Evaluation of Clinical and Client Care Program 2012-2013 to 2016-2017

Immediate Outcome #1: First Nations individuals, families and communities have access to Clinical and Client Care Services (including federal hospitals).

Most health professionals surveyed agreed that First Nations individuals, families and communities have access to the clinical and client care they need in the communities. According to nursing inventories conducted in 2016, all R/I communities have access to essential clinical and client care during regular weekday hours (8:30 to 17:00 Monday to Friday), and urgent services after hours delivered by health care professionals on-call. The regular hours of operation may vary slightly across the nursing stations. Some stations close occasionally, providing emergency only services during staff rotation or on days when they are short staffed.

Of the 368,374 visits reported to Health Canada-managed CCC services in nursing stations and health centres with treatment across the four regions in 2015-16^{Footnote 11}, 63 percent were made during regular hours and 37 percent occurred after-hours. While after-hour services are provided to ensure that R/I communities have access to urgent care, program utilization data indicates that only 15 percent of after hour visits were urgent (urgency of after-hour services varied across the regions, from 95 percent in Alberta to 33 percent in Ontario and 10 percent in both Quebec and Manitoba^{Footnote 12}).

According to data from approximately 19 communities with First Nations-managed CCC services, the severity of cases seen in 2013-14 compared to 2014-15 has decreased. In 2013-14, one-third of the 156,000 visits accessed urgent care services, compared to less than one-fifth of the 130,000 visits in 2014-15 qualifying as urgent care.^{Footnote 13}

Visitation data for the two federal hospitals indicate that there were about 7,900 visits annually to the PEMH over the past two years (2015-16 and 2016-17), while the Norway House Hospital has admitted an average of approximately 500 patients annually providing for an occupancy rate of about 50 percent^{Footnote 14}. Non-urgent care accounts for over 60 percent of the visits to PEMH, with the demand attributed, by hospital representatives, largely to a lack of physicians in surrounding health clinics and rural hospitals (e.g., diversion from surrounding communities, clients prefer to access a physician at the hospital due to waiting times at the clinic). According to the hospital representatives, wait times at the hospitals vary depending on the level of acuity of conditions patients are presenting with, which are currently considered to be reasonable. In a survey, conducted by PEMH in February 2017, 42 percent of 49 emergency room patients indicated that their condition was always or usually addressed by a physician within one hour of their presentation to the Emergency Room, 34 percent said sometimes, and 16 percent said never. The average wait time for the Norway House Hospital from arrival at the Emergency Department to admission was 3.3 hours in 2015-16, which is skewed by the large numbers of non-urgent cases. A study of Emergency Room wait times in Winnipeg hospitals shows that emergency department wait times for a small number of patients (10 percent of non-urgent visits) are long (at least 4.7 hours), while the more urgent cases, experience wait times of approximately 42 minutes.^{Footnote 15}

In response to questions about whether R/I First Nations communities have access to services comparable to those in other similar communities, most key informants argued that there are no other similar communities. Communities served by the CCC program are unique in their challenges, particularly with respect to the degree of geographic isolation and accompanying transportation issues (65 percent of health professionals surveyed identified transportation issues as constraining access to services)^{Footnote 16}, the model of care (nurse vs. physician-driven), access to diagnostic tools (e.g., point of care), the involvement of multiple levels of government in the delivery of services (e.g., the federal government, provincial government, and the band), the social determinants of health, infrastructure, and historical circumstances. Some key informants argued that any efforts to assess comparability should focus on equality of outcomes rather than achieving comparability of resources with the provincial systems. Given differences in the challenges faced by R/I First Nations communities, it was argued that equality of resources will not result in equality of outcomes.

A comparability of access study conducted by Health Canada using a sample of three communities meeting similar criteria, across three regions, concluded that access to services in First Nations remote communities was comparable, on most measures, to those provided in provincial rural communities. The study found that the nurse-to-population rate was generally higher in Health Canada facilities. However, the physician-to-population rate and visiting physician hours were lower in First Nations communities.^{Footnote 17} Access to physicians varies depending on the needs and remoteness of the communities, and is negotiated with provincial partners. Most health professionals surveyed as part of the evaluation identified long waiting times to access other health professionals or specialists (82 percent) or physicians (65 percent) as factors constraining access to care in the communities. In one of the communities assessed as part of the Quality Improvement Onsite Assessment, there was a two-month wait time to see a physician in the community. Nearly all community members and health professionals, interviewed as part of case studies, expressed concerns regarding access to physicians and other health specialists, particularly mental health professionals. Most key informants, including nearly all health directors interviewed, emphasized the challenges with respect to accessing mental health professionals and provincial mental health services, including difficulties scheduling appointments. Similar concerns were noted in regional 'Key Issues and Deficiency' documents (2016), which highlight challenges in accessing the resources needed to address acute mental health care issues (e.g., grief, acute anxiety, domestic violence, suicidal ideation with no plan, substance abuse).

While the Health Canada comparability of access study found that the nurse-to-population rate was higher in the communities where CCC programming is offered, the majority of key informants indicated that there is still a nursing shortage given the strong demand for services. Close to two-thirds of the health professionals surveyed identified nursing shortages as a major factor constraining access to services. This was particularly highlighted by health professionals from Ontario, where about 80 percent of respondents reported nursing shortages. A few health directors noted that access to the CCC services is not equal in all communities, indicating significant differences with respect to workloads and access to provincial care.

Immediate Outcome #2: A trained nursing workforce is in place to provide CCC services.

Health Canada has taken multiple steps over the past few years to set out the guidelines and improve training compliance among Health Canada employed nurses. The updated national policy on Mandatory Training (revised 2015) outlines the roles and responsibilities for Health Canada employed nurses in obtaining and maintaining certifications in the following five mandatory courses: Advanced Cardiac Life Support (ACLS), International Trauma Life Support (ITLS), Pediatric Advanced Life Support (PALS), Controlled Substances, and Immunization. Recertification is required every two (PALS, ACLS) to three years for mandatory training courses.

Most key informants noted that the national training policy (which includes responsibilities for monitoring compliance, and increased resources) has helped to improve compliance rates. As of March 2017, 60 percent of the 337 Health Canada nurses, across four regions, were fully compliant across all of the mandatory training. This is up from 46 percent in March 2016 and 27 percent in June 2015. Differences in the level of compliance across regions and type of training are indicated in Table 4. To achieve full compliance, regions must ensure that nurses have up-to-date certification in all five mandatory training courses. As illustrated in the following table, failing to meet requirements in one course (as was recently the case for PALS recertification in Quebec), would result in none of the nurses being in full compliance with the mandatory training. Consequently, this criteria negatively impacts overall compliance rates.

According to the document review and key informants, fluctuations in mandatory training compliance over time and across regions is a function of turnover (e.g., new nurses must obtain the mandatory certifications) and the availability of relief nurses to cover for existing nurses requiring recertification. At least three mandatory training courses (ACLS, ITLS, PALS) are delivered in the classroom, which requires nurses to travel out of the community and relief staff to be scheduled to provide replacement. The program estimates that a maximum of 40 hours per year is required for training for both full-time and part-time nurses. To put that in perspective, at this level and based on the number of Health Canada nurses employed as of March 31, 2017 (n=337), approximately 1,800 days each year would have to be filled by relief nurses to achieve 100 percent compliance.

Most regional FNIHB representatives, as well as some health directors, noted that insufficient resources are available to cover the costs of replacement, training and travel expenses. Accessibility of the mandatory training courses can also be challenging. About half of surveyed health professionals noted that the training is difficult to access. Depending on the region, the courses may be offered only once a month, on weekends, or when enough nurses have signed up for the course to be scheduled. Nurses strongly prefer not to be taking training during their scheduled time off. Some frustrations were expressed by Health Canada nurses during community visits regarding having to search for, schedule and pay for the training themselves, with some reporting that they received reimbursement only months after it had been completed.

To address some of these issues and reduce reliance on traveling for training, about half of key informants suggested that Health Canada should work more closely with the academic and other institutions to implement a combination of the following: make some parts of the mandatory training available online, increase the use of telehealth for training^{Footnote 18}, and provide on-site instruction for aspects of training that require hands on experience. In British Columbia, FNHA representatives highlighted e-Health initiatives as a promising practice to deliver training. These initiatives have provided two-way live video conferencing support for clinical and health-related education to about 150 First Nations communities across British Columbia.

In addition to national mandatory training, each region provides a number of essential training activities for nurses, which are in line with the provincial requirements, such as Cardiopulmonary Resuscitation (CPR), Transportation of Dangerous Goods, Nurse Safety Awareness Training, Workplace Hazardous Materials Information System, and other relevant skills development training. The regions are also responsible for providing orientation to new nurses. To deliver training, regions use various strategies such as telehealth, train-the-trainer for immunization courses or CPR, and having paramedics provide training on-site.

A few key informants noted that the National Onboarding Checklist (2017) was developed to standardize the onboarding process, provide information about various roles, responsibilities, and the clients, and offer links to additional resources. As part of the onboarding process, during their first few weeks, new nurses receive orientation and mentoring at the regional office and in the community. Over half of nurses surveyed agreed that new nurses are provided with the orientation and mentoring support they need. However, close to a third disagreed that the orientation was adequate. The case studies indicate that there can be significant differences across communities in terms of the quality and duration of the orientation as well as the emphasis placed on mentoring. For example, one of the visited communities offered a well-structured on-site orientation for the first two weeks, delivered by a nurse practitioner. The orientation included an overview of the nursing station policies, organizational structure and management structure as well as an introduction to the community in terms of culture, language and political structure. In other communities, there was less emphasis placed on formal orientation ("nurses learn by doing"), particularly where there has been turnover at the management level (e.g., nurse manager or nurse-in-charge). Most health directors noted that there is a need for more comprehensive onboarding, orientation and mentoring process for new employees to adequately prepare them for remote practice environment (e.g., longer orientation with more hands-on training with remote practice skills and environment, standardization of process, understanding of 'how things work').

In R/I First Nations communities, nurses face emergency situations that require training beyond what basic nursing education programs provide. The Department specifies mandatory training for these nurses to complete, including courses in areas such as immunization, cardiac life support, and the handling of controlled substances in First Nations health facilities. Specified mandatory and essential training requirements, along with the clinical practice guidelines, aim to prepare the nurse to work in this challenging environment, and enable them to practice to the full extent of their education, training, and competencies, and foster inter-professional collaboration.

The most common challenge related to training, reported by 54 percent of health professionals, is that training does not reflect the full range of competencies needed to work in R/I First Nations communities. Various gaps and issues were identified in the health professionals survey, case studies, and document review, which can be divided into three categories:

• The limited relevance of some parts of training courses to providing essential health services in R/I communities. For example, ACLS/PALS training includes topics that are based on having access to a physician when the situation requires interventions outside the nurses' legislated scope of practice, and the ITLS training is viewed to be targeted towards paramedics rather than nurses. Over 10 percent of nurses surveyed reported that the training they received is not fully aligned with community needs, such as mental health and addiction-related training, prenatal counselling, nutrition, chronic disease management, case management, and the over-prescribing of antibiotics. CCC internal program documents (2016) highlighted that nurses are not well trained in Canadian Triage and Acuity Scale as the standard classification for triaging patients.
• Limited access to management training on operational, management and human resources issues for nurses-in-charge or nurse managers (highlighted in the case studies as a gap by the nurses-in-charge). Given the workload and other training requirements, such training to the extent that it is available, is not a priority for nurses in management positions. Over half of health professionals surveyed identified a lack of time as a barrier to accessing needed training.
• Lack of training related to information collection, data management and use of technology. For example, all nurse managers spoke about the importance of systematic and consistent information records in patient charts for effective case management. The level of technology utilization (e.g., telehealth equipment) is dependent upon the skills of the staff and can be impacted by turnover, highlighting the need for ongoing technical training.^{Footnote 19}

The need for more formal cultural sensitivity training was identified by most key informants including about half of health directors, and nearly all health staff participating in interviews as part of the case studies. A few regional FNIHB representatives called it the most significant gap in training. About half of nurses interviewed, most of whom had been employed by Health Canada for less than two years, noted that, when hired, they received some cultural sensitivity training; however, the overall volume of material covered as part of their orientation makes it hard for them to retain that part of the training.

The review of practices in British Columbia shows that FNHA implements a formal mentorship program for new nurses, including a cultural safety component. The regional FNHA representatives interviewed emphasized their commitment to cultural training for all health providers, and other initiatives that integrate culturally safe practices in health service to meet the needs of First Nations. To improve delivery of cultural training, the FNHA has established mandatory cultural competency training for all FNHA employees (online module); integrated First Nations cultural safety and humility within health services by signing the first-ever Cultural Safety and Humility Declaration between British Columbia's health authorities and the Deputy Minister of Health for each regional health authority in British Columbia; developed and delivers a webinar series on cultural sensitivity and humility (delivered by the Chief Executive Officer); and created an evaluation framework to measuring the impact of cultural safety and humility interventions^{Footnote 20}.

Immediate Outcome #3: Quality Clinical and Client Care services are delivered (includes hospitals)^{Footnote 21}

Most program representatives (FNIHB and health directors) noted that relevant standards and policies are in place to ensure that the health services are of high quality. The policies are most commonly developed by the national office and then adjusted by regions to ensure alignment with provincial standards. Policies and tools that have been created and updated to ensure high-quality services include a National Education Policy, FNIHB Health Facilities Safety and Security Policy updates (March 2016), Infrastructure-Related Health and Safety Risks, and Patient Safety Incident Management. Key informants also reported that new quality improvement processes and tools have been developed to ensure quality services, such as the 'Essential Service templates' which are used as a tool for ensuring the minimum resources required by nursing stations are in place. In September 2016, FNIHB piloted a quality improvement on-site assessment process in two R/I nursing stations to inform the nurse-in-charge and nurse managers of gaps so that they can develop a plan to address the issues.

Most nurses strongly or somewhat agreed that nurses make good use of relevant policies and standards in their practice. The Clinical Practice Guidelines were identified as the most commonly used policy document (91 percent of health professionals surveyed reported using it daily). Other policies commonly used by health professionals surveyed include: Nursing Station Formulary and Drug Classification System (75 percent use it on regular basis); FNIHB Policy and Procedures on Controlled Substances (58 percent); and to, a lesser extent, the Diabetes Canada Practice Guidelines (39 percent). In addition, nurses reported frequently using anti-infective guidelines, hypertension guidelines, public health and immunization documents, and various specialized guidelines (e.g., cervical screening, pediatric guidelines, etc.).

Some gaps in policies were identified, of which the most common were gaps and outdated standards in the Clinical Practice Guidelines (identified by 71 percent of nurses) in areas such as mental health, Sexually Transmitted Blood Borne Infections, Human Immunodeficiency Virus, antibiotics use, diabetes care, etc. About one-third of the health professionals interviewed during case studies, noted that they look to provincial standards for best practices with respect to some of the gaps observed. Most participants in case studies also identified gaps or issues related to procedures or protocols (e.g., governing issues such as communication and information sharing between programs, operating policies, procedures or handling complaints).

Staff turnover negatively impacts quality of care^{Footnote 22}. The community members who were interviewed as part of the case studies most commonly defined quality of care in terms of the relationship and trust they have developed with their health care providers. In fact, the literature shows that patient perception of health care quality and treatment outcomes are highly correlated with the level of trust that has been established, and effective communication, as well as perception of professional competency.^{Footnote 23} In one community, health staff spoke of a physician who has been able to build a strong relationship with community members over time, which resulted in increased visits, decreased cancellation of scheduled visits, and more individuals (particularly older men) opening up about their mental health Similarly, health directors identified a stable nursing staff as a key determinant of quality of care, which enables nurses to become more aware of local health concerns, familiarize themselves with the community, and connect with clients over time. A literature review conducted in Ontario (2017) found that four principles (respect, trust, self-determination, and commitment) underline successful approaches and meaningful ways of engagement with First Nations communities. Commitment is seen as part of the engagement process, which takes time and community presence among other things^{Footnote 24}.

While the proper assessment and diagnosis of the client conditions or symptoms is a key determinant of quality of service, over half of health care professionals surveyed reported major gaps in services related to diagnostics (e.g., X-rays, EKGs, blood sampling). Regional reporting templates, specifically the essential care templates, also identified issues related to diagnostic tools in some communities (lack of point of care testing^{Footnote 25}, broken X-ray machines, etc.). In all but one of the communities^{Footnote 26} visited, community members raised concerns as to whether assessment of their conditions made at the nursing stations were appropriate (e.g., some community members believe that their health concerns were not properly assessed or diagnosed by on-site health care professionals). In the absence of needed diagnostic tools and with limited access to other health professionals, nurses interviewed feel they are often caught between the demands from the community members to be transferred out for further diagnosis and treatment, and the pressures to minimize medical transfers. Some nurses noted that, without convincing diagnostics, their decision to medivac a patient can be challenged by a receiving physician. Paramedics interviewed as part of the case study talked about a need for I-STAT^{Footnote 27} point of care testing that would help them to make more accurate diagnoses and improve the decision-making processes such as when to medivac a client.

The case study of the PEMH hospital further illustrates some of the factors contributing to high-quality health services. The document review and interviews indicate that the hospital is well managed with a stable and highly experienced nursing staff. There has been a strong emphasis on team building activities, safety improvements, and standardization of policies, procedures and forms. A number of committees have been established to plan, develop policies and procedures such as discharge planning improvements, and provide quality assurance. Families, patients and selected members of the communities are invited to provide input via one-on-one meetings or focus groups. These activities and approaches led to high client satisfaction with the services. The community members interviewed as part of the case study were generally satisfied with the services. A survey of Emergency Room clients, conducted by the hospital, showed that 63 percent of respondents rated their experience at PEMH as seven or higher (on a scale of 0 to 10, where 10 is the best experience possible). In comparison, a market research study reported that only 19 percent of Manitobans were satisfied with the hospitals in their province^{Footnote 28}. When asked about factors that constrain quality of care, the hospital representatives interviewed noted that infrastructure remains the major challenge, particularly in the Norway House hospital (e.g., they cannot apply for accreditation because of the aging infrastructure).

According to the FNIHB Approach to Accreditation (Fall 2016) document, the Branch is committed to increasing the number of accredited health services, with a particular focus on nursing stations, by encouraging new organizations and communities to begin and remain in the accreditation process, providing ongoing support to those already engaged in the process, and establishing accreditation as an ongoing priority at all levels within FNIHB. Interest in the accreditation process has grown as the benefits of health services accreditation have been recognized. A survey^{Footnote 29} reported in the Accreditation Dashboard (2016) found that accreditation leads to more appropriate care being provided to patients/clients (agreed to by 100 percent of health center representatives), better staff safety (100 percent), improved patient/client safety (97 percent), and greater pride in their organization's health services (97 percent).

Visits to an accredited health center in Quebec and the PEMH, an accredited hospital, confirmed some of these findings. PEMH has been part of the accreditation process since the 1970s, and currently holds an accreditation status with commendation. The hospital representatives interviewed highlighted the usefulness of the accreditation process in ensuring that proper policies and procedures are in place (e.g., work-life policy, patient safety policy and cultural tools, organizational standards and policies, family center, family in-patient plans, and social workers). Representatives from the accredited nursing station in Quebec noted that accreditation helped them to standardize and strengthen processes, and has been used as a marketing tool to recruit nurses (e.g., nurses are reassured that the operations and management of the centre are effective and up to standards).

Some key informants (FNIHB and a few other representatives) highlighted the importance of accreditation in ensuring standardization of practices and quality of care across all regions and communities. Accreditation is an ongoing process. It can be a lengthy and costly process that requires the participation of players at various levels, which can be very challenging given the number of stakeholders involved in the delivery of health services in First Nations communities. According to program documents and interviews conducted with representatives from accredited facilities, to be successful, accreditation must be established as a priority for the organization, and funding and human resources must be invested in quality improvement. For example, PEMH has a dedicated accreditation coordinator who is responsible for ensuring that accreditation standards are met.

According to documents provided by the program, two transferred nursing stations in Quebec have been accredited to date and two transferred nursing stations in Saskatchewan have been accredited as part of the Athabasca Health Authority. In addition, up to three non-transferred nursing stations in Alberta (John D'Or, Garden River and Fox Lake) have begun the accreditation process.

Intermediate Outcome #1: Clinical and Client Care services are sustainable

One component of a sustainable program is the sustainability of its workforce, meaning the balance between the registered nurses needed to deliver the program and the supply of those nurses (i.e., the ability of the program to put those resources in place on a sustained basis)^{Footnote 30}.

As of March 2017, there were 221.5 FTE nursing positions in communities with services managed by Health Canada, most of which were in Manitoba (107 FTEs) and Ontario (88), while the remainder are in Alberta (18.5) and Quebec (eight).

CCC's nursing positions are filled by a complement of nurses who are:

1. Attached to a nursing station or health center and working full-time or part-time with Health Canada (regular nurses);
2. A member of a Health Canada resource team, not permanently attached to a nursing station or health centre with treatment (resource team nurses); or,
3. Employed by an agency which has a contract with FNIHB (agency nurses). The resource team nurses and agency nurses may fill ongoing vacancies as well as positions temporarily vacated by a nurse who must leave for training or is on vacation.

Staffing challenges are a reality faced by the nursing profession as a whole. Most recently, the Canadian Institute for Health Information released data indicating that "since 2013, there has been a decline in the number of new registered nurse graduates obtaining a license to practice in Canada, with the average annual growth of -3.2 percent, compared with 2.8 percent since 2007."^{Footnote 31} However, in addition to this overarching impact to the field at large, it is important to consider that rural and remote health care settings have an even smaller pool of nurses to draw from^{Footnote 32}, as fewer nurses are willing to relocate to these regions^{Footnote 33}. The literature review identified that in 2010, approximately 11 percent of RNs (including nurse practitioners) and 18 percent of licensed practical nurses worked in rural and small town settings, indicating an overall decrease in the percentage of nurses working in rural settings during the years of 2003-2010.^{Footnote 34}, ^{Footnote 35} As it pertains to remote nursing stations, the unique demands of the context within which nurses provide care, invites an even narrower criteria to determine suitability for the position. The literature suggests that personal suitability is a key consideration for nurses to withstand the complexity and challenges created by the isolated, geography and cultural dynamics present in the remote northern settings.^{Footnote 36} The literature review highlighted that in order for nurses to be effective in northern communities, they had to "possess a calm, skillful approach to challenging patient care situations and be extremely adaptable to change of all sorts, including the stability of client health conditions, availability of resources and equipment, and weather".^{Footnote 37} In addition, nurses in remote settings interviewed through the Misener study described the impact of working in remote settings, as often more intrusive on a nurse's personal life since the need is not necessarily contained to their scheduled working hours."^{Footnote 38}

As a result of a shortage of nurses in Canada, and more specifically a shortage of nurses willing to work in R/I locations, it has long been a challenge for FNIHB to fill its nursing positions. The document review shows that vacancy rates averaged 30 percent to 40 percent in the period prior to the term covered by this evaluation. The high vacancy rates contributed to a heavy reliance on agency nurses to meet the shortfall in the supply of nurses. This increases the cost of the program to Health Canada, in that the cost of an agency nurse is over twice the cost of a fully-costed regular nurse. As such, program efforts to improve sustainability have focused primarily on the supply of regular nurses and, to a lesser extent, the supply of resource team nurses.

To help reduce the vacancy rate and improve program sustainability, Health Canada implemented the NRRS. Key elements of the NRRS included a streamlined job application process, a marketing campaign, a center for nurse recruitment and website, development of nursing pools and optimization of the staffing mix (e.g., recruiting more nurse practitioners). As shown in Table 5, over the three-year period from April 1, 2014, to March 31, 2017, Health Canada hired part-time and full-time registered nurses to fill positions representing 116.4 FTE positions. The hiring rate is defined by the total number of funded FTE nursing positions, and averaged about 18 percent.

As indicated in Table 6, the recruitment program was successful in reducing vacancy FTE rates, which declined from 26 percent in December 2014 to approximately 16 percent in March 2017.  

Despite the progress that has been made, the benefits of the NRRS have been offset, to some degree, by continuing turnover amongst the nurses. While Health Canada has been successful in hiring 116.4 FTE nurses (198 nurses in total, full-time and part-time) for its regular nursing staff and resource teams over the past three years, 93.3 FTE nurses have departed (157 nurses in total, full-time and part-time), resulting in a net increase of 23.1 FTEs. The staff turnover rate for the past three years has averaged 17.1 percent and amounted to 19.8 percent in 2016-17.

In 2016-17, the level of hiring in terms of FTE positions (38.1), outlined in Table 5, was almost the same as the level of departure (36.8 FTEs) noted in Table 7.

Two factors were identified by key informants as possibly contributing to the increased staff turnover rate in 2016-17, relative to the previous year. Issues identified were associated with challenges experienced through the Phoenix Pay System and the movement towards hiring recent nursing graduates who may be more likely to only work in the communities for perhaps two to three years until they have enough experience to gain employment elsewhere.

Over three-quarters of health professionals surveyed agreed that the level of turnover amongst clinical and client care nurses is high in the community or communities in which they work. The three contributing factors reported most often are work stress (87 percent), wages and benefits being better elsewhere (66 percent), and the remote and isolated nature of the community (54 percent).

Working conditions included concerns related to a variety of issues including facilities and accommodation, lack of support from management, harassment, vicarious trauma, and workplace conflict. "Other" challenges included issues such as staffing issues (e.g., understaffed centres), hours and workload, and issues with the Phoenix Pay System.

During the community visits, nurses often spoke about work stress and burnout. Contributing factors included long working hours including extended on-call hours (all five communities reported that they are understaffed relative to the demand for services); the stress associated with ensuring that urgent cases are transported out of the community in a timely manner; and being the target of verbal abuse and blame. According to program internal documents, general violence towards nurses, including verbal and physical threats, has been on the rise. This issue of violence against nurses is not unique for Health Canada nurses. A recent discussion paper published by Canadian Federation of Nurses Unions highlights the increase in rates of violence against nurses across Canada as well as globally.^{Footnote 39}

To increase recruitment and retention, nurses suggested that staffing levels increase and that Health Canada and community leaders should work together to ensure that nurses are accepted, respected and have basic needs met while in the community (safety; appropriate accommodation with basic requirements met - like pots and pans for cooking)^{Footnote 40}. Having strong management support and a supportive on-site team and flexible schedule were the factors most commonly noted as contributing to retention. Some stakeholders (e.g., regional health authorities and associations) suggested that increased emphasis should be placed on recruiting directly from the communities as well as reinforcing a positive message, through elementary schools and through summer camps, about the benefits of getting into health professions. The representatives from Saskatchewan noted that, while they continue to struggle with recruitment, turnover rates in that province have declined as a result of some communities successfully recruiting Indigenous nurses and offering a better wage package.

When asked about the promising practices regarding the recruitment and retention of nursing staff, BC FNHA representatives interviewed emphasized the investments they made in promoting health careers (particularly scholarships, bursaries and support for health and wellness education provided to recruit and retain First Nations and Indigenous individuals in the health system). Health Canada made similar investments through the Aboriginal Health Human Resources Initiative (AHHRI), which was established to support education and training activities related to health programs and services. When asked if they have made use of the Initiative, most regional representatives and about half of Health Directors reported being aware of it but very few have used it (e.g., amounts were too small; it was not applicable for their communities). A few respondents used the AHHRI for mental health and addiction workers, and health managers training. About three-quarters of health professionals surveyed were not familiar with the AHHRI.

Intermediate Outcome #2: Clinical and Client Care services (including hospitals) are responsive to the needs of First Nations in remote and isolated communities.

Nearly all community members interviewed as part of case studies reported that they are generally satisfied with the services received at the nursing stations. Where concerns were raised, they related largely to communication issues (e.g., inability to raise concerns about a specific nurse or treatment) or the limited access to other services (such as mental health services, physicians, pediatricians, and transportation to hospitals) which are largely beyond the scope of the CCC program itself. The health professionals surveyed were somewhat divided in their opinions as to whether community members are satisfied with the quality of clinical and client services (40 percent agreed with the statement that community members are satisfied, 29 percent neither agreed nor disagreed, and 20 percent disagreed).

The findings of the case studies, surveys and interviews point to two key factors as influencing responsiveness: having clear avenues available through which community members can engage and communicate their concerns; and providing continuity of care. Transferred communities may have some inherent advantages both with respect to communicating with the community and coordinating services. The health professionals who work only in First Nations managed nursing stations were more likely to report that community members are satisfied with the clinical and client care services than respondents who work only in Health Canada nursing stations. Seventy-four percent of health professionals who work only in First Nations managed communities agreed or somewhat agreed that community members are satisfied, as compared to 38 percent of those who work only in Health Canada operated nursing stations. These two factors are further discussed below:

• Clear avenues for community members to raise and communicate their concerns. Responsiveness requires an understanding of community needs and concerns. Some key informants (FNIHB regional representatives and health directors) highlighted the importance of a formal feedback mechanism and process through which the community can be meaningfully engaged in service improvement and can express their opinion and concerns (e.g., determining clinic hours, quantity of staff, security concerns, etc.). In the two transferred communities visited as part of the case studies, Health Directors serve as an avenue of communication between the clients and the clinic, and respond to client concerns. In the Health Canada managed communities which were visited, there were no formal avenues for raising issues and concerns with management (e.g., community members did not know where, how or to whom they would talk to about concerns related to treatment received at the nursing station). Recognizing the need to improve communication, FNIHB regions have developed a communication strategy for each community which identifies processes and tools in place to communicate services and engage community members. The evaluation was not able to verify to what extent these strategies have been implemented or their effectiveness. The BC FNHA review illustrates an alternative approach to improve communication and responsiveness; the FNHA has established eight Aboriginal Health Improvement Committees with the goal of identifying health care service issues in remote communities, creating resources specific to their communities, and working together towards finding solutions to these issues (e.g., developing local cultural resources, encouraging cultural safety in health care).
• Continuity of care. Continuity of care is impacted by the coordination of services across various service providers along the continuum. At the community level, a strong factor contributing to integrated and coordinated services is well respected and trusted nurse managers and health directors who serve as a catalyst for information sharing and collaboration. For example, in a transferred community in Quebec, the Band Council meets with the Health Director regularly, who in turns works very closely with the nurse-in-charge to communicate the needs and share the responsibilities. At the provincial level, an Indigenous advisor liaison position was created a few years ago to improve coordination of services between the province and the community. In some Health Canada managed communities, for example, nurses work very closely with community care workers to share information and discuss scheduled appointments, medication or follow-up care.
  
  However, while there are examples of effective coordination, both key informants and health professionals expressed concerns regarding the level of coordination overall. Most key informants noted that coordination with provincial governments is limited, and some noted challenges related to siloed health programs delivered by various providers (e.g., lack of information sharing which creates difficulties related to case management). Similarly, only 19 percent of health professionals surveyed agreed that there is good coordination between the federal and the provincial government with respect to the delivery of clinical and client care services.
  
  To help address these issues, some formal collaboration mechanisms have been established. Alberta established a Health Co-Management committee, which brings together FNIHB , provincial and First Nations partners. They worked together on developing a joint action health plan which allowed for a higher-level policy planning and service integration and coordination. Another example where effective collaboration is occurring at the national and regional levels is an initiative that brought together multiple partners (nursing associations, universities, unions) to support the recruitment of nurses through implementation of marketing strategies, development of programs for rural and remote practice, and training activities (e.g., Health Canada Sustainability Report 2016-17-Q3, notes that a training partnership has been pursued with the Department of National Defence). However, most key informants were not able to identify any formal collaboration mechanisms established to address interjurisdictional issues with respect to data sharing, privacy legislation, or expended access to care (access to mental health professionals).

Strong management capacity (particularly in terms of stable and experienced staff) and effective community engagement, were identified by health directors as key to building community capacity and supporting the processes for transferring the management of services (to date, 34 percent of the nursing stations and health centers with treatment have been transferred). A few health directors stated that institutional distrust of government and its intentions remains a barrier to community engagement, communication and ultimately the effective transfer of services. This mistrust continues to create barriers to effective data collection and information sharing.

Health Canada's quality improvement policy defines cultural safety and cultural competencies as "integrating knowledge about First Nations individuals, families and communities into specific health program and services standards, policies, practices and attitudes." An on-site assessment completed by Health Canada in two nursing stations in 2016, assessed cultural competency based on two criteria: whether translators and cultural training were available. The assessments concluded that translators are available but that cultural training is provided inconsistently.

When asked about culturally safe services in this evaluation, most key informants also talked about the extent to which cultural training is provided to health professionals. A majority reported that some cultural training is provided as part of the orientation but is not provided consistently across communities. Seventy percent of health professionals surveyed agreed that the services are provided in a manner that is culturally safe to First Nations. However, some health professionals noted that all health staff should be more culturally sensitive and aware of consequences of colonialism, the impact of negative stereotypes on service provision, and the importance of relationship building and understanding traditional practices. Most health directors noted insufficient cultural sensitivity in the delivery of care (e.g., lack of understanding of First Nations history and culture, social determinants of health, stereotypes in diagnosis and care).

Interviews conducted with health professionals during the case studies illustrated that no common understanding exists regarding what are considered culturally safe services or practices. Examples ranged widely:

• Simply recognizing traditional medicine (e.g., encouraging clients to share any health concerns for which they may be using traditional medicine to ensure that the primary caregiver has a more complete picture of the health status of their patients).
• Providing advice regarding traditional medicine (e.g., advising patients who are diabetic about how to participate in the traditional activities or treatments such as fasting while not compromising their health).
• Making translators available (particularly for elderly residents and for after-hours care when community health workers are not available).
• Using culturally appropriate language (e.g., in one study, First Nation representatives talked about the difference in the traditional and western view of health and health care, noting the relative emphasis on wellness rather than curing the disease^{Footnote 41}).
• Having appropriate physical spaces through which to deliver the services (e.g., having rooms that are spacious and able to accommodate large families, and in-patient rooms, which have space for family members to spend a night; the PEMH also has built a gazebo at the back of the hospital for family members to gather).

Long Term Outcome: CCC programming contributes to the health status of First Nations in remote and isolated communities

Health professionals provided examples of different ways in which CCC services contribute to positive health outcomes including lives saved by stabilizing patients and transferring them to hospitals, increased immunization rates, and better management of chronic illnesses resulting in people living longer and having better quality of life. Some nurses noted that having dedicated resources for pre-natal programs improved the health of mothers and babies. Community members noted the positive impact of the services on their lives by not having to leave the community to receive essential care.

However, perceptions of key informants and health professionals regarding the impact of the CCC Program on the health status of First Nations in R/I communities are tempered by the continuing disparities in the health outcomes of the residents, relative to the Canadian population as well as by a lack of data on service outcomes. While over half of health professionals surveyed agreed that the CCC services have contributed to the health of First Nations individuals, this contribution is not necessarily reflected in improving health outcomes. A majority of key informants, about 15 percent of the nurses surveyed, and some provincial representatives reported that health outcomes of First Nations communities have not improved. Some key informants argued that on-reserve health has declined in recent years due to a high burden of diseases (e.g., obesity, diabetes, complex trauma issues, addictions). They attributed the limited improvement made with respect to health outcomes, to the continuing challenges in providing more coordinated and integrated health care across entire spectrum of programs, and the failure to address social determinants of health.

To improve outcomes, some key informants stressed the need to move further towards a population health approach that is more responsive to the unique characteristics of First Nations populations and find systemic solutions to addressing health care issues, rather than a series of initiatives that each focus on one aspect of health care. They noted that improving health outcomes will require rethinking the entire spectrum of health system interventions, from prevention and promotion to diagnosis, treatment, and management of care. Key informants also suggested increasing access to data on health outcomes for planning purposes, and assessing the impact of services on health outcomes. Furthermore, it was expressed that there is a need for a greater focus on health prevention. For example, most health directors and some nurses noted that services focus too heavily on treating the symptoms and not the causes of the health issues. Other suggestions brought forward by key informants for improving health outcomes included: being more responsive to mental health concerns, increasing the level of integration with the provincial system, increasing early access to diagnosis, and dealing more effectively with diseases which are increasing in incidence (e.g., diabetes, respiratory issues, obesity).