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International Journal of Drug Policy 19 (2008) 195–204

Research paper

Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing practice

Bernadette (Bernie) Pauly ∗ School of Nursing, University of Victoria, Box 1700, Victoria, BC V8W 2Y2, Canada

Received 1 October 2007; received in revised form 11 February 2008; accepted 27 February 2008

bstract

ackground: People who are street involved including those experiencing homelessness and substance use are at increased risk of morbidity nd mortality. Such inequities are exacerbated when those facing the greatest inequities in health have the least access to health care. These oncerns have rarely been addressed in bioethics and there has been a lack of explicit attention to the dominant societal and organizational alues that structure such injustices. The purpose of this paper is to describe the underlying value tensions that impact ethical nursing practice nd affect equity in access to health care for those who are street involved. ethods: In this paper, findings from a larger qualitative ethnographic study of ethical practice in nursing in the context of homelessness

nd substance use are reported. The original research was undertaken in two ‘inner city’ health care centres and one emergency department ED) to gain a better understanding of ethical nursing practice within health care interactions. Data were collected over a period of 10 months hrough face-to-face interviews and participant observation. esults: In order to facilitate access to health care for those who are street-involved nurses had to navigate a series of value tensions. These alue tensions included shifting from an ideology of fixing to reducing harm; stigma to moral worth; and personal responsibility to enhancing ecision-making capacity. A context of harm reduction provided a basis for the development of relationships and shifted the moral orientation o reducing harm as a primary moral principle in which the worth of individuals and the development of their capacity for decision-making as fostered. onclusions: Implementation of a harm reduction philosophy in acute care settings has the potential to enhance access to health care for people ho are street involved. However, explicit attention to defining the harms and values associated with harm reduction is needed. While nurses

dopted values consistent with harm reduction and recognized constraints on personal responsibility, there was little attention to action on the ocial determinants of health such as housing. The individual and collective role of professional nurses in addressing the harms associated ith drug use and homelessness requires additional examination. 2008 Published by Elsevier B.V.

e; Harm

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eywords: Health inequities; Access to health care; Ethical nursing practic

People who are homeless and using drugs are at risk for a ide range of physical and mental health concern (Wright & ompkins, 2005). They experience higher rates of morbidity nd mortality than the general population (Cheung & Hwang, 004; Spittal et al., 2006; Wright and Tompkins). They also ace significant barriers in accessing health care services ncluding discrimination, lack of health care coverage, and

ransportation (for example, Barkin, Balkrishnan, Manuel, ndersen, & Gelberg, 2003; Butters & Erickson, 2003; reund & Hawkins, 2004; Gelberg, Browner, Lejano, &

∗ Tel.: +1 250 721 6284; fax: +1 250 721 6231. E-mail address: [email protected].

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reduction; Homelessness; Substance use

rangua, 2004; Hwang & Gottlieb, 1999). Thus, those expe- iencing significant inequities in health often have reduced ccess to health care services (Hart, 1971; Starfield, 2006). nequities in health and lack of access to health care are orally concerning as they are rooted in unjust social con-

itions that structure poverty, and homelessness and are otentially remedial (Starfield, 2006; Whitehead & Dahlgren, 006). Such inequities are serious ethical concerns that are nly beginning to garner attention in bioethics (Brock, 2000;

aniels, 2006; Sherwin, 1992). Of particular concern is the lack of attention in bioethics

o the dominant societal and organizational values that shape ealth care interactions and injustices in health care. Failing

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o attend to these values in health care delivery limits the chievement of fairness (justice) in allocation of resources nd diverts attention away from the social determinants of ealth and the conditions that produce poor health outcomes or those experiencing disadvantage (Brock, 2000). The pur- ose of this paper is to describe the underlying value tensions hat nurses must navigate to enhance equity in access to health are for those who are street involved, particularly those who re homeless and using drugs. The findings reported in this aper are drawn from a larger study of ethical nursing prac- ice in the context of homelessness and substance use (Pauly, 005).

ackground

nequities in health

Those who are street involved, are at risk for increased ealth problems related to violence, accidents, substance use, ack of housing, poor nutrition, stigma and discrimination e.g. Kreiger, 1999; Wright & Tompkins, 2005). Specific ealth problems differ according to individual circum- tances, age, gender and ethnicity (Hwang, 2001, Cheung

Hwang, 2004). For example, women are at higher risk or depression, sexual abuse, HIV and sexually transmitted iseases than men (Cheung & Hwang). Men are more likely o experience substance use, and older men are at greater isk of hypertension and other cardiovascular disorders Hwang). Those who use drugs are further exposed to ultiple drug-related harms including HIV/AIDS, Hepatitis , bacterial infections, cellulitis, endocarditis, abscesses, verdoses and addiction (Hunt, 2003). Not surprisingly, eople who live or work on the street do not have a life span imilar to other groups. People experiencing homelessness re at risk of premature mortality as a result of HIV/AIDS, verdoses, accidents and suicide (Barrow, Herman, Cordova,

Struening, 1999; Cheung & Hwang; Hwang, 2000; Spittal t al., 2006). Spittal et al. found that women who use njection drugs had a mortality rate of 50 times that of the eneral female population in British Columbia. This elevated ate was associated with unstable housing and HIV infection. he increased risk of mortality applies to men, women and outh who are homeless and/or street involved. At the same ime, those who are street involved face a myriad of barriers n accessing existing health care services further limiting he resources available to address health needs (Aday, 1993; all, 1999; Hall, Stevens, & Meleis, 1994; Stevens, 1992).

nequities in access to health care

Stevens (1992) argues that for nurses to work towards the

oal of enhancing access, equitable access to health care ust be framed within a broad sociopolitical context that

ncludes attention to financial, geographic, qualitative and nteractional barriers to accessing health care. Lack of health

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nsurance, lost or stolen health care cards, transportation, harmaceutical costs, lack of eye or dental care are struc- ural barriers to accessing health care (Barkin et al., 2003; utters & Erickson, 2003; Freund & Hawkins, 2004; Hwang Gottlieb, 1999). In addition to financial and geographic factors, the nature

nd quality of interactions with health care providers can ffect access to health care (Stevens, 1992). In research xploring the experiences of individuals who are homeless, xperiencing addiction or mental illnesses in multiple com- unities in the United States, United Kingdom and Canada,

egative attitudes, judgements and perceived discrimination ave been identified as important barriers to accessing health are (Butters & Erickson, 2003; Crockett & Gifford, 2004; nsign & Planke, 2002; Gelberg et al., 2004; Napravnik, oyce, Walter, & Lim, 2000; Stajduhar, Poffenroth, & Wong, 000). In particular, those who use illicit drugs felt that their ast or current status as a ‘drug user’ was a barrier to access- ng health care and affected the quality of care they received. epatitis C, HIV/AIDS and mental illness are prevalent

mong those who are street involved and have been associated ith stigmatizing experiences for affected individuals (Bird, ogart, & Delahanty, 2004; Crisp, Gelder, Rix, Meltzer, & owlands, 2000; Crockett & Gifford, 2004; Dinos, Stevens, erfaty, Weich, & King, 2004; Valdiserri, 2002; Zickmund, o, Masuda, Ippolito, & LaBrecque, 2003). Negative experiences, stigma and discrimination in health

are reduce the likelihood of people accessing care in the uture, and will affect patient outcomes (Browne, Johnson, ottorf, Grewal, & Hilton, 2002; Kreiger, 1999; Stevens, 992; Varcoe, 2004). Experiences of stigma may result in eelings of worthlessness, depression, isolation, anger, anx- ety and fear (Dinos et al., 2004; Zickmund et al., 2003). eelings of worthlessness associated with the stigma of hav-

ng a socially unacceptable disease and illicit drug use may nadvertently be reinforced by the attitudes and responses of ealth care providers. In one study, perceived discrimination n interactions with health care providers by people with HIV nd low socio-economic status was correlated with higher evels of depression and post-traumatic stress symptoms, an ncrease in AIDS-related symptoms, poorer physical health nd less satisfaction with care (Bird et al., 2004).

Registered nurses have a professional ethical commitment o provide nursing care on the basis of need regardless of thnicity, race or class and to promote social justice through he development of equitable health policy (Canadian Nurses ssociation, 2002). However, those who are homeless and sing drugs are among those identified by nurses as ‘diffi- ult’ (Carveth, 1995); ‘unpopular’ (Johnson & Webb, 1995), those that nurses do not like’ (Liaschenko, 1994) or frequent yers (Malone, 1996). Differences in the quality of care of

hose identified as ‘difficult’ include delaying care, avoiding

atients, inaccurate assessments, withholding of treatment, roviding limited care (e.g. physical care only), providing ess information, inappropriate behaviours such as rough- ess in providing care and negative responses to patients

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Carveth, 1995; Corley & Goren, 1998; Johnson & Webb, 995; Stevens, 1992). Such behaviours are inconsistent with thical nursing practice. Several of these authors have identi- ed that the context or culture of health care is an important actor in the development and communication of attitudes, tereotypes and judgements involving social criteria (Corley

Goren, 1998; Johnson & Webb, 1995; Stevens, 1998). Registered nurses working in the community in primary

ealth care centres and as street nurses are often a first point f contact for people experiencing marginalization associ- ted with homelessness and substance use. Some authors ave found that those who are street involved highly valued he respectful nonjudgemental care provided by street nurses nd when care is delivered in primary health care settings Hilton, Thompson, Moore-Dempsey, & Hutchinson, 2001; olitzer et al., 2001; Stajduhar et al., 2000). However, little is nown about the values that are embedded in these cultures hat serve to counter perceptions of stigma and discrimina- ion and enhance access to health care. The primary aim of he larger study was to contribute to a better understanding f ethical nursing practice as a means of enhancing equity in ccess to health care for those who are street involved in the ontext of homelessness and substance use (Pauly, 2005). In his paper, the focus will be on the values tensions that nurses ust navigate to enhance equity in access to health care.

ethodology

Ethnographic designs are particularly appropriate when he aim is to understand practices and experiences within broader cultural context (Hammersley & Atkinson, 1995; oper & Shapira, 2000). In particular, Hoffmaster (1993) as argued that ethnography is an important methodol- gy for research in ethics with the potential to reveal the ay in which ethical concerns are historically and cultur-

lly situated and yield important knowledge necessary to mprove ethical practice within professions. The characteris- ic features of ethnographic work are participant observation, olism, context sensitivity, sociocultural description and the- retical connections (Stewart, 1998). In addition to these haracteristics, this research project was informed by social onstructionism (Crotty, 1998), critical theory (Lather, 1991) nd feminist processes for doing research (Anderson, 1991).

Ethical approval for the study was granted by the sites here the research was conducted and by a University Ethics eview Board. Staff and clients in the sites were informed bout the study through verbal presentation and/or posters.

ritten informed consent was obtained from all primary articipants. Verbal consent was obtained from secondary articipants.

Over a period of 10 months, data were collected in three

ites including two primary health centres and one emergency epartment (ED). Both of the primary health care health cen- res and the ED were located in large Canadian cities and all ere identified as serving an ‘inner city’ population charac-

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erized by homelessness and substance use. Data collection ethods included 203 h of participant observation and for- al interviews with 26 primary participants including 13

egistered nurses, 4 people accessing health care who had revious or current experience with homelessness and sub- tance use and 9 other health care team members in the three ites. In addition, multiple informal interviews with nurses, ther health care providers and people on street and in the linics were a source of data. The study was conducted over years and completed in 2005. Data analysis proceeded concurrently with data collection.

nsights from initial observations were followed up in sub- equent observations and observations/hunches were shared nd discussed with participants as the research proceeded. ata analysis was conducted using Lincoln and Guba (1985)

pproach to qualitative analysis. Immersion in the data was chieved by reviewing transcribed interviews and field notes ystematically to be able to identify activities, events, and onversations that described ethical practice and interactions or insights into the social context. The operations of uni- izing and categorizing, as described by Lincoln and Guba 1985), were employed in the analysis of the data. Consis- ent with feminist processes for doing research, the nurses nvolved as primary participants were invited to discuss the merging findings during and at the end of the data collection nd analysis. Feedback from participants was recorded and reated as an additional and valuable source of data rather han as validation of data.

The criteria for reliability and validity in feminist research nclude dependability, adequacy, reflexivity and catalytic alidity (Hall & Stevens, 1991; Lather, 1991). Dependability as enhanced by documentation of methodological, analyt-

cal and reflexive field notes, discussing findings with the articipants, and through feedback from members of the issertation committee. In addition, it should be noted that ependability increases with prolonged engagement, persis- ent observations, use of multiple observers and comparison f multiple data sources in the analysis. All of these were inte- ral to the design of this study. In order to achieve adequacy, hroughout the process of the research, continual question- ng by the researcher of methods and the impact of the study n a social and political context was a central activity (Hall

Stevens, 1991). In this study, field notes, discussions with issertation committee members and opportunities to engage ith people during observations and sharing of observations

nd findings were employed as strategies to enhance reflex- vity.

Drawing on the tenets of critical theory, Lather (1991) roposes catalytic validity which “represents the degree to hich the research process re-orients, focuses and energizes articipants toward knowing reality in order to transform t, a process Freire (1973) terms conscientization” (p. 68)

o enhance rigor. It was anticipated that participants in this tudy might gain insight into important and relevant aspects of heir practice and the context of their practice. Nurses directly nvolved in the study commented on the value of the research

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n highlighting their work and helping them to articulate what hey do. In addition, there was an explicit intent to generate nsights that could enhance the development of ethical prac- ice of practitioners with those who are street involved. These ave been shared with practitioners and policymakers.

indings

In fostering ethical nursing practice, nurses had to con- tantly navigate a series of value tensions that shaped practice ith those who are street involved. These value tensions high-

ight dominant but often unattended values in health care that an both facilitate and constrain access to health care ser- ices. The value tensions identified in this study included hifting from an ideology of fixing to reducing harm; stigma o moral worth; and from focusing on personal responsibility o enhancing decision-making of individuals.

ixing/reducing harm

In the acute care setting nurses repeatedly described the ulture of health care as one in which they had to “fix” ndividuals who presented in the emergency department. An mergency department nurse describes,

“We have to fix them fast so we can take the next person or we end up plugged. And that of course is a frustration for us. What we ideally like to do is treat the acute and send them elsewhere. And as an ED nurses that is where our focus is. Let’s treat the acute, don’t dig too deep.”

Nurses in the ED described that their primary focus is o fix people as quickly and efficiently as possible so as to

ove them through the department ED. However, those who ere experiencing mental health or substance use problems ere among those whose health and social issues were not

menable to fixing easily or quickly. As one nurse said, “I an’t fix it in 15 min with a shot.” Another nurse indicated “I ant to see people leave our department fixed and some of

hese at risk population you can’t fix.” Nurses were partic- larly frustrated by “fixing people up” only to have them eturn again and again. For example, people who repeat- dly returned to the emergency department for treatment f multiple abscesses. “You pump them full of antibiotics, ou cure their abcesses and they go back out and do it gain. It’s very frustrating.” The dominant ideology of fix- ng in the ED left nurses feeling frustrated and with a sense f failure at their inability to fix the complex health and ocial issues of people experiencing homelessness, mental llness and drug use. Clients also recognized the limits of

health care system focused on fixing in responding to

heir needs. One woman with a long history of schizophre- ia described herself as broken and said that health care roviders could not fix her. A man with a history of sub- tance use and repeated emergency department admissions

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ndicated that when “they can’t fix you, they give up on you”. hese clients expressed a feeling of being ‘unfixable’ and bandoned.

The dominant ideology of fixing in the culture of the emer- ency department was in direct contrast to the dominant value f reducing harm described by nurses working in the primary ealth care centres. Both of the primary health care centres in his study had an expressed philosophy of harm reduction. In hese centers, nurses were involved in the implementation of pecific harm reduction strategies. Annie, a nurse, described,

Instead of saying, looking at that broken crack pipe, would you like a plastic tip for your crack pipe is what you say, that broken crack pipe, I’ll bet you that bothers you. I have a plastic tip in there. Would you like that for your crack pipe? You know, understanding that abstinence from drugs is often not an option in this drug saturated environment as we say. It isn’t even an option to get past that and to get on to the next thing that is, how can I make using drugs safer for you? You know. It’s acceptance isn’t it.

In the presence of a harm reduction philosophy and pproach to care, there was a move from a focus on fixing eople to accepting that people ‘fix.’ Nurses described harm eduction as associated with reducing the direct harms of drug se and sexual activity through needle exchange, distribution f safer crack kits and condoms. However, nurses also used he term harm reduction to describe their work in reducing a road range of social harms such as homelessness, violence nd poverty.

And obviously that’s the way you should be treating all your clients. You’re figuring out who they are, where they’re at at moments, and how to work together. So you meet whatever few little goals you have even if that’s you know, a good night’s sleep that night. It’s not about telling them what’s good for them. And so that definitely is abso- lutely relevant in my mind about what I think/see as harm reduction everywhere.

Working in harm reduction meant that nurses tried to con- istently minimize harm for individuals not just harm of drug se, but social harms that were impacting health or well being. ne nurse stated, For example, if a woman was in an abusive relationship,

ow can harm be reduced if she is unable to leave her part- er? If someone refused hospitalization, what could be done o reduce harm that was both safe and acceptable to the indi- idual? In one situation, a nurse helped prevent the harms ssociated with a loss of housing for one man. She described he development of her relationship with him over time on utreach and his eventual willingness to seek services at the

ealth care centre for multiple physical and mental health oncerns. When he was in danger of being evicted due to he disorderly state of his apartment, she was able to help im maintain his housing by ensuring that his apartment

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as cleaned. In this situation, she reduced the harm that ight have arisen if he had been evicted and become home-

ess. Reducing harm was a primary moral imperative among urses working in a harm reduction context that was used o guide their actions and decisions in providing care. While urses supported strategies that reduced the harms associated ith drug use, they moved beyond specific harm reduction

trategies and worked to reduce the harms associated with the ulnerability of homelessness, violence and poverty. Nurses onsistently asked the reflexive question, “What can be done o reduce harm for this person in this situation?”

While nurses and other health care providers in the primary ealth care settings endorsed and supported harm reduction as philosophy, they identified situations when it was perplex-

ng or difficult to discern whether or not they were reducing arm such as in the care of pregnant women who were using rugs or when someone might be putting the community at isk by not completing a course of antibiotic treatment. One urse describes her process of reflection on such situations,

But that becomes hard when you have a woman who’s pregnant who comes in and asks for a rig. Because your instinct is, that first reaction is to say you shouldn’t be using; you have a baby. But the harm reduction would be, well, we could prevent that baby from being exposed to HIV into an infection and that the mom might end up being in hospital and needing antibiotics, a skin infection or something like that. The Mum becoming desperate and doing some kind of drug that’s more harmful for the baby lets say than what heroin is. By this attitude of ’don’t harm the baby’ are we then actually putting the baby at more risk because then the Mum is also being judged when she comes in to health care so if something does come up, she’s not going to come back and see us because we’ve judged her and said no, we’re not giving you that needle. I think what happens then is that when you are practicing harm reduction and that people do have a right to health care, is that then people feel that they can trust you and fall back on you; that well, I will be treated with respect here and will be treated as a human being. So then they’re more likely to access care when they need it and if there is going to be a change in their life, they’re willing to walk through this door.

In this situation, protection of mother and child was seen o be enhanced by a harm reduction approach that would pre- erve access to health care and ensure an ongoing relationship f trust into the future. Preservation of a trusting relationship as often identified as an important priority and means for

educing harm both now and into the future. In addition, a hifting from fixing to reducing harm acted as an antidote to tress and burnout for health care providers.

tigma/moral worth In formal and informal interviews, all participants (nurses,

lients and others) repeatedly described concerns about peo-

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le being treated as ‘not quite’ or ‘less than human’ in health are interactions. People who were street involved described eeling like an alien, a ‘piece of garbage’ or ‘a piece of shit.’ ome nurses acknowledged these kinds of concerns. One ED urse said,

Oh well, if they come in complaining of pain, automatically they’re drug seeking. They’ve run out of their own drugs. They’ve run out of money to buy their own drugs so they have to get free drugs now. And they’ll just keep coming back in and you automatically just label them. I’ve done it myself and it’s a horrible thing but it does happen. You know. And you kind of brush them off. I find most street people here don’t get treated like people.

Feelings of ‘Being treated like garbage’ and labeling ighlight concerns about lack of respect and worth and dehu- anization of people who are street involved. All participants spoke of their concerns about the verbal

nd non-verbal behaviours of health care providers that com- unicated a fundamental disrespect of the worth of people ho are street involved and the underlying message, that

hose who are street involved are unworthy or undeserving f care.

On a day when I was doing outreach with a nurse, I heard a frontline worker refer to people being treated like a piece of garbage by ambulance personnel. So, I immediately asked her to explain it to me. She told me, she feels offended when she hears an ambulance attendant say, “Do you really want to go to hospital?” combined with a smile that says, “I don’t believe you.” She described that this can be translated to mean,” I don’t want to waste my time, you’re a piece of garbage.” She was quick to add that this did not apply to all ambulance personnel by saying, “Some have hearts and know how to relate to people in (this area).”

Such behaviors reflect a complex interplay of social, eco- omic, political and historical forces that are enacted within ealth care interactions. One of the issues repeatedly encoun- ered during this project was the view that people who were epeat users of the system are wasting time and resources. ome nurses’ raised concerns about the financial costs to the ealth care system generated by repeat “users”. This high- ights the way that an ideology of fixing in combination with unding pressures and societal values related to worth may lay out in allocation of health care resources.

Regardless of the nurses expressed the belief that all eople including those who are street involved are wor- hy and deserving of health services proportionate to their eeds. Such values are embodied in professional codes of thics and are commonly expressed professional ethical val- es (Canadian Nurses Association, 2002). However, there

as evidence in this study of care being rationed to those

onsidered less deserving as result of their social status in he ED driven by an ideology of fixing, financial pressures nd societal norms.

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Those who were street involved described wanting to be reated as a “real person” when they accessed health care. ne man, who had been coming to one of the primary health

are centres for several years, described it as “the last chance afé.” He explained,

I mean they’re the kind of folks who ignore their health [and] they maybe don’t take care of themselves because their life changes so erratically, radically. And but so a lot of people who normally wouldn’t bother with their health or the system. They have been seen as and treated as non- relevant, non worthwhile. You just disappear. We’re not on the radar but here we’re just [people, not street people] Word gets around, so you know.

His comments are reflective of many who identified that he centre as a place where they could access respectful onjudgemental health care. Within the primary health care entres, nurses and others consistently resisted rationing are and strived to maintain their awareness of times when ationing based on social criteria was a potential concern.

Nurses and others in the primary health care centres escribed a variety of strategies for preventing rationing ased on social criteria and ensuring access to health care for ndividuals often perceived as difficult or challenging. One urse described constantly trying to be alert to of when she as “getting her back up” in response to particular clients. hen clients were in need of acute care resources, nurses orked to disrupt negative chains of judgement to ensure that

ndividuals received treatment appropriate to their needs. For xample, a nurse might call the emergency department and lert them that a client was coming who was very ill and in eed of resources even though the individual might swear at hem. Nurses and other team members were encouraged to ork with individuals with whom they had a good relation-

hip and shared the care of individuals found to be difficult, emanding or challenging among the team. One nurse stated,

And so each one of us has a particularly difficult client that we really click with or that we go to bat for a lot. Or you’ll hear the voice and you’ll go out and see them or whatever. And that very same person may be somebody that everybody else doesn’t really relish seeing. So that can be changing, but it’s the same in any environment. If the negativity starts to get too big, and that gets in the way. It generally doesn’t. I think there are a lot of people with relatively like-minded philosophies.

This nurse highlights the importance of having shared val- es among team members. Nurses indicated that other team embers often provided “a fresh perspective.” For example,

ne day, a nurse consulted a physician indicating that she

as not sure if she believed the patient’s story, the physician

ndicated that he thought the patient was quite genuine and er symptoms were consistent with her diagnosis. After the urse turned to me and said, “See when one of us writes some-

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ne off, somebody else sees something different.” Working s part of a team was a source of support and helped nurses nd other team members to stay focused on shared values ncluding the importance of ensuring that individuals who ften have limited access to health care have access to health are resources proportionate to their needs.

In ensuring that everyone receives care proportionate to heir needs, health care teams had to constantly balance ccess to health care against efficient use of resources and afety. Health care teams worked to ensure access to health are and manage resources, particularly human resources, isely. The following example illustrates a case conference

n which the team discussed concerns about a women who as been repeatedly accessing the health care centre.

The team discussed the number of times each of them had seen Joyce over the past few days. They identified that in this situation, continuity of care with the same practi- tioner was needed. Since the centre often triaged anxious patients so they were seen quickly to prevent escalation among others, Joyce was being seen repeatedly several times a day by different practitioners. The team discussed the need to have her assigned to one practitioner only and restrict her visits to once a day. One of the staff indicated that once a day was a lot but someone else observed that once a day was better than the current multiple visits per day. Someone asked “are we willing to call the police if needed?” The manager indicated that she didn’t want to do that until Joyce had received a psychiatric assessment. They talked about precedence in which other clients had been restricted to one practitioner and a limited number of visits per day or per week. They recalled past times when they had needed to set limits with some violent and aggres- sive drug dealers. Through discussion, they determined which practitioner, given individual case loads, would be Joyce’s primary provider. In that discussion, the practi- tioner assigned to her care was asked if she would be able to set these limits with Joyce. She said she would have to.

The team through thoughtful and direct dialogue sought o preserve Carol’s access health care and manage available esources wisely. Together they agreed on and committed to plan of action that could be followed up with the individual

nvolved. Second, health care teams in the primary health care cen-

res had to balance access to health care with real or perceived hreats to personal safety and security of team members. Team

embers were alert to potential threats to themselves and oth- rs and constantly talked through concerns to assess whether heir feelings of being threatened were a manifestation of egative judgements or of substantive concern. There was recognition that often an angry or aggressive responsive

rom an individual arose from their past experiences and was manifestation of survival mechanisms needed on the street r in prison. Only rarely would an individual be banned from ccessing services in one of the community health centres.

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anning only occurred in the face of serious threats to safety nd after extensive team consultation. In the face of such hallenges one nurse said that the manager helped to remind hem of their values.

And I think those are things that [our manager] brings to the clinic. And not very often, but now and again she’ll have to put down her foot in a staff meeting and say, we’re not barring this patient because this is what we do and this is what we’re about and we are here to serve that very type of person who is angry and you know, whatever. So she’s good at keeping us on track.

This manager played a key role in ensuring that the team pheld shared team and organizational values. The nurses in his centre were consistently able to raise their concerns about he treatment and care of individuals to the manager and were upported to take actions that helped enhance equity in access o health care. For example, one nurse was able to have a ban ifted for a man who had been barred from a shelter. With he support of the manager, she fostered dialogue between he man and the shelter to address the behaviours that had ead to the ban. Nurses consistently worked to resist negative ocietal values related to the worth of those who are street nvolved through a variety of strategies that were supported y other team members and managers in order to facilitate nd preserve access to health care.

ersonal responsibility/enhancing decision-making

Nurses and those who were street involved described the roblem of individuals being blamed or found to be at fault or their poor health. One woman, who accessed care from urses at a primary health care centre, described the attitude f some health care providers as “well why the hell are you ere? You shouldn’t be here, right, because you know, you o this to yourself.” Frequently, nurses espoused the view hat individuals on the street are survivors. They acknowl- dged and respected their capacity to survive situations such s family dysfunction, abuse, traumatic injury and loss. Thus, mplicitly recognizing the social conditions that shape their ife situations and fostering respect and moral worth of indi- iduals. In order to resist the view that individuals were not aking responsibility for their health, nurses expressed the iew that individuals while responsible for their choices may ave had limited opportunities to develop decision-making apacity.

In this study, nurses continued to offer and keep open hoices even when individual behaviours were not consistent ith what the provider might think was in the best interest f the person. For example, if a client decided to discontinue reatment such as antiretroviral medication for their HIV, if

omeone did not show up for an appointment or if they went n a drinking binge after going through detox, they were not abelled as making bad choices, noncompliant or failing to ake responsibility. Rather nurses kept the door open by con-

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inuing to offer choices regardless of previous decisions or ehaviours. They might describe the person as still precon- emplative, meaning they are not yet ready to make a change ut reinforcing that they need to keep working with the per- on. However, if a nurse perceived that the harm was life hreatening and they were in need of care, they might say “this s serious, you have to go or you could die.” Nurses working n harm reduction worked to balance the client’s right to say no’ and encouraging but not coercing an individual to take ction.

The shift from personal responsibility to enhancing devel- pment of decision-making capacity reflects a continuing alue on autonomy rooted in liberal individualism but instead f expecting autonomy nurses focused on assisting individu- ls to develop the capacity for autonomous decision-making. n order to resist blaming individuals for failing to take per- onal responsibility for their health, nurses shifted to focus n the development of decision-making capacity in order to nhance access to health care. While nurses recognized the ocial conditions that constrained decision-making capac- ty, their actions focused on enhancing individual autonomy ather than effecting change in the social conditions.

iscussion

The ideology of fixing is consistent with dominant iomedical value systems that operate in health care that mphasis a focus on disease and cure of disease and ill- ess as the measure of success (Storch, Rodney, Pauly, rown, & Starzomski, 2002). The focus on reducing harm s a dominant value system that operated within a context f harm reduction helped to foster access to health care. arm reduction has been described as being characterized by

he key principles of pragmatism; humanistic values; focus n harms; balancing costs and benefits; and hierarchy of oals (Canadian Centre of Substance Abuse, 1996; Hilton, hompson, Moore-Dempsey, & Hutchinson, 2001; Hilton, hompson, Moore-Dempsey, & Janzen, 2001; Hunt, 2003). he findings in this study are consistent with the key prin- iples of harm reduction. A focus on reducing harm may be iewed as a more ‘ethical’ approach to working with peo- le experiencing social disadvantage because they are not orced to change and their choices are respected while trust nd opportunities to access health care are preserved. Gunn,

hite, and Srinivasan (1998) state “harm reduction encom- asses abstinence as a desirable goal, but recognizes that hen abstinence is not possible, it is not ethical to ignore

he other available means of reducing human suffering” (p. 191). While a key priority of harm reduction, as described by urses in this study, was to reduce harm associated with drug se, reducing harm became a moral imperative that propelled

urses to act to reduce the harms associated with social con- itions affecting the health of those who are street involved uch as assisting with access to housing, income or other ealth and social services. However, there were often sig-

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ificant barriers encountered in attempting to mobilize such ervices and resources.

These findings suggest that the presence of a harm reduc- ion philosophy fostered a focus on reducing harm as a ey contextual feature of ethical nursing practice enhancing ccess to health care for those who are street involved. It may e that the adoption of a harm reduction philosophy created a afe climate for fostering a different set of values or that indi- iduals with already established values were drawn to work in ettings that serve those who are street involved. Regardless, hese findings suggest the need to develop nursing curric- la and practicums that enhance students’ knowledge of the ocial conditions that shape the lives of those who are street nvolved and knowledge of harm reduction.

Expanding harm reduction approaches to hospital pro- rams and services has been successful in several settings Young, Fish, Browne, & Lawrie, 2002). Although such pro- rams have not been rigorously evaluated, improvements in elationships with clients have been reported. Thus, pointing o the need for the development of harm reduction policies ithin acute care settings and increased understanding of the arms associated with street life among health care providers. hile nurses and other health care providers in the primary

ealth care settings endorsed and supported harm reduction n practice, there are significant ethical tensions associated ith implementation of harm reduction. This is an area for

uture research and exploration to better understand and equip roviders to respond to the perplexing issues raised by the doption of harm reduction philosophy and policy.

While harm reduction may contribute to shifts in the oral orientation of health care providers, it has limitations. arm reduction has been most often applied to reducing the arms of drug use, focusing on decriminalization of illicit rugs and preventing disease rather than the harms associated ith homelessness, violence and vulnerability especially for omen (Dykstra et al., 2007). Harm reduction shifts the line f personal responsibility for drug use to being responsible for afer drug use (Fischer, Turnbull, Poland, & Haydon, 2004;

iller, 2001). While harm reduction fosters social context hat can enhance access to health care, it is not sufficient to ddress inequities in health that are deeply rooted in social onditions such as homelessness and poverty (Pauly, 2008). arm reduction falls short of shifting the context from one of ersonal responsibility to social responsibility for reducing nequities. Thus, harm reduction is only a partial response o address inequities in health and access to health care for hose who are street involved (Pauly).

While expanding harm reduction initiatives on the basis f reducing the consequences of drug use is well supported, n explicit ethical analysis of the values underpinning harm eduction is needed in order to ensure enactment of harm eduction in a manner consistent with ethical practice aimed

t reducing inequities in health and access to health care. here is a need to link harm reduction with perspectives on ocial justice in order to redress injustices in social structures Pauly, 2008). An ethical commitment to social justice by

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urses suggests that action which addresses the determinants f health inequities such as housing is needed. Nurses have he potential to play a key role in bringing issues related to onsideration of a broader range of harms into harm reduction nd drug policy debates.

In this study, nurses promoted autonomy of individuals ithin health care interactions and health care relation-

hips by respecting choices and enhancing decision-making apacity. Nurses recognized that individuals may have had imited opportunities to develop decision-making capacity. he recognition of constraints on decision-making capacity is onsistent with Sherwin’s (1998) notions of relational auton- my. Autonomy was understood as a capacity to be developed nd more consistent with notions of relational autonomy ather than autonomy informed by liberal individualism Beauchamp & Childress, 2001; Sherwin, 1998). These find- ngs suggest that opportunities to enhance decision-making apacity exist within health care interactions. When indi- iduals made choices that were contrary to what providers erceived was in their best interest, nurses, working within context of harm reduction, sought to minimize harm rather

han abandon individuals on the basis that they were refusing are. These findings provide insights into the way that nurses orking with individuals balanced one principle against

nother in everyday practice. Some nurses in this study embraced actions to enhance

utonomy and reduce harm for those who are street involved. urses were more likely to take such actions when they orked with a supportive interdisciplinary team and manager. imilar to other research, ethical practice was enhanced when urses had strong leadership and were members of effec- ive interdisciplinary teams (Rodney et al., 2002; Varoce et l., 2004). However, taking action was in the context of pro- iding care to individuals. In this study, nurses did not take ction to redress the broader social conditions that contribute o inequities in health and access to health care for those who re street involved. This raises questions for nurses about indi- idual and collective roles in effecting justice in policy and ractice to address inequities in health and access to health are and the role of policy in the enactment of social justice n nursing practice.

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