Nursing Practice in Rural and Remote Canada

What is rural nursing?
Rural and remote health care settings in Canada are characterized by the economics, demographics and social structure of the area. According to the Kirby Panel Report (2002), 95% of Canada’s territory is rural and approximately 30% of the population inhabits rural and remote areas (as cited in Nagarajan, 2004). The defining characteristics of rural Canada are outlined in the Kirby Panel Report (2002):
  • includes small towns outside major urban areas in addition to rural and remote communities (as cited in Nagarajan, 2004)
  • rural populations are declining—younger generations search for greater opportunities for education and work elsewhere and older adults search for better long-term care facilities (as cited in Nagarajan, 2004)
  • rural populations near urban centres or in recreational areas are increasing (as cited in Nagarajan, 2004)
  • higher unemployment rates and lower educational levels (as cited in Nagarajan, 2004)
Life expectancy is shorter and infant mortality rates are higher in rural areas compared to the rest of Canada (Chenier, 2002). Overall, the health of rural residents is worse than that of urbanized areas (Nagarajan, 2004). The Romanow Commission Report states that rural and remote areas are “not a single, homogeneous population,” (Nagarajan, 2004). The population is diverse in age, gender, and ethnicities; therefore, nursing practices still require specialized skills. The minimal support and resources make rural nursing an exigent and challenging profession necessitating a wide range of knowledge and experience. On occasion, rural nurses require a little creativity in dealing with unique situations where they may find themselves the primary caregivers. Rural and remote nurses practice in isolation; therefore, they must also be self-motivated and exhibit initiative. Unfortunately, the complexity and responsibility of these professionals remains unacknowledged. The minimal funding received from the federal government is insufficient. This in turn puts the health of almost one third of Canadians at risk. (Ashley)

What difficulties do they face?

Nurses working in rural areas face many challenges. Isolation may hinder communication as patients may be unfamiliar with medical terminology generally understood in urban areas. Similar to culturally sensitive nursing outlined by Leininger (2002), a nurse entering the rural nursing profession must be prepared with knowledge and experience prior to entering the placement in order to satisfy the different needs of their patients. Patients from rural areas operate differently compared to urbanized communities. Due to the lack of citizens in these remote areas, nurses do not receive the recognition they deserve. They are often considered “invisible” compared to nurses working in urbanized areas (Macleod, 1999, p. 168). Rural nurse receive little recognition which may lead to a lack of confidence in their profession and inaccurate care (Macleod, 1999, p.168). Many nurses feel busier, urban areas offer greater employment opportunities.

Policies and standards mainly focus on urbanized areas which are unsuitable for rural settings (Macleod, 1999, p.168). This causes inaccurate levels of care to be administered as the overlooked policies for rural nursing are put into the same category as urbanized guidelines. Rural nursing deserves an individual set of policies to account for their unique health care setting. Possible candidates are drawn away from this career as there are very few job opportunities available for accompanying spouses. Rural nurses hardly fall under the radar, contributing to the lack of interest in nursing in those areas. It has been found that job availability and preferences for particular health care agencies or communities are influencing factors in a nurse’s decision for employment (Macleod, 1999, p. 167). Encouraging members of rural and remote communities to enter the health care field would minimize the nursing shortage in those areas.


Rural health experts developed a research agenda on key health care issues facing rural Americans. These issues are:
  • access to care
  • supply of primary care physicians and other health care providers
  • health promotion and disease prevention
  • health care technology
  • organization of services for vulnerable rural populations
  • consumer choice and the rural hospital (AHCPR, 1996)

In days gone by, limited resources presented the greatest challenge for rural nurses. Underserved rural areas are geographically vast with a wide range of unique patients. The rural nurse needed to be well informed for various cases; this is much easier today with access to the internet. The use of health information technology has improved the situations for nurses and patients in rural areas.

Unfortunately, many remote communities do not have funds for higher pay. More government support is needed for financial concerns in these communities to increase the number of facilities, education and training opportunities in such places. Sometimes, even the basic needs of food and water cannot be met in underserved communities.

Nurses truly enjoy a leadership role in rural communities i.e. health promotion in proper nutrition and exercise for school-aged children and awareness of online journal information regarding health for all ages. They are involved in training local community members to assist health care workers.

Rural Nursing Demographic Data -------------------------------------Reasons Students Choose Rural Nursing

Rural_Nursing_demographic_Table.gif Major_Factor.gif

(LEFT)In a demographic data sample, 63% of graduate and 37% of undergraduate students coming from rural areas, of which 91% are from USA and 9% from Canada, chose to practice in a rural setting. The proportion of Canadian responses was notably low; however, this number reflected the demographic makeup of conference attendees (Bushy & Leipert, 2005).

(RIGHT)Figure 1 - (Part A) highlights thematic findings from the survey in which respondents identified personal , professional , and financial factors that influenced their career choice. (Bushy A, Leipert BD, 2005).
Figure 1 - (Part B) also highlights major themes of the anticipated challenges in rural nursing practice; specifically, contextual features of rural environments, professional realities of rural nursing, and patient related considerations (Bushy A, Leipert BD, 2005).
For Figure 1 - a general description of the common themes will be presented, interspersed with relevant quotes as submitted by the respondents on the completed surveys. (Bushy A, Leipert BD, 2005).

Preparing nurses for rural practice
Successful nurses in rural practice must be able to evaluate communities’ health needs. To achieve this, requires a good understanding of morbidity and survival rates, as well as, the development of suitable nursing care for individuals and communities with different needs and resources. Nursing educators must make students aware of special demands of rural practice. They must identify specific needs and be aware of the constraints of fewer available resources to creatively plan a range of care within local social norms. As well, students need to be attentive to increased responsibility which may require new strategies to effectively deliver care in remote and sparsely populated rural areas. If, while training, students are exposed to the special challenges and rewards encountered in rural settings, more nurses would choose these posts and would possibly stay long-term.

    Bushy A, Leipert BD.(2005). Factors that influence students in choosing rural nursing practice: a pilot study. Rural and Remote Health. Retrieved from

    Chenier, N.M. (2002, October 24). The federal role in rural health. Retrieved from

    Effken, J. & Abbott, P. (2009). Health IT-enabled Care for Underserved Rural Populations:
    The Role of Nursing.
    Journal of the American Medical Informatics Association 16(4) pp.439-445

    Improving Health Care for Rural Populations . Research in Action Fact Sheet. AHCPR Publication No. 96-
    P040, March 1996. Agency for Health Care Policy and Research, Rockville, MD.

    Institute of Medicine (IOM) (2004). Quality through collaboration: The future of rural health. Washington, DC: National Academy Press. Retrieved from http://www.iom.ed u/?id=29734

    Leininger, M. (2002). Culture care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13(3), 189-192.

    MacLeod M. We’re It: Issues and realities in rural nursing practice. Chapter 8. in Ramp W, Kulig J, Townshend I and McGowan V Eds. Health in Rural Settings: Contexts for Action. Lethbridge: School of Health Sciences, University of Lethbridge, p. 165 to 178, 1999.

    Nagarajan, K.J. (2004). Rural and remote community health care in canada: beyond the kirby panel report, the romanow report and the federal budget of 2003. Canadian Journal of Rural Medicine, 9(4), Retrieved from