Association andwith World HealthOrganization guidelines. College ofRegistered NursesofBritish ColumbiaandtheCanadianNurses foris consistentwithacceptedstandards nursingpracticeassetoutby the professional ofregistered nursingpractice.Harmreduction andethicalstandards setting. The authorsdescribenursing practiceatInsiteanditsalignmentwith inaharmreduction relationships withclientsanddelivering healthservices those whouseinjectiondrugs. Nursescontributetothisgoalby buildingtrusting overdose deaths.Oneofthegoalsthisfacilityistoimprove thehealthof referrals, mitigatethespreadandimpactofblood-bornediseasesprevent .Ithasbeenshown thatInsite’s increasetreatment services evidence-based responsetotheongoinghealthandsocialcrisisincity’s injectionfacilityin Insite, asupervised , BritishColumbia,isan ABSTRACT INSITE: GAINING

in NursingPractice

BRIAN K. SMITH/VANCOUVER COASTAL HEALTH PEER-REVIEWED FEATURE

BEVERLY CIRO SARGENT MEAGHAN IRENE BERNADETTE LIGHTFOOT PANESSA HAYDEN THUMATH GOLDSTONE PAULY RN RN, MSN RN, BSN RN, BScN, MScPH RN, BN, MSc RN, PhD

he effects of illegal substance use has long been associated with concerns people with mental illness (Wood & Kerr, present significant challenges to about morality. Not surprisingly, harm 2006), resulted in a concentration of T civil society. Addiction to illegal reduction practices have been criticized as impoverished and vulnerable people living substances reflects a complex milieu unethical and, by extension, inconsistent in this area. This situation, combined with of unmet health needs and co-existing with the ethical practice of health-care a ready supply of illegal drugs, led to one issues such as mental illness and cultural providers. of the worst HIV and HCV epidemics in dislocation that lead to a loss of social the western world, with HIV prevalence cohesion (Alexander, 2008). Unsafe INSITE PAST AND PRESENT rates of between 17 and 30 per cent and injection of illegal substances such as Insite, a supervised injection facility, HCV rates that are greater than 90 per and crack cocaine is associated is part of a coordinated response to cent among those who use drugs (Tyndall with blood-borne pathogens such as HIV the ongoing health and social crisis et al., 2006). and hepatitis C (HCV), injection-related experienced by residents of the Insite opened on Sept. 22, 2003, infections, endocarditis and death due Downtown Eastside in Vancouver’s following strong advocacy efforts by to overdose. Those addicted to such urban core. This crisis, precipitated by community stakeholders and health drugs are vulnerable to poor health and a marked decrease in social housing and social service professionals to will benefit from the health and social and a mass deinstitutionalization of augment existing resources with support that nurses provide (Pauly, 2008). Harm reduction is a philosophy that allows nurses to work with individuals Insite’s objectives “where they are at,” without requiring a • Improve the overall health of drug users, including reducing the incidence of reduction in drug use (International Harm overdose death and disease transmission. Reduction Association, n.d.) and is an • Reduce the harms associated with illegal drug use (e.g., crime, discarded essential element of the prevention, care needles, public drug use) that affect communities. and treatment continuum and an integral • Increase access to health and social services by intravenous drug users. component of mental health, addiction • Reduce social, legal and incarceration costs associated with drug use.

BRIAN K. SMITH/VANCOUVER COASTAL HEALTH and primary care delivery. Illegal drug use

April 2009 17 “The central position of the nursing station in the injection room enhances the nurses’ ability to observe clients for overdose symptoms, anaphylaxis, risky injection practices and injuries.”

access to supervised injection, and with syringes and drug-related paraphernalia, used needle and syringe exchange sites political leadership from three levels of and no observed increase in drug dealing — a place where used syringes and government (Gold, 2003; Small, Palepu, around the site have been noted (Wood needles can be safely disposed of and & Tyndall, 2006). The federal government et al., 2004; Wood et al., 2006). Clients where sterile equipment to prevent HIV, provided an exemption for Insite under have reported less rushed injecting (80%); HCV and other blood-borne illnesses is Section 56 of the Controlled Drugs and injecting less outdoors (71%); and fewer provided. In addition, it provides a key Substances Act; the site opened with incidents of unsafe syringe disposal point of access for health and social the support of the Vancouver Police (56%) (Petrar et al., 2007). Bayoumi and services. An integrated team of registered Department, which recognized that public Zaric (2008) found that Insite is a cost- nurses and registered psychiatric nurses, order would best be served by referring effective program as a result of preventing mental health workers and peer workers people who use injection drugs in public overdose events, reducing risk behaviour is available from 10 a.m. to 4 a.m. daily. spaces to a health service (DeBeck et al., associated with the transmission of HIV On average, between 700 and 1,000 2008). and increasing referrals to methadone clients utilize Insite in an 18-hour period. Positive outcomes have been treatment. Under nurses’ supervision, they inject documented in over 25 peer-reviewed An external advisory panel, appointed pre-obtained illegal or prescription drugs. journals since Insite opened. Milloy, Kerr, by Health to review the Nurses, who do not provide or administer Tyndall, Montaner and Wood (2008) report evidence related to supervised injection any substances, offer pragmatic guidance, that despite over 1,000 overdose events sites, concluded that Insite has had a at the facility, no deaths have occurred. positive impact on the public health These authors suggest that between two of the community and on clients and and 12 deaths per year may have been neighbourhood residents, service prevented. The facility has also been providers and business owners (Expert associated with reductions in HIV risk Advisory Committee, 2008). No adverse behaviours (Wood, Tyndall, Montaner, & effects were found in relation to drug use Kerr, 2006). Weekly attendance at Insite patterns, crime or public disorder. and contact with a supervised injection Insite is operated by Vancouver Coastal site addictions counsellor were associated Health (the regional health authority) in with more rapid entry into detoxification partnership with the not-for-profit PHS programs, and there has been a 30 per Community Services Society. It provides cent increase in the use of detoxification a range of low threshold, client-focused services, associated with entry into longer health-care services, including needle term treatment and less use of the site exchange, harm reduction education, (Wood et al., 2006; Wood, Tyndall, Zhang, primary nursing care, health and social Montaner, & Kerr, 2007). Reductions in care referrals and addiction treatment.

open public injecting, fewer discarded Insite is one of the city’s most widely BRIAN K. SMITH/VANCOUVER COASTAL HEALTH

18 BRIAN K. SMITH/VANCOUVER COASTAL HEALTH The health teaching andhealthassessments. opportune timefor nursestoengage in Clients nursingcare services. primary one-on-one addictioncounselling andfor treatment roomisusedfor confidential health andsocialconcerns. The adjoining to receivewithavarietyof assistance injection, injection practicesandinjuries. After overdose the nurses’clientsfor toobserve ability intheinjectionroomenhances station and bandagesareprovided. water, alcoholswabs, tourniquets,filters injection equipmentfor preparingdrugs, this meet the high volume of clients in need of (Due seat atoneof12 well-lit, mirrored booths. substance the injectionroom,inform staff ofwhat andreducebarriers). confidentiality her participant) caneitherregisterwithhisor first area byhealthworker. amental At the treatment areoptimized. clients minimized harms health Clients Once spacepermits,individualsenter Clients own service central visit, to teaching associated in limited name health some a symptoms, then are and they client position is greeted a prepare opportunities or capacity, and clients intend serious care (who with with care of and anaphylaxis, in an to the approach is injections to challenge.) the the so referred addiction use alias inject; nursing that reception ability to and (to engage potential this nurses are to take ensure risky to Sterile as

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where are invited torestinthechill-out lounge, (located management andtreatmentprogram make with peerworkers andwithstaff, whocan them. The loungeisaplacetoconnect of healthpromotion. services. discrimination (Butters &Erickson, 2003; lack care, includinglack offinancialresources, barriers and homelessnessencounteranumberof disability. People experiencing addiction septic cellulitis, osteomylitis, endocarditis, HIV, HCV, illnesses,pneumonia, mental concurrent Many racism andsocialisolation(Small,2005). exacerbated by poverty, homelessness, experience reduction care activitiesthatareguidedby aharm nursing relationship buildingandprimary 20) thatisrootedinclient-centred nursing population, toahighlymarginalized services street. juice —amuch-needed respitefromthe opportunity torestandenjoy coffee or Relationship building. Insite of referrals are arthritis, transportation, nurses framework to upstairs) nurses The burdened philosophy accessing medical health using lounge can to acute provide the a or inequities continue comprehensive (see conditions with to also mainstream Onsite and injuries stigma other vital figure chronic core gives Insite clients to health that withdrawal external and and observe principles such on clients and

are physical health page

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nfb.ca/webextension/bevel-up/index.php?vw=1 the NationalFilmBoardofCanadaatwww3. workers andhealth-careprofessionals. audiences ofinstructors,students,community schools anduniversitiesacrossthecountryto Care conference,hasbeenshownatnursing 2007 CanadianAssociationofNursesinAIDS questions toaskaftereachvideochapter. comes withtheDVDcontainssuggestionsfor and thecomprehensiveteachingguidethat are usedtolaunchmorein-depthdiscussions, and health,safety. Interviews withexperts ethical issues,relationshipbuilding,sexwork cover suchtopicsascommunication,legaland is followedbyeightinstructionalchaptersthat with minormedicalissues.Thedocumentary for thosewhoarewillingtotakeit,anddeal testing forHIVandSTIs,helptofindhousing injection techniques,encourageclientstoget give outcleanneedlesandcondoms,teachsafe alleys ofVancouver’s DowntownEastside.They the streetsandinroominghousesback follows ateamofnurseswhodotheirworkon a hard-hittinglookatthelifeofdrugaddicts.It documentary andaninstructionalcomponent. of Canada,theDVDconsistsa45-minute for DiseaseControlandtheNationalFilmBoard like themselves.Co-producedbytheBCCentre a specializedteachingtooltohelpothernurses Vancouver’s streetnurses,whosawtheneedfor interactive DVDthatisthebrainchildof Drugs, UsersandOutreachNursing,an the dilemmaofwhattodonext. to thehospital,andnursesarefacedwith and mayhavepneumonia.Butsherefusestogo the nursessuspectshehassufferedastroke is alsoadruguser. Beckyisinterribleshape; alley withherpregnantteenagedaughter, who know well.Sheislivingbehindatrailerinan when they run across Becky, a heroin addict they Two streetnursesareoutontheirdailyrounds reduction nursing focuses onharm Educational tool Bevel Upisavailableforpurchasethrough The film,whichpremieredinVancouver atthe The documentary, directedbyNettie Wild,is That real-lifescenecomesfromBevelUp:

. Crockett & Gifford, 2004; Ensign & Panke, community partners to promote health compatible with professional and ethical 2002; Hwang & Gottlieb, 1999; Napravnik, and address the complex social needs of standards. However, previous analyses Royce, Walter, & Lim, 2000). Past or clients. Partnering with programs like the have demonstrated that the values current status as a “drug user” has been Vancouver Native Health Clinic for HIV of harm reduction and the practice of reported as a significant barrier. Nurses care and treatment, Sheway pregnancy supervised injection are consistent with use a holistic approach that focuses on outreach program, and the BC Centre for existing professional and ethical standards developing dignified, caring and trusting Disease Control’s street nurse program of nursing practice (Griffiths, 2002; Pauly, relationships and building foundations for for STI screening supports Insite’s Goldstone, McCall, Gold, & Payne, 2007; change through personal empowerment. continuum of care philosophy. Nurses Wood, Zettel, & Stewart, 2003). Through these relationships, nurses gain also regularly refer clients to resources The Code of Ethics for Registered insight into practical strategies appropriate for housing, income assistance and food Nurses (Canadian Nurses Association, to addressing identified individual client support. 2008) states that nurses have a care needs. responsibility to use current research in A high proportion of clients identify as PROFESSIONAL AND their practice. Additionally, the College of aboriginal. Nurses emphasize a culturally ETHICAL STANDARDS Registered Nurses of safe approach to care that builds trust Nurses in any practice setting may (CRNBC) professional standards (2008) and empowers clients by reinforcing the encounter ethical concerns associated direct nurses to base their practice on idea that each person’s knowledge and with illegal drug use; they may find the best evidence available from nursing reality is valid and valuable. This approach themselves caught between evidence and other sciences. A growing body of facilitates open communication and allows and ethics on one hand and policy and law research indicates that Insite offers a safe the client to voice concerns about nursing on the other. Nursing practice at Insite environment where overdose deaths care that he or she may deem unsafe. has come under attack from the public, have been prevented, risk behaviour Primary nursing care. Insite can be politicians and health-care professionals associated with the transmission of blood- a client’s first point of contact with the who have suggested that it is not borne diseases has been reduced and health-care system. Primary nursing care activities include overdose management, basic and advanced first aid, rapid point Insite’s nursing framework of care HIV testing, immunizations, acute and chronic wound care, reproductive health, screening and treatment for sexually transmitted infections, counselling, and referrals to external health and social services. The facility circulates the “bad date” list of dangerous patrons of sex trade workers and provides support and crisis management for clients in the event of sexual assault. Education. Clients are often most receptive to health teaching after they have injected. In small group settings or one-to-one, nurses educate them on the importance of handwashing, the filtering of drugs prior to injection, the use of sterile injecting equipment and sterile water, the cleansing of skin with an alcohol swab, vein care, and proper needle insertion. They also instruct clients on overdose prevention by advising on how to assess drug purity and encouraging them to never inject alone. Partnership and referrals to health

and social systems. Nurses work with BRIAN K. SMITH/VANCOUVER COASTAL HEALTH

20 “Nurses in any practice setting may encounter ethical concerns associated with illegal drug use; they may find themselves caught between evidence and ethics on one hand and policy and law on the other.”

referrals to detoxification services have all times, they strive to remain non- June 9, 2009, to make necessary increased (Milloy et al., 2008; Wood et judgmental. changes to the current drug laws. al., 2006). Furthermore, needle exchange, Insite has pushed the boundaries of Further, it ruled that closing Insite counselling, referral and safer injection community-based health care in North would be a violation of the right to life, education services are consistent with America, and nurses, as key participants liberty and security under Section 7 of current evidence and best practices for in advocating for the development of the Charter of Rights and Freedoms reducing the harms of drug use (World Insite, have helped reduce barriers to (PHS Community Services Society Health Organization, 2008). accessing health-care services. Through v. Attorney General of Canada, 2008) The provision of supervised injection partnerships with other agencies and and would deny individuals access to education falls within the scope of organizations, they are engaged in trying an essential health-care service. practice as set out by CRNBC, and it is an to improve clients’ access to affordable accepted disease prevention approach for housing and adequate income. Current CONCLUSION those who use drugs (Wood et al., 2003). Canadian drug laws that criminalize certain The individual, population and The code of ethics states that nurses psychoactive substances bring tensions health system benefits of Insite are have a responsibility to provide “persons between law enforcement and public well documented (Wood et al., 2006). in their care with the information they health responses to illegal drug use to the The practice of its nurses is guided need to make informed decisions related forefront. There is mounting evidence that by core principles of harm reduction to their health and well-being” (CNA, these laws are actually contributing to the and health promotion that are central 2008, p. 11). harm done to society and to individuals to achieving Insite’s objectives and Nurses can experience difficulties who use these drugs (Haden, 2002). In consistent with professional and in maintaining relationships with and the face of uncertainty about the federal ethical standards. continuing to provide care for clients government’s willingness to continue to All nurses should be well informed in the face of challenging interpersonal extend exemptions from Section 56 of the about harm reduction interventions situations. Nurses at Insite provide Controlled Drugs and Substances Act, the and their place in the prevention, care care on the basis of need and do not PHS Community Services Society and the and treatment continuum, so that they discriminate in the provision of care based Vancouver Area Network of Drug Users can humanely care for those who use on social attributes. They preserve dignity took legal action to seek relief from the drugs by referring to and advocating through their respect for humanity and need to obtain ongoing extensions. Last for all types of evidence-based their acknowledgment of the inherent May, the B.C. Supreme Court ruled that addiction supports. n worth of each individual, helping to Insite should remain open and continue counteract the judgments that those to operate as a health-care service. The

BRIAN K. SMITH/VANCOUVER COASTAL HEALTH who use drugs encounter every day. At Court gave the federal government until

April 2009 21 Acknowledgment: The authors are indebted to Insite clients, who have BEVERLY LIGHTFOOT, RN, IS A CLINICAL COORDINATOR, INSITE, taught them much about surviving a life of severe marginalization. The authors VANCOUVER, BRITISH COLUMBIA. acknowledge the support and encouragement of Sarah Evans and Dr. David CIRO PANESSA, RN, MSN, IS AN ADJUNCT PROFESSOR, UNIVERSITY OF Marsh and the support of Vancouver Coastal Health, the PHS Community BRITISH COLUMBIA SCHOOL OF NURSING, VANCOUVER. Services Society and the British Columbia Centre for Excellence in HIV/AIDS in the preparation of this manuscript. Kevin Pendergraft assisted in the preparation SARGENT HAYDEN, RN, BSN, IS A CLINICAL COORDINATOR, INSITE. of the manuscript, and Lori Campbell, Misty Bath, Greg Slawson and Jamie MEAGHAN THUMATH, RN, BScN, MScPH, IS CLINICAL PRACTICE Fortier were involved in developing the figure. INITIATIVES LEAD HIV/AIDS, VANCOUVER COASTAL HEALTH AND AN ADJUNCT PROFESSOR, UBC SCHOOL OF NURSING.

IRENE GOLDSTONE, RN, BN, MSc, IS DIRECTOR, PROFESSIONAL EDUCATION & CARE EVALUATION, BRITISH COLUMBIA CENTRE FOR EXCELLENCE IN HIV/AIDS, VANCOUVER.

BERNADETTE PAULY, RN, PhD, IS AN ASSISTANT PROFESSOR, UNIVERSITY OF VICTORIA SCHOOL OF NURSING AND A RESEARCH ASSOCIATE, CENTRE FOR ADDICTIONS RESEARCH OF BC, VICTORIA, BRITISH COLUMBIA.

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