Realistic expectations: The changing role of paraprofessional health workers in the first nation communities in Canada

Context: First Nation communities in Canada rely on a mix of non-Indigenous professionals and large numbers of Indigenous paraprofessionals to deliver healthcare. Formerly allowed to perform controlled acts in emergencies, the direct care role of paraprofessionals is now restricted because of concerns about liability and accountability. As such, they are limited to health promotion and prevention activities. Objectives: Focusing on the largest group of Indigenous health workers, viz. Community Health Representatives (CHRs), for illustration purposes, this paper (1) examines the evolving role of First Nation health workers, and (2) discusses the proposed introduction of competency-based standards for their education, certification and regulation. Methods: The paper is informed by findings from open ended, semi-structured and focus group interviews, as well as qualitative survey data, derived from seven studies done in Ontario, Canada. Outcomes: Paraprofessionals face conflicting and sometimes unrealistic expectations. Past practices have accustomed community members to hands-on care, however, professionals will no longer delegate tasks requiring clinical skills to them. Moreover, First Nation leaders are concerned about liability for their paraprofessional employees' actions. The paper discusses issues related to paraprofessional competence, preparation for practice, and continuing health education. It then presents the National Indian and Inuit Community Health Representatives Organization's proposal to establish a scope of practice and set of competencies that can form the basis for national practice and training standards, accreditation and regulation. Conclusions: In Canada or elsewhere, changing practice environments may require adjustments in the roles played by Indigenous health workers. The case of First Nation Community Health Representatives illustrates a strategy for role transformation.