Evidence-based nursing in Greenland: Pioneer spirit and long-term strategies for education and research

While healthcare in many Nordic countries is increasingly centralized, some nurses are working very much on their own. This applies to nurses in Greenland, who provide care for patients in some of the world’s most rural and remote areas. Still, they share the same ambition of evidence-based care as their colleagues around the world.

Greenland

Greenland is the world’s largest island, but although it is the size of Europe, the population consists of only 56,000 inhabitants. Almost 80% of the country is covered by ice, there are no roads between the 16 towns and 60 settlements along the coast, and transportation takes place by boat, helicopter, flight, snowmobile, or even dog sled. The capital is Nuuk, with about 16,500 inhabitants. Greenland has had a self-government act since 2009 but is a part of the Danish Kingdom. The primary language is Greenlandic while a second is Danish, and English is taught in all primary schools as well.

The healthcare system in Greenland

Due to the geography and climate, healthcare in Greenland faces many challenges, of which two are most significant. First, the sparsely populated and remote areas where the population lives in small villages and settlements, in some areas lead to unequal access to health services and treatment delay. ¹ Telemedicine is being established to underpin local interventions and overcome the huge distances, but the technology still has to be further developed, and health professionals have to develop skills in how to make the best use of it. ² Second, the Greenlandic healthcare system is in lack of educated personnel. A large proportion of the higher educated health professionals such as medical doctors and nurses come from other countries (mostly Denmark) and for a limited period. This implies a high turnover among health professionals and the cost is a breach of continued development and evidence base for healthcare.

Nursing education

Working as nurse in Greenland is quite demanding and requires solid professionalism along with flexibility, especially concerning transfer of knowledge to the local context. One way to meet these challenges has been to strategically focus on and invest in nursing education, which was initiated in the mid-nineties. The Greenland Bachelor of Nursing programme has a duration of four years compared to the Danish programme which takes three and a half years, ³ since nurses in Greenland often work with few colleagues, they need to learn how to take on management responsibilities for general and acute care, as well.

The theoretical education takes place at the University of Greenland, Ilisimatusarfik, while the clinical education takes place at local hospitals and healthcare centers, along with Queen Ingrid's hospital in Nuuk and international placements. The teaching language is Danish, but as a result of a new language strategy Greenlandic-speaking teachers at Master's level now constitute the majority of the permanent teaching staff. Fourteen nursing students are admitted every year, and since the beginning a total of 164 Greenlandic nurses have been educated, which constitutes half of the Greenlandic nursing work force. In addition, nurses have participated in Diploma programmes in arctic care, management, intensive care, and child healthcare, along with Master’s programmes in nursing.

Education and research go hand in hand

To evidence-base education as well as local healthcare, culturally relevant and context-specific knowledge is most needed. Coherent with this strategy, the Greenland Centre for Health Research (GCHR) was created in 2008, as an independent health-research institution, and became part of the Institute at Ilisimatusarfik in 2013. ⁴ With the establishment of the GCHR and the association of a number of medical professors, the anchoring of health research and health researchers in Greenland has increased considerably, and it appears that the quality of the nursing education as well as the conducting of health research mutually benefit from taking place ‘under the same roof’.

Research

To support education also at PhD level, the PhD programme ‘Arctic studies – health and social studies’ was developed in continuation of the nursing programme. Through a research cooperation agreement with the Department of Clinical Research at the University of Southern Denmark in Denmark, the first author joined as head of research in 2009. Since then, scientific knowledge concerning Greenlandic nursing and topics of relevance for Greenlandic healthcare and the community as such have been continuously developed, for instance cultural perspectives on health practices, everyday life with illness, ⁵ and palliative care in Greenland. ⁶ Up until now, the establishment of the PhD nursing programme has been successful, as three students have completed their PhD education at the Institute of Nursing and Health Science, University of Greenland. One is at present enrolled, and several others are on their way to preparing a study focus.

Furthermore The PhD Council, frameworks and guidelines for joint PhD degrees has developed. The aim is to ensure that the students are given the possibility of double enrollment and establishment of international research relations for instance at other Arctic Universities. Now there are five PhD students enrolled at the GCHR with an adjunct medical professor as their supervisor.

Future perspectives

Along with education of nurses and researchers, there are several ongoing health projects related to the Institute and to the GCHR, and to summarize, there has been a stable development from a unilateral focus on education towards a bilateral focus on education and research. The next step is to bring back the newly created knowledge to patients and nurses in new studies that are closely related to clinical practice and focus on implementation and evaluation. As an example, the second author has recently been employed to lead a clinical research project concerning patient involvement in hospital care. ⁷ Altogether, this development is just as much the result of a pragmatic approach as it is the result of a strategy, but we find it fair to conclude that on a small scale it is sufficiently in line with the development of the nursing profession in other Nordic countries.