by Lynn McIntyre MD, MHSc, FRCPC,Suzanne Officer BEd, MA, and Catherine Simpson BA, MA,

Introduction

1. Caring for women in the health context means caring for the whole woman. Having health professionals who know how to care for the whole woman is partly the role of education and training. Education and training affects women and women's health in many ways: women comprise the majority of health workers; as women have entered traditionally male-dominated health professions, they have shaped their professions; women health workers are most affected by health care restructuring in Canada; women health workers are continual learners; and women are the prime caregivers in society. This paper provides a Canadian perspective on women's issues pertaining to education and training within the health professions.

Women Reshaping Their Health Professions

2. Appendix 1 presents a gender profile of the predominant health professions in Canada. Nursing is clearly a female-dominated profession with 96.1% of registered nurses in 1994 being female. Occupational therapy and physiotherapy are also female-dominated professions with 95.2% and 85.2% of female practitioners, respectively. Pharmacy currently has 47% of practitioners who are female. The gender profile of the medical profession varies with practice area: 43.4% of general practice physicians are women, while only 17.4% of specialist physicians are women. Dentistry is dominated by male practitioners, although 44% of current dental students are female. Dental hygienists and assistants are almost exclusively female.

3. Examining only the proportion of female practitioners currently in a profession, however, fails to capture the dynamic changes in that profession, particularly for those such as medicine and pharmacy that have experienced a gender shift. It is also interesting to consider the implications of these gender balance changes on professional education itself. The following sections describe the experiences of women in various health professions.

Nursing

4. Nursing has traditionally been a female-dominated profession. Nurses' traditional roles have undergone a major evolution over the last decade or so with the commitment to baccalaureate level of entry for all nurses in Canada by the year 2000, and with the growth of nursing specialization. Nurses are also the major health worker group feeling the negative effects of health care reform through their experience of job loss, job relocation, and job stress.

5. The nursing profession includes certified nursing assistants (CNAs) or registered practical nurses (RPNs), registered nurses, baccalaureate prepared nurses, clinical nurse specialists with advanced educational preparation at both the master's and doctoral levels, and research-prepared master's and doctoral nurses. In some jurisdictions, CNAs/RPNs have sought professional autonomy from the registered nursing profession1.

6. Traditionally, nurses were educated to a generic level of preparation and developed professionally in terms of skills and techniques through the work setting. A major stride towards an enhanced educational preparation for the nursing profession began1 when, in 1982, the Canadian Nurses Association adopted the goal of the baccalaureate degree as entry into the profession by the year 2000. Education within the profession has changed significantly with hospital-based or community college-based diploma schools of nursing having entered into collaborative educational arrangements with university schools of nursing, or in some cases having closed (Grenier and McQueen Dewis, 1995). Baccalaureate preparation includes a longer time period of study, a significantly modified curriculum, increased attention to community and family components of health care, is less hospital-based, and incorporates university goals of undergraduate education related to life-long learning, critical thinking, and written and verbal communication (Grenier and McQueen Dewis, 1995; Dalhousie University, 1995).

7. Specialization in nursing has arisen as a result of expanded knowledge requirements and technology in the health field. In a review of the history of nursing specialization in Canada, Melchior-MacDougall (1992) describes the early specialization field as a response to relocation of nursing practice from the hospital to the community or workplace setting. Public health nurses were recognized as nursing specialists in the 1920s. They have since seen their mandate shift from a community nursing perspective to a primary health care focus on community development and health promotion (Beddome et al., 1993; Yiu Matuk and Chadwell Horsburgh, 1992).

8. In recent times, nursing specialization of registered nurses has followed medical specialization with occupational health nurses being recognized as the first post-registered nurse certification group in 1984 (Melchior-MacDougall, 1992). Since then, other groups have sought specialization status including neurosciences nursing (Melchior-MacDougall, 1992) and emergency nursing (Birkland, 1994). While technological advances in nursing have increased requirements for nurses with specific educational preparation and experience, nurses receive minimal compensation for their comparative advantage in these areas. A lack of recognition of differing nurse preparation thinking has prevailed in hospital salary structures. For example, in Alberta, with seven years of experience, a nurse reaches the top of the wage scale, thus stifling initiative for further educational investment (Cuddy, 1990).

9. Nursing specialization has also occurred at the master's and doctoral levels with the emergence of the advanced clinical nurse specialist role. In this age of government cost-cutting within health care systems, it has become evident that physician-delivered health care is an expensive commodity. Appropriately educated nurses can effectively deliver some of this health care at a greatly reduced cost. For example, nurses in these roles have been a significant and influential trend in the care of the elderly.

10. Canada and the United States differ significantly in their concept of the clinical nurse specialist/nurse practitioner. In the United States, this role is well-developed; in Canada the role (or roles) is still a matter of widespread debate (Haines, 1993). For some in the nursing community, this specialization option has engendered a great deal of concern because of the potential for nurses' hard-won identity and autonomy to be subsumed under a medical or disease-based model of practice (Gottlieb, 1994). However, others see this as an opportunity to expand the clinical role of nurses and they view it as a positive advance in nursing practice.

11. Educationally, advanced practice and specialization options create a demand for the teaching of clinical skills to nurses that are more commonly taught to physicians, an activity that has not been a traditional component of baccalaureate preparation. Trying to balance this learning with the distinctive nursing role is a challenge for educational programs.

Medicine

12. According to Canadian Medical Association (CMA) figures for 1993-94, 51% of first year medical students in Canadian Schools of Medicine were women (Rafuse, 1995). Women comprise 24.3% of the physician population with 42.8% of Canadian women physicians being less than 35 years of age, thus the number of women physicians is rising steadily.

13. This gradual increase in the number of women physicians in the medical profession has definite ramifications for health care education and practice in Canada. Women physicians tend to choose general and family practice over specialization (Sanmartin and Snidal, 1993). They are underrepresented in the academic ranks and rarely hold professional or institutional decision-making positions (Burns, 1995; Mizgala et al., 1993). This limits their influence in the medical policy arena and in medical education.

14. Women physicians are particularly poorly represented in the surgical specialties (Mizgala et al., 1993). As physician numbers are reduced in future as a resource of health human resource constraints, there may be even fewer opportunities for women to become surgeons unless female medical graduates develop a new-found preference for the surgical specialties.

15. The development of educational options attractive to women could lead to women choosing to pursue a surgical career. For example, a survey of Canadian women surgeons revealed that most delayed childbearing until their surgical training was over. While these women were largely satisfied with their career choice, in retrospect, 44% felt that their maternity leave was too short (Mizgala et al., 1993). Institutional maternity leave policies were often lacking where they worked. An Australian study found that the most important determinant of medical specialty career choice for women, compared with men, appeared to be the flexibility of training with opportunity for part-time training, flexible working hours and part-time practice (Redman et al., 1994).

16. The literature supports that women physicians practise their professions differently than men. A study of men and women in family practice revealed that women had fewer hours of work, more office-based practice, lower patient loads, spent more time with each patient, and had less diverse practices than male counterparts (Norton et al., 1994). Single women physicians work 44.4 hours per week compared with single men physicians who work 47.6 hours (Rafuse, 1995). For women physicians with children and a partner at home, the average work week is 36.4 hours whereas men physicians in the same situation work on average 50.7 hours (Rafuse, 1995). When domestic responsibilities are considered, the majority of women physicians contribute twice to three times the number of hours of men with respect to family obligations (Rafuse, 1995).

17. This pattern mirrors the experience of working Canadian women where a number of surveys have reported that about 75% of women working full-time reported that they were "mainly responsible" for their family's health care. Other surveys have found that women do up to twice as much domestic work as men (Dowler, Jordan-Simpson & Adams, 1992). Clearly women physicians are no different.

18. Women physicians also earn less (Skinulis, 1993) and report a higher level of stress (Donaldson, 1993). Women physicians also share with a majority of working women, in both single and two-partner households, concerns about the availability of various options and types of family supports such as day care.

19. With growing numbers of women in medical school and growing awareness of barriers to women's participation in the full range of medical career options, it has become imperative to develop new initiatives that allow women medical trainees greater flexibility within their classroom and clinical education schedules. Female physicians require an expanded variety of options when developing their practice patterns early in their professional lives because of competing family obligations. Freedom to take time off for family-related concerns without risk of penalty within their professions is also a relevant concern.

Pharmacy

20. Pharmacy is perhaps the profession that has been most changed by the rise of women practitioners. This change has occurred in the type of practice of women pharmacists and in their clinical orientation. In Saskatchewan, for example, two-thirds of the pharmacy workforce is female and under the age of 35 (Muzzin et al., 1994). When the shift began, there were fears that a shortage of pharmacists would result as women pharmacists decided to stay home or work part-time to raise their children. Indeed, in the 1960s, only two-thirds of female graduates worked full-time during most of their careers. By the 1980s, however, this figure approached 90%. Still, there is evidence to suggest that younger female pharmacy graduates are delaying marriage and childbearing in order to pursue their careers (Muzzin et al., 1994).

21. How have women changed the pharmacy profession? Women graduates have tended to work in pharmacies run by corporations rather than independent businesses. Fewer than 10% of Canadian pharmacy owners are women. However, younger women now seem more interested in owning and operating their own pharmaceutical business than their older female counterparts (Muzzin et al., 1994).

22. Women pharmacists' focus on clinical pharmacy and pharmaceutical caregiving has also shifted the profession from its previous dominant focus on small business management. Pharmacists are now more engaged professionally in patient counselling about drug use, monitoring for drug interactions, and tracking patient drug profiles. This may be related to the different philosophical orientation of women towards the "care motive", rather than the "profit motive" (Muzzin et al., 1994). Other commentators have, however, suggested that pharmacy's significant transition to pharmaceutical care is more related to professional maturation than to gender effects (Hepler & Strand, 1990).

23. The educational imperatives arising from the change in the role of the pharmacist suggest that pharmaceutical care and disease-state management, professional skills, and an understanding of patient outcomes related to drug management should be included in the curriculum (Dalhousie College of Pharmacy, 1995; Perrier, et al., 1995). Across both Canadian and American pharmacy programs, there is a high level of interest in developing curricula aimed at practitioner-based outcomes (Grussing, 1987; Commission to Implement Change in Pharmaceutical Education, 1993 a&b).

Other Health Professions

24. In the other health professions, women continue to encounter difficulties managing employment and family obligations and seek more flexible work schedules and professional educational development.

25. Physiotherapy in Canada has had one of the highest attrition rates of any profession (Wolpert and Yoshida, 1992). Much of this attrition is attributable to childbearing and family demands. When physiotherapists were asked to suggest options that might enable them to continue employment, they mentioned flexible hours/scheduling, job-sharing options, better salaries and benefit packages, improved professional recognition, and a greater share of the input as part of the health care team.

26. Major shifts are also occurring within the physiotherapy profession because of health care restructuring. In Ontario, for example, there has been a reduction of physiotherapy positions within hospitals and rehabilitation centres. On the other hand, there has been a significant increase in the number of private physiotherapy practices (Dininny, 1994). In a sense, this female-dominated profession is now called upon to reorganize itself from a public service profession to a professional service business.

27. Greater numbers of physiotherapists are also opting to pursue graduate education in order to broaden their career alternatives which include academia, clinical research, clinical teaching, research consulting or a combination of any of these. This move will tend to raise both the profile and stature of the profession for those considering a career in this area (Wolpert and Yoshida, 1992). Increasing demand by practising physiotherapists for advanced physiotherapy education is being responded to by increased flexibility and availability of this education through the use of part-time studies and distance education.

28. Occupational therapists believe that their graduates have been educated for "the future" for some time. Occupational therapy embodies the spirit of many of the reform initiatives seen in health care today, such as recognition of the need for a client-centred perspective, community practice, and direct access to clients. The profession is also oriented towards primary health care, health promotion and community development, with a desire to work in independent versus hospital-based settings (Chilton, 1994). These attributes of occupational therapy education prepare its graduates to assume new roles in the health care system. However, until the current health reforms, there were limited community practice opportunities for occupational therapists; there are still too few such opportunities.

29. The Canadian Association of Occupational Therapists is strongly committed to seeing the development of programs of continuing education that assist therapists to take a comprehensive approach to their clients' life task demands (Madill, 1987). The Association also sees collaboration among the various health professions as a primary objective within continuing education programs, one of the few professions to specifically mention a collaborative approach to post-professional education.

Analysis

30. Much of the previous discussion has described how women health workers are responding to, and in some cases, shaping the health professions and how this shaping has assisted the evolution of these professions in terms of education and training, and accommodation to female practitioners' family obligations. University of British Columbia professor, Arminée Kazanjian has taken a gender hierarchy approach to analyze the health professions (Kazanjian, 1993). She notes that the dominant professions, particularly of medicine and dentistry, are male-dominated. Women are over-represented in the supportive professions, reflecting the traditional division of work in the family.

31. She argues that income inequalities in the health professions seem more related to gender dominance than to relative educational attainment or responsibility differences. Physiotherapy, requiring equal educational time to pharmacy, is more poorly paid than pharmacy, perhaps because physiotherapy has been a traditional woman's profession. Retail pharmacy is the most poorly remunerated career option of that profession, perhaps because of its large proportion of salaried women.

32. Kazanjian's gender hierarchy analysis extends as well to the relative value of specialization in male- versus female-dominated professions. She reiterates the lack of salary recognition for advanced nursing education, citing British Columbia which has extremely poor salary increases for nurses who achieve higher educational attainment. She proposes that the reason that physiotherapy, occupational therapy, medical social work, and dietetics have a higher perceived hierarchical status than nursing, despite being female professions, is their higher degree of autonomy over their work. Autonomy over one's work in all these professions is not a function of the skills or decision-making required for job performance but is perhaps related to historical or even current proximity to medical direction.

33. Kazanjian's analysis is very similar to Butter et al.'s (1987) United States-based study entitled, "Gender Hierarchies in the Health Labor Force". The authors describe gender-based segregation in the American health work force where valued work functions, prestigious positions, and scare resources are controlled by men. They have developed a health occupations matrix which categorizes occupations according to the primary functions, predominant work setting, and level of autonomy. In their analysis, occupations that comprise functions of teaching, caring, and counselling patients are less valued that those that are more technical or diagnostic, which are less valued than occupations that are curative (Butter et al., 1987). Utilizing their analytic framework, it would appear that as nursing has become more technical through specialization, it has been rewarded with more prestige. Similarly, pharmacy's move to pharmaceutical care could be interpreted as a shift from its technical base towards a more autonomous and valued role.

34. It seems appropriate at this time to establish a linkage between education and training issues for Canadian health professionals and the Beijing Platform for Action. Canada has somewhat of an envious position with respect to many of the Beijing resolutions regarding education and training of women (United Nations, 1995). Women and men have relatively equal access to and equal treatment in education and health care, although work still needs to be done to enhance the flexibility of educational programs for women learners and to respond to the total needs of women as health system clients.

35. Canada could go further in adopting a gender perspective in its health programs, policies and educational efforts. As we will see, the boundaries of the gender division of labour between reproductive and productive roles still leave women as caregivers in our system and the major providers of domestic labour despite other employment.

36. Inequalities between men and women in the sharing of power and decision-making persist in the health system between female-and male-dominated professions. Women have not yet achieved equality in leadership positions in the health or educational system and barriers to this achievement, such as those posed by family responsibilities, must be addressed.

37. While the struggle of women health workers for greater respect and power equity continues, educational programs of all professions must respond to the needs of their students and the future of their professions. Thus, whatever advances are made in the education and training of women health workers that accommodate their needs, and meet the demands of their evolving professions, attention must be paid to reducing the power and status differential among the professions and between men and women within professions. Stereotypes of gendered roles in the health professions and a lack of participation in policy decisions by women health practitioners must be eliminated, not only for their sake, but for the optimal care of their patients and clients.

38. It is now time to turn from the perspective of the woman health professional to consider whether the health of women is being well-served by health practitioners, regardless of their gender.

Health Professional Education That Addresses Women's Health Needs And Issues

39. It is difficult to know whether or not what is taught in a health professional program addresses women's health needs and issues. This is because current curricula for health care provider education are not published in the literature. Knowing what is taught, as well, does not necessarily speak to whether or not health professionals are skilled in working with women, for example, in the context of their health needs, sensitivities, and issues. Curricular time may not equal knowledge and skill acquisition. Thus, practitioner outcomes, rather than curricular inputs and processes common to accreditation requirements of the past, are an emerging focus of health care provider education evaluation (Dalhousie College of Pharmacy, 1995; Perrier, et al., 1995). It also does not matter so much whether the health care provider is male or female; it is the outcomes in terms of knowledge, attitudes, beliefs, skills, and abilities that matter.

40. This section presents some case examples of innovative health care provider curricula including basic and clinical education regarding women's health and gender issues.

Midwifery Education in Canada

41. Until the last few years, Canada was the only country in the industrialized world where midwifery was not a recognized profession (Blais et al., 1994). A 1985 survey of the provinces showed that Newfoundland was the only province that legalized the role of midwives. In New Brunswick, midwives operated outside the law and were considered to be "alegal" while in the remaining provinces and territories their status was debatable. This situation is now being redressed by relevant midwifery legislation in Ontario, Quebec, Alberta, and British Columbia (Blais et al., 1994).

42. The establishment of midwifery in Canada is one outcome of the ongoing struggle by women to overturn the medicalization of the childbirth process (Relyea, 1992). Midwifery is about choice for women (Klein, 1994). It represents a woman-centred approach to pregnancy and childbirth and is a superb example of a women's health issue that has been addressed by women for women.

43. Although, in many countries, midwives are trained as nurses first and then go on to midwifery education, there is little agreement about the need for generalized nursing training as the foundation for this profession (Field, 1992). In Canada, the "direct entry" baccalaureate education model has been preferred (Klein, 1994). The direct entry model represents autonomy, self-regulation, and rejection of the medical model of instruction related to midwifery practice.

44. Even though the law in some provincial jurisdictions is recognizing the practice of midwifery, many physicians do not acknowledge it as a legal practice. In Ontario, the primary problem reported by midwives is prejudice on the part of some physicians concerning the relatively large salaries ($55,000 per year) paid to midwives in this era of health care recession (Sears Williams, 1994; Stahl, 1991). Some doctors dispute the suggestion that the health care system can afford to add yet another layer of provider (Sears Williams, 1994).

45. Using Kazanjian's (1993) gender hierarchy analysis, the midwifery profession in Canada is positioned to succeed. It has established autonomy over its educational preparation and practice, is commanding reasonable remuneration, has taken power directly away from the medical profession, and has established a broad-based coalition of policy supporters who have assisted its legalization.

Family Medicine Training and Women's Health

46. Family medicine is the medical specialty of primary health care. It arose from general practice with the intent to better prepare physicians for their role as primary medical caregivers. Maheux and colleagues (1992) found that residency-trained family physicians were younger, more likely to be female, and more sensitive to the psychosocial aspects of care.

47. The more holistic care given by family practitioners may be attributed to an effort on the part of their educators to have them attend to the needs of the whole person. Because women's health is an important component of family practice and because there was concern from various specialty training bodies that women's health was insufficiently covered in the Family Medicine residency programs, a women's health curriculum was developed and published in a report of the Joint Working Group on Family Medicine in Obstetrics, Gynecology and Women's Health (Crombie et al., 1990). Recognizing that women's health issues extend beyond reproduction, the Working Group recommended that residency programs cover women's health issues such as mental health, impact on health of roles and relationships, health care concerns of special groups, violence against women, occupational health, and conditions more common among or specific to women. It was suggested that clinical exposure to sexual assault teams, shelters for battered women, homeless women, and unwed mothers would be helpful.

48. McCall and Sorbie (1994) were interested in the outcomes of such training recommendations from the Joint Working Group Report. They conducted a survey of Canadian family medicine programs in 1992 to examine the contribution of family medicine training to these physician's understanding of women's health (McCall & Sorbie, 1994) They found that Canadian family medicine programs did a credible job teaching their residents about violence against women, as well as women's health conditions such as osteoporosis and breast cancer. Social determinants of women's health such as poverty were less well covered. Half of the programs provided special educational opportunities to work with special groups of women such as single mothers and older women, although, immigrant and aboriginal women were less often targeted. Placement experiences continued to be traditional although sexual assault team participation occurred in up to 50% of programs (McCall and Sorbie, 1994).

49. One of the respondents to the survey provided an interesting commentary on teaching around 'women's health issues': "Many of these issues are taught as part of global subjects and not specifically in relation to women, eg, violence, poverty, single-parent families" (McCall and Sorbie, 1994). It does appear that medical and other health professional education in Canada attempts to teach its future practitioners to care for the 'whole person', rather than separate women or others into individual teaching target groups. The trend is for health care providers to be educated to be sensitive to patients and clients in terms of their ethnicity, race, religion, age, lifestyle choices, or living conditions. Women's issues may very well be integrated within these broader emphasis areas. The onus, of course, on educators is to be assured that health professional students possess the knowledge, attitudes, beliefs, skills, and abilities as well as sensitivities in these areas.

50. The Beijing Platform for Action (United Nations, 1995) warns against gender-biased education of health providers. While gender-bias is not as apparent in Canadian health professional curricula as in the past, further attention must be paid to ensuring that health care providers are sensitive to, and knowledgeable about, the health issues and concerns of women.

Gerontological Nursing

51. By the year 2010, 25% of Canada's population will be over 65 years of age (Jenny, 1993). Over the next 25 years, the number of Canadians over 65 years old will double (Cuddy, 1990). Although these seniors will represent a generally healthier group than their predecessors at a similar age, chronic illness will be an issue for approximately 70% of those over the age of 65 (Cuddy, 1990). Consequently, as with the rest of the population, there will be demands on health care from seniors in the form of risk reduction counselling, health maintenance information, and quality of life education for the healthier seniors, as well as a variety of health supports for the less healthy.

52. The number of nurses in the geriatric field is increasing and will need to continue to increase in answer to these needs. More attention to gerontology within all health-related fields will be an educational necessity in the twenty-first century. Added to the situation of greater numbers of older, chronically ill citizens, are the financial constraints of the current era that have resulted in shorter average hospital stays for all patients with an attendant increase in the demand for community health nursing services for seniors following discharge.

53. Gerontological nursing education attempts to address the myth that it does not take much skill or expertise to take care of older people. Gerontological nursing has evolved into a specialty with its own technology, knowledge, and expertise (Pearson and Small, 1994). The Canadian Gerontological Nursing Association found that there were at least 62 gerontological programs available to nurses in Canada (Miller and Hirst, 1993). Among the five programs offered in Alberta, all were designed to meet the needs of adult learners using a variety of approaches such as evening classes, intensive study periods, and distance education (Miller and Hirst, 1993).

54. For entry-level nurses in Canada, gerontological content is becoming more prominent in the nursing curriculum (Beckingham et al., 1992). In 1988, the five university health sciences centres in Ontario formed the Ontario University Coalition for Education in Health Care of the Elderly. The nine degree-granting schools of nursing in the province identified parameters and principles underlying curricula for gerontological nursing. The promotion of healthy aging was the central theme of the province-wide curricular plan (Beckingham et al., 1992).

55. The work of the coalition continues. Evaluation of curricula outcomes has been advocated. The inclusion of gerontological content in nursing curricula has been slow, however, because of a number of factors, including faculty interest and expertise, student preference, availability of clinical settings, and competing interests (Beckingham et al., 1992). Multiculturalism was noted as a challenge to include in the context of gerontological curricula.

56. There is a paradox. The demographic reality is that we are facing a crisis in caring for an aging, largely female, population over the next decades. Gerontological education of health professionals is touted as an imperative and a field with its own body of knowledge. Yet programs and professions resist reorienting their instruction to respond to the reality of caring for the elderly. Society seems prepared to leave the burden of care for the elderly with women as lay caregivers who provide custodial care (Dowler et al., 1992). The gender lens permits us to see that women's personal and career equality is subordinate to the sacrifices they are expected to make as caregivers. This devalues both caregiving women and the elderly (also often women) they care for. The question of whose responsibility it is to provide care to a family member, and what resources are expected to support that care, is also a matter of public debate.

Aboriginal Health

57. Aboriginal Canadians have a well-documented history of poor health. Infant and post-neonatal mortality rates are twice the national average, life expectancy is significantly reduced, and unintentional and intentional injury death rates are several-fold higher than the Canadian average (Mardiros, 1987).

58. The Medical Services Branch of Health Canada has begun to transfer health services to First Nations self-determining groups. A high priority is the training of aboriginal people to serve within and manage their health system. Relevant educational programs are being revised to better reflect specific cultural concerns as well as to provide appealing options that will encourage aboriginal students to enroll in and complete the courses. The educational effort must also be responsive to the need for a blending of indigenous health traditions with accepted North American health care practices (Mardiros, 1987). One model for aboriginal self-government is in the Northwest Territories.

59. In the Northwest Territories, the health care system, while largely modelled after that in the rest of Canada, is greatly dependent on community nurses as the primary health care providers (Morewood-Northrop, 1994). Prior to the transfer of health service responsibility to the territorial government in 1988, the turnover rate for nurses was about 70%. However, following the transfer, this rate dropped by thirty percent. The primary problems identified by nurses working in these isolated areas were lack of in-service, job-sharing, and independent living quarters. Nurses felt inadequately prepared for their professional roles in the north, working conditions were onerous, and off-duty quarters were inadequate. Attention to these issues has been cited as a contributor to a reduced turnover rate (Morewood-Northrop, 1994).

60. Other initiatives have been developed and implemented in response to health concerns specific to these northern regions. In the area of perinatal health, a committee of local aboriginal women has been formed to direct prenatal care, choice of birthing locations (to review policy that required transfer of near-term mothers to hospitals away from their communities and was enormously unpopular), and the integration of traditional and modern midwifery practices. In the area of nursing education, a Northern Nursing Diploma Program in Yellowknife, has been established to recruit and retain native northerners as registered nurses.

61. Improved aboriginal health care in Canada is one of the most challenging education and training imperatives in the country. Aboriginal women will be central to these efforts as both recipients of culturally sensitive care delivered by well-prepared non-aboriginal and aboriginal health care providers, as health care providers themselves educated to meet the health needs of their communities, and as non-formal caregivers within their communities. This is not unlike the model of health in development used in international development, a model that is based on basic human needs, sustainability, and relevance (CIDA Strategy for Health, 1996, forthcoming).

62. The Beijing Platform for Action (United Nations, 1995) also speaks to the issue of indigenous women. Addressing the distinct concerns of aboriginal women is an enormous responsibility of all Canadians and health workers must assist aboriginal women to strengthen their position in society.

Health Reform and Women's Health

63. All Canadian provinces are currently in the throes of major health reform. These reforms are based on the principles of primary health care and aim to: improve overall health; coordinate and integrate services; shift from hospital- to community-based health care delivery; and refocus on health promotion/disease prevention.

64. Implementation of the primary health care approach requires that all health professionals have a better understanding of its inherent principles of accessibility, essential preventive and curative services, and attention to the broad determinants of health. Therefore, the educational community must respond with an incorporation of these principles into appropriate courses, curricula, and fieldwork opportunities. A focus on integrated health care necessitates a similar educational focus on interdisciplinary learning and team health care management and delivery.

65. Health reform in Canada is also linked to financial reduction. There is little, if any, extra funding available to be redirected to support the new health paradigm. In most provinces, the restructuring of the health care system has led to the closure of hospital beds and dislocation of health workers, the majority of whom are nurses. The most likely location of future nursing practice for these displaced workers will be in community settings and in entrepreneurial practice. There, they will need skills in population-based approaches and community development, including disease prevention and health promotion strategies. For nurses, post-diploma nursing education must respond to these needs. Support for part-time learners, often with families or other obligations, is a key issue.

66. The Beijing Platform for Action (United Nations, 1995) also speaks to the effects of structural adjustment on women workers. The economic transformation of the health system in Canada has increased the unemployment of women and made others more vulnerable. Public expenditure must be reallocated to redress this outcome. The Platform urges that lifelong learning opportunities be provided to women in ways that meet their needs and aspirations.

67. The identification of women as non-traditional learners in Canada is important because it may encourage a new focus on women and their specific needs within the learning environment. Heading the list is a need for more flexibility in scheduling and completing course and training requirements. Some possible alternatives include: distance education options, part-time/semestering, credit for previous learning/experience, and multiple alternate time schedules. The addition of subsidized child care services would be also welcome for many female students.

68. Before leaving this section on health reform, it might be helpful to consider the relevance of the reports of the United States Pew Health Professions Commission to Canadian health professional education (Shugars et al., 1991; O'Neil, 1993). The Commission's "Agenda for Action" comprised 17 competencies including the skills, attitudes, and values that future health professionals must address (de Tornyay, 1992). In many ways, Canada is ahead of the United States in terms of the strategies that promote health, rather than sickness, orientation of its system. Likewise, consumers are a major focus of Canadian health reform, as is the emphasis on outcomes and accountability. Information management, opportunity for continuous learning, and attention to the diversity of the population, are of concern to both the Canadian and American systems. The Commission has proposed the development of interdisciplinary teaching, practice, and research programs for the care of complex patient populations, and this is an area that needs more development in Canada (de Tornyay, 1992). At the very least, Canada and the US can learn from each other in terms of the directions proposed by the Pew Commission.

69. In conclusion, Canadian women are beginning to challenge the traditional limits of the health professions. They are the recipients of increasing health care responsibility in a time of fiscal restraint and reductionism. The shifting health paradigm has created a need for a relevant learning environment, open and attractive to all women. Key concepts in this new environment centred on the primary health care approach will be flexibility, support, and responsiveness.

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Endnotes

1 Legislation for self-regulation of certified nursing assistants is currently before the Nova Scotia legislature.

Appendix 1

Gender Breakdown of Selected Canadian Health Professions

Healthy Living Features

Healthy Pregnancy

Oral Health

Travel Health

Sun Safety

Assisted Human Reproduction