position, primary place of employment, province/territory of residence); work community characteristics (population size, distance from advanced referral centre); practice responsibilities (promotion, prevention, and population health/mental health programmes; assessment/mental health assessment); and workplace factors (job resources, job demands, experience of violence, witness to violence).

In relation to the occupational stress and motivational research traditions (i.e. Job Demands-Resources Theory) (Bakker & Demerouti 2017), overall job-related resources and job-related demands were measured with the 24-item Job Resources in Nursing (JRIN) Scale and the 22-item Job Demands in Nursing (JDIN) Scale (Penz et al. 2019). The JRIN had total summated scores ranging from 24 to 120, interpreted from low (24–56), medium (57–88). and high (89–120) levels of work-related resources. Similarly, the JDIN’s total summated scores ranged from 22 to 110, interpreted as low (22–51), medium (52–80), and high (81–110) levels of work-related demands. The mean score for each of the six subscales within each scale was interpreted from a low level of agreement on that particular subscale (1.0–3.0) to a high level of agreement (>3.0) consistently with the originally published version of the scales (Penz et al. 2019).

Analysis

Quantitative data were analysed with IBM SPSS Statistics 24. Sample characteristics were examined with descriptive statistics (frequencies and proportions). Group differences were evaluated with the χ2 test for categorical variables and Student’s t-test for interval variables, and z-tests for significance (P < 0.05). A total of 132 responses (ranging 61–511 words each) from an open-ended question asking what it means to be a nurse in rural and/or remote Canada were analysed for similarities and differences, coded, and organized into broad categories using a codebook. The most common challenges and concerns regarding provision of mental health services and the context of this care in rural and remote communities were identified.

Results

A total of 9.8% (n = 338) of the sample of registered nurses (RNs), licensed practical nurses (LPNs), and registered psychiatric nurses (RPNs) indicated mental health as their sole area of practice or one of their areas of practice from a list of nine practice areas. The responses were clustered into two distinct groups. One group (n = 182; 5.3%) comprised nurses who indicated their area of practice to be mental health only. The second, mental health plus group, (n = 156; 4.5%) included nurses who indicated their area of practice to be mental health and at least one other area of practice, most frequently, acute care, hospice/end of life/palliative care, or long-term care (See Fig. 1). Over half of the mental health only group were RPNs (54.4%, n = 99), followed by RNs (32.4%, n = 59), then LPNs (13.2%, n = 24). Close to half of those within the mental health plus group were RNs (46.8%, n = 73), followed by LPNs (30.8%, n = 48), then RPNs (22.4%, n = 35). Of the total sample of 134 RPNs, 73.9% (n = 99) were in the mental health only group and 26.1% (n = 35) were in the mental health plus group. Of the 132 RNs, 44.7% (n = 59) were in the mental health only group and 55.3% (n = 73) were in the mental health plus group. Of the 72 LPNs, 33.3% (n = 24) were in the mental health only group and 66.7% (n = 48) were in the mental health plus group.

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Areas of practice for Registered Nurses (RNs), and Licensed Practical Nurses (LPNs), and Registered Psychiatric Nurses (RPNs), who worked in mental health plus one or more other areas of practice.

Characteristics of nurses

The majority of nurses who described their area of practice as mental health only or mental health plus other areas were female, over 44 years of age, and held a staff nurse position (Table 1). Mental health only nurses were significantly more likely to be over the age of 54, while mental health plus nurses were more likely to be in the 35–44 year age range. Significant differences were found in place and region of employment. Most of the mental health only nurses were employed in mental health or crisis centres (50.3%) or hospitals (34.8%), while most of the mental health plus nurses were employed in a hospital (47.4%) or in primary care (23.4%). More mental health only nurses worked in the four western provinces where RPNs were registered (Manitoba, Saskatchewan, Alberta, and British Columbia); and more mental health plus nurses worked in the three northern territories (Yukon, Northwest Territories, Nunavut). There were also significant differences in both size of community and distance to advanced referral centre. Relatively few mental health only nurses worked in a community with a population of less than 1000, with most working in communities with over 10 000 people. Subsequently, more of the mental health only nurses were in closer proximity to an advanced referral centre. In reference to comparing services provided between the two groups, significantly more nurses in the mental health only group provided mental health programmes (e.g. education, wellness groups, support groups) in their nursing practice, and were responsible for mental health assessments (e.g. addictions, depression, suicide, committal).

Table 1. Characteristics of nurses who describe their area of practice as mental health only or mental health plus other areas Variables

Mental health only

n = 182 n (%)

Mental health plus

n = 156 n (%)

Chi-square

P-value

P-value by category (z-test) Gender 0.992 Male 26 (14.6) 22 (14.6) Female 152 (85.4) 129 (85.4) Age 0.027 <35 29 (15.9) 36 (23.1) 0.09692 (−1.6611) 35–44 24 (13.2) 36 (23.1) 0.01778 (−2.3722) 45–54 55 (30.2) 37 (23.7) 0.18024 (1.3388) >54 68 (37.4) 42 (26.9) 0.04136 (2.0421) Province/Territory <0.001 Provinces with RPNs 119 (65.4) 64 (41.0) <0.00001 (4.4805) Provinces without RPNs 50 (27.5) 52 (33.3) 0.242 (−1.1702) Northern territories 13 (7.1) 40 (25.6) <0.00001 (−4.6626) Primary position 0.285 Manager 18 (9.9) 24 (15.4) Staff Nurse 148 (81.3) 121 (77.6) Clinical Nurse Specialist 16 (8.8) 11 (7.1) Area of current practice Acute care 91 (58.3) Primary care 46 (29.5) Community health 51 (32.7) Long-term care 62 (39.7) Home care 30 (19.2) Hospice/End of life/Palliative care 68 (43.6) Mental health 182 (100.0) 156 (100.0) Other 30 (19.2) Place of primary employment <0.001 Primary care 17 (9.4) 36 (23.4) 0.00046 (−3.4954) Mental health centre/Crisis centre 91 (50.3) 17 (11.0) <0.00001 (7.6577) Hospital 63 (34.8) 73 (47.4) 0.01928 (−2.3397) Nursing home or long- term care facility 5 (2.8) 15 (9.7) 0.00714 (−2.6864) Community-based health care and other 5 (2.8) 13 (8.4) 0.02144 (−2.2974) Population of primary work community 0.003 < 999 11 (6.1) 20 (13.2) 0.029 1000–9999 83 (46.4) 85 (55.9) 0.084 ≥10000 85 (47.5) 47 (30.9) 0.002 Distance to advanced referral centre <0.001 0–99 km 41 (23.2) 24 (15.8) 0.095 100–199 km 58 (32.8) 34 (22.4) 0.036 200–499 km 47 (26.6) 35 (23.0) 0.459 500–999 km 15 (8.5) 20 (13.2) 0.171 ≥1000 km 16 (9.0) 39 (25.7) <0.001 Promotion, prevention, and population health Mental health programmes 163 (89.6) 99 (63.5) <0.001 <0.001 Assessment Mental health 167 (91.8) 112 (71.8) <0.001 <0.001 Violence Experienced violence 104 (58.8) 85 (56.3) 0.652 Witnessed violence 108 (61.0) 95 (63.8) 0.611 T-Test Means (SD) JRIN summated 82.26 (12.83) 78.42 (12.14) 0.008 JRIN subscales Supervision, recognition and feedback 3.42 (0.99) 3.22 (0.96) 0.064 Collegial support 3.96 (0.73) 4.01 (0.64) 0.456 Staffing and time 3.13 (0.87) 2.80 (0.89) 0.001 Technology 3.32 (0.76) 3.23 (0.83) 0.331 Training, PD, continuing education 3.19 (0.82) 3.00 (0.86) 0.043 Autonomy and control 3.51 (0.76) 3.38 (0.78) 0.111 JDIN summated 50.96 (10.26) 52.29 (9.85) 0.311 JDIN subscales Work-related travel 2.41 (0.88) 2.45 (0.94) 0.713 Preparedness/Scope of practice 2.36 (0.43) 2.40 (0.44) 0.375 Equipment and supplies 2.36 (0.77) 2.51 (0.80) 0.091 Isolation 2.19 (0.72) 2.31 (0.71) 0.125 Comfort with working conditions 2.63 (0.72) 2.82 (0.66) 0.012 Safety 2.68 (0.78) 2.77 (0.86) 0.320 Blank cells indicate Not Applicable. Bold font indicates significance level of p ≤ 0.05 † Independent samples t-test, two-tailed significance with equal variances assumed.

The average summated scores for the JRIN and JDIN scales indicated medium work-related resources and medium work-related demands overall for both groups. That is, resources were not critically low and demands were not critically high for both groups. Small, but significant differences between groups on particular subscales were noted. The nurses in the mental health plus group had significa

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