1. Nursing Care Management of Dying Persons in Rural & Urban Areas of Ontario May 19, 2010 Sharon Kaasalainen, RN, PhD

2. Project Team Members Co-Principal Investigators: Sharon Kaasalainen & Kevin Brazil (McMaster University) Co-Investigators: Denise Marshall, Kathleen Willison & Alan Taniguchi (McMaster University), Donna Wilson (University of Alberta), and Lise Fillion (Université Laval)

3. Background Nursing plays a key role in the coordination and delivery of palliative care services in rural and urban settings However, rural nurses are faced with many unique challenges: – difficulty separating their personal and professional lives – working alone in very isolated roles – having limited access to continuing educational opportunities

4. Background Nurses need to be equipped with adequate knowledge and tools for decision-making to provide quality palliative care to rural and urban clients MacLeod et al. (2004) found that there were lower proportions of rural nurses with advanced education compared to urban nurses who were employed in clinical support roles

5. Research Purpose To examine the role of community nurses in the delivery of palliative care services for rural and urban populations →compared differences between rural and urban nurses related to: (1)current level of involvement and practice patterns related to palliative care (2)extent of interdisciplinary collaboration (3)job satisfaction (4)self-efficacy in palliative care (5)barriers and facilitators to providing palliative care

6. Methods: Design Exploratory cross-sectional survey design that included both quantitative and open-ended questions

7. Screening Question: Definition of Rural A community that is located at least 80 kilometers away from the nearest large (i.e., population of 100,000 or more) city; or A community that is considered to be sparsely inhabited (i.e., less than 150 persons per square kilometre); or A community with a population of 10,000 or less → Based on this definition, how would you describe yourself? □ All of my clients live in rural settings □ Most of my clients live in rural settings □ Some of my clients live in rural settings □ None of my clients live in rural settings *

8. Methods: Recruitment & Procedure Nurse managers from Victorian Order of Canada (VON) identified ‘high rural’ and ‘high urban’ nurses Mailed a postal survey along with a $5 gift certificate Modified Dillman approach – 2 follow-up contacts at the end of weeks 2 and 4 (2 nd copy) Survey took approximately 20 minutes to complete

9. Results: Sample 159 community nurses completed the survey; 60% response rate – 84 rural nurses & 75 urban nurses Nurses were primarily Registered Nurses (67%) over 46 years of age (59%) 61% of nurses reported having some palliative care training, mostly in-house training (36%)

10. Results: Practice Patterns Both rural and urban nurses reported – Spending almost a third of their time providing palliative care – Being most active in assessing pain and other palliative symptoms – Assisting clients and their families to access and navigate the health care system – Supporting clients and their families in making decisions related to location of death Rural nurses spent significantly more time in travel than urban nurses (t=2.66, p=0.01)

11. Results: Management of Palliative Symptoms Nurses reported that pain was the symptom that they managed most often; followed by irregular bowel functioning, and fatigue No significant differences between rural and urban nurses related to how often they managed palliative symptoms

12. Results: Interdisciplinary Collaboration & Job Satisfaction Urban nurses reported that interdisciplinary collaboration occurs to a larger extent in their practice environment than rural nurses Both urban and rural nurses reported being – fairly satisfied with their current job – less satisfied with the extent of their interdisciplinary collaboration

13. Results: Self-Efficacy in Palliative Care Rural nurses reported being significantly more confident in their ability to provide palliative care than urban nurses (t=1.95, p<0.05) – Rural nurses were more confident in their ability to: communicate with others related to palliative care issues (t=2.16, p=0.03), and engage in patient management activities related to palliative care (t=2.86, p=0.01) compared to urban nurses

14. Rural Travel distance & time Bad weather conditions MDs lack training in palliative care No home visits from MD Nursing shortage Poor accessibility to equipments, medications & services Isolation of client at home Urban Fewer relationships between patients and the care providers because of larger amount of clients to care for Less time spent with each client Lack of family doctors Lack of transportation Inadequate knowledge base Results: Barriers to Providing Optimal Palliative Care

15. Rural Good support from family, friends & neighbours Close-knit social network Physicians who make house calls Palliative care volunteers Local Community Care Access Center (CCAC) Urban More services available & closer to them better continuity of care Access to experts in palliative care Results: Facilitators to Providing Optimal Palliative Care

16. Conclusions Rural and urban nurses had similar roles in palliative care but rural nurses spent more time in travel and were more confident in their ability to provide palliative care Study results may help develop strategies to better equip nurses with the knowledge, tools, and skill sets that they need in order to provide specialized and quality palliative care in an informed and competent manner

17. Next Steps Phase 2 Complete qualitative study using grounded theory approach to explore how nurses manage palliative care clients in rural and remote settings at a more indepth level

18. Thank you Sharon Kaasalainen kaasal@mcmaster.ca