Providing Healthcare in a Supervised Injecting Facility: Nursing Culture at Insite

Canadian Association of Nurses in AIDS Care ConferenceApril, 2007

Introduction

BackgroundNorth America’s first Supervised Injection Site (SIS), Insite opened in September, 2003Open 18 hours per day, 365 days per yearPilot project with extensive research/ evaluation component (ESIS)Jointly operated community health initiative

Vancouver Coastal HealthPortland Hotel Society

Goals

Public Health InterventionIncreased public health (affecting OD death, transmission of disease, contraction of injection-related infections).Bridging marginalized population to primary health care, addictions treatment, and social services.Increased public order.

The Team

Interdisciplinary Team

Program workersPeer workers (LINES)Registered Nurses Counselors

Insite at a Glance

Reception Desk

Insite at a Glance

Reception Desk

Program staff welcome participants into InsiteProvide needle exchange services

Insite at a Glance

Injection Room

Insite at a GlanceInjection Room

Participants are greeted in injection room with sterile suppliesNurses and Program Workers make first contact

Key opportunity to identify harm reduction needs of participants, physical (head to toe) and psychosocial assessments

Insite at a GlanceChill Out Lounge

Insite at a Glance

Insite at a GlanceChill Out Lounge

Peer workers are the link between our harm reduction program and the local community.Peer workers bring experience, skills and expertise in harm reduction practice particular to the local population.

Insite at a Glance

Insite at a Glance

Infection Control

Hand washing encouraged prior to participants initiating injection practicesDisinfecting of each booth after every use

Insite at a Glance

Harm ReductionTeaching best practice when injecting

Encourage site rotationCleansing site with alcohol swabsFiltering/cooking drugsUsing tourniquets Doing test dosesDiscarding used supplies into sharps box

Insite at a Glance

Harm ReductionNursing Teaching Tools

On-site education sessions for participants, including safer techniques and risks associated with IV drug useParticipants can practice safer injecting techniques with use of prosthetic arm

Insite at a Glance

Treatment RoomOne-on-one time spent with clientsWound care & injuriesAssessments, vital signsFoot carePregnancy testingFlu shotsPsychosocial supportReferrals

Insite at a Glance

A quick glimpse of some of our chronic wounds:

Rethinking Harm ReductionInsite - More than the Sum of its Services

Nursing PracticeNeeded to Evolve - to maximize access and meet the complex scope of participant needsVolume of Participants (average 750 visits/day) -precipitates high degree of intensity– must keenly search out opportunities to engageMarginalization – psychosocial & medical determinants of health are poor, infection rates are high, most participants are profoundly poor, limited links to health care services

Rethinking Harm Reduction

Insite – More than the Sum of its ServicesLow Threshold Service – Insite is for the most disenfranchised group - chaotic, multiple-barriered, hard to serve, generally very low functioning - insite staff ‘level the playing field’ to ensure equal access for those at riskRelationship building – the most 'real' role we can fill is to be a fellow human being and walk alongside users, witness their lives, and advocate for a better quality of life with and for themConflict and de-escalation – crucial skill-set and dependent on a ‘team approach’ and staff self-awareness

Rethinking Harm ReductionInsite – More than the Sum of its Services

Sacred Space – many participants were instrumental in developing Insite and feel sense of pride and ownership – Insite is also a comfort zone or ‘safe haven’Boundary Issues & Burnout – staff must be very aware of maintaining own boundaries yet be able to engage with participants with empathy and without judgmentRe-visioning Success - often what we can do is simply keep users alive - success is measured simply by being able to continue providing the service

The ResearchApprox. 8000 registered participants – 750 average visits per dayHighest number of visits in an 18 hour day so far: 1050In a 1 year period from 2004 – 2005, there were 272 overdose interventions with no deaths to date (Tyndall et al, 2005)Rates of addiction treatment access are twice as high amongst IVdrug users who use the SIS compared to those who do not (Wood etal, in press)In a 1 year period from 2004 – 2005, 2171 individual referrals were made with majority (37%) being referred for addictions counseling (Tyndall et al, 2005)Public disorder in DTES is impacted positively by SIS – 75% reduction in public drug use consumption (Wood et al, 2004)90% of Insite participants are Hepatitis C +35% of Insite participants are HIV +

Case Study

Male client, HIV + for 18 yearsRapidly deteriorated over the last year.Links made from Insite include: housing (shelters), detox, recovery housing, primary care, active participation with community palliative program. Currently a client of CTCT

Letter written by one of our participants:"They saved my life when I did too much drugs and went into seizures. And they did not ignore me when I was crying. They talked to me when I kept leaving the hospital and coming back to Insite to do more drugs, they went out of their way to get me back to the hospital because I had Osteomyelitis of the collar bone due to drugs. I could have died from it. They came to visit me. It takes a special person to do this kind of work. They helped me get into detox, they listened to me. They planted the seed suggesting a certain recovery house that they knew would fit for me. I have gone thru detox, I relapsed and they did not judge me...I am now in a recovery house. I have a choice to go back out using or stay clean and take care of myself, I choose to stay clean."

Qualitative Research:

Insite Participant InterviewsI  can  turn  around,  I  can  look  in  the mirror,  I  can  see  the nurse. They’re watching,  right?  If anything goes wrong,  I mean… you  could  yell.   But  if  you  are  by  yourself…you could yell  if  anything  happened, nobody  answers. Nobody listens. Nobody  lifts a  finger. Nobody.   Y’know?  ‐ Female Participant # 47The one nurse, she told me to come  in every day and she’d pack it [soft‐tissue infection] and dress it.  They took care of me right from the get‐go and, like, right from the onset of it, right  ‘til  it was done.   And…I mean,  it was  excellent.    –Female Participant # 50

Qualitative Research

Insite Participant InterviewsI’ve had a coup le of abscesses, and there was another one, a big  bump  and  I  thought  this  one’s  gonna go  abscess  too.  She  gave me  some  advice  of what  to  do  about  that,  and  I followed  her  advice  and  it  didn’t  abscess,  and  the  bump went away.–Male Participant #9This man I know overdosed, and like, they were on it. They were quick. They didn’t waste any time. They were prompt, and…they  were  experienced.  They  knew  what  they  were doing. Yeah. They came and Narcaned him, and 911 – the ambulance  – came  and  took  the  guy  out.  Like,  they were right on it… the guy was going to die, and I think they were really  good.  They’re  experienced,  in  other  words,  in  that type of thing. ‐ Female Participant #30

Nursing Culture at Insite

“In one word, describe what nursing at Insite means to you:”

HumanitarianPassion

DynamicHumblingPrevention

Cutting-EdgeA necessityChallenging

Nursing Culture at Insite

“Why have you chosen to work at Insite?”“I believe that people with addiction issues are severely marginalized in our society, and our current medical system is not able to meet their unique healthcare needs. I am proud to work at Insite where we accept each individual for where they are at in their addiction, and offer them easily accessible nursing care.” -E.G.“The situation on Vancouver's DTES is dire. I wanted to become engaged in a way that attempts to restore humanity and reflect value for human lives. Canada is one of the world's wealthiest nations on earth yet Vancouver's DTES remains third world, with many of the residents very ill, living in squalor and chaos. I didn't want to be someone who looks the other way.” - C.P.

Nursing Culture at Insite

“Why have you chosen to work at Insite?”“Originally, to get into HIV care. I stayed because I love working with this population. They have so much to teach me, and I have so much to teach them. Insite does important work that saves lives. That's why” – D.P.“I will always remember the spiritual enlightenment I experienced when I had my first real contact with a client from Insite. It is this empathy and love which reinforces why I have chosen to work with the DTES. I am honored to have the opportunity of sharing my knowledge of health prevention and health promotion with such a marginalized group and at the same time treating each client as an autonomous beautiful human being.” B.L.

ReferencesTyndall, M.W., Kerr, T., Zhang, R., King, E., Montaner, J.,

Wood, E. Attendance, drug use patterns and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, In Press November 2005.

Wood, E., Kerr, T., Small, W., Li, K., Marsh, D., Montaner, J., Tyndall, M. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users.CMAJ 2004, 171 (7) 731-734.