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Homelessness & Health in Canada

Manal Guirguis-Younger
Ryan McNeil
Stephen W. Hwang

Part II-Policy & Programmatic Responses to Homelessness & Health

Chapter 9. Close to the Street: Nursing Practice with People Marginalized by Homelessness and Substance Use

Bernadette Pauly

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1Nurses are often an initial and ongoing point of contact for persons marginalized by homelessness and substance use in health care settings. As such, nurses are uniquely positioned to facilitate access to health care for people who have poor health and face multiple barriers to care. In particular, persons marginalized by homelessness and substance use often encounter stigma and discrimination when accessing health care. Professional standards for ethical nursing practice include promoting health and well-being, preserving dignity and promoting justice and health equity (Canadian Nurses Association 2008). The promotion of justice means that nurses do not discriminate in the provision of care on any basis and refrain from judging and stigmatizing behaviours. However, specific concerns related to exclusionary 'othering', in which others are differentiated on the basis of class, race, gender or some other aspect, contribute to negative processes of engagement and are prevalent in health care (Canales 2000; MacCallum 2002; Peternelj-Taylor 2004; Varcoe 2004). Further, nurses have a specific professional commitment to the promotion of equity in health and health services.

2This chapter discusses findings from an ethnographic study exploring access to health care for people marginalized by homelessness and substance use within nurse–patient interactions and the environment in which these interactions took place. A key finding was that forging a chain of trust in a climate of distrust fosters access to health care. This chain of trust is triple-linked, consisting of interlocking interpersonal, organizational and systemic linkages. Health care access is negatively impacted when these links are weak or broken. Strategies for enhancing access to health care for people marginalized by homelessness and substance use through enhancement of ethical nursing practice are also discussed.

Stigmatization, Discrimination and Health Care Encounters

3People impacted by homelessness and substance use often encounter stigma and discrimination when accessing health care services (Butters and Erickson 2003; Crockett and Gifford 2004; Gelberg et al. 2004; Lloyd 2010; McLaughlin et al. 2006; Stajduhar et al. 2004; Trevana, Simpson and Nutbeam 2003; Wen, Hudak and Hwang 2007). Negative attitudes of health care providers have been implicated in the development of stigmatizing experiences and discriminatory practices associated with class, substance use, disease conditions or other factors such as race or ethnicity.

4Stigma is the outcome of social processes that result in social devaluing and spoiled identity in which individuals are marked on the basis of negative attributes (Goffman 1963). Stigmatization results in either enacted stigma, where individuals are actively discriminated against, or perceived or felt stigma, where stigmatized individuals internalize negative beliefs (Goffman 1963). Stigma is highly contingent on an individual's social location and "entirely dependent on social, political and economic power" with power imbalances between those who are the subject of stigma and those who stigmatize (Link and Phelan 2001). Stuber, Meyer and Link (2008) argue that stigmatization and discrimination share common features, "including exposure to negative attitudes, structural and interpersonal experiences of discrimination or unfair treatment and violence perpetrated against persons who belong to disadvantaged social groups" (351). Further, people may be subject to intersecting stigmas associated with age, sex, gender, sexual orientation, race, ethnicity socioeconomic status or disease (Benoit and Shumka 2009; Wailoo 2006). For example, the stigma associated with homelessness may combine with other stigmatizing conditions, such as mental illness, hiv/aids, hepatitis C and substance use, and contribute to discrimination (Harter et al. 2005; Takahashi 1997; Wolitski et al. 2009).

5Researchers have reported that homeless persons often encounter negative experiences or judgments when accessing health care (Ensign and Planke 2002; Gelberg et al. 2004; Stajduhar et al. 2004). For example, Wen, Hudak and Hwang (2007) found that homeless persons either implicitly or explicitly connected unwelcomeness with feelings of discrimination. The stigma associated with drug use has contributed to negative experiences in health care settings for this population (Butters and Erickson 2003; Crockett and Gifford 2004; Lloyd 2010). Stigma and discrimination decrease the likelihood that individuals will access health care in the future and may contribute to further marginalization and feelings of low self-worth and may also manifest in physical and mental health concerns (Bird, Bogart and Delahanty 2004; Browne et al. 2002; Dinos et al. 2004; Krieger 1999; Wen, Hudak and Hwang 2007; Zickmund et al. 2003).

6In contrast, several studies have found that registered nurses providing primary care outreach and provision of care in community health centres are perceived more positively by marginalized populations (Hilton et al. 2001; Politzer et al. 2004). For example, a Vancouver evaluation of the street nurse program was found to foster the development of relationships and enhance access to heath care. However, there is limited understanding of ethical nursing practice and strategies within nurse–patient interactions that might provide insight into reducing barriers and fostering access to health care services for those marginalized by homelessness and substance use.

Methodology and Methods

7An ethnographic approach that drew on critical and feminist perspectives was used to examine access to health care and ethical nursing practice in interactions between nurses and persons experiencing homelessness and/or substance use and the environment in which these interactions occur. The specific research objectives were to: describe the nature of interactions and the development of relationships between nurses and marginalized populations, (2) explicate the underlying factors (social, political, economic and historical) supporting and limiting the enactment of professional standards and practice by nurses within these relationships, (3) explore the impact on access to health care and (4) identify the insights of clients and nurses that would contribute to the development of more equitable access to health care services. A detailed description of the methodology is provided elsewhere (Pauly 2008b).

8Data collection methods included qualitative interviews with 26 primary participants (13 registered nurses, four people accessing health care, nine non-nursing health care staff) and 203 hours of participant observation at two community health care centres (chcs) and one emergency department (ed). Interviews and participant observation were conducted over a period of 10 months. All interviews and field notes were audio recorded and transcribed verbatim. Both the chcs and the ed were located in western Canada and were identified as serving an inner-city population in areas associated with poverty, homelessness and substance use. Data collection and analysis occurred concurrently. Inductive methods of data analysis as described by Lincoln and Guba (1985) were used. Immersion in the transcripts and field notes through multiple readings contributed to the identification of activities, events and conversations that provided insight into nurse–patient interactions within the social context that facilitated or inhibited access to health care. Consistent with feminist approaches, nurse participants were actively consulted at various points to clarify and extend the analysis. Criteria for reliability and validity in feminist research including dependability, adequacy, reflexivity and catalytic validity were employed to ensure rigour in the study (Hall and Stevens 1991; Lather 1991).

9Ethical approval for the study was granted by each site as well as the University of Victoria. Initial information sessions were conducted in both chcs to inform staff about the study. Written consent was obtained from all primary participants for interviews and observations. Throughout the study, staff members in each setting were informed about the study when observations were conducted. Verbal consent was obtained from individuals who were observed during nursing care delivery.


10All participants emphasized that people marginalized by homelessness and substance use were often distrustful of mainstream health care services and expressed an avoidance or reluctance to access health care, particularly in hospitals. One participant echoed the feelings of many: "I'm not going to go, I don't go to hospital unless I absolutely, desperately have to go, unless I am on my deathbed." Client participants relayed a range reasons for avoiding hospital care, including fears of being overlooked, prejudged and treated like garbage by a system that focuses on addressing acute concerns and getting people through quickly (Pauly 2005). Distrust was exacerbated by a 'culture of fixing' in the emergency department and embedded in personal experiences of past trauma and being on the street, where "trust is a lousy survival tactic" (Pauly 2008b). In this climate of distrust, re-establishing trust with people experiencing homelessness and substance use was central to the work nurses did to facilitate access to health care services. Rebuilding trust occurred on three interrelated levels: interpersonal, organizational and systemic.

Interpersonal Linkages

11Building trusting relationships over time. In this study, nurses felt that each client interaction was an opportunity to build trust that could facilitate access to health and ancillary services. A nurse describes:

It is a process over time. Yeah. It doesn't … it certainly doesn't happen on the first visit. It certainly takes a while, and sometimes the first visit is … just meeting their immediate needs but letting them know that the door is open … Really … the basis of providing access to care is that relationship and that sense of trust.

12Multiple interactions build interpersonal trust over time and are necessary to facilitate access to health care services. Some key features of building interpersonal trust were preserving respect, not brushing concerns off and sensitivity to life circumstances.

13Preserving respect. Client participants' fears of being "overlooked", "prejudged" and "treated like garbage" highlight the lack of respect they often experience in health care relationships. All participants noted the importance of respect in health care encounters and relationships and a desire to be treated "like a real person". One client participant remarked, "I just want a doctor that respects me and treats me like a person." This client participant continued:

You know, [the street nurse] has seen me when I've been so stoned I could hardly walk or talk or anything, gibbled, or you know, doing the chicken or whatever they call it, flailing away. And he doesn't degrade me for it. Like you know [the street nurse] accepts the fact that I'm a junkie and I'm going to be a junkie the rest of my life. But I'm still a good person inside. I mean I have compassion for people. I try and help people out. You know he understands I have compassion for people.

14Nurses and health professional participants endeavoured to see their clients as persons with unique value and worth, not as 'addicts', 'junkies' or 'the homeless'. Some nurses described their clients as 'survivors' and admired them for how they coped with daunting life experiences and the daily challenges of homelessness, poverty and life on the street.

15As suggested by the quote above, a key to respecting clients was the ability to move beyond judgments and stereotypes. One nurse describes how it was easy to fall into the trap of thinking of her clients in stereotypical ways:

I think what I do is that I'm able to split my thoughts and how I react to these guys. When I'm on [the street] Christmas shopping and when I'm having my glass of wine in a wine bar, I do think of my clients as scumbags, addicts, who broke into my car. Get an f'in life, go to work … I do think of it that way. And when I come here and I'm actually physically caring for them … and I'm actually wiping the purulent discharge from the horrible festering cellulitis all over their body and they're telling me how hungry they are because they've only had this whatever it is. I can chit chat with them and really feel for them. So again, it's overcoming all these prejudices, right? Also, you know … it's the environment that's along with it … you live the middle-class life, it's so totally removed… . Actually physically doing it without having this colonial attitude that I'm doing good for these poor little souls and helping them.

16This nurse describes how one has to navigate judgments about personal responsibility that are part of societal norms while not taking up an attitude of servitude and charity and striving to find genuine compassion.

17In light of past experiences and the hypervigilance necessary for survival on the streets, nurses were aware that clients were both hypervigiliant and attuned to negative judgments when accessing health care. One nurse describes, "You know I think they are so sensitive about everything because they've been so bruised and so damaged and everything is seen as a reprimand, a spank, put in the corner. They're not able to decipher that out." In response, nurses described being hypervigilant and super sensitive to non-verbal and verbal behaviour that might communicate negative judgments. One nurse noted:

You always have to be checking yourself doing a mental check, saying oh, because now I'm more aware of it than I was. So that's why yesterday I thought, I'm getting my back up, I need to take a deep breath because I'm not going to be able to help this guy if I'm feeling defensive. It's just a question of breathing through it and recognizing what it is that's triggering me.

18This excerpt demonstrates the challenges of being self-aware and recognizing when one is being triggered by a client's behaviour and monitoring potentially negative responses that could reduce access to care.

19While health care interactions are a precious opportunity to show respect, nurses described the challenge of maintaining respect in the face of disrespect. For example, one nurse observed:

It means you have to constantly find respect for people that constantly step on you and don't do what it is you're there to help them do…. And you secretly lose respect for someone that yells at you from the door. You can't help it … when somebody says, Fuck off! Well okay, I will fuck off. You know. And it's very hard not to develop that attitude and just take yourself out of it.

20'Taking yourself out of it' could mean withdrawal from the person or situation or refusing to take it personally. One social worker indicated it would have been easy to say something harsh to someone who was being verbally abusive but recommended a more respectful approach:

But it was that kind of behaviour [respect] that would throw people off more than. And [I] got to let you know this isn't okay but the last thing I'm going to do is do this dance with you. I'm going to take every opportunity I can to model something different. You're deserving of respect, I'm deserving of respect. So, let's work on that.

21When respecting a client became difficult, often due to violent behaviour, nurses and other health professionals emphasized the importance of preserving and respecting a client's right to receive health care services without judgment. Several participants expressed the belief that the chc was the last stop for health care and that it would be ethically wrong to limit care even in the face of challenging behaviours. In preserving a client right to access health care, nurses had to navigate two tensions: (1) management of health care resources and perceived threats to personal safety and security (Pauly 2008b).

22Not brushing people off. Nurses listened and acknowledged clients concerns and sought to never 'brush clients off'. Nurses strived to view all presenting concerns as serious and worthy of time and attention. For example:

A man came into the exam room and told the nurse he thought he had glass in his scalp from a broken bottle. As he pulled and picked at his hair, the nurse put on disposable rubber gloves and explained she would have a look and patiently began parting his hair and examining his scalp. After a few minutes, she said, "I can't see anything." The interaction ended abruptly as he jumped up and said, "Well okay, I must have gotten it all out." Later, the nurse explained that he has come in many times before with the same complaint and that he often picks his scalp until it bleeds. She suspected it was a side effect of cocaine use. As I had watched the interaction, I had assumed from the nurse's behaviour, that she had taken seriously his request to see if there was any broken glass in his scalp.

23Nurses were attentive to the presenting concerns regardless of their perceived validity. Such an approach can become a tangible way of showing respect to clients who are frequently 'brushed off' not just in health care services but every day.

24In their interactions with nurses, clients frequently expressed anger and frustration at their life situations, such as conflicts with family and friends, housing difficulties and money problems. Nurses listened patiently to these concerns and, once clients had expressed their frustrations and the client was ready to move on, nurses would often calmly ask about the reason for their visit and what assistance they needed. One client describes the powerful impact this has:

I've been in rages sometimes and gone and see the … nurse and totally calmed down because I got everything off my chest in five minutes, right. From a totally raging animal to nice mellow guy again in five minutes. I talk to the [nurse], I tell him you haven't got the golden pill but you've got the golden ear… . You know just getting things off my chest. And if I didn't see [the nurse] there, I probably would have gone downtown and got in a fight and took my rage out on somebody else right rather than talking to the [nurse]. A lot of times it's just the listening part means the whole world of difference from freakin' out and going totally ballistic. You know when you're right on the edge, maybe haven't made money for a day or so and somebody's in jail and you're trying to get her out of jail. And you're right on the edge, you know, you're full of rage. You can talk to the [street nurse] for five minutes or the other girl and you know you get it all off your chest.

25After a few minutes of expressing their frustration, clients were frequently observed to experience a shift in demeanor from anger or frustration to calm. Not brushing these concerns off did not imply agreement or necessarily require additional action by the nurse. Rather, listening conveyed respect and helped build relationships that were essential to facilitating access to and provision of nursing care. Some nurses expressed a view that listening to clients about whatever was on their mind helped them to get to know them better, what their worries and concerns were.

26Sensitivity to life circumstances. Sensitivity to life circumstances helped to contextualize individual behaviours and choices and foster respect for clients. One nurse noted that clients often felt embarrassed and apologized for the odour of their feet when they take their socks off for an exam. Rather than judging them as a "rude stinky street person", she observed that being on the street makes it difficult for people to shower every day and they don't always have access to clean socks. Thus, rather than judging them for their appearance and cleanliness, the nurse situated these encounters within the context of life on the street, specifically lack of access to showers and resources to promote personal hygiene. Another nurse noted:

Trying to put yourself in their shoes and understanding the issues that they're talking about and sometimes it's the hardest thing because it's hard for them to communicate their reality and it's hard for you to understand them because the living situations are so different… One patient told me the [medication she is on] and I told her it's important to drink lots of water to minimize side effects. And I asked her how many glasses of water she drinks and she says, "Well, I just drink coffee in the pharmacy where I pick up my methadone then maybe I buy a coffee in McDonald's. But I don't drink water in my A hotel. It's undrinkable. It's disgusting." So to get to the bottom of these details is crucial for people's treatment. You need time and you have to then think of solutions that … you would not otherwise think in any other situation.

27Recognizing that clients' decisions are shaped by the context in which they live and recognizing that the life circumstances of their clients was different than their own provided an avenue to avoid judging behaviours and fostered provision of care that was situated and relevant to the life circumstances of the client. As illustrated above, telling someone to drink water when they do not have access to water is ineffective and would not promote proper medication administration. It is necessary to constantly think in terms of 'what would this be like if I didn't have housing and access to taken for granted privileges such as water, showers, privacy and so on?'

28Individuals' ability to care for their health is profoundly shaped by their individual living situations, social position and access to resources. Some nurses were quick to caution that you may never know a client's whole story or could only understand to degrees the effect of poverty, addiction and violence on clients' behaviours and choices. Rather than expecting individuals to share their life story, nurses assumed there was also more to individual client situations than they might ever know, need to know or understand.

Organizational Linkages in Building a Chain of Trust

29Organizational linkages are vitally important in building a chain of trust. Key organizational linkages in creating a climate of trust that fostered access to health care were harm reduction, outreach and inter-agency trust. The absence of these conditions inhibited access to health care for those marginalized by homelessness and substance use.

30Harm reduction: meeting people where they are. Nurses working in chcs recognized harm reduction as an organizational philosophy, a set of strategies and a practical approach to working with homeless and substance using populations. They described harm reduction as integral to ethical nursing practice, the development of relationships with clients and the consequent increased access to health services. Harm reduction created a relational space in which relationships between health professionals and clients could develop without judgments related to substance use. The context of health care delivery shifted from a 'culture of fixing' substance use to accepting that people 'fix'. Some of the nurses and other participants in the study described harm reduction as taking the pressure off trying to fix people and instead putting the focus on keeping them safe. A philosophy of harm reduction shifted moral values to (1) focus on reducing harm associated with substance use and living conditions, emphasize the moral worth of clients and (3) enhance the decisionmaking capacity of clients (Pauly 2008b). For chc nurses, harm reduction meant being ready for change but not expecting it and not giving up. One nurse noted, "Ethical practice is when the person can keep coming back without judgments, without recriminations". Another nurse stated, "We don't fire people and we don't give up on them". Nurses consistently tried to minimize harm not only from substance use but also the other harms associated with homelessness and street-involvement that might impact health and well-being. Reducing harm became a moral imperative for guiding ethical nursing practice.

31Outreach: meeting people on their turf. Outreach from the chc provided an important organizational linkage to help rebuild the chain of trust. Nurses and health professional participants described the importance of meeting clients 'on their turf'. One outreach nurse noted:

Outreach is a golden opportunity to be able to intervene and change the situation. Although you've had many no gos, no shows, whatever, you can't ever assume that you're going to be able to turn that around. That's what we wait for, that golden opportunity and it happens. It happens and you have to be there. You have to actually be there where they are to make it happen and that's why our model of being in shelters being like we set it up in the [downtown hotel], being at the shelter. We run the clinic there. You know, we need to do much more of that.

32Outreach helped to provide care to clients reluctant to access health services or unable to access health services due to competing survival needs.

33Outreach provided nurses with an opportunity to get to know and build trust with clients outside of clinical settings and allowed them to become an initial point of contact for health information, education, counselling, assessment and referral. 'Curbside consults' were common as outreach nurses moved agency to agency. Although nurses were primarily employed by chcs, clients considered them to be 'street nurses' because of their outreach role. Nurse outreach to homeless and drop-in shelters was considered an important component of services at one of the chcs. One nurse noted:

When you've been [there] consistently, clients recognize that. They go, 'Oh, I've seen you around before.' And they'll talk to you. Frontline workers who've been there for a long time … you've become a consistent presence for them too, so they'll start advocating and pull people in to come and see you. So I'll go up to [one shelter] and often there's a frontline worker [who will] say, 'We told them you'd keep coming around and you're okay.' So they'll see you. So that's really important, the consistency.

34Those chc nurses who did outreach consistently were able to build trust with both drop-in staff and clients. They were directly linked to the chc and could facilitate the development of trust with the chc, thereby facilitating access that fostered earlier intervention and treatment for people who often avoid and delay health care.

35Inter-provider trust. Trusting relationships between nurses and other team members in their health settings facilitated access to a broader range of health services. Nurses who had established relationships with health professionals in their setting helped to extend the chain of trust for clients and achieve access to a broader range of services. For example, an outreach nurse noted:

Often what I'll do is if I think someone really would benefit from counselling, then well, I'm coming in and I'm talking with you. I say, 'Yeah that's fine but I think you're at a point where you would really benefit from someone that has expertise that I don't have.' And then I'll go and see if [the counsellor] is free and then I'll bring them down and say, 'Let me introduce you to the [counsellor]. If you feel this is someone that you could talk to, that you feel comfortable with, then this will be great.' So sometimes, just initiating contact and bringing them down. Then they put a face to the [counsellor]… If you know, he doesn't have anybody, he'll sit down with them for five minutes and go, 'Well, what's going on? We'll make an appointment…' Then people tend to follow him through then with that [i.e., the appointment]… I'm always advocating for the other practitioners too. 'Oh, you've got an appointment coming up with Dr. So and So.' 'Well I don't really like doctors.' 'Yeah, I don't either, but you know [laughs] this is a good one. I think you'll like this one.'

36By establishing trusting relationships with other professionals in her organization, this nurse was able to facilitate access to a wider range of health services for her client. Nurses stressed that working with like-minded colleagues was particularly important to the development of inter-provider trust. Where team approaches were valued and the role of nurses was understood and respected, health care teams facilitated client transitions between health care providers. In the absence of trust and respect for other roles, access was inhibited.

37Working in physical proximity as part of an interdisciplinary team provided multiple opportunities for hallway consults and referrals. In the presence of trust, this fostered a shared care approach, which improved the ability of team members to address multiple and complex client health needs. One client noted:

I can get in quickly when I need to. I can see the nurse and she consults the doctor so I don't need an appointment with the doctor. This is the whole package. I can get my drugs here even have my blood drawn (But not have X-rays). Much better than going to emergency where you have to wait five hours.

38Clients highly valued coming to one location and having access to an integrated team of health care providers. Health centre managers were integral to fostering the development of teams that are supportive and able to work together. For example, in one centre, the manager played a central role in establishing the values of the centre, reminding the team of their mandate and keeping everyone on track, especially in difficult situations. An additional benefit of shared care approaches is that nurses were not left to deal with challenging clients alone. Nurses cautioned against hiring nurses and making them solely responsible for caring for homeless and street-involved populations, as this would potentially lead to burnout.

Systemic Trust: Disrupting Negative Judgments and Missing Linkages

39To rebuild trust in the health care system, chc nurses disrupted negative chains of judgment and worked to build inter-agency trust. However, there were often fundamental links missing that limited nurses' ability to facilitate access to health and social services.

40Disrupting negative chains of judgment. Negative chains of judgment—that is, negative labels passed from one provider to another— led to adverse experiences and limited access to health services. For example, one nurse explains:

You're seeing how other staff, treat certain clients, so you can see that domino effect… . I mean, when I worked emerg, it was amazing that the ambulance guys would come in and go, oh yeah, so and so again; blah, blah, blah and then that is passed on to the triage nurse and then passed on to the nurses you're giving report to… . And you're passing that on to the doctor and so that judgment is all the way down and it was something that it took me a long time to realize… . Then all of a sudden you're at the bedside and someone shows up, like a family member or a friend, and they're giving you a different take on what the parmedics picked up. And all of sudden it's like, oh, I feel bad because we had that judgment happening and so we've been treating that person a certain way and there's actually something else much more complicated going on and we're compromising care because of that… . And you see that often with overdoses and things like that. Oh, you're bringing in another overdose. You know. How to break that chain. So that's something that you have to be aware of.

41This example highlights how judgments are played out in health care systems. Societal beliefs that individuals are at fault of their poor health are at the root of these judgments and have the tendency to blame individuals for their current situations. Participating nurses attempted to break negative chains of judgments by facilitating access to health care in emergency departments and hospitals. One nurse described calling the ed to facilitate the admission of a client living with hiv:

His hemoglobin just dropped in his boots and he just showed up one day, like, so white he was yellow, short of breath, just standing there but did not want to go to the hospital because he was always mistreated. I was the one who ended up calling the emerg doc, and right away, he's well, how come I'm talking to the nurse not to the doctor [i.e., referring physician]. I said, well right now I've got a man with a hemoglobin of 30. He needs to come in and I'm giving you a heads up. And I said, now he's going to swear, you're all fuckin' assholes and idiots and he hates doctors, but that's just who he is and we love him [laughs]. And so the emergency room doctor actually laughed. The patient stayed there for a couple of days, got some transfusion and came out and said, they treated me really well. They even fed me.

42This client returned several times and was willing to do so because of his initial positive experience. The referring nurse indicated that her goal was to help the physician focus on how sick the client was and shift away from viewing the client as only a 'homeless person' or 'drug user'.

43Inter-agency trust. Trust between nurses, health care providers and agencies is integral to enhancing access to health and social services. Access becomes compromised when there is little or no trust between agencies. One nurse manager noted:

I think the agencies themselves need to trust each other and to know about each other. Extremely challenging [here]. There's so much history… Everybody has some kind of historical view of where they're working and who their next door neighbours are and what they doing and how they're doing it… Everybody thinks that they're … doing the right thing and everyone else is doing it wrong. And, if only the other person over here could understand that this is the way it should be done, we could save the population, which of course isn't true. Because, if we could save this population, if someone has the answer … we'd know that because all of the people would be all better, cured and going off and that is not happening… Nobody seems to want to see that and to really look and see that maybe there is more than one [route to take]… Maybe sharing what I'm doing, instead of holding onto it tightly, would be a good thing.

44When there is a lack of trust between providers and agencies, providers may refuse to refer individuals to those agencies because of fears that their clients will be mistreated. In such situations, agencies became distrustful of each other and services were more likely to be fragmented and marginalized. When linkages of trust between agencies were developed, there was an increased capacity to foster access to needed services for clients. Inter-agency meetings and collaboration on projects provided opportunities to develop relationships, but such opportunities were rare and often not formalized due to limited time and resources.

45Missing and absent linkages. There were frequently missing linkages, barriers or gaps that prevented clients from accessing needed services. Of particular concern, there were missing linkages with detoxification programs, hospitals, prisons and housing. Clients were repeatedly unable to gain timely access to detoxification services simply because such services were not accessible. One nurse explained:

Ready for detox and you fill out the forms and you fax it and tell [them to wait]. You want to do the best for people who have decided that now's the time and want to detox, [the best] would be to take them there, put them in a cab right now. While they're ready.

46Wait times averaged four to six weeks, and if the client was admitted after two weeks, they were required to fill out the form again. After being told this, one client replied, "I can't wait a month, I don't know if I can wait a week." He turned around and walked out and the nurse did not fill out the form. Nurse and health professional participants grew weary of filling out these forms, which led to the false impression that there was a decreased demand for these services.

47There was a lack of linkages with hospitals, prisons, community resources and housing. A specific concern was clients being 'dumped into the community'—that is, discharged to the shelters or community directly from hospitals or prisons without any discharge planning around housing and community supports. As one social worker said, "Discharge to a shelter is not a discharge plan." Nurses pointed out that being discharged to the shelter is very different than being discharged to home where one can rest and convalesce in a safe place. In a shelter, clients may not be able to access their rooms during the day to rest.

48Central to the problem of 'dumping' is the lack of affordable housing in the community. Attempts to link individuals to housing were often unsuccessful due to high costs of rent and low vacancy rates in the cities where the research was conducted. In particular, there was lack of access to housing that tolerated drug and alcohol use. In one city, low-cost supportive housing had policies that restricted access even to individuals currently on methadone. Thus, individuals frequently returned to the shelters even after going through detox and rehabilitation only to re-enter the cycle of homelessness and drug use. Further access to affordable housing was impacted by welfare reform and shelter rates that prevented those on social assistance in finding affordable housing.


49Access to health care services for persons who are marginalized due to homelessness and substance use is facilitated by the rebuilding of trust at three interrelated levels: interpersonal, organizational and systemic. Trust in health care is often taken for granted but is at issue when there is uncertainty about another's behaviour and how one might be treated (Smith 2005). Lack of trust can negatively impact access to health care. Trust is most often understood at the interpersonal level and reflects a moral concern for the other (Smith 2005). Rebuilding interpersonal trust between nurses and clients is the first link in building a chain of trust that can facilitate access to the health and social services needed to address complex health and social care challenges. Organizational policies supporting harm reduction and outreach enabled nurses to meet people 'where they were at' and 'on their own turf' and contributed to development of trust. Interprovider trust fostered access to broader range of health and social services within chcs. Disrupting negative chains of judgment and building inter-agency trust fostered access but highlighted gaps and missing systemic linkages. These findings suggest that health care providers rebuild trust not only interpersonally but organizationally and systemically to enhance access to health care.

50The importance of respect for persons regardless of their behaviours is underscored and strategies for conveying respect highlighted. The importance of being treated as a person and not being brushed off are similar to the findings of Wen, Hudak and Hwang's (2007) discussion of welcomeness and unwelcomeness in health care encounters for homeless persons. These findings extend this discussion by providing insight into strategies nurses use to facilitate welcoming encounters. Guirguis-Younger, McNeil and Runnels (2009) found that past experiences, having a client-centred approach and engaging in inter-professional knowledge exchange were important strategies in caring for homeless populations. This study provides further insight into the professional knowledge that nurses use in enhancing access and delivery of care as well as the importance of inter-provider and inter-agency trust to delivery of services.

51While respectful behaviours foster trust and access, they also ensure that health issues are not overlooked because the person is a 'frequent flyer' or seen as less deserving (Corley and Goren 1998; Malone 1996). Of particular interest is the importance of health care providers being able to see patients in an appropriate life context in order to overcome judgments and plan care appropriately. This suggests that knowledge of the life circumstances of clients is important and that potential insights from fields of study such as cultural safety may be important areas for exploration (Anderson et al. 2003; Browne et al., 2009). Cultural safety is, in part, a means of engaging nurses in reflexive praxis and the development of situated knowledge that promotes awareness of stereotypical discourses that impact the provision of health care to various groups.

52Registered nurses have dual professional and ethical commitments to respect the dignity of all persons through provision of care on the basis of need regardless of race, ethnicity, gender or other conditions and to promote social justice through the development of equitable health care policies (Canadian Nurses Association 2008). Harm reduction is consistent with professional and ethical nursing standards of practice (Lightfoot et al. 2009; Pauly et al. 2007). Although harm reduction is a partial approach to tackling health inequities among those marginalized by homelessness, nurses can embrace and advocate for harm reduction as part of their commitment to social justice and reducing inequities (Pauly 2008a).

53Although not solely responsible for creating the conditions in which trust is fostered at organizational and systemic levels, nurses, through their actions, can disrupt prevailing negative judgments and promote inter-provider and inter-agency trust to facilitate access to health care. Further, nurses can seek and use opportunities to raise issues related to inter-agency collaboration, lack of discharge planning and missing linkages to managers and other leaders. Nurses have unique knowledge of missing linkages and the way in which lack of access to services and housing negatively impact health. Through engagement and participation in team, organizational and community activities nurses can bring such issues to the fore and inform solutions. Advocating for primary health care, harm reduction and housing are consistent with promotion of social justice and equity for those marginalized by homelessness and substance use.



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Associate Professor in the School of Nursing at the University of Victoria and a Scientist in the Centre for Addictions Research of British Columbia. Her research focuses on health equity, homelessness and substance use. She has conducted research related to ethical nursing practice in the context of homelessness and substance use, needle exchange services and effectiveness of transitional housing in breaking the cycle of homelessness for people recovering from substance use problems

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