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Nursing practice, continuity of care, and maternal-infant health outcomes in a remote First Nations community Tarlier, Denise Susan

Abstract

The purpose of this ethnographic study was to explore nurses’ primary care practice, continuity of patient care, and clinical health outcomes in one remote First Nations community in Canada. This work was underpinned by previous conceptual work in (a) primary health care, (b) The Nursing Role Effectiveness Model (i.e., a structure-process-outcomes model), and (c) continuity of care. Continuity was conceptualized in terms of relational, informational and management continuity. Clinical health outcomes were explored through quantitative data abstracted from patient chart review on two selected health indicator conditions: (a) prenatal care and (b) infant care through the first year. Focusing on maternal-infant outcomes offered a window through which to explore nurses’ practice and examine continuity at the individual level and importantly, to extrapolate findings related to continuity and fragmentation beyond the individual level to implications at the community and population levels. Indicator condition criteria, originally developed for the Burlington Randomized Trial of nurse practitioner practice, were revised and updated to reflect current clinical practice. Additional data from patient chart reviews were collected to provide context for the quantitative outcomes data. Ethnographic data collection strategies included interviews with nurses, other health care professionals and paraprofessional staff, field observations (including observations of nurse-patient encounters), and document and artefact review. Four over-arching themes emerged from analysis and interpretation of the data: (a) nurses’ work, influenced by a broader context of inequity and marginalization, occurred at the margins of mainstream nursing practice, (b) health outcomes and continuity of care were characterized by fragmentation, (c) nurse-patient encounters were suggestive of relational disengagement and (d) dissonance existed between perceptions of health care and demonstrated health outcomes. Nurses’ practice was subjected to and shaped by the same contextual issues that were associated with inequity and marginalization in this study. Until this context, specifically the social determinants that exert such profound influence on the health of aboriginal Canadians, begins to shift, shifts in nurses’ practice are unlikely to be either effective or sustainable.

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