1. Top of page
  2. Abstract
  3. Bridging the Gap—Case Study
  4. Conclusion
  5. Voices from the Saint Elizabeth Experience
  6. References

Access to education, communication, and support is essential for achieving and maintaining a skilled healthcare workforce. Delivering affordable and accessible continuing education for healthcare providers in rural, remote, and isolated First Nation communities is challenging due to barriers such as geography, isolation, costs, and staff shortages. The innovative use of technology, such as on-line courses and webinars, will be presented as a highly effective approach to increase access to continuing education for healthcare providers in these settings. A case study will be presented demonstrating how a national, not-for-profit health care organization has partnered with healthcare providers in these communities to support care at the local level through various technology-based knowledge exchange activities.

Nursing practice in rural, remote, and isolated First Nation communities across Canada is variable and complex, requiring a wide range of knowledge and skills. In the majority of First Nation communities, particularly isolated (accessible only by air) communities, the principal primary care providers are nurses (1). Nurses in these settings are often the only professional healthcare provider and typically have limited clinical resource supports and geographically isolated clinical and management supports; yet, they provide care to residents of communities who experience the poorest health status of all Canadians (2,3).

Canada’s First Nations, Inuit and Métis Peoples have a health status that is well below the national average and worse than that of the general Canadian population on “virtually every measure of health and every health condition” (4, p. 10). Life expectancy for First Nations and Inuit is lower compared with their Canadian counterparts, with the four leading causes of death for First Nations being injury and poisoning, circulatory diseases, cancer, and respiratory diseases (4).

Providing current and relevant continuing education (CE) activities for nurses is an integral part of maintaining a highly competent nursing work force in Canada (5). Increasing access to CE for nurses may also improve delivery of health care in rural and remote communities, where nurses are typically the first healthcare contact for community members (6). Access to CE opportunities can ensure that healthcare providers in First Nations communities are providing care based on the best available evidence. Ensuring that this evidence is integrated within the context of care and provided in a culturally safe manner is critical to providing the best care possible.

Access to relevant CE is also a key factor in retaining nurses in their positions. The Canadian Nurses Association advocates that nurses must continuously update their knowledge, skills, and judgments to provide safe and competent care (7). Information technology has become an essential tool in the clinical setting, and as such, the practice of nursing has become integrated into the world of computers (8). Studies have linked access to educational opportunities with job satisfaction and workplace commitment and a recent survey by the Aboriginal Nurses Association of Canada documented that overwork, burnout, and lack of access to professional development and education opportunities are some of the reasons nurses in isolated First Nation communities choose to leave their positions (2,9). Penz et al. also found that mean scores for job satisfaction were significantly lower (< .001) among nurses who perceived barriers to participation in CE activities (5). As job satisfaction is linked to retention, there is a strong case for supportive working environments that ensure access to CE.

However, access to CE for healthcare providers working in rural and remote communities is impacted by multiple barriers. Nurses in these settings routinely face barriers related to having the time, support, and resources to participate in CE (5). In a national survey conducted with nurses in rural and remote communities, 67.1% of survey participants (= 2838) perceived barriers to participation in CE activities. A content analysis on the open-ended question “what are those barriers” revealed three primary themes: rural community and work life (including geographical isolation, inadequate staffing levels, and lack of access to and availability of educational opportunities); time constraints; and financial constraints (5).

Barriers related to costs to attend sessions, coupled with a lack of time and impacts on continuity of care (related to limited staff, sometimes sole nurse) provide sound rationale for workplace access to CE. Penz et al. assert that “nurses who work in rural and remote settings must have direct access to the most relevant and current educational opportunities within their practice environment” and point to the use of technology (including tele-health, video-conferencing, and on-line distance education) as one means to overcome these barriers (5). A Canadian Health Services Research Foundation (CHSRF) report on “The Nature of Nursing Practice in Rural and Remote Canada,” identified a significant need to explore new ways to provide relevant CE to nurses in these settings, pointing to a “pressing need for providing professional supports at a distance, both in person and using information technology” (10).

The use of technology to support CE in rural, remote, and isolated communities has the benefit of overcoming access and time constraints, allowing learners to access information on their own and when convenient. Moreover, education that uses information technology has been demonstrated to be equal to or superior to traditional learning methods (e.g. textbooks, classroom instruction) for learning outcomes and learner satisfaction (8,11,12).

Bridging the Gap—Case Study

  1. Top of page
  2. Abstract
  3. Bridging the Gap—Case Study
  4. Conclusion
  5. Voices from the Saint Elizabeth Experience
  6. References

For the past 12 years, Saint Elizabeth has partnered with First Nations communities to support care at the local level through the innovative use of technology. Saint Elizabeth is a social enterprise dedicated to the health of people and communities and is involved in virtually every aspect of health care—from system design to service delivery. Saint Elizabeth is continually looking for ways to impact change to create a wiser, more equitable, and humane healthcare system. A dedicated First Nations, Inuit and Métis (FNIM) Program is a key initiative that demonstrates how Saint Elizabeth lives out a vision to Honour the Human Face of Health Care.

Wise Practices

The FNIM program places a particular emphasis on the incorporation of wise practices in knowledge exchange activities. Wise practices are practices that focus on “locally appropriate actions, tools, principles or decisions that contribute significantly to the development of sustainable and equitable social conditions.” (13, p. 19). Wise practices engage community members, from youth to Elders, in a reassertion of fundamental belief structures, values, and ceremonial practices and are based upon the sharing of power, skills, knowledge, and cultural experience. Wise practices reflect the richness of relationships and respect unique and different experiences and views (13). The incorporation of wise practices and “Indigenous Knowledge” into knowledge exchange activities is achieved through the sharing of community wise practices in e-learning events and the full and meaningful involvement of healthcare providers in the development of CE initiatives of the Saint Elizabeth FNIM Program.

@YourSide Colleague

Currently, more than 1200 healthcare providers from over 350 FNIM communities and organizations across Canada are actively participating in the program’s knowledge exchange activities through a bilingual national portal for community sharing of wise practices and information, which includes access to 10 health-related courses available through an award-winning e-platform, @YourSide Colleague. @YourSide Colleague is a secure web-based learning and knowledge-sharing program that includes courses developed for and with community-based healthcare providers from First Nations communities across Canada in areas such as Diabetes Care, Chronic Obstructive Pulmonary Disease (COPD) Care, Cancer Care and Elder Care. @YourSide Colleague provides culturally relevant on-line learning that reflects the latest evidence and leading practices, with a round-the-clock access to a virtual support network of peers and experts. Built on collective wisdom and collaboration, @YourSide Colleague enhances quality of care at a local level, reduces the sense of isolation of healthcare providers, supports local care decisions, and is relevant and responsive to community needs.

This innovative use of technology provides a cost-effective and accessible approach to CE that combines the flexibility of self-directed learning with real-time learning events and peer-to-peer collaboration, without ever having to leave the community. First Nations have identified the @YourSide Colleague program as an effective vehicle to support local capacity and First Nation-driven health programs and services (14). It is an education initiative that is successfully overcoming barriers to learning and is gaining national recognition as a leading practice in e-learning, recognized in 2009 with a Public Leadership Award from the Institute of Public Administration of Canada (IPAC)/Deloitte and selected as a leading and innovative model of service delivery by The Canadian Partnership Against Cancer.

Approach and Key Strategies

The Saint Elizabeth FNIM Program harnesses the collective knowledge and wisdom that exists across a vast network of communities and organizations to positively impact healthcare delivery at the local level. Knowledge exchange activities include communities of learning within @YourSide Colleague as well as real-time e-learning events such as webinars and video conferences. Over 1,200 e-learning events have been delivered to thousands of community healthcare providers in topic areas such as Cancer Control (including survivorship and palliative care), Chronic Disease Prevention and Management, Diabetes Management, Wound Management, Aboriginal Women and Leadership, and Sexual Health. Health care providers in First Nation communities are provided access to the courses and e-learning events at no cost. The program uses numerous strategies to ensure an engaging learning experience for participants. The following case study highlights the approach and benefits realized through the innovative use of technology to deliver CE to healthcare providers working in First Nation communities.

Certified Diabetes Educator Study Group

The Saint Elizabeth Virtual Certified Diabetes Educator (CDE) Study Group was developed as a result of a needs assessment that identified a need to improve the knowledge and competency of healthcare professionals providing diabetes education within First Nation communities and increase the number of Certified Diabetes Educators (CDEs) in these communities. In 2011 and 2012, Saint Elizabeth created, hosted, and facilitated a national virtual CDE study group led by Saint Elizabeth’s Advanced Practice Consultant for Chronic Disease Management (an experienced educator and CDE). Participation was made available at no cost to any interested healthcare providers from First Nation communities who were eligible to write the Canadian Diabetes Educator Certification Board (CDECB) examination, and those interested in writing the examination in the future. A marketing and communication strategy was developed to share information regarding the availability of the study group to First Nation communities throughout Canada through the Saint Elizabeth FNIM program portal page. Saint Elizabeth also opened participation to any interested healthcare providers outside of First Nation communities planning to write the CDECB examination in 2012. A total of 161 inquiries regarding the Study Group were received for the 2012 group from seven provinces and one territory (for the purpose of this case study, the 2012 study group will be presented and discussed).

In February, 2012 a series of webinars was held that provided information regarding the CDECB examination eligibility and application process, and provided an overview and demonstration of the format, timelines, and various technologies (webinars, on- demand recordings, and on-line forum) that would be used to facilitate the virtual study group and support the exam candidates. Following the information sessions, participants had the option of registering to participate in the 14-week Virtual CDE Study Group. Eighty-four regulated health professionals from diverse diabetes education roles and practice settings throughout Canada chose to actively participate in the CDE study group over the 14-week period preceding the 2012 national examination (active participation is defined as participation in more than two live webinars or viewing of the on-demand webinar archived recordings over the 14-week study group period). Of the 84 active participants in the study group, 26 practiced in First Nation communities (31%). The participants came from a mix of professional disciplines with the majority of the group practicing as Registered Nurses (55.4%), followed by Registered Dietitians (37.5%), Registered Pharmacists (5.4%), and Registered Practical Nurses/Licensed Practical Nurses (1.8%). Seventy-five of the active participants indicated that they were registered to write the CDE examination in 2012, and 23 of those registered to write the examination were from the First Nation subgroup (31%).

Format/Delivery Method

All participants in the Virtual CDE Study Group were provided access to Saint Elizabeth’s @YourSide Colleague courses “Diabetes Care” and the First Nation course “Diabetes Circle of Care.” In addition, a “2012 CDE Study Group Community of Learning” (CoL) was established within the @YourSide Colleague learning platform. At Saint Elizabeth, a Community of Learning is defined as a group consisting of a membership that can be either open or restricted, brought together through either self-selection, assignment, invitation, and may or may not involve membership selection criterion. The CoL is established and sustained by shared learning goals, common objectives, and mutual benefit, for the purpose of new learning, consolidation of past learning, and sharing of knowledge, wisdom, and experience. A CoL exists for a predetermined period of time, and adjourns and often dissolves on the achievement of the shared learning goals and/or objectives and/or at a predetermined point in time. A CoL has a leader/facilitator who serves as a navigator on the participant learning journey. CoLs are often not geographically connected or homogenous, but often exist over significant distances, and are supported to come together through online meeting platforms and/or online discussion and posting forums.

At the start of the study, group participants completed a self-assessment to evaluate existing strengths and learning needs related to the various exam competencies. The study group facilitator assisted participants in understanding the CDECB exam competencies, the weighting of exam competencies, the exam format, distribution of questions, and the method for setting the passing grade. Participants were guided through a facilitated discussion regarding the recommended and supplementary reading list for the examination, and were provided with additional links to free on-line resources in a wide range of exam competency areas to address a variety of learning styles. Study resources that provided information regarding many available formal and informal educational programs and offerings were posted within the CoL. Twelve percent of active participants indicated that they had previously completed or were in the process of completing some form of “formal” education, programs, or courses specific to diabetes education.

Fourteen weeks of facilitated live webinars were offered on a range of exam competency areas. Each week, there was a one-hour webinar with an expert guest speaker, live chat, and interactive on-line polling questions. In advance of each weekly webinar, the study group facilitator posted within the CoL the exam competencies that would be covered and provided supplemental resources and recommended readings. Each live webinar was recorded and archived within the CoL for “on-demand” future viewing and to support late additions to the study group and/or those unable to attend any particular session. Study group resources, announcements, questions and answers, tips, tools, and study aids were also posted in the CoL throughout the 14-week study group.

Participants were encouraged to share experiences, perspectives, resources, and questions, and participate in discussions during the live webinars and in the CoL. Participants with expertise in various exam competency areas were encouraged to facilitate or co-facilitate during the live webinars that aligned with their expertise and experience. Access to the study group facilitator for support between live sessions and outside of the CoL was made available over the phone or by email, and all participants had access to support from Saint Elizabeth FNIM Program Engagement Liaison. Technical support for @YourSide Colleague and webinars was also provided as requested/needed.


Over the duration of the study group, the 84 active participants viewed 929 hours of on-demand webinar archived recordings, and participated in the live weekly webinar sessions a total of 609 times, for a total of over 1538 hours of learning. In addition, they launched/logged into the CoL 3278 times, and opened/read discussion postings 2039 times, for a total of over 88 hours of time spent within the on-line CoL (many CoL postings linked to websites and resources outside of the @YourSide Colleague environment. Time spent reviewing the actual external content is not tracked or included in this figure).

The week following the national CDECB examination, an additional “post exam debriefing” session was offered and was attended by 22 of the Study Group participants. Participants were live polled to determine to what extent the study group resources and presentations were relevant to the examination and 92.8% of participants replied “very relevant to the exam.” Approximately 7 weeks following the completion of the CDECB examination, an evaluation survey link was emailed to all active participants. There was a 75% response rate to the survey (= 56). The following represent selected outcomes from the evaluation survey:

  •  88% exam pass rate.
  •  100% would recommend participation in the CDE Study Group to other CDE exam candidates.
  •  90% of participants from First Nation communities indicated that they would be able to apply the knowledge gained through participation in the study group to their practice.
  •  90% of participants from First Nation communities indicated that what they liked most about the study group was that no travel was required and that they were able to access the sessions from home.
  •  90% of participants from First Nation communities either strongly agreed (70%) or agreed (20%) that participation in the Saint Elizabeth CDE Study Group better prepared them to write the CDE Certification examination.
  •  100% of participants from First Nation communities liked the combined on-line posting forum/weekly webcast format for the study group.

The Saint Elizabeth Virtual CDE Study Group successfully engaged with and supported a diverse group of regulated health professionals from across Canada, bringing together diabetes educators from First Nation communities with those from other practice settings on a shared journey to obtaining national certification as Certified Diabetes Educators. All of the CDECB exam candidates from First Nation communities who were aware of the study group before registering for the examination indicated that the availability of this study group was a significant factor in their decision to write the examination. Providing an accessible and flexible approach with various participation options proved to be a successful strategy for increasing knowledge and practice competencies of those providing diabetes education in First Nation communities, and for supporting and increasing the number of CDE’s practicing in Canadian First Nation communities and non-First Nation communities alike.


  1. Top of page
  2. Abstract
  3. Bridging the Gap—Case Study
  4. Conclusion
  5. Voices from the Saint Elizabeth Experience
  6. References

Healthcare providers in rural, remote, and isolated First Nation communities are gathering on-line to exchange knowledge and share their unique approaches to integrating leading practices in the provision of care to their clients. Health teams stand to benefit from a commitment to CE and life-long learning that includes the opportunity to connect, share, and learn with others. The innovative use of technology is a promising approach to increase access to CE, decrease the sense of isolation of healthcare providers, and share leading and wise practices.

Voices from the Saint Elizabeth Experience

  1. Top of page
  2. Abstract
  3. Bridging the Gap—Case Study
  4. Conclusion
  5. Voices from the Saint Elizabeth Experience
  6. References

I have learned so much from the sharing of experiences. I found the group discussions were invaluable.

∼ Community Health Nurse, BC

With @YourSide Colleague®, we are responsible for the direction of our education. It allows us to decide when, where and how we will learn.

∼ Home and Community Care Tribal Coordinator

Wow. I just completed the Diabetes Program. Meegwetch, Quanna, Daigoo, Mahsi etc...a big Thanks. You did a great job of putting this together. I very much enjoyed it. The links are fantastic and there are so many accessible/free tools.

∼ Diabetes Circle of Care Course Participant, NWT

The CDE Study Group through Saint Elizabeth was invaluable!! To be able to network with others in my profession (Nursing), as well as with other health care professionals, was an incredible learning opportunity. I passed the exam and say without hesitation that the CDE Study Group played a huge role in my success with the exam.

∼ Registered Nurse, ON/CDE Study Group Participant

I am very grateful for the learning that I participated in. My patients are grateful, and I feel like I have a better understanding. While I did not write the exam this year, I find that I continue to immerse myself in any and all learning that will help me be a better educator. Thank you for this great forum!!

∼ Registered Nurse, ON/CDE Study Group Participant

Very beneficial to me personally and grateful to be able to participate. Wonderful that you are able to share this learning experience with so many who would otherwise be on their own. Thank-you to all who gave of their time to help us. Very knowledgeable group of professionals.

∼ Registered Nurse, NFLD/CDE Study Group Participant

I’m very thankful to have had the opportunity to share in this study group. I am the only one working in this field in my community and therefore my support group was the online participants.

∼ Registered Nurse, AB/CDE Study Group Participant


  1. Top of page
  2. Abstract
  3. Bridging the Gap—Case Study
  4. Conclusion
  5. Voices from the Saint Elizabeth Experience
  6. References
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