By Megan Kirk, PhD Candidate, University of Victoria, ISECN Regional Coordinator for North America
A team of researchers at the University of Victoria in Victoria, British Columbia, Canada have been studying the implementation and impact of public health renewal in two Canadian provinces, British Columbia and Ontario, since 2009. This program of research, now titled “Research in Public Health Systems and Services” (RePHSS), is led by Drs. Marjorie MacDonald, Trevor Hancock, and Bernie Pauly. My dissertation research fits within this broader program of research, but focuses on how the implementation of public health renewal in British Columbia has specifically impacted public health nursing practice.
In order to put my dissertation research into context for readers unfamiliar with the health system in British Columbia, health services are provided by five regional and two provincial health authorities. Health authorities are responsible for the organization and delivery of health services, including public health services. Public health in the province is integrated into the larger health care system. Since the early 2000s, public health renewal has been taking place across the province. This was initiated by the development and implementation of the Core Public Health Functions, which identify the essential functions of public health.
What I have found missing in many of the public health renewal conversations, which focus on the ability of the public health system to adequately meet the health needs of the population, is the role and contribution of public health nurses within the system. Public health nurses work towards preventing disease, promoting population health, and reducing health and social inequities. Given that public health nurses are the largest component of health professionals in the Canadian public health workforce, it is important to have a better understanding of how recent public health renewal changes have impacted their services. To date, there is little research investigating how the implementation of public health renewal has been experienced on the front-lines of public health practice.
Public health nurses in Canada are guided by The Canadian Community Health Nursing Standards of Practice (Community Health Nurses of Canada, 2011) – commonly referred to as “The Standards” – which help to define the scope and depth of their practice. This document helps to explicate how their role and activities continually evolve to meet the needs of different individual and population groups. Public health nurses partner with community members and agencies to address conditions affecting the health status of community members. There are seven standards of practice outlined in this document, the first of which is health promotion, the core pillar that unites our work together in ISECN.
I began data collection for my dissertation research in January of this year and am currently finishing up the last few interviews with public health nurses. I have interviewed 30 public health nurses and managers from across three regional Health Authorities in British Columbia, providing a diversity of perspectives through the local contexts in which public health nurses work. For instance, I interviewed public health nurses who work anywhere from a one-nurse office in a rural town to a team-based setting in large city centers, and experiences ranging across numerous public health programs. In my analysis to date, I have used constant comparison to generate high level themes to get a sense of my preliminary research findings. I hope to offer an initial sense of key ideas that are emerging early on in my analysis of the qualitative interviews.
Public health nurses spoke to the nature of organizational change that they have experienced since the beginning of public health renewal in the province. They expressed how the way in which organizational and program changes are communicated and implemented within the health setting is important. Public health nurses felt respected when they were included in and consulted about program and service changes. This process was much more empowering and the changes were more likely to be embraced by the nurses. Unfortunately, this was not often found to be the case with recent organizational change. The continuous change over in management witnessed by nurses and the shifting nature of priorities greatly impacted public health nurses in their practice. They explained how often even before one program gets off the ground, restructuring takes place and everything they were working on comes to a halt. The nurses expressed concern over how their practice has become increasingly centered around the demands of the system and not the clients themselves. Changes seem to reflect the needs of the system, not the needs of clients.
Overlapping with the nature of organizational change is the second theme: the quality of healthcare leadership. This theme was key for public health nurses in my study. Public health nurses spoke to the experience of having leadership that understood and supported the nature of public health nursing practice, and would advocate on their behalf. It was this form of leadership, where nurses saw the manager as a leader, that garnered respect and more understanding when things didn’t go as planned or desired. On the flip side, public health nurses were frustrated when managers were hired to lead them but didn’t understand their practice, and were constantly questioning them about the importance and meaning of their work.
Public health nurses spoke with great concern over the changing nature of their practice. Across all three Health Authorities in British Columbia, public health nurses reported on the increasing standardization of the programs and services offered, with lessening flexibility to respond to community needs as they arise. They expressed concern over the decline of collaboration with community partners that were not deemed an important part of their work. This concern is rooted in the fact that their practice is reflecting less of the community need, and instead is becoming prescriptive, top down, and system driven. They believe that in order to effectively improve population health they need guidance and support in implementing standardized programs, but require enough flexibility to attend to needs in diverse settings. There seems to be less room for big picture thinking in addressing community needs and more time allocated to scheduled clinic hours and program administration. Many public health nurses experienced varying levels of ethical distress in witnessing community need and yet feeling unsupported in addressing the concern.
Public health nurses expressed a variety of common ways of coping with recent practice changes. Some nurses who were close to retirement have opted for this route instead of staying in an organization where they often feel discredited for the knowledge and expertise that they have. Some expressed that they are ready to move on to another nursing position where they would wish to feel more autonomy in their practice. Others have expressed the desire to stay and wait for the opportunity to fight for their practice, which they firmly believe in. Public health nurses were frequently feeling demoralized by how their practice has been undercut in a variety of ways. Many times, they spoke to going underground with their activities that leadership deemed unimportant and not part of their role.
Public health nurses need to be valued for the knowledge and expertise that they bring to the table. They have been historically viewed as part of the community fabric and it is this level of integration that offers public health nurses insight into addressing community need. Public health nurses are an important means to healthier communities through their ability to recognize unmet needs and their position to advocate for change to improve health and reduce inequities. They are struggling within the current climate of health care decision making and budget cuts to public health in British Columbia. In the end, they want the system to act as a compass to guide their work but desire the flexibility to use their nursing judgement to address issues as they arise. Public health nurses offer local knowledge and represent marginalized voices that, if captured, have the potential to continue to strengthen our health system.
Community Health Nurses of Canada. (2011). Canadian Community Health Nursing Professional Practice Model & Standards of Practice. Toronto, ON: Author.
Published: May-August 2016, HPC