People who are street involved such as those experiencing homelessness and drug use face multiple inequities in health and access to health care. Morbidity and mortality are significantly increased among those who are street involved. Incorporation of a harm reduction philosophy in health care has the potential to shift the moral context of health care delivery and enhance access to health care services. However, harm reduction with a primary focus on reducing the harms of drug use fails focus on the harms associated with the context of drug use such as homelessness, violence and poverty.
Ethical analysis of the underlying values of harm reduction and examination of different conceptions of justice are discussed as a basis for action that addresses a broad range of harms associated with drug use.
Theories of distributive justice that focus primarily on the distribution of material goods are limited as theoretical frameworks for addressing the root causes of harm associated with drug use. Social justice, reconceptualised and interpreted through a critical lens as described by Iris Marion Young, is presented as a promising alternative ethical framework.
A critical reinterpretation of social justice leads to insights that can illuminate structural inequities that contribute to the harms associated with the context of drug use. Such an approach provides promise as means of informing policy that aims to reduce a broad range of harms associated with drug use such as homelessness and poverty.
The purpose of this paper is to describe the meaning of needle exchange programs from the perspectives of users who access such programs.
We conducted observations, 33 semistructured interviews and two focus groups with users at four needle exchange sites. Qualitative description was used to analyse the data.
Participants described experiences of trauma, abuse, violence and physical injuries that had damaged their lives and led to the use of drugs to numb the pain. Respect for persons and the development of trust with outreach staff for clients who use injecting drugs supported clients to feel safe in what for many was an unsafe world. Participants described the important role that needle exchange services play in reducing and countering negative stigma, as well as in providing access to clean supplies and to other services.
The findings attest to the benefits of having trusted, safe needle exchange services that not only reduce risk behaviours that prevent infections, such as HIV and hepatitis C, but also open the door to other services. This finding is particularly important given that the majority of those interviewed were homeless and living in poverty. The need for both fixed sites and the integration of harm reduction services as part of a broader network of primary health-care services was reinforced.
The limitations of rational models of ethical decision making and the importance of nurses' human involvement as moral agents is increasingly being emphasized in the nursing literature. However, little is known about how nurses involve themselves in ethical decision making and action or about educational processes that support such practice. A recent study that examined the meaning and enactment of ethical nursing practice for three groups of nurses (nurses in direct care positions, student nurses, and nurses in advanced practice positions) highlighted that humanly involved ethical nursing practice is also simultaneously a personal process and a socially mediated one. Of particular significance was the way in which differing role expectations and contexts shaped the nurses' ethical practice. The study findings pointed to types of educative experiences that may help nurses to develop the knowledge and ability to live in and navigate their way through the complex, ambiguous and shifting terrain of ethical nursing practice.
Moral distress is a phenomenon of increasing concern in nursing practice, education and research. Previous research has suggested that moral distress is associated with perceptions of ethical climate, which has implications for nursing practice and patient outcomes. In this study, a randomly selected sample of registered nurses was surveyed using Corley's Moral Distress Scale and Olson's Hospital Ethical Climate Survey (HECS). The registered nurses reported moderate levels of moral distress intensity. Moral distress intensity and frequency were found to be inversely correlated with perceptions of ethical climate. Each of the HECS factors (peers, patients, managers, hospitals and physicians) was found to be significantly correlated with moral distress. Based on these findings, we highlight insights for practice and future research that are needed to enhance the development of strategies aimed at improving the ethical climate of nurses' workplaces for the benefit of both nurses and patients.
Harm reduction is part of a comprehensive approach to dealing with the harms of drug use. Although the evidence to support implementation of harm reduction strategies for illicit drug use is abundant, it is unlikely that scientific knowledge alone will be enough to facilitate the adoption of harm reduction strategies in many health-care settings. The authors examine the ethical, legal and social context of harm reduction as it pertains to illicit drug use to assist nurses in providing safe, competent and ethical care. Included is an examination of values and accompanying responsibility statements from the Canadian Nurses Association's Code of Ethics for Registered Nurses that can guide nurses in their ethical reflection and provide insights into ethical practice.
Nurses are frequently portrayed in the literature as being silent about ethical concerns that arise in their practice. This silence is often represented as a lack of voice. However, in our study, we found that nurses who responded to questions about moral distress were not so much silent as silenced. These nurses were enacting their moral agency by engaging in diverse, multiple and time-consuming actions in response to situations identified as morally distressing with families, colleagues, physicians, educators or managers. In many situations, they took action by contacting other healthcare team members, making referrals and coordinating care with other departments such as home care and hospice, as well as initiating contact with groups such as professional regulatory bodies or unions. Examining the relationship between ethical climate, moral distress and voice offers insights into both the meaning and impact of being silenced in the workplace.
Insite, a supervised injection facility in Vancouver, British Columbia, is an evidence-based response to the ongoing health and social crisis in the city's Downtown Eastside. It has been shown that Insite's services increase treatment referrals, mitigate the spread and impact of blood-borne diseases and prevent overdose deaths. One of the goals of this facility is to improve the health of those who use injection drugs. Nurses contribute to this goal by building trusting relationships with clients and delivering health services in a harm reduction setting. The authors describe nursing practice at Insite and its alignment with professional and ethical standards of registered nursing practice. Harm reduction is consistent with accepted standards for nursing practice as set out by the College of Registered Nurses of British Columbia and the Canadian Nurses Association and with World Health Organization guidelines.
Promoting health equity is a key goal of many public health systems. However, little is known about how equity is conceptualized in such systems, particularly as standards of public health practice are established. As part of a larger study examining the renewal of public health in two Canadian provinces, Ontario and British Columbia (BC), we undertook an analysis of relevant public health documents related to equity. The aim of this paper is to discuss how equity is considered within documents that outline standards for public health.
A research team consisting of policymakers and academics identified key documents related to the public health renewal process in each province. The documents were analyzed using constant comparative analysis to identify key themes related to the conceptualization and integration of health equity as part of public health renewal in Ontario and BC. Documents were coded inductively with higher levels of abstraction achieved through multiple readings. Sets of questions were developed to guide the analysis throughout the process.
In both sets of provincial documents health inequities were defined in a similar fashion, as the consequence of unfair or unjust structural conditions. Reducing health inequities was an explicit goal of the public health renewal process. In Ontario, addressing "priority populations" was used as a proxy term for health equity and the focus was on existing programs. In BC, the incorporation of an equity lens enhanced the identification of health inequities, with a particular emphasis on the social determinants of health. In both, priority was given to reducing barriers to public health services and to forming partnerships with other sectors to reduce health inequities. Limits to the accountability of public health to reduce health inequities were identified in both provinces.
This study contributes to understanding how health equity is conceptualized and incorporated into standards for local public health. As reflected in their policies, both provinces have embraced the importance of reducing health inequities. Both concepualized this process as rooted in structural injustices and the social determinants of health. Differences in the conceptualization of health equity likely reflect contextual influences on the public health renewal processes in each jurisdiction.
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In the current era of providing health care under pressure, considerable strain has been placed on nurses workplaces. Underneath the economic and organizational challenges prevalent in health-care delivery today are important values that shape the ethical climate in workplaces and affect the well-being of nurses, managers, patients and families. In this article, the authors report on the outcomes of Leadership for Ethical Policy and Practice, a three-year participatory action research study involving nurses, managers and other health-care team members in organizations throughout British Columbia. By using an ethics lens to look at problems, participants brought ethical concerns out into the open and were able to gain new insights and identify strategies for action to improve the ethical climate. Nurse leader support was essential for initiating and sustaining projects at six practice sites.
There has been ongoing confusion about the meaning of advanced nursing practice (ANP) and the nature of ANP roles in Canada and elsewhere. A broad range of roles and titles have been adopted throughout Canada in an attempt to delineate specialized and/or advanced roles within nursing. One key objective in a recent three-phase study of ANP in British Columbia was to clarify the role and understanding of advanced nursing practice and related roles within the larger healthcare system. Our intent in this paper is to describe the understandings of ANP that emerged in Phase I of this recent study and to compare registered nurses' understandings of ANP to the characteristics and competencies identified by the Canadian Nurses Association (2002) framework. (Note: The term "nurse," as used in this paper, refers to "registered nurse.") We conclude by identifying future directions for development of advanced practice roles.