Health worker perspectives on Greenlandic healthcare – resources, sustainability and work-life-balance

ABSTRACT

Greenland faces severe challenges with the recruitment and retention of health workers. A healthcare reform from 2010 did not have the expected effect. On this background we explored health worker perspectives on barriers and opportunities for improvements. To generate knowledge of opportunities and challenges in delivering culturally relevant healthcare, and knowledge of conditions for developing a sustainable work environment. Interviews with healthcare staff from all regions were carried out and analysed within a hermeneutic-phenomenological approach. Although better cohesion of healthcare and improved communication across health units was experienced, lack of support, training, and high staff turnover overloaded the permanent staff leading to staff flight and increased use of short-term health workers. Following a need among the population, health workers call for increased focus on health promotion. They request leadership that includes local knowledge and skills to prioritise, organise and develop culturally safe healthcare, based also on the perspectives of service users. Greenland has dedicated health workers holding local knowledge of significance for care and treatment. Prioritisation of health promotion is considered necessary and satisfactory but must be supported by strategic leadership. Further, a satisfactory work-life seems closely related to recruitment and retention.

Background

Like most other countries around the world, Greenland is experiencing major challenges with recruiting and retaining healthcare staff. A healthcare reform in 2010 aimed to address this but up till now it has had no noticeable effect.

On this background we explored health worker perspectives on barriers and opportunities for action. In the following, structural and organisational conditions for healthcare in Greenland are described in detail leading to a presentation of methods and discussion of findings.

Conditions for healthcare in Greenland

Greenland is a welfare society where public services such as social security, healthcare and education are financed via income taxes. Please refer to Table 1 for a short introduction to Greenland’s geography, history, and population. The national Queen Ingrid’s Hospital in Nuuk provides advanced treatment of the most prevalent diseases like heart-, lung- and musculoskeletal diseases, diabetes, and cancer. Regional hospitals and health centres provide less specialised treatment, and in the settlements, health service is provided by short- or uneducated health workers. Patients in need of advanced treatment are evacuated to Nuuk, which is expensive, time consuming, and often gruelling for seriously ill patients.

Table 1.

Facts of Greenland.

Greenland is the world’s largest island, situated in the Arctic east of Canada. From 1721 to 1953 Greenland was a Danish colony, later being incorporated as Danish county in 1953. In 1979 home-rule, and in 2009 self-government was introduced in Greenland. Greenland has 56,000 inhabitants, scattered in 18 towns and around 55 settlements along the enormous coastline 2650 km from the north to the south. The capital Nuuk has 20.000 inhabitants, the towns 1000–5000 inhabitants, and the settlements from just a few people to 300–400. No roads connect the places of residence. Transport takes place by boat, helicopter, flight, snowmobile and dog sled, and is extremely sensitive to weather conditions. 6–7000 permanent residents come from other countries [36], predominantly Denmark. Since the immigration from around 4500 b. c. of Inuit from Alaska and Canada to Greenland, northerners from Iceland, whalers and tradesmen from Europe, and the colonisers from Denmark have socialised with the original population, e.g. by marriage. Most Greenlanders identify themselves as Inuit, with the young generations doing even more so since a showdown with the Danish influence started in the 1970’ies. App. 50000 residents inside Greenland speak Greenlandic language, Kalaallisut [37]. Within Kalaallisut, different dialects are spoken in East-, South-, North- and West Greenland. With the introduction of self-government in 2009, Kalaallisut became the official language. However, newspapers and radio broadcasts are published in both Kalaallisut and Danish. Further, both languages are spoken in Inatsisartut (the Government), and Danish is still predominant in higher education and in healthcare.

Health status

Social inequity in health has been steadily increasing since 1993. The large social differences are linked to place of residence, education, and work [1]. Income in the small towns and settlements is an average of two thirds of the income in the five larger towns [2]. This comes with considerable variations since the basis of support in the form of natural resources is distributed differently, and access to work is fluctuating. Difficult social conditions often lead to social problems like abuse, violence, and generally poor quality of life. Thus, self-estimated health follows the scope of prosperity: The poorer economy, the poorer health experience. In line with this, the burden of illness is heaviest in the rural areas [3].

Access to health care

The infrastructure and the following challenges are described in Table 1. However, telemedicine was established in all health units in places of residence with more than 50 residents in 2008. Telemedicine is used for communication between Greenlandic specialists and specialists outside Greenland. Specialists from the national hospital supervises health workers through telemedicine, and local health workers hold consultations with service users in the small towns and settlements.

Lack of staff

There is a nursing education, and a basic health education situated in Nuuk, but too few are educated (see the section “Health education”). Young Greenlanders go to Denmark for specialist education, but most doctors, therapists and other specialists are recruited from outside. However, it is becoming still more difficult to recruit these personnel groups, which affects the working conditions and -environment in the health units negatively and causes more health workers leaving their workplaces – a vicious circle.

Therefore, the health system is populated by a large proportion of short-term health workers from outside Greenland, and 1000 employment contracts are entered per year in a healthcare system with a total of 1600 employees [4].

The short-term health workers usually know very little about Greenlandic culture, language, and healthcare, and communication between patients and the not Kalaallisut-speaking health workers is a great challenge, as many patients, especially outside Nuuk, mainly speak Kalaallisut.

Furthermore, the heavy flow of short-term employees requires many resources from the permanent staff concerning introduction, interpretation, cultural mediation and conflict management due to misunderstandings. However, it should be emphasised that there has always been a core of resident Kalaallisut-speaking nurses and health workers, mainly educated in Greenland. Their work efforts are crucial for the coherence of the healthcare system [5].

Relationship-based health provision

In small communities the residents know each other well, which is often a positive thing. But the lack of anonymity can also be negative. In all health units, patients and health workers will know each other from private contexts. This can cause patients to hold back information or concerns, fearing that their confidence will be revealed to outsiders. Further, health workers, through years of knowledge about certain family problems, can develop a fixed view of the family and ignore opportunities for change [6].

Community health workers are usually recruited among the inhabitants of the settlement. These often stand alone with the problems, and not seldom come in the firing line of their fellow villagers’ dissatisfaction with health care.

Health education

Since the early 1990’ies Greenland has educated nurses on Bachelor of Science level and a range of skilled health workers such as healthcare assistants and -helpers, community health workers, rescue personnel, dental hygienists and more. Health educational institutions are placed in Nuuk, and students from the rural areas must move to Nuuk during education.

Dropout from education is generally high, at the nursing education around 40 %, often due to poor wellbeing, for example trauma in earlier life, difficult family situations, and homesickness [7].

However, despite all logistical, relational, and educational challenges, healthcare is largely offered in all inhabited places, and people can contact healthcare services 24/7 despite place of residence.

Healthcare reform

The healthcare reform in 2010 changed the health organisation from 16 districts to five health regions (Figure 1). The background was a changing pattern of illness with an increasing number of elderly and chronically ill, in addition to the persistent challenges in recruiting and retaining staff. The aim was to strengthen primary healthcare, ensure holistic local care, prevent illness and admissions, and make jobs more attractive [9].

Figure 1.

The new division of the country into five health regions, showing regional hospitals (“regionssygehus”), health centres (sundhedscentre’) and health stations (“sundhedsstationer”/’bygdekonsultationer’.). The regions follow the general administrative division into municipalities [8].

As the map illustrates, distances are huge. Between most towns there are no daily flights, journeys often include shifts to helicopters, and the schedules do not always fit together. A journey from a settlement or a small town to Nuuk can take up to two days. In bad weather the journey can be extended to several days.

Following the reform, each region has a hospital with doctors, therapists and other specialists besides nurses and healthcare assistants. Healthcare centres have fewer if any specialists, and health stations in settlements are run by short- or uneducated community health workers.

Specialists perform regular treatment journeys to the health centres and settlements. Between these, doctors, nurses and therapists have frequently online or telephone contact with community health workers and patients.

There has been varied use of telemedicine equipment, but in many places, it actually does work as intended. Due to wear and age, the original equipment has now (2022–24) been replaced by more modern equipment, significantly easier to operate.

Evaluation of the reform

The implementation of the reform was evaluated in terms of leaders’ perspectives in 2017. The evaluation concluded that healthcare was experienced as better organised and coherent, and health units more uniformly functioning and updated concerning resources, equipment, and treatment offers. Nevertheless, some health centres reported to be drained of resources and health worker positions due to cut downs. The reform did unfortunately not have any noticeable effect on recruitment and retention, and improvement of recruitment and retention of health workers was once again recommended [10].

In 2020 user perspectives on health care services as such were investigated. The investigation pointed to pivotal themes such as the importance of mutual dialogue between users and health workers, information about local treatment offers, and alignment of differing expectations. A better sense of community with health workers was considered a perquisite for service users to be able to take co-responsibility for their own treatment. This included high quality interpretation which was strongly called for [11].

Following these evaluations, a health commission was set up in 2020 to analyse health practice in selected areas and come up with suggestions for improvements. Further, an investigation of health practices from the health workers’ perspectives was required [12]. The findings from this are presented in the following.

Aim

To generate knowledge of opportunities and challenges for health workers to deliver culturally relevant healthcare for service users, as a prerequisite for developing a sustainable work environment.

Methods and materials

The study was initiated by the Greenland Health Commission and conducted by the authors (TA and LS) together with lecturers from Institute of Health and Nature at Ilisimatusarfik from March to September 2021. TA and LS are of Danish origin and have each lived and/or worked in Greenland for more than a decade as senior researcher and professor, respectively.

Scientific frame and starting point

Following the aim and having a focus on resources and potential, the study was conducted on the grounds of a qualitative, hermeneutic-phenomenological approach that involved individual interviews with health workers who themselves had experienced the implementation of the healthcare reform [13].

Interviews

A semi-structured interview guide was developed based on the focus areas of the healthcare reform: regionalisation, recruitment and retention, shared care, equal access to healthcare, telemedicine, and further education and training. Interview questions focused on the knowledge that the individual health worker had developed through his or her daily work: What dilemmas and opportunities were experienced under the given conditions? What could be different? What should be developed?

The interviews lasted an average of one hour and were audio-recorded and transcribed verbatim. Following the wish of 12 informants, the interviews were conducted in Kalaallisut. These interviews were transcribed verbatim and after that translated to Danish language by bilingual Greenlandic student assistants on bachelor’s and master’s levels. Further, samples of their translations were checked by a Greenlandic lecturer with equal skills in Kalaallisut and Danish language.

Informants

The data material consists of 21 transcribed, individual, qualitative interviews with 21 multidisciplinary informants, representing all five health regions and elderly care in two municipalities (Table 2). All informants were residentials in permanent positions. The informants had worked in healthcare for between 6 and 50 years with an average of at least 18 years. All except one were female.

Table 2.

Overview of informants.

Education and functio	Place of work	Seniority
Healthcare helper1	Health Center	21 years in healthcare
Healthcare assistant2	Regional Hospital	50 years in healthcare
Healthcare assistant	Health Center	25 years in healthcare
Healthcare assistant	Health Center	14 years in healthcare as interpreter, helper and assistant
Healthcare assistant with a specialisation in childcare (8 months)	Health Center and the associated settlements	Not informed
Healthcare assistant	Health Center	12 years in healthcare
Community health worker3	Settlement	23 years in healthcare
Nurse4 and supervisor for community health workers in the associated settlements	Health Center	18 years in healthcare
Nurse and supervisor for community health workers in the associated settlements	Regional Hospital	31 years in healthcare
Nurse	Medical department in the national hospital	13 years in healthcare
Nurse	District psychiatry in a town	16 years in healthcare
Nurse	Health Center	34 years in healthcare
Ward nurse	Regional Hospital	6 years in healthcare
Doctor	Regional Hospital	24 years in healthcare
Nurse	Patient hotel	20 years or more in healthcare
Nurse	Patient hotel	20 years or more in healthcare
Dental hygienist5	Regional Hospital	19 years in dental care
Dental hygienist	Health Center	31 years in dental care
Nurse	Nursing home	Not informed
Healthcare assistant	Nursing home	2 years in elderly care
Healthcare assistant	Nursing home	9 years in elderly care

¹Education: 1 year and 3 months.

²Education: 2 years and 10 months

³Education: 5 months.

⁴Education: 4 years.

⁵Education: 2 years.

The informants were identified by the health management or the local leaders, based on their work experiences and possible interest in participating. We have no reason to believe that the informants were identified because of their attitudes or that they held back possible critics.

Data analysis

Firstly, to ensure sufficient saturation, the transcripts were read by both TA and LS to get an overall sense of the entire material and identify empirically based meaning units of which we primarily focus on recruitment and retention in this article.

The following thematically structured analysis focused on the content to identify patterns and variations in the material, thus developing meaning, clarifying understandings, and adding new perspectives such as other studies and findings [13]. During this process, the overall structural and organisational framework and local conditions in healthcare served as background for the informants’ experiences and scope for action [12].

Ethics

The study was approved by the Research Ethics Board for Health Research in Greenland (KVUG 2021–01) and conducted by agreement with the local regional and municipal authorities. Prior to the interview, the informants received information in Kalaallisut/Danish about the purpose of the study and the course of the interview. All invited gave written informed consent to participate. Their identities have been anonymised. The student assistants who transcribed the interviews imposed a duty of confidentiality, which they were already familiar with, being part of their study and future profession. Materials are kept secure according to the data management policy of Ilisimatusarfik.

Results

Initial analysis

Many dedicated, hard-working health workers in the regional hospitals, health centres and health stations were involved in a daily struggle, not only to provide adequate healthcare in their local communities 24/7, but also to combine work and leisure time in their daily life in a satisfactory and balanced manner. This circumstance, which was well known in society, negatively affected the recruitment of permanent staff.

The frontline health workers had knowledge and input of significance for use of telemedicine, prioritisation of healthcare needs, improved dialogue with service users, and education and training. In their opinion, experience-based knowledge should be included in future development of health care, just like space should be created for reflections, initiatives, and creativity, as this might lead to services that were more efficient, of higher quality, and better adapted to the needs of the population. Further, job satisfaction seemed closely linked to the possibilities of working together with service users, families and local communities around issues such as health promotion and lifestyle matters.

These initial findings will in the subsequent be elaborated within the following themes and associated subthemes: Challenges in settlements, health centers and regional hospitals’, Short-term jobs’ and ‘A sustainable work situation for health workers.

Themes	Subthemes
Challenges in health stations, health centres and regional hospitals	Health stations Health centers Regional hospitals
Short-term jobs
A sustainable work situation	The importance of training and reflection on practice Prioritisation of health promotion and prevention improves the well-being of both service users and health workers The need for staff leadership Collaboration with service users and work satisfaction

Theme 1: challenges in health stations, health centers and regional hospitals

Health stations

In settlements, a local resident has usually taken on the role of the community health worker by employment. Many are unskilled in health matters, many cannot operate the telemedicine equipment, and communication with the nearest health centre can therefore be sub-optimal. However, where training has taken place, telemedicine communication works well, and the staff experience good professional and human support. A health worker with many years of experience in a settlement says:

You feel safe when the doctor can take a view on the patient together with you […]. We in the settlements keep in contact and help each other. For example, in a settlement there was a heart patient, and they did not know what to do, but I helped them via Skype.

However, community health workers are on their own most of the time, they must be available 24/7 and, as local representatives of the healthcare system, they are in a vulnerable position.

Health centers

Some informants do express satisfaction with parts of the reform. Firstly, they find that communication with regional hospitals and experts in the national hospital in Nuuk has improved, and that transfer of patients from health centres in rural areas to Nuuk is now easier and faster. Secondly, the reform has increased the focus on use of telemedicine.

However, at health centres in small towns, staff members find that their opportunities for professional dialogue and managerial support have been reduced since the regionalisation. A nurse in a health centre says:

Before the regionalization we had many specialized health workers like bioanalytic, midwife, surgical nurse, child health nurse etc., but they have now been moved to the regional hospital. So, I miss the day-to-day joint reflection.

Staff members find that staffing has decreased, while the amount of work has increased. When the number of health workers is cut, especially small units become vulnerable. A healthcare assistant in a small health centre says:

We are now three instead of four health workers, and if we have worked all night, we can’t rest the next day but must go on for the next eight hours. And when we have a day off, we can’t get a proper rest because we can be called to work. So, there may be periods where we work almost day and night.

Because of a deteriorating work environment several local permanent staff members have left their jobs and been replaced by short-term employees. Therefore, shifts and workloads are increasing for the remaining, which makes working conditions difficult to combine with a good family life. A nurse in a health centre says:

When you live here permanently, you have a family, you have a life, you want to have a life - but you almost can’t!.

Regional hospitals

Health workers in regional hospitals find that their workload has increased as they are assisting smaller units via telemedicine, organising treatment journeys, and performing other administrative work. In addition, the restructuring of healthcare has not created the attractive professional environment which was the intention; specialists are not attracted, some even leave their positions. A leading nurse in a regional hospital describes the consequences:

Alle four nurses in the hospital ward are short-term nurses who are here for three or six months. They almost never return because of the workload. The Greenlandic nurses who live here do not want to work in the hospital because of the current extra work with introducing and translating for the nurses from outside. Consequently, our daily work is about “closing gaps” – there is no time for developing the workflows.

The quote illustrates that the regionalisation instead of creating a stimulating professional work environment in the regional hospitals, has caused the opposite: Increased workload hinders nurses in what they find meaningful and satisfactory, namely improving and developing the health work.

Summary of theme 1

Some informants do experience the improvements that were highlighted by managers in the evaluation of the reform: better cohesion of the healthcare system and improved communication across health units. But unintended consequences fill more in daily work, especially in the smaller units, such as lack of communication and professional support, and increased workload leading to staff flight and increased use of short-term health workers.

Theme 2: short-term jobs

Being difficult to hire permanent staff, an unintended effect may be that short-term health workers were described in negative terms. It should therefore be pointed out that all units did appreciate that vacancies were filled at all. Temporary health workers perform many specialised tasks that would otherwise be left to less qualified health workers, or not performed at all, such as surgeries and prenatal care.

However, as most temporary health workers are employed for short periods,¹ they cannot perform long-term tasks in the local community. In addition, differences in language and culture mean that the permanent staff must spend time on introducing and interpreting. One health worker at a health centre says about the extra workload:

Sometimes it feels like I am doing nothing else but educating the short-term nurses – educate, educate, educate. It is not easy to develop healthcare because you use so much time on educating. And it is not only here [in this health center], but everywhere.

On the positive side, a health worker points to the fact that when having a well-functioning health unit, the short-term nurses tend to return time and again, and their introduction is therefore limited.

Summary of theme 2

Short-term health workers solve many necessary tasks and add positive, professional input, but the impact is often limited, ineffective, and time-consuming which overloads the permanent staff. It is indicated that better working conditions can make short-term health workers return, which would make better use of their potential and create a better working environment for all.

Theme 3: a sustainable work situation for health workers

The importance of training and reflection on practice

Health workers call for further education and regular professional discussions to perform their work adequately, or even just complete their allotted tasks. Many feel drained of energy without advice and support from colleagues. One health worker explains:

I feel we’re not getting the chance to learn more, and if you’re not learning but working all the time, you might feel less motivated to do your work. And if you can’t talk to anyone about things that happen at work, you can get emotionally overloaded, and if your emotions take up too much space, you might not feel like working that much.

The staff members encounter service users with difficult issues including violence, abuse, and serious illness. This may put an extra mental strain on them and may awaken painful personal emotions or old traumas in themselves, too. This is often exacerbated by lack of joint reflection and mutual support, especially in the small health units, where permanent staff members are few, and problematic issues may concern close neighbours. A health worker in a health centre says:

You can easily feel like you’re forgotten and unsupported by your colleagues at the regional hospital.

The lack of joint reflection can make health workers focus narrowly on their own work. For example, if the daily work is characterised by staff shortage and obscurity it can be a personal coping strategy to concentrate on one’s own limited tasks. On the other hand, training courses, dialogue with colleagues across healthcare units and regions, and joint reflections on daily work seem to provide a broader and deeper perspective on practice.

Finally, many shortly- or uneducated health workers, who are given special responsibilities such as preparing surgical equipment, performing dental care, or caring for chronically ill citizens, express job satisfaction and pride in their work. In addition, their colleague’s express appreciation for their skills and emphasise the significance of having good cooperation with such local staff members. In a dental clinic, the dental hygienist says:

We are such a good team that I cannot imagine that the uneducated [but trained]be replaced by educated persons.

Summing up, further education and joint reflection across professional groups and health units is a prerequisite for performing adequate service of good quality for service users, and for getting human support to cope with the work. Thus, increased education and joint reflection accommodate opportunities for good healthcare, job satisfaction, and staff stability.

Prioritization of health promotion and prevention improves the well-being of both service users and health workers

Health workers’ knowledge of the local populations’ needs often has low priority in relation to outreach work, health information or health promotion, as urgent tasks are prioritised.

Still, health workers take independent initiatives and approach tasks creatively if they have the energy and opportunity. For example, a community health worker in a settlement where visits by a child health nurse are limited, started to visit new parents and offer them maternity care. Likewise, she visited the elders to discover potential needs. Further, a nurse in a health centre who recognised a need in the small, isolated communities for information about sexual assault and sexual health, allied with a social worker and the police and went to the settlements and held meetings with the residents, who appreciated this very much.

The informants express, that working in healthcare is meaningful. However, “filling gaps” due to staff shortages or correcting things done badly is frustrating. Regarding the low priority given to health promotion and prevention, a nurse says about the healthcare reform:

Actually, I had been looking forward to becoming a “health center” and not a “hospital”. I thought, now we are going to do a lot of health promotion, I had really looked forward to it – but it has not really become like that … .

Summarising, there is a considerable untapped potential for health promotion and prevention, as local health workers have their finger on the pulse of what the population wants and needs and have visions for action possibilities. A focus on health promotion and prevention and giving time and space to creative enterprise seems to meet the relevant needs of local communities and in addition create job satisfaction for health workers.

The need for staff leadership

Although health workers appreciate working independently and taking initiatives, management support is vital for their motivation. Some informants experience support and encouragement. A healthcare assistant says:

It’s important that your superiors notice what you’re doing, not just to be commended, but to be told something or asked how things are going, that’s very important and it’s always nice when that happens.

Appreciation is important, but management must also take an interest in the framework and content of the work. Many informants miss this kind of leadership, especially in cases where managers are located in a regional hospital and not sufficiently aware of the smaller units. A nurse in a health centre says:

First of all, it’s about professional development, which I think is important […] Management must think it’s important to have qualified staff living here permanently. That calls for better working conditions and for the management to listen to what needs to be done here, or ask the health workers, for example: “What needs to be improved? Can we help you with that? What do you think is important?”. Help us, or push us in the right direction, or push us upwards, you see.

If a region has a long-term, value-based strategy for improving working conditions through education, training, and employee involvement, health workers seem more likely to stay in their job. A manager of eldercare in a municipality, where exactly such a strategy is being implemented, tells that the health workers were excited about being involved, indicating that involvement and common discussions on values and long-term plans for healthcare practice promotes enthusiasm and work satisfaction.

Summing up, the analysis points to a need for managers to not only appreciate the health workers’ efforts, but also to recognise their knowledge and competencies and involve them in discussing and planning. A more inclusive kind of leadership seems to have potential to promote both quality of care for service users and health workers’ experience of doing a good job.

Collaboration with service users and work satisfaction

The study did not inquire specifically about collaboration with service users, as this was not included in the healthcare reform.² However, many informants stated clearly that collaboration with service users is of great importance to health workers.

Successful collaboration involves health workers acknowledging and listening to the users, connecting their reasons for contacting healthcare to the context of their everyday lives, and including their perspectives. A nurse in a health centre with responsibility for telemedicine-communication says:

You must signal that you have the time and that you are able to accommodate their [the users’] feelings and life stories and understand their situation. That, I think, is of great importance for building up trust between the health care system and the users.

The study demonstrates the benefit of a professional focus on service users’ well-being and quality of life in a broad sense. The nurse continues:

If people feel that we close the door, that it is difficult to get an appointment or to call us – then they become more anxious, and then they return to us again and again. But as soon as we do a proper job when they first come to us – then they do not come back.

Improved collaboration between health workers and service users, involving health workers’ accommodating approach to the users, mutual understanding and dialogue can enhance health worker well-being.

Summary of theme 3

Health workers are generally very dedicated to their work and concerned with delivering good and culturally relevant healthcare to the population. Current structures and organisations of health practice following the healthcare reform have promoted this in some respects. However, various challenges are experienced.

A lack of joint professional reflection and further education is a threat to the quality of healthcare, and health workers call for collegiate support to cope with challenges in the meeting with service users. Suboptimal communication across health units is part of this problem.

Health workers consider health promotion and prevention important for service users and local communities, exactly as the healthcare reform does. But healthcare structures are deficiently designed for this task. Some health workers have overview and surplus to practice health promotion, but it seems to be an exception.

In this connection, health workers call for leadership to involve their knowledge and reflections to create a framework for health promotion and other efforts with a development perspective. This also involves collaboration with service users because dialogue and mutual understanding is a prerequisite for culturally safe healthcare and thereby also a sustainable work situation for health workers.

Discussion

In this section we discuss the implications of the findings for improving the quality of healthcare and for developing a sustainable work-life for health workers at the same time. However, before doing so we will go through the strengths and limitations of the study.

We consider it a strength that the informants represented all five health regions and many different health settings and professions. Most informants had been in permanent positions for more than a decade. However, only one of the informants were male, which may have resulted in a skewed perspective on working conditions, collaboration etc. On the other hand, this is quite representative for gender distribution in practice. In addition, the presence of only permanent staff members did not spread any light on the short-term staff members’ perspectives. Including these might have added valuable information concerning recruitment and retention and – as the short-term staff had experiences from health care settings outside Greenland – presumably also “new eyes” on organisation and professional development.

It was a strength that most interviewers were speaking both Kalaallisut and Danish so the informants could express themselves in their preferred language. Translation to one mutual language – Danish – was necessary to analyse and validate the findings within the research team. Some meaning may have been lost or misinterpreted during this process, although considerable efforts were put into avoiding this.

Humanistic health research is a young discipline in Greenland, with studies starting around 2010 at Institute of Health and Nature, Ilisimatusarfik [14–17]. Within cultural and social sciences, however, there has been a longer tradition for research in community development and social health [18,19].

Local needs and the significance of local health workers

Greenland is a mix of urban and rural areas. Short-term staff from outside are called for to fill certain positions, but basically Greenland can run its own healthcare in collaboration with foreign specialists and extended internal tele-communication. Thus, in health units outside Nuuk, most health workers are local permanent residents.

As it appears, living and working conditions vary a lot between locations. Likewise, health issues and needs and expectations of service users are diverse. International research in rural health shows that this is common for rural areas [20,21]. This means that local health workers have unique knowledge about health issues in their local communities and unique opportunities to deliver culturally relevant healthcare when including service users’ perspectives. Consequently, knowledge about local health practice is necessary for rural perspectives to inform national health policies [22]. Among others, this goes for prioritisation and development of health promotion, frequently articulated in strategies and plans, but seldomly put into practice.

As emphasised in United Nations’ 16th goal for sustainable development, the active inclusion of users’ values and future perspectives in institutions is a means to strengthen a democratic, peaceful and just society (https://sdgs.un.org/goals/goal16). Thus, frontline health workers are of decisive importance for an inclusive and democratic healthcare practice. As the findings of this study illustrate, frontline health workers possess knowledge of importance for structuring and organising culturally relevant healthcare all over the country.

The significance of these efforts in Greenland was recognised during a visit of the Regional Director from the World Health Organization (WHO) in 2023 to various health facilities in towns and settlements. Following this, the healthcare staff received an award “in recognition of the staff’s great contribution to health and well-being […] despite difficult conditions and staff shortages” [23].

The award is highly deserved and a huge recognition for the health workers. But if the praise is not followed by action to improve the existing difficult working conditions and staff shortages, there will probably be even fewer employees to improve health and well-being in the future, and those who remain will most likely run the risk of burnout.

In the following, we discuss potentials for developing healthcare by building on the existing resources that have emerged through the exploration of health worker perspectives. This is in line with new tendencies in rural health research where there is a focus on local dynamics, resources, and capacity-building instead of a one-sided focus on problem-solving on a structural level [20–22,24,25].

Health promotion and a meaningful work-life

Initially, the healthcare reform intended to have an increasing focus on health promotion and prevention to keep people from hospital treatment by strengthening local and holistic primary healthcare and make healthcare jobs more attractive [9,p.6]. This is in line with WHO’s concept of health promotion that health does not merely refer to the absence of illness, but to people’s entire lives in social contexts and their possibilities to influence these [26]. Greenland joined WHO’s Ottawa Charter of Health Promotion in 1986 [4].

Health workers experience a local need for health promotion and prevention, but the dominant impression is that these must give way to urgent tasks. The same observations were made in an investigation of nursing practice in small towns and settlements a couple of years after the implementation of the healthcare reform [16]. That study reported a diversity of health promotion interventions, such as health education in connection with a bingo event or nature excursions aimed at the whole family. However, the interventions demanded extra efforts and were often hindered by urgent tasks. Furthermore, there was no consensus on the direction and focus of future interventions (ibid.).

Besides relieving a pressure on the healthcare system, health promotion and prevention accommodate perspectives for better quality of life for individuals and for empowerment in local communities [21,22,27].

As our informants’ state, they are happy to go the extra mile, but not just to “keep the wheels turning” in the healthcare sector. There is a need to implement a development approach in healthcare, by linking professional development with health promotion. As also found by Olesen et al. [11], our findings show that mutual understanding about health and a good life is a prerequisite for dialogue about culturally relevant, sustainable health interventions.

The importance of telemedicine

Telemedicine is a main focus area in the healthcare reform. Much communication consists in exchange of professional knowledge about a patient’s treatment and care. But as our findings show, telemedicine is also used for collegiate communication on challenging work situations.

Especially in the small health units, health workers miss professional support, presumably because small health units often lack permanent employed managers and therefore are led from the distance of a regional hospital.

Since telemedicine was established, the use of the equipment has depended on training and on whether specific health workers found it useful [28]. Some nurses described the health workers in the health stations, especially the elder, as “technology-scared”. But it was emphasised that insisting on training and using the equipment daily gradually made them learn to handle it, so that they eventually found telemedicine extremely useful and indispensable. However, this educational effort needs support from managers as it takes time from more urgent tasks.

In 2022–24 a new national telemedicine system was implemented, much easier to handle than the old. Simultaneously, people have been more customised to using technology, and we assume that using telemedicine gradually will be extended.

Also, the general population is positive towards telemedicine. Residents in rural areas find that telemedicine facilitates access to healthcare which makes them feel more secure [29].

Opportunities for collegiate support

Health workers in small health units express their need for support, both professional, collegiate, and management support. Being a small group of colleagues, it can feel exhausting to cope with a large workload, various kinds of challenges in the work, and maybe a lack of skills. Some feel left alone and forgotten by their colleagues in the larger health units. This is a common situation in rural areas [21,22].

In a research project across five Northern and Arctic countries, Abelsen and colleagues found that managers’ support of team cohesion was an important prerequisite for retention of health workers. Team cohesion accommodated opportunities for the team to socialise and learn from each other, and to achieve some control over their work environment such as shift scheduling, joint posts, strategic planning, and professional development [22]. Thus, social relationships and social learning (or what we call “joint reflection”) can break isolation and give input to deal with the problems health workers face.

These findings are very much in line with our findings concerning a sustainable working environment and indicate that it is possible to carry out as well. Transferred to conditions in Greenland, it would be health workers in small health centres and health stations in particular, who could benefit from such cohesive teams which could easily be organised online.

Health education

In some Arctic regions there are good experiences with online education of nurses and skilled health workers, and students who get the opportunity to stay in their local community during education are more likely to work there as professionals afterwards [21,30,31].

As also exemplified in our study, professionals with inside knowledge of the local communities have better prerequisites to perform health offers in accordance with local needs and wishes than outsiders have [21,22]. But as stated, there is a need for training and education. Many community health workers are motivated for education but have no opportunities to move to Nuuk for a period because of family and other obligations in the settlement [32]. This speaks in favour of establishing online education on all levels. At the time of writing, experiments with online education are going on within the basic health educations in Greenland.

Joint reflection and learning and the use of resident health workers

Resident health workers were burdened with introducing and educating short-term health workers, and with interpretation, cultural mediation, and conflict resolution. This is a well-known phenomenon, by some called “cultural load” when a few health workers are the only ones knowing the language and culture of service users and how the healthcare system works [35]. It often leads to exhaustion and burnout and possibly also dropout of job or even profession [33].

Out of more than 200 nurses educated in Greenland approximately half of them have left the healthcare system [4]. Their reasons for leaving have not been investigated, but it is most likely that exhaustion due to cultural load is one of them.

A solution to these challenges is to create a better working environment by intensifying local further education and joint interprofessional reflection across health units. In a small and widespread healthcare system like Greenland’s there is no room for sticking to professional boundaries. Task-shifting combined with interdisciplinary collaboration is a common practice in remote areas with few health professionals [21].

The increasing number of chronically ill and elderly people calls for follow-up care and health promotion that are better taken care of by local health workers supported by specialists via telemedicine, than by short-term specialists. Besides, our findings indicate that training and assigning more responsibility to short or uneducated health workers creates professional pride. Thus, there is a large untapped potential for training shortly educated health workers to solve tasks that are currently being solved by nurses, presumably reducing the need for temporary staff.

Staff management

As clearly evident in our study, health workers are basically dedicated and motivated. But their dedication can be threatened by the lack of support.

Under the assumption that public sector employees are basically motivated because they enjoy using their professional skills and want to be of benefit to service users and society at large, researchers in public administration and democracy emphasise the following leadership qualities:

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• The most important task is to provide clear directions for their staff giving them confidence that they can reach the goal together.

• Setting out plans in close dialogue with employees will enhance ownership.

• It is vital that managers mobilise the practice-based knowledge that professionals possess and constantly develop in their everyday communities of practice. Leadership is a co-creation with those who do the frontline work. Although the staff does not always have the answers, local development must be created together [34].

This view on leadership is most likely shared by healthcare managers. However, following the healthcare reform, the focus of regional management teams seems to have been on making regional management co-operation itself work, and on sorting out financial and administrative problems. A consequence of this is less emphasis on the experiences of frontline staff and service users [10].

Strategies on national level can be used to promote and guide development and organisation in entire health systems [22]. This highlights the need for supporting managers in working on a strategic level, involving health workers in planning and developing sustainable, value- and evidence-based healthcare.

Conclusions

In Greenlandic healthcare, staff in all functions perform the extensive and impressive task of providing care and treatment to ill, injured and frail citizens under very difficult climatic and organisational conditions. However, increase in chronic conditions and greater longevity call for an intensified focus on health promotion and prevention, based on local knowledge, a challenge which health workers find necessary and satisfactory to handle.

Our study points to a close connection between recruitment, job satisfaction and long-term employment, and – further – a close connection between job satisfaction and supportive, development-oriented managers to develop culturally relevant health promotion and care.

Recommendations: To create a sustainable work environment and strengthen recruitment and long-term employment, it is mandatory to Strengthen the strategic and local focus on health promotion and prevention as a prerequisite for developing meaningful healthcare that meets the expectations and needs of the population. Create a framework for mutual dialogue between service users and providers Build on local professional resources and experiences. Create flexible (online) forums for competence building and joint reflection. Create a framework for dialogue between management and staff about values, prioritization, organization, and evaluation.

Disclosure statement

No potential conflict of interest was reported by the author(s).