https://www.infirmiere-canadienne.com/blogs/ic-contenu/2025/06/02/mieux-etre
Nurses are ideally positioned to help combat chronic disease through novel approaches
By Celise Hack
June 2, 2025
istockphoto.com/SabrinaBracher
Nurses’ roles as trusted health-care providers enable us to foster strong relationships within the community, empowering populations to take an active role in managing their health. Now more than ever, the complex needs of Canada’s rural and remote populations require the leadership and strength of nurses.
The issues facing public health post pandemic remain complex. Although our current acute and reactive health-care system is well poised to address many of the health-care needs of our population, it continues to struggle with the issues posed by complex, multi-morbidity chronic disease processes.
Federal, provincial, and municipal governments have acknowledged the difficulty in addressing the systemic factors driving chronic disease. Governments recognize that each community and its population is unique, and that the support and services they require to effect change will be different. The mental, physical, and financial costs of chronic disease on an individual, provincial, and national level have increased significantly post pandemic, and thus, creative, multi-system approaches are required to address the complexity of these issues.
Government and private industry grant programs have been implemented with the goal of allowing communities to develop grassroots solutions to meet the health and wellness needs of their populations.
In this article, I will outline the challenges posed by the dramatic increase in chronic disease, and share the opportunities nurses have to effect change at the community level with grant funding. I will use the Community Well organization, which I founded in rural Saskatchewan in collaboration with other community members, as an example.
Increase in rates of chronic disease
According to Statistics Canada, the prevalence of chronic disease conditions has increased since 2020; “45% of Canadians lived with at least one major chronic disease in 2021 and 1 in 12 had three or more chronic conditions” (Statistics Canada, 2023).
The causes of chronic diseases are complex and require a comprehensive approach. These diseases are largely preventable and predominantly caused by a set of systemic, societal, and individually modifiable risk factors. These conditions are the leading causes of morbidity and mortality provincially, and are the primary driver of individuals requiring hospitalization, surgery, alternative levels of care, and long-term care placement.
It is estimated that chronic diseases account for 65 per cent of all deaths; in total, it is estimated that “chronic diseases and other illnesses cost the Canadian economy $190 billion annually, with $122 billion in indirect income and productivity losses, and $68 billion in direct health care costs. The direct cost of chronic diseases accounts for about 58% of the annual health care spending in our country … [T]he cost of diet-related disease in Canada in 2015 was estimated at $26 billion/annum” (Chronic Disease Prevention Alliance of Canada, 2017, p.1).
These conditions are not curable through traditional acute care medicine, and result in decreased independence, increased acute care and reactive health-care visits, decreased quality of life, polypharmacy, and loss of work productivity.
Financial support creates opportunity for nurses
As a direct-care RN working in these conditions, I increasingly came to believe that an approach outside of our reactive, over-taxed health-care system was necessary to address the systemic factors driving disease in the community.
The provincial government of Saskatchewan and the federal government introduced grant programs for which communities could apply, with the goal of creating programs and supports for older adults to age well, independently, and in their communities. Essentially, governments and corporations are looking for opportunities to hand financial and creative responsibility back to communities to help solve the complex and unique health-care needs of each population.
Nurses living and working within these communities have a unique opportunity to step into leadership roles in their municipal governments or through the creation of non-profit boards, apply for grant funding either from a government program or independent business, and implement health and wellness programs and support not available through the traditional health-care system.
To begin this process in our rural community, located approximately 200 kilometres from the major city centres of Regina and Saskatoon, I met with our town council, health advocacy board, member of the legislative assembly, invested members of the community including our school principals, business owners, and members of our rural municipality council, senior citizens’ board, long-term care home manager, primary care manager, and pharmacy. I presented concerns about the state of health care in our rural communities and proposed a variety of programs and ideas that could be implemented at the community level.
The Community Well is formed
From this meeting of community members, a group of interested individuals met again and formed a board called the Community Well in November 2023. Our board consists of myself (a registered home-care nurse), the manager of our primary health-care centre, our community’s pharmacists, the chair of the senior citizens’ committee, our town leisure services director, a community speech-language pathologist, and an interested older adult who loves to volunteer.
We applied for and received a Saskatchewan Seniors Mechanism Facilitating Independence grant, the Saskatchewan Parks and Recreation Association’s Forever in Motion grant, a Saskatchewan Lotteries grant, a Parkland Valley District grant, and a federal New Horizons for Seniors grant.
Goals established
We distributed a survey to our community in both online and paper format to better understand what programs and supports our community was lacking. Based on these meetings, survey results, and my work as an RN, our group’s initial goals were formed as follows:
- Increasing access to fitness and wellness programs targeted directly toward the senior population with the goal of improving mobility, flexibility, and mental health, and maintaining and improving chronic disease outcomes and overall health and wellness of all participants
- Increasing education and access to health services by providing information and resources on current services offered in our community and health region and how to access them
- Empowering senior community leaders to become involved in the organization and planning of education and information sessions
- Reducing isolation by networking seniors in our program and with existing community groups
- Improving health outcomes of involved members and decreasing the need to access acute and primary care by providing information and access to health-care professionals who can guide them in chronic disease management, and providing guidance on how to use electronic tools and resources to assist with their health care, such as eHealth Saskatchewan.
Events planned with partners
With these goals, the Community Well formed multiple partnerships across our community and facilitated and organized multiple community events. Our projects included the following:
- A seniors’ tech café (a tech support workshop partnering our library, high school, and older adults)
- A fraud awareness seminar (partnering the RCMP, library, and Royal Bank)
- An ongoing globe walk program (partnering with the Saskatoon Council on Aging, leisure services, our hall manager, and a donation from the credit union)
- Chronic disease management courses (partnering with our town’s pharmacy)
- Creation of a health-care bursary (in partnership with our Health Advocacy Board)
- A “grandpals” letter-writing exchange program (in partnership with our elementary school and LTC home)
- A cognitive kitchen/cooking class program (in partnership with the University of Regina and our community hall)
- The creation of a social program focused on hand–eye coordination
- Free seniors’ matinees and transportation to our community theatre
- A community-wide service directory highlighting volunteer services specifically for older adults in our community.
Furthermore, our board was able to purchase two power-lift recliners and a shuffleboard table for our assisted living seniors’ complex, and through our programming have encouraged many pre-existing community groups to create and offer programs with a focus on socialization, health, and wellness.
The Community Well completed its second consecutive year of sustainable health and wellness programming through grant funding exclusively, and remains committed to providing chronic disease management and healthy living supports to our rural population.
Community wellness projects fall within nursing
Nurses are uniquely positioned to drive significant change in chronic disease management within rural populations, where health-care resources are often scarce and access to specialized services is limited.
By leveraging nursing expertise in patient care, health education, and community engagement, nurses can fill critical gaps in the health-care system. We can provide much-needed support and continuity of care for individuals who have chronic conditions, offering them new and creative solutions and ideas separate from our traditional roles. Applying for grant funding, soliciting private sponsorship, and increasing community engagement in healthy living and addressing modifiable lifestyle factors all lie within the core competencies of nursing.
Nurses’ roles as trusted health-care providers enable us to foster strong relationships within the community, empowering populations to take an active role in managing their health. Now more than ever, the complex needs of Canada’s rural and remote populations require the leadership and strength of nurses.
I encourage all nurses to continue to find the means to shift and improve the delivery of health care in new and creative ways, like the great nursing leaders who came before us.
References
Canada Life. (2024). What are the financial impacts of chronic disease? www.canadalife.com/insurance/group-benefits/financial-impact-chronic-disease.html
Chronic Disease Prevention Alliance of Canada. (2017). 2018 Pre-budget Submission to the House of Commons Standing Committee on Finance. https://www.ourcommons.ca/Content/Committee/421/FINA/Brief/BR9073636/br-external/ChronicDiseasePreventionAllianceOfCanada-e.pdf
Statistics Canada. (2023). A glimpse at the health of Canadians. https://www.statcan.gc.ca/o1/en/plus/5102-glimpse-health-canadians
Celise Hack, RN, works at the Foam Lake Health Centre in Saskatchewan.
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