Sustaining nursing practice in Greenland: insights from a positive deviance study on motivation, resilience, and holistic care in arctic healthcare

Abstract

Health disparities in the Arctic remain substantial, with Inuit populations experiencing shorter life expectancy and higher morbidity than global averages. Nurse shortage exacerbates these challenges, and Greenland continues to rely on nurses from other countries. Despite these constraints, health outcomes have improved over time, including increased life expectancy, enhanced diabetes care, and better child growth indicators. To sustain professional well-being and retention in the Greenlandic nursing workforce, this study explores how nurses deliver high-quality care under constrained conditions, and what motivates them to remain in healthcare using a positive deviance framework. Ethnographic fieldwork was conducted across five Greenland regions, involving participant observations and interviews with nurses and students across professional roles. Across backgrounds and seniority, nurses demonstrated a shared passion for their work, with patient encounters central to practice. Resilient communities, shaped through collaboration and humour, supported creative problem-solving and a strong sense of responsibility, extending from individual patients to healthcare and society. Nurses sustain their practice through patient-centred values, community resilience, improvisational competencies, and commitment to societal well-being. Using a positive deviance perspective, insights from effective nursing practices can inform nursing education and Arctic healthcare, improving patient care, job satisfaction, staff retention, and long-term cost efficiency.

Introduction

In Greenland, nursing care is delivered across vast geographical distances, under harsh climatic conditions, and amid significant infrastructural challenges. These conditions complicate the provision of a comprehensive healthcare system, and place substantial demands on nurses and other healthcare professionals [1–3].

At population level, health outcomes in the Arctic continue to be characterised by marked inequalities. Indigenous populations, including the Inuit in Greenland, Canada, and Alaska, continue to experience shorter life expectancy and higher morbidity compared to national averages in high-income countries such as the Kingdom of Denmark and the Nordic region [4]. These disparities reflect a complex interplay of historical, social, environmental, and systemic factors that continue to shape health and healthcare access in circumpolar regions.

Despite these persistent challenges, notable improvements have been achieved. In the 2020s, life expectancy in Greenland was approximately 71 years for men and 77 years for women, representing an increase of approximately six years for men and five to six years for women since the 1990s [5]. These figures slightly exceed the global average of approximately 70 years for men and 76 years for women [6]. In addition, the quality of care for chronic diseases, particularly diabetes, has also substantially improved [7], and Greenlandic children’s height and weight up to puberty are increasingly approaching European standards, reflecting advances in child health and nutrition [8]. However, ensuring equitable access to healthcare across Greenland remains challenging. Persistent barriers include a combination of geographical remoteness, extreme weather conditions, shortage of healthcare personnel, linguistic and cultural barriers, and other systemic constraints that hinder accessible health services [9,10]. In particular, the Greenlandic Health Care Service (Kalaallit Nunaanni Peqqinnissaqarfik) faces a chronic shortage of nursing staff and remains heavily reliant on nurses recruited from other countries who are often employed on a short-term contract, and unfamiliar with the language and culture. Consequently, Greenlandic nurses often assume additional responsibilities regarding the introduction and supervision of temporary staff, as well as translation from Greenlandic to English or Danish to facilitate communication and cultural adaptation [11]. At the same time, certain components of the healthcare system appear to function effectively despite these constraints. Increased use of telemedicine, in combination with a growing emphasis on prevention and health promotion, has contributed to improvements in service delivery and health outcomes [12].

Healthcare service in Greenland

Greenland is part of the Kingdom of Denmark but assumed political responsibility for its own healthcare system in 1992. Despite this shift, the system remains largely structured according to Danish models and guidelines, which are not always adaptable to Greenland’s unique geographical, climatic, cultural, and demographic conditions [3].

Healthcare delivery in Greenland is organised into five regions, coordinated through Queen Ingrid’s Hospital (DIH) in the capital, Nuuk. DIH has the country’s largest capacity, with 185 beds and departments in medicine, surgery, anaesthesiology, intensive care, radiology, and psychiatry. In addition to DHI, regional hospitals are located across all five regions, supported by health centres in smaller towns, nursing stations, and village consultations in settlements [11] (Figure 1).

Figure 1.

Greenland’s healthcare regions, each with one regional hospital, and affiliated healthcare centres, health stations, and settlement clinics [11].

A major organisational and managerial challenge in providing accessible healthcare services is Greenland’s geography. As the world’s largest island, twice the size of Europe, with a population of only about 56,000 inhabitants dispersed across vast distances, access to care is severely constrained. Transport between healthcare facilities is only possible by plane, helicopter, boat, or dog sled, and adverse weather conditions frequently delay the transfer of patients and citizens [3]. Human resource shortages further exacerbate these challenges. Greenland has 5.2 nurses per 1000 inhabitants, well below the Danish and European averages of 16.7 and 8.4 [13]. Consequently, access to health services varies considerably, ranging from specialist physician care in the capital to consultations with healthcare workers with limited medical training in remote settlements. Patients requiring acute or specialised care are often transported to the nearest appropriate facility within Greenland or abroad, such as hospitals in Iceland or Denmark [14].

Despite these constraints, nurses play a pivotal role in maintaining access to healthcare, particularly in remote and underserved areas [15–17]. Thus, an internal inventory of the Greenlandic health system from 2022 showed that of the 305 standard nursing positions, only 57.5% were occupied by permanent nurses, 100 of whom were native-born; the rest were in short-term positions resulting in a lack of clinical experience, inability to speak Kallaalisut (Greenlandic language), and insufficient understanding of the culture. Still, empirical evidence indicates that nurses in Greenland independently manage approximately 60% of all patient contacts without physician involvement; in 76% of these cases, they assess themselves as competent in performing the required tasks. This high degree of professional autonomy not only ensures access to healthcare under challenging conditions. It also indicates that nurses’ adaptive practices can foster innovative and context-sensitive solutions in everyday clinical work, and that this may positively impact their professional wellbeing [18]. However, athough a substantial body of research has documented the structural challenges characterising healthcare and nursing in Arctic and Greenlandic contexts [1–4,9,10], there is limited empirical knowledge about the nurses and the nursing practices that actually function effectively within these constraints.

Research gaps and objectives

This study examines how nurses can deliver high-quality care under constrained conditions and seeks to identify the factors that support their professional well-being and motivate them to maintain their professional engagement within the Greenland healthcare system, using positive deviance as analytical framework.

Methodology

Positive deviance

The term deviance refers to behaviour that deviates from the norm, while positive emphasises that such deviation results in improved outcomes for patients and service users [12]. Positive deviance is an evaluative framework that focuses on identifying and understanding practices, whether organisational, team-based, or individual, that achieve exceptional results despite facing the same constraints and challenges as less successful counterparts. This approach provides insight into strategies and practices that are already effective in real-world contexts. The core assumption is that if certain practices succeed under existing conditions in one setting, they can be adapted or implemented in other similar contexts [12].

The positive deviance framework adopts a bottom-up perspective that draws on the practical knowledge of nurses and other healthcare professionals with direct experience of effective practices [12]. To capture and examine this knowledge, this study employed a qualitative research design comprising participant observation [19], ethnographic interviews [20], and semi-structured individual interviews [21].

Participant observation and ethnographic interviews

A total of 115 hours of participant observation [19] were conducted, with approximately one week spent at each hospital and health centre across Greenland’s five healthcare regions. The first author of Danish origin, and the second author, of Greenlandic origin—both nurses—participated as observers. They engaged in most daily activities at each location, including morning planning meetings, telephone triage, patient care, meal distribution, medication administration, and other routine tasks. Outside Nuuk, staff rooms served as central spaces for breakfast, lunch breaks, and informal gatherings. These settings functioned as a central site of observation where staff members spontaneously engaged with observers and shared insights into the nursing work.

The observations focused on situations in which nursing practice functioned well and where nurses thrived, both individually and collectively. Attention was paid to identifying characteristics of effective patient care, nurse well-being, and motivational factors in daily work.

Ethnographic interviews [20] were conducted concurrently with participant observation, as the observers interacted with staff members throughout their shifts. Adopting an apprentice-like stance, the observers approached staff with the attitude of “We are here to learn from you” and posed open-ended questions such as, “What made you choose to do it that way?” or “What were you thinking in that situation?” Informal conversations emerged naturally during fieldwork and encompassed both professional matters and personal experiences, reflecting the social dynamics of the workplace.

In total, 29 individuals participated in the study, including nurses in temporary, permanent, and managerial positions, as well as interdisciplinary colleagues and nursing students present during fieldwork. Of these, ten were subsequently selected for in-depth individual interviews [21].

Personal interviews

The ten individual interviews lasted between 30 and 105 minutes (see Table 2) and were conducted by the first and second authors at regional hospitals or health centres. The interviews took the form of extended, conversational exchanges designed to deepen and contextualise insights generated through participant observations and ethnographic interviews [21]. A semi-structured interview guide was used to ensure alignment with the overall study aim [21].

Semi-structured interview questions

The semi-structured interview guide was developed from the overarching research questions and informed by the positive deviance framework. As shown in Table 1, the research questions are presented in the left column; they were focusing on a typical workday and are reformulated into everyday conversational questions presented in the right column [21].

Table 1.

Semi-structured interview Guide.

Research Area	Questions
Professional information	For how long have you been a nurse? What has been your primary role as a nurse?
Work Life	Tell me about your work life. Describe a typical workday. Describe a good workday. Tell me about a day that was particularly challenging.
Well-being	What aspects of your work matter most to you? What are your hopes or aspirations for your professional life? What makes you happy at work? What is a day like when you go home feeling happy or frustrated? What frustrates you at work?
Retention	How long have you been in your current position? What is it like to work on retaining nurses in your organisation? What makes you stay at your current workplace? What makes you consider leaving your workplace? What is your experience of working with nurse retention in your organisation? What limitations do you see in relation to retaining nurses?

Participants

As shown in Table 2, a total of 29 participants were interviewed, all of whom were engaged in nursing practice in Greenland. Interviews focusing primarily on nursing education were excluded from the final analysis (four clinical nurse supervisors and four nursing students). From the remaining interviews, 10 participants were selected for in-depth analysis to ensure analytical focus and manageability. The selected cases represent nurses engaged in clinical practice across substitute, staff, and managerial roles, with variation in seniority, professional responsibilities, and work settings. This selection enabled comparison across roles while retaining sufficient depth to explore everyday clinical nursing practice under Arctic conditions. All names were changed to ensure anonymity.

Table 2.

Overview of participants.

Name	Role	Experience	Origin
Signe	Nurse	3 months	Denmark
Emma	Nurse	6 months	Denmark
Kirsten	Nurse	28 years	Denmark
Hannah	Nurse	16 years	Denmark
Michelle	Nurse	4 years	Denmark
Heidi	Department Nurse	22 years	Denmark
Aviaq	Department Nurse	9 years	Greenland
Aminnguaq	Department Nurse	5 years	Greenland
Kristina	Regional Nurse	7 years	Greenland
Augustine	Regional Nurse	7 years	Greenland

Analysis

The analysis of 215 pages of field notes and interview transcripts was conducted in three phases: an initial holistic reading, a coding phase, and thematic synthesis [22]. Throughout the analytical process, interpretation was informed by the positive deviance framework [12].

First, all the authors read each interview in its entirety and independently to gain a comprehensive understanding of each participant’s perspective and perceived roles within their local healthcare context. Attention was paid to both explicit statements and implicit meanings, with a focus on how participants described their work, collaborative relationships, challenges, and perceived scope for action [22].

Following this holistic reading, the empirical material was coded in accordance with established qualitative procedures [22]. This process combines deductive coding, guided by the positive deviance framework [12], and inductive coding, which allows new patterns and meanings to emerge directly from the interview data. Each interview was segmented into meaning-bearing units, which were then assigned concise codes that identified key statements, practices, or experiential patterns [22].

These codes served as building blocks for the final phase of the analysis. Related codes were grouped into overarching themes that reflected crosscutting patterns and highlighted dimensions of exemplary nursing practices under challenging conditions [22]. This strategy enabled the identification of patterns that not only described structural and organisational challenges but also revealed how nurses actively created conditions for high-quality care despite their constraints [22].

The first three authors, who conducted the participant observations and interviews, were involved in all stages of the analysis. All authors collaborated during the final analytical phase and engaged in ongoing discussions of holistic readings and emerging themes. This collaboration contributed to a deeper and broader understanding of the underlying values and meanings embedded in the participants’ practices. All authors brought diverse nursing backgrounds, research perspectives, and professional experiences to the study: two were of Greenlandic origin, and two were of Danish origin; all engaged in nursing education and research related to nursing practice in Greenland.

Ethics

This study was approved by the Ethics Committee of Greenland Health Services (KVUG 2022-09, 2022-20; Case No. 2022-13906) and conducted in accordance with the UN Declaration of Human Rights and Scandinavian Guidelines for Nursing Research. All participants provided written informed consent after receiving oral and written information in Kalaalisut and Danish. Participation was voluntary, and participants had the right to withdraw at any time. Data were anonymized and securely stored using coded identifiers accessible only to the research team [23,24].

Findings

In the holistic reading, all participants described persistent challenges related to the recruitment and retention of both permanent staff and temporary nurses capable of independently managing a broad range of nursing responsibilities. At the same time, the findings revealed that many nurses developed context-specific and often creative solutions within strong professional communities, supported by present and pragmatic leadership. These dynamics were described and illustrated in the form of a narrative field note in Table 3, in which a newly qualified nurse has been observed for a day shift.

Table 3.

Narrative fieldnote from an observation in a regional hospital.

As soon as I stepped into the hospital, I was struck by special energy. It felt almost as if the atmosphere had been waiting for me. There was lightness in the air, a sense of warmth that is hard to put into words but could be felt instantly. Even though it has been 12 years since I last was here, it was clear that the sense of community and spirit is still alive. People here still truly care for one another. I had come to observe a newly qualified nurse whom I had known since her student days. Back then, she had been quiet and a little uncertain, but what I encountered now was an entirely different version of her. From the very beginning she seemed calm, confident, and at home. She welcomed me with open arms and natural warmth. We spoke briefly about her workday, and she described her patients and tasks with clarity and confidence. I was quickly impressed by how independently she worked. She simply shined; that was the best word I could find. She coordinated referrals, assessed patients, made phone calls, consulted with the doctor, dispensed medication, and spoke with patients, all with a sense of composure and ease. By midmorning it was time for a coffee break. The whole staff gathered: nurses, healthcare assistants, physiotherapists, as well as cleaning and kitchen staff. I was struck by how strong the sense of togetherness was across professions. Everyone chatted and laughed as if they were a big family. Later I observed her [the newly graduated nurse] with two patients. The first was a chronic patient who needed a blood pressure check. She consulted with the doctor and quickly arranged a new medication, which she packed and handed out. Everything happened calmly and professionally. The second patient was a man with COPD [Chronic Obstructive Pulmonary Disease]. She carried out several measurements such as lung function, blood pressure, and weight while also engaging him in a conversation about his health and lifestyle: smoking, exercise, and daily routines. It was informal, yet deeply meaningful. The patient joked, “So, can I run a marathon now?” They both laughed. Still, she managed to convey the seriousness of the situation, that his lung function had declined, without making him feel anxious. She clearly knew her patients well. She knew who usually came early, who was struggling, and how their treatment plans were progressing. It was obvious that she had built strong relationships and had a firm grasp of the bigger picture. We also talked about her workflows. She used the systems COSMIC and COSPEX and relied on both digital and physical lists to sort and prioritise. She mentioned how helpful it was to have a regular doctor which she could consult with; she never feels completely alone with responsibility. I was struck by how much she learned on the go. She stepped into a rather complex nursing position with only a short introduction and had to pick up everything quickly, from foot care to handling medical equipment. “I just turned the machine on and figured it out,” she said with a smile. It was truly a history of “learning by doing”.

The narrative field note describes how this newly qualified nurse rapidly has grownto fulfil her professional role, demonstrating clinical competence alongside warmth and independence, supported by strong relational ties with both patients and interprofessional colleagues. Although the participating nurses differed in experience, personality, role, and seniority, they demonstrate a shared, strong passion for nursing, which is central to understanding how they remain motivated and maintain high-quality practices under challenging conditions.

At the core of this passion lies the nurse-patient encounter, as we see it demonstrated in the nurses’ relation to the two chronically ill patients in the narrative (Table 3), which provides meaning and professional pride, even under demanding circumstances. This encounter is supported by resilient, interprofessional communities that supports professional wellbeing, and in a broader sense enable nurses to endure periods of chaos and develop creative solutions, allowing them to take on new tasks and function despite their limited resources. Overall, motivation is reinforced by a commitment not only to individual patients’ well-being but also to the healthcare system and society at large. Ultimately, the patient remains central, as every professional action has consequences for an individual’s life and health.

To further examine how such strengths coexist along with frustrations and structural barriers in everyday practice, we moved forward in analysing the interview material, and based on selected quotations, four themes were identified: passion for patients, resilient communities, creative problem-solving, and responsibility for healthcare systems and society.

Passion for patients

The nurses express professional pride and satisfaction in delivering care that is aligned with their professional values.

All participants describe what they perceived as the core of nursing: the ability to establish close, attentive, and meaningful relationships with patients. However, being unable to realise such relationships properly could lead to frustration and a sense of powerlessness.

“Hannah” recounts an episode in which a doctor overlooked a humeral dislocation that she herself had identified and that she knew required urgent reduction. She explains: “It was reduced the following day at 1 p.m., which has resulted in the patient now having nerve damage.” Her narrative emphasised permanent harm to the patient, which could have been avoided. The anger and frustration she expressed appeared to stem not only from the clinical error but from a sense of powerlessness in the professional role. “Hannah” states: “… because I could not cope with being in a position where I had to act as a guarantor [for this doctor’s work].”

Such frustration appeared to be rooted in the passion for doing what was right for patients. “Emma” highlights this point when comparing her current position in Greenland with her previous employment in Denmark:

“Back then, I could easily go home feeling inadequate… I also felt that I did not always manage to check in on my patients… Fortunately, I feel that I am allowed to do that here, even when we are busy.”

“Emma” feels guilt and professional inadequacy when she was unable to prioritise patient contact in her previous job. In Greenland, however, she can “check in on patients,” which likely reflects not only an aspect of care as a physical and emotional presence, but also clinical attentiveness, observing any changes in symptoms that may require intervention. In such a situation, “Emma” experiences satisfaction and motivation.

For “Aviaq”, a head nurse, the passion for patients is expressed as a core value: “… it is my principal concern that patients should feel seen and heard… Treat others as you yourself would like to be treated.” The quotation serves as both a professional and ethical guideline for herself and the staff. “Aviaq” relates this to her own experiences as a patient, formulating “good nursing” as meeting patients with the same respect, care, and dignity that oneself would wish to receive in a similar situation.

When asked what characterises a good day, “Aviaq” replies: “A good day for me, as a nurse, is going home with the feeling that you have made a difference for the patient…” She experiences inner satisfaction and meaning when she and her colleagues have done something for the patient that creates relief and security. Thus, the core of nursing is articulated as caring for and being with patients, through which quality of practice can promote professional pride.

“Hannah” describes her working conditions as “a bit like a field hospital” and emphasises that she and her colleagues must “set the bar very high in terms of quality, because if we just say, “never mind,” then it turns out really poorly.” The metaphor of a field hospital symbolises working under pressure and with scarce resources. Nevertheless, she insists that indifference, expressed in a “never mind, it will be fine” attitude, must be avoided maintaining professional pride and ensuring quality in patient care. “Kirsten” expands on this with her experiences at the health centre where she works:

“No, but we can still provide nursing care, at a high professional level, I think. And perhaps we even must provide it at a higher professional level than what one might expect, because people tend to think, what can you really do in such a small place? Well, we can.”

At a health centre, “Kirsten”s’ experience is that she and the rest of the staff provide nursing care at a high professional level. She stressed that the positive impact of nursing should not be underestimated, even when resources are limited. In contrast, nurses must perform at an even higher professional level than expected, precisely because they must cover so many functions holistically:

“… it is a small town, and we know each other well, and many of the patients we have seen many times before. That also means that I do not only know the patient, but also his relatives… It also means that I can use this enormously in a holistic practice of my profession.”

She highlighted that it is precisely close relationships and familiarity with the patient and family that make holistic nursing possible, comprising an effort to understand the patient’s overall life situation and tailor care accordingly.

Further, she describes this as “that kind of systematic and almost detective-like review of their symptoms.” This “detective work” refers to an investigative, curious, and systematic process of making sense of the patient’s condition, which is an essential part of “Kirsten”s’ nursing and one of her motivations for seeking a position in Greenland. She had “a strong desire to return to the roots of my profession.” This wish to reconnect with the core of nursing, understood as being close to patients, including a desire to be free from bureaucratic and systemic demands that, in her previous employment, had disrupted practices.

Professional pride and meaning in nursing stem from the opportunity to provide holistic, patient-centred, and quality-conscious care. This appears to motivate nurses to remain in their profession despite the challenging conditions.

Resilient communities

Awareness of workplace communities appears to be essential for accessing professional support, coping with chaotic workdays, establishing a framework for work, and maintaining the quality of care.

Workplace communities are not always available because there are often many temporary short-term nurses. For example, “Signe” and “Emma”, although only employed for three and six months, respectively, appear to have become part of the community and received support from their Greenlandic colleagues. The sense of community must be consciously developed and include all staff members. Regional nurse “Augustine” explains: “For example, here we go on outings, berry-picking trips, and all sorts of things. I think that also creates togetherness” - shared activities that strengthen cohesion among colleagues. Practices that extend beyond immediate work at the hospital and are rooted in everyday traditions with local and cultural significance, such as berry picking, are widespread and highly appreciated activities in Greenland during the late summer.

Resilient communities help nurses cope with the challenges that inevitably characterise working life in Greenland’s healthcare system. Temporary nurse “Signe” said directly, “I like my work, but the biggest part is having good colleagues you can exchange ideas with but also have fun with.” Although she was anxious about answering the phone during the evening and night shifts out of fear of acute situations, she stressed that things had gone well when drawing on dialogue and exchanging experiences with colleagues.

“Michelle” emphasises another dimension of community: “You can also talk about private things…” For her, motivation is not necessarily linked to a need for professional sparring but to trustful relationships. Thus, community extends beyond professional boundaries and creates security and collaboration in patient care.

In general, humour plays an important role in nurses’ narratives, as part of everyday workplace culture and as a relief opening in chaotic situations. “Hannah” describes: “So it’s more where there’s actually some good humour, and we help each other along the way…” Humour functions as a social bond that creates a positive atmosphere and makes it easier to complete tasks together. By contrast, “Signe” describes humour as a coping strategy in extreme situations: “It was chaos… we just sat and laughed in the end, because it was so much… And that was also lovely.” Here, laughter functions as a release, a way of restoring hope and energy to move forward together throughout the day and perhaps into the next shift, despite chaos.

Collaboration ensures the professional quality of patients in terms of local support and health services in Greenland. The nurses often knew each other about their previous employment or education. “Heidi” says, “I have worked over at [town name omitted], so I know them over there, and they know me. We also call each other.” Knowing each other in earlier workplaces represents a baseline of trust that makes it easier to reach out for help. This sense of community across the country means that “Heidi” does not feel alone with challenges; she can call others for help.

All participants, regardless of their roles, mentioned the importance of the community in job satisfaction and quality. For example, “Kirsten” highlighted the local community at a health centre:

“… and there we just must work closely together, and that is mutually enriching, because none of us knows everything, and neither do I. Even though I am an experienced anaesthetic nurse, there is really, really a lot I do not know… we all have something we are good at, and no one can do it all, so I think that is not negative.”

In sum, community functions not only as a source of motivation, professional support, and a resilience factor in a demanding work life, but also enhances the ability to facilitate the necessary creative problem-solving that is needed in difficult conditions.

Creative problem-solving

In many remote areas, patients cannot be quickly transferred to larger hospitals because transportation is difficult and time-consuming. Therefore, nurses must often find temporary and creative on-site solutions to stabilise patients until further help is available, explaining what makes a good day for them:

“Well, it’s a day where… there’s a little bit going on all the time, and I like that. And, yes, if someone comes into the emergency room and does what needs to be done. And, if it’s new things, and you realise you can do this … because that’s also how you develop.”

“Emma” appeared to enjoy variations in tasks and activity levels. She values the systematic completion of tasks, particularly in the emergency room, where she can handle assignments that she has not tried before, which contributes to her professional growth. “Aviaq” supports this perspective, saying, “For me, it’s important to learn something every day. Whether it’s something small or something big.” For her, professional stagnation must be avoided. Even minor insights and experiences are important sources of motivation and joy at work.

“Michelle” also highlights responsibility and professional development: “I actually like having responsibility and making decisions on my own to a certain degree.” She seems to thrive on the independence that characterises nursing in Greenland and the responsibility it entails; however, by adding “to a certain degree,” she marks the importance of balance, as responsibility must be manageable, to ensure patient safety.

“Hannah” recalled a case of a patient suffering from pneumothorax, in which both doctors and nurses struggled to make a chest drain work properly. Together with a paediatrician who had no prior experience in drainage, she had to improvise: “We simply had to redo the chest drain… and that was basically by going on YouTube, talking with some doctors in Denmark, and trying to make it work, because the parts didn’t fit together.” When the equipment could not be connected, “Hannah” finally involved her partner, who had plumbing experience, and he suggested, “If you heat one of the tubes with hot water, you can fit it over the other, and when it cools down, it will contract and hold tight.”

This improvised solution worked “well enough” until the patient could be stabilised and transferred by plane to Nuuk. “Hannah” had to step far outside her usual professional field, drawing on creativity, external online resources, and her partner to ensure treatment.

“Kirsten” described another situation involving an elderly patient suffering from multiple fractures, in which the department lacked the necessary equipment for traction: “We don’t have any equipment for it. But then… we found some things in storage and put together an improvised traction… it turned out to be a really good plaster traction… and it fulfilled the function exactly as needed.”

“Kirsten” also emphasised teamwork in the process: “We just make agreements with each other, and not much needs to be said.” Here, improvisation is not only a technical fix, but is also executed by a well-functioning team, where coordination flows almost wordlessly. Between these lines, one senses pride and satisfaction, both in that the solution worked for the patient and that her team succeeded.

Creativity and collegial collaboration thus enable nurses to maintain quality of care, finding both meaning and motivation in their work despite highly challenging conditions.

Responsibility for health care system and society

Last but not least, the nurses described a strong sense of responsibility as a central source of motivation, ensuring patient care, fostering workplace engagement, and, from a broader perspective, contributing to the healthcare system and society at large. Taking responsibility is not only a burden but also a driving force that gives work meaning and value.

Nurses’ sense of responsibility extends beyond their own professional development and the individual patient, as well as the workplace and society. “Aminnguaq” expresses, “When you know it so well, you also feel that you have the responsibility to make it work.” Her familiarity with the hospital, its routines, and colleagues created an inner obligation to contribute actively to the maintenance of everyday functioning. She narrates how she accepted that her summer holiday was cancelled because otherwise, there would have been no one to perform X-rays: “And of course, you are entitled to say no if you’re not on call, but then you have that thought, what about the patients?”

In general, responsibility seems deeply embedded in nurses’ professional identities. “Kirsten’ took 17 shifts in a row (starting at 7:00 and remaining on call for the rest of the day). She explained, “Who else would take them?”

“Aviaq” likewise demonstrates strong engagement in her role as head nurse not only in daily management but also in relation to the hospital: “If we had just a little more equipment, or one more anaesthetist, then we could have treated them ourselves. We could have spared the citizen from transfer, the family from separation, and all that.” Her sense of responsibility spans both the individual patient and the organisation, aiming to ensure patient continuity and security while also contributing to the sustainable development of the health system.

As highlighted above, “Aviaq” articulates a broad responsibility that extends beyond individual patients to the well-being of society. “Kirsten” reinforced this point as follows:

“Of course, money always has an appealing effect, but not for me. I won’t work for free; that’s not the point. But I don’t think money motivates my nursing. I think it is the nursing profession that is evolving.”

“Kirsten” emphasises that financial incentives are not the main motivation for nursing. Instead, she stated that she was driven by commitment to the profession and that she was concerned that the healthcare system was not evolving in line with the needs of the population.

Thus, nurses’ motivation is closely connected to this strong sense of responsibility, which is not perceived as a burden but as a source of meaning, professional pride, and connection to patients, colleagues, and society.

Discussion

This study investigated nurses’ work and everyday knowledge in Greenland. By aligning the findings with public health and nursing models, the discussion highlights how passion, responsibility, and engagement in Greenlandic nursing are interrelated and structurally conditioned [25]. Furthermore, we argue that these elements can only constitute resources for health promotion, disease prevention, and treatment when supported and developed. As the analysis draws on the concept of positive deviance [12], attention is directed toward practices that succeed despite structural barriers and are grounded in nurses’ everyday clinical experiences in smaller towns and settlements. The findings showed that nurses’ motivation and job satisfaction were closely linked to opportunities to provide holistic, person-centred nursing care based on the everyday lives of patients within their local communities.

Based on these findings, Figure 2 illustrates how nurses situate care within four interrelated levels: patient/family, community, healthcare system, and Greenlandic society. This analytical framing resonates with Dahlgren and Whitehead’s “rainbow model” in which an individual’s health is shaped by relational, structural, and societal health determinants [26]. From this perspective, nurses’ clinical practice in Greenland requires attention not only to individual patient needs but also to the broader social, organisational, and societal contexts in which care is delivered, emphasising that health is not solely the result of individual choices or professional care [16].

Figure 2.

Nursing care for patients and families within the healthcare system and society.

In the Arctic context, this multilayered perspective becomes particularly important as geographical, cultural, and organisational conditions strongly influence both care practices and citizens’ opportunities for healthcare [3].

At the patient level, the well-being and life situation of an individual gives meaning to nursing, generating professional pride. The nurses described a profound responsibility to ensure that patients felt respected and cared for. This resonates with the Danish philosopher Knud Ejler Løgstrup’s ethical demand, which emphasises the silent responsibility we always carry for the life of the other in our hands [27]. In these findings, the normative dimension of Løgstrup’s philosophy appears not merely as abstract theory but as an embodied experience shaping everyday practice. This may be explained by the Scandinavian caring science tradition shared by both Greenlandic and Danish nurses, where Løgstrup’s ideas, mediated through the work of the nurse and philosopher Kari Martinsen, have had a significant influence on education and clinical practice [28]. Professional pride is closely tied to this ethical commitment. Nurses describe deep professional satisfaction when they can provide high-quality, holistic care, even in resource-limited settings, and this pride strengthens both their identity and job motivation. Our findings further suggest that Scandinavian caring philosophy does not simply provide a theoretical framework for interpreting nursing in Greenland from a Westernised perspective. Rather, its ethical principles appear to resonate with Indigenous Inuit understandings of relationships and holistic care, making the philosophy an ethical language through which everyday nursing practice in Greenland can be understood. Although Greenland is a multicultural society undergoing change, yet it is still deeply rooted in Indigenous and Inuit values, health and everyday life. Within Inuit traditions, the importance of family, community, kalaalimernigt (Greenlandic food), nature, timi (body), tarneq (soul), and anersaaq (spirit) is emphasised as central to health [25,29]. From this perspective, evidence-based nursing in Greenland cannot be reduced to the application of Western standardised guidelines alone but must be understood as a holistic practice that incorporates community-based indigenous knowledge systems alongside biomedical and theoretical evidence [16].

Although Scandinavian caring philosophy and Indigenous Inuit knowledge systems emerge from different philosophical and cultural traditions, they converge in their understanding of caring as a holistic and relational practice. In both traditions, holistic care is not merely an ethical ideal but is realised through everyday practice, where responsibility is enacted in concrete relationships with patients, families, and communities. Together, they provide a broader understanding of holistic nursing in Greenland, where the ethical responsibility embodied in the nurse–patient relationship is realised within the wider relationships that connect patients, families, communities, culture, and place.

This broader, shared understanding of caring is also reflected at the community level. As illustrated in the narrative field note, the close relationship between staff, patients, families, and the local community formed an integral part of everyday nursing practice. Colleagues, family, and local networks provide resilience, trust, and support. The findings show how small Greenlandic towns, where “everyone knows everyone,” can shape nursing practice. When in work, this closeness fosters person-centred care and collegial trust and solidarity, enabling staff to share responsibility, improvise solutions, and maintain morale despite shortages [2,11].

Nurses described these relationships as family-like, emphasising resilience as a collective value embedded in nursing culture rather than as an individual attribute. Studies have confirmed that workplaces nurturing resilient communities, where challenges are understood as shared rather than seen as individual burdens, are more successful in retaining staff [30]. In the Greenlandic context, collective resilience emerges as crucial for sustaining professional well-being and long-term healthcare capacity [25]. However, our data also revealed the costs of such closeness, expressed through narratives of exhaustion and feelings of inadequacy.

Thus, responsibility, engagement, and passion enable both resources and potential burdens shaped by the degree of support offered by the surrounding societal, organisational, and community layers.

As illustrated, collaboration is necessary because the setting is small with few staff members. Thus, collaboration is not only required but also valued positively, as no one can manage all tasks alone despite many years of experience [30]. Individuals have different strengths. An anaesthetic nurse, such as “Kirsten”, smoothly manages acute care. In this context, locally trained staff who were born and raised in Greenland often possess in-depth knowledge of local conditions and culture, which is important for providing holistic care. However, a review of the Greenland healthcare system revealed a strong demand among healthcare professionals for competency development to manage complex, locally specific clinical tasks independently [11].

At the healthcare system level, structural and organisational conditions both enable and constrain practices. However, the findings indicate that nurses often demonstrate solidarity with the system itself, taking on responsibilities beyond their formal roles to ensure continued functioning. This may involve working extended shifts to cover staff shortages, performing tasks usually reserved for physicians, or improvising when equipment is lacking. Such practices reflect a strong loyalty to the system, where personal sacrifice is accepted to “make things work.” Autonomy and mutual trust are central here. In the Greenlandic context, where distances are vast and physician support is limited, nurses work independently, make critical decisions, and improvise solutions in acute situations [2,18,31].

At the broadest level, nurses expressed solidarity with Greenlandic society as their engagement extended beyond the immediate workplace, encompassing a moral obligation to safeguard the health system as a societal good and promote the well-being of their fellow citizens. The nurses described this responsibility as enduring and collective, reinforcing their professional pride while deepening their engagement. Research supports the idea that solidarity can function as a job resource that fosters job satisfaction and retention [32].

Although grounded in the Greenlandic context, these findings may have wider relevance for nursing in the Arctic and other geographically remote settings, where geographical isolation, workforce shortages, and limited resources place demands on nurses' ability to provide safe, high-quality, and sustainable care [4,6,9]. The findings show how nursing practice is embedded in multiple interconnected layers, from individual patients to the community, system, and society. Nurses’ ethical commitment reflects the relational dimension; their professional pride stems from providing holistic care despite limited resources, and their autonomy enables decisive actions in complex situations. However, when organisational and systemic barriers undermine these foundations, frustration may arise. These findings may have wider relevance for Greenland, Arctic, and other geographically remote settings, where supportive systems, collegial communities, and responsive leadership are crucial for sustaining ethics, professional pride, and clinical autonomy as resources for high-quality and sustainable health practice.

Methodological strengths and limitations

Applying a qualitative approach proved useful for the study purpose. In the presentation of the overall findings, we developed a narrative field note, based on empirical notes, to describe some of the context and clinical situations at play. This was followed by thematic analyses based on interview data. Integrating fieldnotes into this might have nuanced the findings further.

A key strength of this study is its use of a positive deviance approach, focusing on successful nursing practices and identifying solutions based on existing resources and competencies rather than deficits. Consequently, the findings should not be interpreted as representative of nursing across Greenland but as an exploration of organisational, professional, and relational conditions that may enable high-quality nursing despite challenging circumstances. This approach enhances contextual relevance, supports locally sustainable improvements, and may reduce resistance often associated with externally imposed interventions in healthcare and educational settings. However, a reliance on locally embedded practices may also limit innovation by overlooking effective approaches developed outside the local context [12,33,34].

Diversity within the author group strengthened reflexivity and ensured that multiple perspectives informed data interpretation. Thus, the joint analysis helped balance insider and outsider views and strengthened the overall credibility and depth of the findings.

Conclusion

Drawing on the concept of positive deviance, this study examined how nursing practice in Greenland is sustained despite severe climatic, geographical, cultural, and organisational challenges. We found that nurses’ motivation and job satisfaction were closely associated with what they described as a return to the core of the nursing profession, the opportunity to deliver holistic, patient-centred care within resilient communities. This return to core nursing values fostered creative problem-solving and enabled nurses to assume extensive responsibilities, extending beyond individual patient care to organisational and societal roles. Guided by the positive deviance framework, we have identified well-functioning nursing practices through participant observation and semi-structured interviews. Cases were selected from transcripts and field notes based on their contribution to coherent patient and citizen pathways within local community contexts, including regional hospitals and health centres. By examining how these positive deviants act differently, the study highlights the way in which their practices create value for patients, colleagues, and healthcare organisations.

These findings suggest that a return to core nursing values, as practiced in Greenland, may constitute a form of sustainable health practice. Opportunities to provide holistic, community-embedded care will enhance nurses’ job satisfaction, which, in turn, supports workforce retention and reinforces the long-term sustainability of nursing provision in the Arctic and other remote areas [35].

Funding Statement

Greenland Research Council [Nunatsinni Ilisimatusarnermik Siunnersuisoqatigiit].

Disclosure statement

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

Data availability statement

The qualitative data supporting the findings of this study are not publicly available due to ethical and confidentiality considerations but are available upon reasonable request.