Community development is an essential component of community health nursing. Community health nursing in Canada’s North is unique due to the transient nature and diverse scopes of practice of health care providers. Expectations related to interprofessional and intersectoral collaboration heighten the complexity of northern nursing practice. The rural and remote location of many communities also increases the cost of professional development and continuing competence. Particularly important is the rich diversity of northern people, but also knowledge and recognition of the legacy of residential schools and colonial practices, which have created health disparities for Indigenous people. Community development approaches built upon collaborative, respectful and egalitarian relationships with both Indigenous people and the intersectoral team are essential to an effective health care system. The purpose of this chapter is to discuss community health nursing competencies necessary for the practice of community health nursing in the North.
Key Terms: Community development, competencies, Indigenous, pan-territorial
Throughout Canada’s North, northern health and human service practitioners work with communities who are often marginalized. A key concept needed within northern curricula is community development. Community-based and participatory approaches embedded in community development are at the core of community work whereby empowerment, social justice, cooperation, participation, and capacity-building come alive. This chapter will focus on four key competencies related to community development, as identified by a pan-territorial needs assessment. Other competencies, based on frequency of knowledge gaps, were selected for a community-development module, including those that address process-based skills, such as asset mapping and proposal writing. Resources to meet these additional competencies, including a link to the northern community development module, can be found at the end of the chapter.
Canada’s Northern Context
The three territories (Yukon, Northwest Territories, Nunavut) are located above the 60th parallel and are each unique, in terms of culture, composition, and context. Indigenous peoples and settlers occupy the three territories. The term settler refers to the colonial practice and power dynamic intended to exert control over Indigenous people and their land (Battelll-Lowman & Barker, 2015). Many remote communities are scattered across the landscape. There is difficulty with recruitment and retention of healthcare practitioners in the territories and turnover compels attention to training and professional development (Kulig, Kilpatrick, Moffitt, & Zimmer, 2015). Service provider competency and understanding of people, communities, and the colonial legacy are essential to address the disparities documented in the Canadian North (McNally & Martin, 2017).
Community Development and Professional Development Challenges
Community development is the process of developing the strength and sustainability of a community. Community strength is evident in the essential skills and assets of the community, along with the collaborative action and problem solving in which community members engage (Bradbury, Starks, Durnford, & Moffitt, 2016; Frank & Smith, 1999; Vancouver Costal Health, 2009).
Barriers for health professionals in accessing continuing education (CE) are a reality in rural and remote settings. Nurses face particular constraints in pursuing CE, including the lack of time, finances, technology, and workplace supports (Santos, 2012). Penz, D’Arcy, Stewart, Kosteniuk, Morgan and Smith (2007) analyzed survey data from 3,933 Canadian nurses working in rural or remote settings and found that although many concerns about access to CE were aligned with those of urban counterparts, nurses in rural and remote settings added isolation/rural location, difficulty finding backfill in small staff pools, and distance to nurse educators and quality education.
Pavloff, Farthing and Duff (2017) concluded that, “the rural and remote nursing work environment, complexity and diversity of nursing care necessitates the need for educational opportunities that are designed specifically for rural and remote nurses.” (p. 90) Northern health and human service practitioners surveyed in a pan-territorial needs assessment reported frequent engagement in community development activities; however less than half indicated that they had received any preparation for the role in their undergraduate education (Bradbury et al., 2016).
Community Development Competencies
In 2012, educators and public health representatives from the three Canadian territories began a collaborative project to explore the community development learning needs of the pan-territorial community health and human service workforce. Community capacity building competencies developed by the Public Health Association of British Columbia (2008) provided a template of competencies relevant to the territories. These 13 community development competencies identified the skills, knowledge, and attitudes required to work effectively with northern communities in this grassroots approach. Research led to identification of key competencies where education gaps exist, revision of language to meet the diverse needs of northern practitioners, and development of a competency-based self-directed learning module. This learning module addressed competencies rated as the greatest need by participants including: advocating for services and policies that influence the health and well-being of many people at the same time; helping communities work through issues using problem-solving and conflict resolution skills; understanding and applying participation action research, community asset mapping and participatory evaluation to gather information; advising on and influencing opportunities to help communities keep their efforts going; and developing strategic plans, grant proposals, project proposals, briefs, options papers and requests for proposals. The remoteness of many northern communities, the transient nature of professionals, and the large territorial Indigenous population, highlights the importance of four other competencies not discussed in the workbook: establishing effective relationships, utilizing a population and social determinants approach to health, encouraging and supporting community-based advocacy, and cultural competency. These competencies will be further explored in this chapter.
Table 1: Community Development Competencies for Northern Practitioners
- Understand the concepts of working effectively in the community and able to build community capacity in my work.
- Able to establish effective working relationships with all kinds of individuals, organizations and groups.
- Able to influence others, foster leadership, mobilize a community to action and help others to successfully work through change.
- Able to use a population and social determinants approach to explore factors that affect health (i.e. income, food, housing, etc.) in order to improve health and wellbeing of groups and communities.
- Able to apply at least two of the following to develop capabilities of others: Group facilitation, Coaching, Consultation techniques, Community engagement processes.
- Able to engage communities to advocate for services and policies that influence the health and wellbeing of many people at the same time.
- Able to ensure information (both written and oral) is passed on and understood by others in a timely and effective way.
- Able to help communities work through issues using problem-solving and conflict resolution skills.
- Able to understand and apply at least one of the following to gather information: Participatory action research, Community asset mapping, Participatory evaluation.
- Able to take into account diverse values, beliefs and cultural practices when working with communities.
- Able to advise on and influence opportunities to help communities keep their efforts going.
- Able to develop two or more of the following: Strategic plans, Grant proposals, Project proposals, Briefs, Options papers, Requests for proposals.
- Able to encourage innovation and support new approaches.
Adapted from BC Core Competencies Project. (2010) by the Public Health Association of British Columbia. Adapted with permission.
Establishing Working Relationships (Competency 2)
The ability to establish effective working relationships with individuals, organizations, and groups is important in the diverse, autonomous, and often complex northern health care environment. In many remote northern communities, health care services are provided in health centres, which are usually staffed with a small number of nurses, who are often the primary care providers (Rahaman, Holmes, & Chartrand, 2017). Other essential members of the team may include one social worker and community health representatives (CHRs). CHRs are often Indigenous community members who play essential roles in health promotion (Cameron, Carmargo Plazas, Salas, Bourque Bearskin, & Hungler, 2014). Consultations are frequently completed via telephone with interprofessional team members in territorial and larger southern hospitals. Local elders, cultural healers, teachers, and police officers become colleagues (Leipert & Reutter, 1998). Building partnerships with these community members is essential to community development success.
Philip, a Registered Nurse (RN), has moved to a remote northern community of 500 people, after five years of working in a large busy hospital in southern Canada. Over 90 percent of the community members are Indigenous. The community health centre is staffed by three RNs, a community health representative, and a social worker. A general physician visits monthly. The only access to the community during the summer is by air, with ice road access during the winter months. Philip has learned about transcultural nursing in his undergraduate education, but has discovered in his practice, that culture is ever evolving and created through relationships. He recognizes that to develop effective working relationships, he must develop connections within the community and come to understand the culture. How can Philip develop these relationships?
Case Study Suggestions:
Philip must learn about the community, its history and culture, from the people. Philip could visit the local band office to introduce himself. He could form a relationship with the community health representative, who is typically a local community member with training in health promotion. Philip should seek advice from the community health representative, or the band office, on local protocol for speaking with elders and requesting to learn from them (for example, in some cultures it is appropriate to offer tobacco or other gift, before asking questions or requesting to learn from the wisdom of an elder). Philip should seek opportunities to attend local community events, such as feasts, or drum dances. Importantly, Philip could request a visit with local elders to introduce himself, and to learn more about the people and their culture. Philip should also complete the history of colonization course offered online by the government, as well as local cultural awareness modules.
Using a Population and Social Determinants Approach (Competency 4)
Practitioners must use a population and social determinants approach to explore factors that affect health in order to improve health and wellbeing of groups and communities. Heath is defined as the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (World Health Organization, 1948, p.1). Canada’s territories are home to many Indigenous people. A history of colonization and racism spawned by Canadian government policies, resulting in intergenerational trauma from residential school experiences, has created great health disparities between Indigenous and non-Indigenous Canadians (McNally & Martin, 2017). The front-line care provider must be cognizant of the social determinants of health specific to Indigenous peoples. Nesdole, Voigts, Lepnurm, and Roberts (2014) state that to facilitate community programming relevant to Indigenous peoples, practitioners must address such determinants as basic physical needs, safety and security, community solidarity and social support, strong families, healthy child development, and critical learning opportunities.
Canada’s Indigenous peoples remain a strong and resilient community. It is important for the practitioner to adopt a strength-based approach to community development. Community care is best when it is based upon the needs of the community, led by the community, and delivered in a culturally appropriate manner (Nesdole et al., 2014). The poor health of Indigenous peoples must be actioned rather than accepted as “status quo” (Rahaman et al., 2017, p. 194). Indigenous people deserve autonomy in health decisions and practitioners must demonstrate reciprocity through mutual respect, communication, and collaboration.
Learning from Mothers, Grandmothers and Great-Grandmothers about Breastfeeding in the Northwest Territories
An example of using a social determinants approach in community development can be seen in recent research to explore breastfeeding in the Northwest Territories. Dr. Pertice Moffitt, the lead in a project funded by the Northwest Territories Department of Health and Social Services, requested the guidance of respected elders to learn about breastfeeding. The Advisory Circle of Knowledge Keepers worked with the project lead in interviewing women, delivering community presentations and developing community resources. The project described the nature of breastfeeding, from a traditional and evidenced informed perspective, and highlights the strengths and resilience of women in the North. The knowledge created will inform practice, policy, and future research (Moffitt, 2018).
Engaging in Community Advocacy (Competency 6)
The ability to engage communities to advocate for services and policies that influence the health and wellbeing of many people is an important step in creating lasting change. Care providers should learn to work with community members to frame the issue, formulate a plan to address that issue and to engage and support community members in leading the way. Considering the diversity of the health and social service care team in remote communities, care providers are encouraged to explore the competing expectations around advocacy from communities, employers, licensing bodies, and their own ethical principles.
Demonstrating Cultural Competency (Competency 10)
Cultural competence in community health practice assumes respect for culturally diverse communities and is informed by cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire on the part of motivated health care providers (Stamler, Yiu, & Dosani, A., 2016). The concept of cultural safety is defined as effective cross-cultural nursing practice, as determined by the clients receiving care (Stamler et al., 2016). Culture is more than a collection of common characteristics. It is a continual, relational process (Browne & Varcoe, 2006).
A cultural safety perspective reminds us that, to provide quality care for people across a range of ethnicities and cultures, we must offer care within the cultural values and norms of the client, which suggests a change in power structure and a focus on the outcomes of health care encounters from a client’s perspective (Brascoupe & Waters, 2009). The provision of culturally safe care is considered an important competency for those working with northern people, as it incorporates an exploration of personal ways of being, privilege and power dynamics, and a recognition of historical and political factors that shape health and social care systems for Indigenous people (Ramsden, 2002).
Many northern employers utilize cultural safety modules and online resources to increase practitioner’s knowledge of Indigenous people and to promote awareness of personal biases which may impede the ability to create an environment where people feel safe in receiving care. The Truth and Reconciliation Committee’s calls to action identify changes to basic education. These actions include “Aboriginal health issues, the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights and Indigenous teachings and practices” (The Truth and Reconciliation Committee, 2015, p. 323), as well as receiving skills-based training in intercultural competency.
Benefit to Practice
A commitment to utilizing the community development competencies has the potential to meet the community development learning needs of care providers who work in any community, particularly rural and remote settings. The transient nature of health care professionals in the north and use of temporary care providers raises many challenges, not the least of which is the ability to partner with community members to identify issues, collaborate on and champion for sustainable solutions. Knowledge and embodiment of the community development competencies can strengthen the knowledge, skills, and abilities of health care providers. A shift in the past decade in the three Northern territories to more community-based and participatory approaches to health and wellness necessitates that health care providers have the knowledge and skills to achieve strategic vision and support community-driven initiatives. The strength-based approach of the competencies can assist care providers to engage with community members and foster empowerment.
Communities of practice were informally created among some participants during the community development project, in 2012. The opportunity to dialogue and interact with colleagues about the learning was valuable in generating new knowledge and shared understanding, and extending the inquiry. As well, consulting and networking with peers is both socially and educationally attractive to health care providers who often work in isolation in rural and remote locations.
This chapter offered a brief exploration of the community development competencies of the health and human service practitioner in Canada’s far North. An understanding of the challenges in accessing ongoing education to address learning needs and the importance of education to develop competencies in community development is critical to working effectively with northern communities. Community development is an empowerment strategy valued by both practitioners and community members, showing a commitment to community development. Initiative on behalf of the care provider to learn and embody these competencies is an important step in reducing health disparities and increasing collaboration with northern people.
Community Development in Northern Canada: A Competency Approach -online module (Northern Institute of Social Justice)
Cultural safety module 1: Peoples’ Experiences of Colonization (University of Victoria)
Cultural safety module 2: Peoples’ Experiences of Oppression (University of Victoria)
Cultural safety module 3: Peoples’ Experiences of Colonization in Relation to Health Care (University of Victoria_
From the Ground Up: An Organizing Handbook for Healthy Communities (Ontario Healthy Communities Coalition)
Strategies for Effective Proposal Writing (Ontario Healthy Communities Coalition)
Community Tool Box (The University of Kansas)
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