Canadian Journal of Nursing Informatics

Telehealth in Rural Canada: Emergent Technologies to Address Historical Issues

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Alex Baylak, BSc – HSc
Noedelle Dublin, BA – Psych
Carissa Eastwood, BSc – Kin
Simran Gill, BSc- Med Surg
Joey Lee, BSc – Kin
Ruveen Mattu, BSc – HSc, RRT
Paula Phelan, BA – Glob St, ECE
Sara Palombi, BSc – Kin, ACSM CEP
William Wilcox, BSc- Kin, Psych
Laura Wilson, BSc – HSc, MPH
Telehealth in Rural Canada: Emergent Technologies to Address Historical Issues

Introduction

When looking at the Canadian health care system through a historical lens, disparities in the accessibility and quality of health care services become clear: rural Canadians have not had equitable access to health care services when compared to their urban counterparts (Laurent, 2002; McCracken, 2019; Sciarpelletti, 2019; TELUSHealth, 2013). Fundamental differences in the challenges faced by rural and urban Canadians when it comes to health care continue to the present day, and health outcomes vary greatly according to the community in which one resides (British Columbia Ministry of Health, 2015; Pong et al., 2011).

Among the most pervasive differences between rural and urban Canadians are the health inequities faced by rural Canadians in terms of access to high quality health care. Rural Canadians experience higher vulnerability to many health conditions, while also facing greater barriers to accessing quality health care compared to their urban counterparts (Goodridge & Marciniuk, 2016; Pong et al., 2011). While the health effects of these inequities have primarily impacted the recipients of rural health care services, those providing care are also impacted. Challenges such as limited resources, inadequate support, and understaffing are prevalent issues in rural communities which have negative implications for the working conditions of rural health care providers. These increased demands placed on rural health care providers have historically led to issues surrounding recruitment and retention, further compounding the challenges already faced by rural communities through perpetuating issues related to understaffing (Lasala, 2017).

Given the inequities and challenges faced by both rural Canadian residents and their health care providers, novel strategies to enhance rural access to care, improve health outcomes, and better support health care providers, have been of paramount importance. Over the last few decades, there have been significant and widespread efforts to utilize telehealth technologies to improve health care accessibility, quality, and safety for rural Canadian patients and providers in order to begin reducing the urban-rural inequities (Goodridge & Marciniuk, 2016).

The goal of this historical narrative paper is to provide the reader with a means to understand the development of telehealth in rural Canada, including the factors that necessitated its development, its history, and the impact that it has had on both the residents and health care providers in rural Canadian communities. For the purposes of this paper, we have utilized the British Columbia College of Nursing Professionals’ (2019) definition of telehealth as the delivery and communication of health care services and information through the use of technology. Ultimately, the paper aims to support a central thesis: The development and implementation of telehealth services in rural Canada has reduced the challenges faced by rural nurses and other health care providers and has improved equity of health care services for residents in rural Canada.

The Unique Realities of Rural Canada

Although each community in rural Canada has their own history, challenges and unique health care needs, there are several common factors that have contributed to the health inequities they face. First, these communities are often geographically distant from larger centres and population bases, leading to limited access to goods (e.g., fresh produce) and services (e.g., health care), and a much greater travel burden to access these services as compared to their urban counterparts (British Columbia Ministry of Health, 2015; Laurent, 2002). Another important difference found between urban and rural communities is the access to health education (Pong et al., 2011). The aforementioned barriers are all factors that need to be addressed in order to create greater health equity for all Canadians.

Health Care Access Issues and Poorer Health Outcomes

At a population level, an inversely proportional relationship has been observed between positive health outcomes and the remoteness of a community (Goodridge & Marciniuk, 2016). Although correlation alone cannot be used to determine the exact cause of the less favourable health outcomes, a possible explanation for this inverse relationship is the lack of access to health services and specialized care in remote communities when compared to the health services and care available in most major population centres. Nevertheless, access to high quality health care is commonly regarded as a fundamental determinant of health, and inadequate access has been implicated as a prominent driving force behind the inequitable health outcomes observed when comparing rural and urban Canadians (Jong, Mendez & Jong, 2019).

Additionally, rural communities often have less developed health care infrastructure in terms of facilities, programs focused on health promotion, and sufficient numbers of health care providers to offer diagnosis and treatment services (Bereket et al., 2013). The effect of underdevelopment in rural health care infrastructure has been observed in the reduced ability of rural residents to maintain their own health and wellbeing, as well as in the need for these residents to travel significant distances to obtain both general and specialized services when they require health care (British Columbia Ministry of Health, 2015; Goodridge & Marciniuk, 2016). The historical deficit in equitable access to health care for rural Canadians has resulted in a significant burden being placed upon residents of rural communities in terms of less favourable health outcomes, travel costs, and time required to access essential health services. The burden of inequity is further compounded by the fact that rural residents are often of lower socioeconomic status than their urban counterparts, with socioeconomic status being considered an important determinant of health (Pong et al., 2011).

Issues Recruiting, Retaining and Training Health Care Providers

In addition to the issues faced by rural Canadian residents, problems related to recruitment and retention of rural health care providers have also been constant issues in Canada, largely stemming from the lack of support, training and resources available to health care providers in rural communities (Kulig et al., 2015; Laurent, 2002; Morse, 2019). Although health care providers often have stressful occupations independent of their geographic location, insight into why rural communities have had disproportionate challenges with retaining health care providers, specifically rural nurses, can be gained through exploring the expanded role that nurses serve in many rural communities (Kulig et al., 2015). In contrast to their urban counterparts, the role of nurses in rural locations often requires nurses to perform as generalists with multi-specialist knowledge and possess the advanced skill sets necessary to serve diverse populations with unique and varied conditions, all while working in low-resource environments (Hunsberger et al., 2009; Kulig et al., 2015). While the autonomy and challenges of rural nursing can provide increased job satisfaction for some nurses, many nurses have found that the additional stress of bearing either increased or full responsibility for the welfare of patients in isolated settings to be overwhelming (Lasala, 2017).

Given the impact that issues faced by rural nurses and other health care providers have had on recruitment, retention and quality of care, it is essential that strategies are developed to better support rural practitioners. Telehealth is one such strategy that is increasingly being used to provide real-time support and professional development services to rural health care providers, aimed at increasing support for rural health care providers, improving job satisfaction, and ultimately leading to higher retention rates (Lasala, 2017; Laurent, 2002; Morse, 2019).

Telehealth in Rural Canada: A Novel and Continuously Developing Technology

In response to the unique challenges of rural health care, telehealth has developed as a prominent option to address the inequities faced by residents of rural and remote communities. Telehealth offers a unique strategy for addressing many of the issues faced by rural communities and can help attenuate the magnitude of difficulties experienced by residents of rural communities when seeking to access health care services. The focus of telehealth services to date has been to reduce barriers to access for rural residents and provide increased support for health care providers in rural areas (Bereket et al., 2013; Goodridge & Marciniuk, 2016; Morse, 2019). Although telehealth alone cannot address all of the inequities faced by rural residents, by supporting disease prevention, early diagnosis, and treatment, overall health outcomes can be expected to improve and the risk of complications due to delayed diagnosis can reasonably be expected to decrease (Bereket et al., 2013; Goodridge & Marciniuk, 2016; Morse, 2019).

In order to supplement the current knowledge base, and to gain a primary perspective on telehealth, our research team interviewed Dr. John Pawlovich and Dr. Don Burke who developed an on-demand telehealth support application called Critical Outreach and Diagnostic Intervention (CODI), for rural British Columbian communities and health care providers.

When assessing innovations in technology and telehealth, Dr. Pawlovich reminded us that “we have not yet evolved, we are in the process of evolving” (J. Pawlovich, personal communication, November 18, 2019). Dr. Pawlovich elaborated further by providing insight into the notion that the process of developing widespread acceptance of telehealth in rural communities is a long journey; “ Mentally, people have to transform their thinking in regard to virtual care. People need to be able to untangle their biases [regarding virtual care]. This applies to everyone, whether it be the patient, nurse or physician” (J. Pawlovich, personal communication, November 18, 2019). Before the implementation of telehealth, the foremost unmet need in rural health care, according to Dr. Pawlovich, was access to health care providers, with the inequity of available services being the second largest concern facing residents of rural communities (J. Pawlovich, personal communication, November 18, 2019). Telehealth impacts the ability of rural nurses and nurse practitioners to deliver specialized care by empowering them to feel comfortable in the management of a variety of diagnoses. Dr. Burke discovered “that nurses are very adept at managing acute illnesses provided the backup support is there whenever it is needed” (D. Burke, personal communication, November 22, 2019). Building on the notion that nurses in rural settings experience different job demands when compared to their urban counterparts, Dr. Pawlovich explains that the expanded roles of nurses working in rural communities can be seen as a result of “the issue of isolation, low resources such as manpower, labs, diagnostic imaging and in-person access to a physician” (J. Pawlovich, personal communication, November 18, 2019).

CODI: A Telehealth Pilot Project

In 2017, Dr. John Pawlovich met with Dr. Don Burke at the British Columbia Rural Health Care Conference while presenting on Telehealth. As a result of the interaction Dr. Pawlovich and Dr. Burke came up with the idea of the Clinical Outreach and Diagnosis Intervention (CODI) to better support rural physicians (Morse, 2019). CODI is an iPhone based application (app) that provides rural and isolated health care providers with instant access to experienced clinical support at any time of day, with the goal of supporting and empowering rural health care providers to improve patient outcomes and provider wellbeing (CODI Inc., 2019).

CODI was launched in 2018 as a pilot app with the intention of addressing the issues facing physicians in rural British Columbia, specifically the perceived lack of support, substantial pressure to meet demands, and anxiety experienced by these physicians (J. Pawlovich, personal communication, November 18, 2019; Morse, 2019). Initially the app was for physician use only, but soon after release the platform was opened up to include any registered nurse or nurse practitioner working in remote/rural medicine to access the support system twenty-four hours a day, seven days a week. The changes made during the pilot stemmed from a realization that rural nurses were frequently finding themselves in situations which required them to make critical decisions and act alone in highly specialized cases, which outlined the importance of having a health care platform which was inclusive to rural nurses (J. Pawlovich, personal communication, November 18, 2019).

As discussed, rural communities have faced significant difficulties surrounding the recruitment and retention of health care providers (Hunsberger et al., 2009; Kulig et al., 2015). In response to these difficulties, the goal of the pilot app was to supply rural health care providers with a direct line of communication to health providers located in other regions of British Columbia. As one of the major contributors to the CODI pilot project, Dr. Pawlovich was able to provide insight into how the app was able to support the unique health care needs of rural British Columbian communities. Dr. Pawlovich explained three main reasons why the pilot app represented an advancement in telehealth services for rural communities. First off, CODI was an on-demand pathway and extremely user-friendly; Dr. Pawlovich stated, “you hit a button and instantly connect to an intensivist.” Secondly, health care providers using the app would immediately be placed in contact with an available doctor employed by the CODI project, whose primary role was to support incoming callers for the pilot app. Third, regarding the selection criteria used for the on-call intensivists, Dr. Pawlovich stated that they were “pre-selected for their compassion” (J. Pawlovich, personal communication, November 18, 2019). Dr. Burke shared his selection criteria as the “Triple A”, meaning the physicians selected were “affable, available and able/adaptable” (D. Burke, personal communication, November 22, 2019). It was important for the on-call intensivist to be friendly and offer immediate availability and support. Given the unique limitations in resources and manpower at rural sites, it was important for the intensivist to think outside the box to handle different situations with these limitations in mind.

Following completion of the CODI pilot project, Doctors Pawlovich and Burke collaborated on the creation of a new telehealth app, which according to Dr. Burke, will build on the positive impacts of CODI (D. Burke, personal communication, November 22, 2019). Additionally, Dr. Burke has confirmed that the Rural Outreach Support Endeavour (ROSe) will be set to launch for Spring 2020, and although it will initially be localized to British Columbia, the app will be designed with the capability to expand to national, and potentially global regions (D. Burke, personal communication, November 22, 2019). Although the pilot has ended, CODI serves as an example of how advancements in telehealth can address the unique needs of rural communities and represents an important development in the pursuit of equitable health care in historically underserved communities. Furthermore, the professional support offered through the pilot app demonstrates the utility of telehealth in improving working conditions for rural health care providers.

The Role of Telehealth in Nursing Practice

Nurses working in rural and remote communities often encounter expanded roles when compared to their urban counterparts. As part of that expanded role, rural nurses often have to adapt to unique and high-pressure situations in order to deliver the care their patient requires, often with little support or resources. This has been documented to contribute to increased stress, decreased job satisfaction, and frequent feelings of being overwhelmed (Hunsberger et al., 2009; Lasala, 2017). Whereas the job duties of rural nurses have not seen a substantial change since the implementation of telehealth services, the role of nurses within the rural health care system has seen improvements to working conditions as a result of telehealth (Laurent, 2002; McCracken, 2019; Morse, 2019; Sciarpelletti, 2019). Through the utilization of telehealth services, nurses working in rural communities are able to consult with physicians and other health care providers when addressing complex cases, allowing the nurse to effectively manage while also providing more time and energy to focus on other aspects of care such as client education and the client’s long-term wellbeing (McCracken, 2019; Robinson, 2018; Sevean et al., 2009; Toh et al., 2016). Telehealth has, and continues to support the expanded role of nurses in ways that help facilitate the needs of both the nurse and the clients in rural communities. When asked about how telehealth has impacted the roles of rural nurses in Canada, Dr. Pawlovich replied:

RN’s always worked in isolation, so no physician was present most days of the month. Now, a physician is available on most days. Critically ill patients have been managed by nurses where they call a physician virtually into the trauma room. There is a team-based feeling (J. Pawlovich, personal communication, November 18, 2019)

Dr. Pawlovich further explained that video conference calls and app-based support makes communication with support teams very convenient to nurses, which has changed the way that nurses are able to approach their expanded roles in rural and remote communities.

Benefits of Telehealth

Telehealth is still a relatively new revolution in rural health care, and although it may represent a way to bridge the gap in health equity between rural and urban centers, the notion that the technology has not yet reached its full potential is echoed in a statement by Dr. Pawlovich; “we have not yet evolved, we are in the process of evolving” (J. Pawlovich, personal communication, November 18, 2019). Although the full potential for telehealth to close the gap in equitable health care faced by rural communities has not been thoroughly studied, there are a number of benefits to the implementation and utilization of telehealth that have been observed. Through a review of the literature surrounding past implementations of telehealth, four main benefits have been clearly identified: reductions in access barriers, reduced anxiety for health care providers, potential improvements to recruitment and retention rates due to attenuation of job related anxiety and stress, and promotion of effective client-practitioner relationships. Among the benefits offered by telehealth, enhanced nursing support and the facilitation of equitable health care delivery are two prominent trends.

Regarding the capacity for telehealth services to provide equitable health care services to rural communities, the most prominent benefit has been a reduction in travel costs and time required by both clients and health care providers. Telehealth has demonstrated the ability to reduce the need for residents of rural communities to travel substantial distances to meet their needs for health care (Jong et al., 2019; Lints-Martindale et al., 2018; McCracken, 2019). Furthermore, through reducing the travel requirements for rural residents, risks associated with travel during hazardous weather conditions in rural areas of Canada may be reduced (Jong et al., 2019; McCracken, 2019;). Whereas the travel costs to rural residents is an important consideration in equitable health care, the utilization of telehealth also has the capacity to significantly reduce the financial burden placed upon the rural health care system by reducing the necessity for medical transfers when an emergency or complex case requires specialist intervention, as specialists can be reached almost immediately in most cases to assist rural health care providers through telehealth services (Jong et al., 2019; Lints-Martindale et al., 2018). Dr. Burke added further support to the cost benefits of telehealth services. In his interview he added that “We decreased the number of transfers” and “Our pilot showed us that we can have a major impact on acute care transfers of approximately one to two patients per week. Keeping in mind that each transfer costs approximately $15-20K, that becomes a substantial saving of health care dollars, some of which could potentially be put back into improved resources and education for those regions” (D. Burke, personal communication, November 22, 2019). With the cost of medical transfers from rural areas to urban centers representing a drain to the budget of rural health care services, the ability of telehealth to reduce the need for those transfers means that there is less strain being placed on the budget of rural health care agencies when trying to fund services for smaller population bases. In addition to the reductions in cost, time, and risk associated with travel and medical transfers, telehealth has also demonstrated an ability to support client education in regard to post-operative care, which historically has required rural residents to either face the aforementioned travel burdens or face the financial burdens of prolonged stay away from their home communities (Robinson, 2018).

When considering the benefits demonstrated by telehealth services, another prominent way that rural health care has been affected is through the reduction of job related anxiety for rural health care providers. Historically a major issue contributing to anxiety and stress has been lack of support (Kulig et al., 2015), which is a reality for nurses working in expanded roles in low-resource rural environments (Hunsberger et al., 2009). Additionally, the factors that increase anxiety have also contributed to issues related to retention and recruitment (Kulig et al., 2015; Lasala, 2017). Where telehealth stands out in regard to addressing the aforementioned concerns is that it offers rural providers the ability to consult in real-time with urban colleagues and specialists and allows immediate access to support in the form of specialist instruction and consultation (CODI Inc., n.d.; Laurent, 2002; McCracken, 2019; Sevean et al., 2009). The impact of having a constant source of support available to help diagnose and treat potentially unfamiliar or complex conditions, has led to significant reductions in anxiety and stress for rural health care providers (Sciarpelletti, 2019). Furthermore, through addressing some of the factors which contribute to issues of recruitment and retention, telehealth has demonstrated the ability to provide a practical solution to address the staffing issues seen in rural communities (Laurent, 2002; Morse, 2019).

While benefits such as reduced travel time, financial burdens, and job related stress have often been discussed in the literature as significant merits of telehealth, the relational implications of telehealth are also important when considering how telehealth impacts the rural client-provider relationship. Telehealth allows clients to access a care provider that is right for them, without the travel burden, opening the door to accessible health care services that are tailored to their needs. This leads to improvements in client-provider communication and continuity of care, ultimately improving the client-provider relationship (Sevean et al., 2009). Through the increased accessibility of health care services to residents of rural communities, residents have the ability to form longer lasting relationships of trust between themselves and their care providers, which facilitates positive outcomes for clients (British Columbia Ministry of Health, 2015; Toh et al., 2016).

Barriers to Telehealth 

While the progressive digitalization of health care (e.g. telehealth services) has contributed to transformative changes in the way health care providers respond to unique challenges experienced in rural health care settings, the implementation of telehealth has faced several setbacks. In order for telehealth services to be widely utilized in the rural communities, notable barriers must be addressed. The largest barriers to telehealth involved technological aspects but other issues such as privacy and high costs of technology were also identified (Peddle, 2007). In terms of technological issues faced by telehealth users, the main issue has been a lack of access to stable high-speed networks in many remote communities (Lints-Martindale et al., 2018; Morse, 2019).

Dr. Pawlovich was asked whether the issues surrounding network connectivity in rural communities had been successfully addressed. Dr. Pawlovich stated “It [network connectivity] is improving, but still lags in comparison to cities” (J. Pawlovich, personal communication, November 18, 2019). To overcome this barrier, Dr. Burke recommends a solution: “We have developed a toll free number so that anyone in need in such an area can at least call us immediately. Once that phone connection happens, then the relationship begins, so to speak” (D. Burke, personal communication, November 22, 2019). In response to questions regarding the success of CODI on retention and recruitment issues in rural communities and the role that telehealth will play in addressing these issues, Dr. Pawlovich explained that although CODI was only a pilot project, he believes that telehealth has the potential to improve recruitment and retention over the long term if properly utilized. Addressing issues of recruitment and retention in rural communities, arguments may also be made that issues related to staffing (e.g. increased workloads due to understaffing and high rates of turnover) could also be rectified through telehealth. In addition to the previous barriers, potential financial concerns involved with the implementation of telehealth were addressed by Dr. Pawlovich, in which he explained, “The cost of software in comparison to the cost of the bulky hardware is improved. Bulky hardware will be historical, and iPads or sleek hardware such as mobiles with access to apps will be the future. This improves access” (J. Pawlovich, personal communication, November 18, 2019). Another notable barrier which has historically affected telehealth has been concern surrounding the lack of substantive policy (Peddle, 2007), which was largely focused around the issue of inadequate policy-making bodies to support the necessary development plans to successfully create a widespread telehealth system. However, as described in a 2015 report by the British Columbia Ministry of Health that discussed a plan for the widespread adoption and implementation of telehealth services across British Columbia, support for telehealth on the level of policy makers has increased and has become a less significant issue than it has been in the past (British Columbia Ministry of Health, 2015). Lastly, telehealth services needed to devote a substantial amount of effort towards creating policies that ensured the patients privacy and confidentiality, as well as liability issues (Peddle, 2007), which reduced the capacity for focusing on issues related to the functional delivery of health care services.

Historical Objections to Telehealth

Despite the realized and potential benefits of telehealth, historically there have been two main objections to the argument that telehealth services are a practical way to address the challenges of rural health care. The first argument originated from a perspective provided by Hoskins and Orkin (2008), which proposed that resources in rural communities would be more appropriately spent on recruiting initiatives and promoting the positive aspects of working in rural communities. Several aspects used to support the perspective held by Hoskins and Orkin (2008) have posed significant issues in the past, mainly that many rural communities have lacked crucial elements such as specialized equipment, highly trained personnel to operate the equipment, and specialists to interpret and act on lab results. However, a focus on recruiting more health care providers and improving perception of the benefits of working in rural areas does not address the issues which affect retention in rural communities. Furthermore, focusing on recruitment continues to ignore the requirements of rural communities to have health care that is able to adapt to their unique needs. Whereas simply trying to convince more health care providers to work in rural communities would fail to address the prevailing issues in rural health care, telehealth has provided a way of addressing issues of retaining health care providers and the support of health services for the end users in rural communities.

Although telehealth has overcome many barriers in the development of its services, the issue of infrastructure has presented a significant constraint on the effectiveness of the technology. A second commonly cited objection to the use of telehealth in remote communities has been the high network bandwidth required to utilize telehealth to its full potential, and the lack of sufficient networks in many remote communities (British Columbia Ministry of Health, 2015; Morse, 2019). However, technology over the past several decades has been rapidly developing, and most areas of the country have access to telecommunications in one form or another, whether it is through phone service or through satellite communication, rural communities are not as isolated as they historically have been in Canada. Due to the improvements in cell phone coverage and the advancement in usability of telehealth services, all a rural health care provider needs is a cell phone with data or internet capabilities to be able to access telehealth services. Dr. Burke (2019) offered further insight into how the development of telehealth is making it more accessible:

Previous models of telehealth involved the use of bulky equipment which could only be setup in one place in the hospital and had many buttons and sign-ins. Getting something like that set up in an urgent situation didn’t make sense, and in fact, simply increased the level of frustration. We have now evolved to having such support on one’s cell phone or tablet, which makes it much more adaptable (D. Burke, personal communication, November 22, 2019)

As a result of the literature supporting the use of telehealth services as a practical strategy to address the unique needs of rural communities, the British Columbia Ministry of Health proposed their plans for progressive implementation of telehealth across British Columbia in a 2015 report. Therefore, it can be said that the historic arguments against the implantation of telehealth have been outweighed by the benefits that telehealth services have offered.

Conclusion

The aim of the current paper was to provide a historical account of the development of telehealth as a means to better support rural Canadian patients and their health care providers. Through an analysis of the unique needs of rural Canadians, as well as how telehealth has evolved to adapt to those needs, the benefits offered by telehealth became clear. The progressive developments in telehealth services over its history have resulted in significant advances in the ability of health care providers to address the inequities seen in relation to the quality and accessibility of health care available to rural Canadians. Additionally, innovations in health care technology represented by pilot programs such as CODI have offered significant improvements to the working conditions faced by nurses and other health care providers working in rural health care roles. Among such benefits are increased professional support and development, and a reduction in health care provider anxiety and stress. In addition to improving well-being, these benefits also helped to address issues related to the recruitment and retention of rural health care providers. The improvement of working conditions and reduction of job related stress represents not just a benefit to rural providers, but also a benefit to the rural communities where they serve.

Despite these advancements and benefits, barriers and objections to telehealth do still exist. Limited access to high speed internet in some rural communities poses issues for the ability of telehealth to be used to its full potential. In addition to technological barriers, there have also been historical objections to the utilization of telehealth as a means of addressing the issues faced by rural health care. While the historical objections to telehealth may have held some level of validity when they were first produced, continuing advances in both telehealth and the technology it relies on have resulted in these objections being refuted by more modern evidence.

Although telehealth can be seen as a relatively recent innovation in health care, it has proven itself to be an effective strategy for addressing the inequities and challenges faced by rural Canadian patients and health care providers.

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ABOUT THE AUTHORS

This paper was collaboratively done by ten Critical Inquiry: Qualitative Research students in the Fall of 2019 during their course work in the BSN-AE Nursing Program at Kwantlen Polytechnic University in British Columbia, Canada.

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