Applied Science, Faculty of
Nursing, School of
DSpace
UBCV
Jiao, Ziqian (Sunny)
Doctor of Philosophy - PhD
University of British Columbia
Background: Harm reduction in health care settings has demonstrated tremendous benefit for people who use unregulated substances. Currently, what is known prioritizes community settings. As acute care settings, particularly emergency departments, grapple with implementing harm reduction, research is urgently needed to examine harm reduction inclusive of barriers and facilitators in these settings. Methods: A case study design was used to explore harm reduction implementation in an ED in British Columbia, Canada. Data collection included: staff surveys (n=99), interviews with staff and clinical leaders (n=20), and organizational policies. The resulting dissertation consists of three manuscripts. The first examined how the ED is organized as a complex adaptive system to implement harm reduction. The next examined how staff practice harm reduction. Finally, as positioning people who use unregulated substances as perpetuators of violence can impact care provision, including harm reduction, the third manuscript explored staff perspectives of patient violence. Findings: Findings demonstrated that an array of system agents (i.e., people, policies) interact to enable harm reduction implementation. Limited access to specialist services, specialist control, non-specialist reliance, and safety concerns, created systemic tensions that hinder harm reduction. Additionally, numerous contextual factors influenced staff capacity to engage in harm reduction including educational preparation, opportunities to leverage collaborative inter-colleague relationships, and support to help patients establish other care connections for ongoing care. The third manuscript findings illustrated how disconnections between what patients need and what staff can offer create conditions that contribute to staff-patient conflict and potential violence. These disconnections are situated within operational constraints of the care system. Other influential factors included staff fear and hypervigilance, expectations around teamwork and autonomous practice, and insufficient training related to violence prevention. Conclusion: ED staff engaged in harm reduction as a technical solution and as a contextualized social practice. Although staff strive to do their best, they must work within constraints of the system. Inconsistent access to education and unsupportive system structures hinder their capacity to carry out their roles. Moreover, problematic system structures also contribute to the potential for violence. Consequently, changes in organizational policy, staff education, specialist support, mentorship, and professional dialogue are urgently needed.
A CASE STUDY EXPLORATION OF HARM REDUCTION IMPLEMENTATION AND RELATED BARRIERS AND FACILITATORS IN AN EMERGENCY DEPARTMENT IN BRITISH COLUMBIA, CANADA by Ziqian (Sunny) Jiao B.Sc.N., The University of Northern British Columbia, 2012 M.H.A., The University of British Columbia, 2016 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Nursing) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) August 2024 © Ziqian (Sunny) Jiao, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the dissertation entitled: A case study exploration of harm reduction implementation and related barriers and facilitators in an emergency department in British Columbia, Canada submitted by Ziqian (Sunny) Jiao in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Nursing Examining Committee: Dr. Vicky Bungay, Professor, Nursing, University of British Columbia Supervisor Dr. Emily Jenkins, Associate Professor, Nursing, University of British Columbia ______ Supervisory Committee Member Dr. Marilou Gagnon, Professor, Nursing, University of Victoria ______ Supervisory Committee Member Dr. Sandra Lauck, Associate Professor, Nursing, University British Columbia University Examiner Dr. Craig Mitton, Professor, School of Population and Public Health, University of British Columbia University Examiner Dr. Amanda Vandyk, Associate Professor, School of Nursing, University of Ottawa External Examiner iii Abstract Background: Harm reduction in health care settings has demonstrated tremendous benefit for people who use unregulated substances. Currently, what is known prioritizes community settings. As acute care settings, particularly emergency departments, grapple with implementing harm reduction, research is urgently needed to examine harm reduction inclusive of barriers and facilitators in these settings. Methods: A case study design was used to explore harm reduction implementation in an ED in British Columbia, Canada. Data collection included: staff surveys (n=99), interviews with staff and clinical leaders (n=20), and organizational policies. The resulting dissertation consists of three manuscripts. The first examined how the ED is organized as a complex adaptive system to implement harm reduction. The next examined how staff practice harm reduction. Finally, as positioning people who use unregulated substances as perpetuators of violence can impact care provision, including harm reduction, the third manuscript explored staff perspectives of patient violence. Findings: Findings demonstrated that an array of system agents (i.e., people, policies) interact to enable harm reduction implementation. Limited access to specialist services, specialist control, non-specialist reliance, and safety concerns, created systemic tensions that hinder harm reduction. Additionally, numerous contextual factors influenced staff capacity to engage in harm reduction including educational preparation, opportunities to leverage collaborative inter-colleague relationships, and support to help patients establish other care connections for ongoing care. The third manuscript findings illustrated how disconnections between what patients need and what staff can offer create conditions that contribute to staff-patient conflict and potential violence. These disconnections are situated within operational constraints of the care system. iv Other influential factors included staff fear and hypervigilance, expectations around teamwork and autonomous practice, and insufficient training related to violence prevention. Conclusion: ED staff engaged in harm reduction as a technical solution and as a contextualized social practice. Although staff strive to do their best, they must work within constraints of the system. Inconsistent access to education and unsupportive system structures hinder their capacity to carry out their roles. Moreover, problematic system structures also contribute to the potential for violence. Consequently, changes in organizational policy, staff education, specialist support, mentorship, and professional dialogue are urgently needed. v Lay Summary Harm reduction in community settings positively impacts people who use unregulated substances. However, we know little about harm reduction in other care spaces – particularly emergency departments (EDs) where people who use unregulated substances regularly attend for care. This dissertation explored harm reduction implementation in an ED in British Columbia, Canada, and related influential factors. By analyzing staff surveys, interviews, and organizational policies, findings showed that ED staff engage in harm reduction through facilitating access to appropriate treatments and supervised consumption, while supporting patients to complete care and make community connections. Staff must also navigate challenges and their efforts are impacted by insufficient education and unsupportive policies. Problematic policies and practices also lead to conditions that contribute to staff-patient conflict and violence. Ultimately, there is an urgent need for changes in organizational policy, staff education, specialist support, mentorship, and professional dialogue to maximize harm reduction in the ED. vi Preface This dissertation represents the original, independent work of the author, Ziqian (Sunny) Jiao. All research undertaken for the completion of this dissertation was approved by the University of British Columbia Behavioural Research Ethics Board, certificate no. H19-02470. This research was conducted with support from my supervisor and dissertation committee, who provided guidance with project development, data analysis, and writing. I developed the research question, designed the research methodology, completed all data collection and analysis activities, and wrote and revised the dissertation to completion. The contents of Chapter 3 of this dissertation have been published in Harm Reduction Journal (2023), volume 20, article number 139, with the following co-authors (in order): Dr. Vicky Bungay, Dr. Emily Jenkins, and Dr. Marilou Gagnon. Chapters 4 and 5 of this dissertation will be further developed and submitted for publication with the same co-authors. For all publications in which parts of my dissertation have appeared / will appear, I was responsible for formulating the research questions, designing the research methodology, completing data collection and analysis, producing the initial draft, and finalizing subsequent revisions. My co-authors contributed to these publications through providing support and feedback related to research study development, data analysis, and academic writing. vii Table of Contents Abstract ......................................................................................................................................... iii Lay Summary .................................................................................................................................v Preface ........................................................................................................................................... vi Table of Contents ........................................................................................................................ vii List of Tables .............................................................................................................................. xiii List of Figures ............................................................................................................................. xiv List of Abbreviations ...................................................................................................................xv Acknowledgments ...................................................................................................................... xvi Chapter 1: Situating the Research Problem and Literature Review ........................................1 Situating the Research Problem ..................................................................................................1 Research Purpose and Questions ................................................................................................5 Literature Review ........................................................................................................................6 The Spectrum of Substance Use ...............................................................................................7 The Prevalence of Unregulated Substance Use in Canada .......................................................9 The Benefits and Harms of Substance Use ...............................................................................9 Social Factors that Impact Substance Use Harms ..................................................................10 Prohibitionist Policies as a Social Factor that Impacts Substance Use Harms ....................11 The COVID-19 Pandemic as a Social Factor that Impacts Substance Use Harms ..............12 Harm Reduction as an Approach and its Key Principles ........................................................13 The Historical Origins of Harm Reduction ............................................................................15 Harm Reduction Interventions Available in the Health Care Context ...................................19 Harm Reduction Interventions that Attend to Social Context ................................................26 viii Harm Reduction Interventions in the ED ...............................................................................28 Contextual Factors that Influence ED Harm Reduction Implementation ...............................30 Current Knowledge Gaps and Rationale for Study ...................................................................32 Outline of Subsequent Dissertation Chapters ...........................................................................33 Chapter 2: Methods .....................................................................................................................36 Situating Myself as a Researcher ······································································ 36 The COVID-19 Context ················································································· 37 Theoretical Positioning ·················································································· 37 Complex Adaptive Systems ··········································································· 37 Critical Perspective ···················································································· 39 Harm Reduction ························································································ 40 Study Design ······························································································ 42 Overview of the Case – the Study Site ······························································ 42 Gaining Entry ··························································································· 44 Data Collection ························································································· 45 Data Source 1: Staff Surveys ······································································· 47 Data Source 2: Interviews with Staff and Clinical Leaders ····································· 48 Data Source 3: Organizational Policies ···························································· 49 Data Analysis ··························································································· 50 Analysis 1 ····························································································· 50 Analysis 2 ····························································································· 51 Analysis 3 ····························································································· 53 Rigour ······································································································ 54 ix Mixed Methods Rigour ················································································ 54 Quantitative Rigour ···················································································· 55 Qualitative Rigour ······················································································ 56 Ethics ······································································································ 58 Chapter 3: How an Emergency Department is Organized to Provide Opioid-Specific Harm Reduction and Facilitators and Barriers to Harm Reduction Implementation: A Systems Perspective ....................................................................................................................................60 Introduction ...............................................................................................................................60 Purpose ......................................................................................................................................65 Theoretical Framework .............................................................................................................65 Methods.....................................................................................................................................68 Research Design .................................................................................................................... 68 Setting .................................................................................................................................... 69 Data Collection ...................................................................................................................... 71 Data Analysis ......................................................................................................................... 74 Findings .................................................................................................................................... 75 Opioid Agonist Treatment: The Interplay of Access and Control ......................................... 81 Withdrawal Management: The Interplay of Access and Reliance ........................................ 86 Supervised Consumption: Interplay of Access and Safety .................................................... 89 Discussion ................................................................................................................................ 92 Limitations ............................................................................................................................. 97 Conclusion ................................................................................................................................98 x Chapter 4: Harm Reduction in the Emergency Department: How Staff Provide Harm Reduction and Contextual Factors that Impact Their Capacity to Engage in Harm Reduction Practice .......................................................................................................................99 Introduction ...............................................................................................................................99 Purpose Statement and Research Questions ...........................................................................101 Emergency Departments, Harm Reduction, and Complexity Theory ....................................102 Methods ...................................................................................................................................104 Research Design ...................................................................................................................104 Setting ...................................................................................................................................104 Data Collection .....................................................................................................................105 Data Analysis ........................................................................................................................107 Findings ...................................................................................................................................108 Participants ...........................................................................................................................109 Harm Reduction in Context ..................................................................................................111 Theme 1: Teamwork .............................................................................................................117 Theme 2: Preparedness .........................................................................................................123 Theme 3: Connections ..........................................................................................................131 Discussion ...............................................................................................................................134 Limitations ............................................................................................................................140 Conclusion ..............................................................................................................................141 Chapter 5: Emergency Department Staff Perspectives of Violence Towards Them: The Disconnect and Divide Between Patients, Staff, and Organizational Structures of the ED......................................................................................................................................................142 xi Introduction .............................................................................................................................142 Methods ...................................................................................................................................145 Research Design ...................................................................................................................145 Setting ...................................................................................................................................145 Data Collection .....................................................................................................................146 Data Analysis ........................................................................................................................146 Findings ...................................................................................................................................148 Theme 1: Timing and Reasons for Patient Violence ............................................................150 Theme 2: Navigating Conflict and Implications for Care ....................................................153 Theme 3: Factors Shaping the Approaches of Staff .............................................................156 Discussion ...............................................................................................................................159 Limitations ............................................................................................................................163 Conclusion ..............................................................................................................................164 Chapter 6: Discussion ................................................................................................................166 Chapter Summaries .................................................................................................................166 Research Relationships and Knowledge Mobilization ...........................................................168 Key Contributions ...................................................................................................................169 Recommendations ...................................................................................................................175 Policy ....................................................................................................................................175 Education ..............................................................................................................................176 Practice and Leadership ........................................................................................................177 Research ................................................................................................................................179 Conclusion ..............................................................................................................................181 xii References ...................................................................................................................................182 Appendices ..................................................................................................................................236 Appendix A: Staff Survey .......................................................................................................236 Appendix B: Staff Interview Guide ........................................................................................244 Appendix C: Staff Interview Consent .....................................................................................248 Appendix D: Leadership Interview Guide ..............................................................................251 Appendix E: Leadership Interview Consent ...........................................................................254 Appendix F: SPH Infographic .................................................................................................257 Appendix G: Letter of Initial Contact .....................................................................................259 xiii List of Tables Table 1: Included Organizational Policies and Their Purpose .......................................................72 Table 2: Diverse Agents of the ED ................................................................................................76 Table 3: Staff Survey: Participant Characteristics and Length of Work .....................................109 Table 4: Staff Perceptions of the Availability of Harm Reduction Interventions ........................112 Table 5: Beliefs About People Who Use Unregulated Substances ..............................................114 Table 6: Results from the Drug and Drug Problems Perception Questionnaire (DDPPQ) .........115 Table 7: Factors Perceived to Influence Harm Reduction Implementation .................................121 Table 8: Education Through Formal Schooling and the Workplace ...........................................125 xiv List of Figures Figure 1: The Spectrum of Substance Use .......................................................................................8 Figure 2: Simple Representation of the Components of a CAS ....................................................67 Figure 3: System Map of the ED ...................................................................................................81 xv List of Abbreviations AAN Addiction Assessment Nurse BC British Columbia BREB Behavioural Research Ethics Board CADS Canadian Alcohol and Drug Survey CAS Complex adaptive system COWS Clinical Opiate Withdrawal Scale DDPPQ Drug and Drug Problems Perception Questionnaire DTES Downtown Eastside ED Emergency Department eOPS Episodic Overdose Prevention Site iOAT Injectable opioid agonist treatment NAOMI North American Opiate Medication Initiative SALOME Study to Assess Long-term Opioid Medication Effectiveness OAT Opioid agonist treatment OPS Overdose Prevention Site PRN Pro re nata ("as needed") RAAC Rapid Access Addiction Clinic RTA Reflexive thematic analysis SPH St. Paul's Hospital THN Take-home naloxone UBC University of British Columbia VANDU Vancouver Area Network of Drug Users xvi Acknowledgments I am immensely grateful for the generous participation of the nurses and physicians who work in the SPH ED, who took the time out of their busy schedules and lives to engage with me, and to share their perspectives, experiences, and insights. Thank you for imparting on me your wisdom and for your candidness. This work would similarly not be possible without the full support of the leadership team at SPH, including Cindy Elliott, Aggie Black, Pat Munro, Elizabeth Dogherty, Naomi Watt, Moses Li, Sam Gill, and Talena Hale. Thank you also to the physician champions for this project, Dr. Kira Rich and Dr. Andrew Kestler. Thank you especially to Cindy and Kira for your passion and incredible support with recruitment efforts. I would like to extend my gratitude to my supervisor, Dr. Vicky Bungay, and committee members, Dr. Emily Jenkins and Dr. Marilou Gagnon, who provided invaluable guidance and support throughout my learning journey. Dr. Bungay, words cannot describe how grateful I am for having you as a mentor over the years. I can only say that it means the world to me that you continue to believe in me. Thank you for challenging me so I can grow, but at the same time, providing with the support and encouragement that I need. Dr. Jenkins, thank you for imparting on me your expertise, and for your impeccable attention to logical coherence and methodological rigour. Dr. Gagnon, thank you for teaching me the importance and impact of theoretical framing, and for enkindling my passion to be an advocate and work toward advancing social justice. I am extremely thankful for funding provided to me by the Social Sciences and Humanities Research Council of Canada (SSHRC), the University of British Columbia (UBC), and the Canadian Nurses Foundation (CNF) in support of my doctoral studies. I would also like to acknowledge my family, my partner Henry and his family, my friends, and colleagues. To mom and dad, thank you for encouraging me to pursue further xvii education so I can continue to learn – not only about the workings of the world and also about myself. Thank you also for your unrelenting belief in me even when I faced obstacles. To Henry and his parents, thank for always being a place of calm and respite when I needed it. Thank you to my dear friends Joyce and Julie for keeping me grounded and for helping me maintain work-life balance. Thank you, Allie, for being my dissertation sister, and to everyone I have the privilege to work with at Capacity for being my academic family. Finally, thank you to Dr. Christine Penney for instilling in me that I have the potential to make a difference in this world. 1 Chapter 1: Situating the Research Problem and Literature Review Harm reduction as a philosophy has the goal of reducing the health, social, and legal harms associated with substance use, drug policies, and drug laws without mandating the cessation of use (CATIE, 2022b; Harm Reduction International, 2022; National Harm Reduction Coalition, 2020). Applied to the health care context, harm reduction has taken various forms and demonstrated tremendous benefit. However, much of the existing research tends to focus on harm reduction in the community setting, describing singular harm reduction interventions and reporting on harm reduction supply distribution and/or patient outcomes. While this knowledge is important, this study was designed to address a gap concerned with harm reduction implementation in the acute care setting – in particular, in Emergency Departments (EDs), and from the perspective of ED staff who are ideally positioned to implement these potentially lifesaving interventions. The intention of this first chapter is to provide the background and context required to situate the research problem, culminating in the need for this dissertation study. I will also present an overview of the current state of knowledge related to the topic of investigation. Finally, I will close the chapter with an outline of the remaining chapters of this dissertation. Situating the Research Problem To situate the research problem, I will begin by presenting harm reduction as an approach to reducing the harms associated with unregulated substance use,1 and establish the need for harm reduction implementation in EDs. I will then provide a brief summary of the existing 1 We recognize that, within the literature, many terms are used to denote the use of substances, including substance use, substance misuse, illicit substance use, illegal substance use, etc. In this dissertation, I use the term "unregulated substance use" to speak specifically to use of substances that are prohibited and criminalized in the Canadian regulatory context. 2 research on harm reduction in EDs, culminating in the identification of a knowledge gap, and resulting in the delineation of the research purpose and questions. Harm reduction is a philosophy and a set of principles that inform policies, programs, and practices with the goal of reducing the negative health, social, and legal harms associated with substance use, drug policies, and drug laws (CATIE, 2022b; Harm Reduction International, 2022; National Harm Reduction Coalition, 2020). Harm reduction accepts that, for better or worse, substance use is a part of our world (CATIE, 2022b; National Harm Reduction Coalition, 2020). Consequently, harm reduction does not deem the cessation of substance use as the criteria for successful interventions and policies (National Harm Reduction Coalition, 2020; Riley & O’Hare, 2000). At the same time, harm reduction does not ignore substance use harms (CATIE, 2022b; National Harm Reduction Coalition, 2020; Riley & O’Hare, 2000). Rather, a harm reduction approach involves supporting people to reduce the harms associated with substance use (CATIE, 2022b; National Harm Reduction Coalition, 2020; Riley & O’Hare, 2000). Applied to the health care context, a number of harm reduction interventions have been reported on in the literature, including drug use equipment and take-home naloxone kit distribution, supervised consumption, oral and injectable opioid agonist treatment, and outreach and housing initiatives (Eydt, 2021; Goering et al., 2014; Gowing et al., 2017; Kerr et al., 2017; Lee & Buxton, 2017; Lightfoot et al., 2009; Malchy et al., 2011; Mattick et al., 2014; Regis et al., 2020; Strike & Miskovic, 2018). These interventions have led to a myriad of benefits for people who use unregulated substances, including reductions in infectious disease transmission, overdose deaths, and unsafe substance use practices, as well as decreases in hospitalizations and admissions to the emergency department (ED) (Amato et al., 2013; Aspinall et al., 2014; Aubry et al., 2020; Chhabra et al., 2020; Fernandes et al., 2017; Goering et al., 2014; Mattick et al., 3 2009; Strang et al., 2019; Ti & Ti, 2015; Turner at al., 2011; Verdouw & Habibis, 2018; Wang et al., 2020). In addition, these interventions have led to improved housing stability, social and community functioning, and quality of life, and increased referrals to detoxification and substance use treatment, including treatment retention (Aubry et al., 2016; Cherner et al., 2017; Chung et al., 2018; Ferri et al., 2011; Kolla et al., 2021; Lightfoot et al., 2009; Mattick et al., 2009; Stergiopoulos et al., 2019). To date, the vast majority harm reduction interventions have taken place in the community setting2 (Eydt et al., 2021; Goering et al., 2014; Kerr et al., 2017; Malchy et al., 2011; McDonald & Strang, 2016; Smye et al., 2011; Strike & Miskovic, 2018). In recent years, however, there has been a burgeoning of harm reduction implementation in the acute care setting, including in EDs (Brar et al., 2021; Brooks et al., 2019; Dogherty et al., 2022; Dong et al., 2020; Drainoni et al., 2016; Im et al., 2020; Jakubowski et al., 2019; Kestler et al., 2019a; Kestler et al., 2019b; Mullennix et al., 2020; Patricelli et al., 2023; Perera et al. 2022; Snyder et al., 2021; Train et al., 2020). Harm reduction in EDs, especially holds great promise. This is because, due to the inadequacy of community level services to respond to their complex needs, people who use unregulated substances frequently present to the ED, which serves as a source of urgent, primary, and social care for this patient population (Cederbaum et al., 2014; Fairbairn et al., 2012; Kendall et al., 2017; Nambiar et al., 2018; Parashar et al., 2014). Furthermore, it has been reported that an alarming 5.5% of people treated for non-fatal opioid overdose in EDs die within one year of their visit, of whom 20.5% die within the first month (Weiner et al., 2020). As such, EDs serve as critical points of contact for people who use unregulated substances, and staff are well positioned to offer evidence based, potentially life-saving harm reduction interventions 2 Community setting refers to care settings that are outside of the institutionalized hospital setting, including, but not limited to, primary care or walk-in clinics, public health units, and not-for-profit organizations. 4 including but not limited to opioid agonist treatment, take-home naloxone kits, and referrals to relevant health and social services (Black et al., 2022; Drainon et al., 2016; Galarneau et al., 2021; Im et al., 2020; Low; 2020; Mayer et al., 2023). Of the existing literature on harm reduction implementation in EDs and contextual factors that may influence implementation, many tend to focus on describing the delivery of specific harm reduction interventions (Mullennix et al., 2020; O'Brien et al., 2019; Prach et al., 2019), reporting on intervention distribution (Devries et al., 2019; Moore et al., 2021; Samuels et al., 2021), or patient outcomes associated with these interventions (Papp et al., 2019; Samuels et al., 2021; Snyder et al., 2021). Conversely, there is a dearth of research related to the experiences of health care providers who implement these interventions (Drainoni et al., 2016; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). Additionally, the existing research tends to utilize quantitative designs, in particular, retrospective cohort and cross-sectional designs (Devries et al., 2019; Dwyer et al., 2015; Hurt at al., 2020; Kestler et al., 2017; Lacroix et al., 2018; Moore et al., 2021; Mullennix et al., 2020; O'Brien et al., 2019; Papp et al., 2019; Prach et al., 2019; Samuels et al., 2021), as well as qualitative designs (Drainoni et al., 2016; Holland et al., 2019; Wiercigroch et al., 2021), with very few leveraging a mixed methods approach (Im et al., 2020; Samuels et al., 2018), involving the integration of quantitative and qualitative data to improve breadth and depth of understanding (Johnson, Onwuegbuzie, & Turner, 2007). Finally, although harm reduction policies and approaches may vary by country, the majority of the available research about harm reduction implementation in EDs is US-based (Devries et al., 2019; Dwyer et al., 2015; Holland et al., 2020; Hurt et al., 2020; Moore et al., 2021; Mullennix et al., 2020; Papp et al., 2019; Prach et al., 2019; Samuels et al., 2021; Snyder et al., 2021), with few studies originating from other countries such as Canada and Australia 5 (Holland et al., 2019; Kestler et al., 2017; Kestler et al., 2019a; Low, 2020; Wiercigroch et al., 2021). As such, there is a notable knowledge gap as to how harm reduction interventions are implemented in non-US EDs, and the types of contextual factors that ED staff experience as facilitators and barriers to implementation – an investigation which would benefit from a mixed methods approach. Without a more comprehensive understanding of facilitators and barriers to harm reduction implementation in ED, current and future implementation efforts may be stymied, with potential detriments for the quality of ED care received by people who use unregulated substances. Research Purpose and Questions With the aim of attending to the current dearth of knowledge related to harm reduction implementation in Canadian EDs, the aims of the research undertaken in this dissertation study were to examine if and how harm reduction interventions are being implemented in the context of an ED located in British Columbia (BC), Canada, and to delineate the types of contextual factors that may influence harm reduction implementation in this setting. To achieve these aims, the dissertation addresses the following research questions: 1. How is an ED located in BC, Canada organized to provide harm reduction? 2. How do ED staff engage in harm reduction practice, and what contextual factors3 influence their capacity to do so? 3. How do ED staff experience patient violence in the context of care provision for people who use unregulated substances? 3 Contextual factors refer to key features of an environment that interact, influence, modify, or constrain intervention implementation and its effectiveness. As such, contextual factors not only serve as the backdrop to implementation efforts (Coles et al., 2017). 6 Please note that Question 3 arose in the context of undertaking this research. This question aligns with the overarching aims of this work as perceptions and experiences of patient violence toward staff impacts the broader context of care for people who use unregulated substances, in which harm reduction is embedded. Furthermore, patient violence toward staff was a topic that was of immense interest to the research site clinical leaders and staff, thereby reinforcing the need to pose and to address Question 3. Literature Review Below, I present a comprehensive overview of the current state of knowledge as related to the harm reduction implementation in EDs and contextual factors that impact implementation. To situate my work in the realm of unregulated substance use,4 I will begin by describing substance use as occurring along a spectrum, ranging from beneficial use to chronic dependence, and as managed through various regulatory approaches, including criminalization and prohibition. I will then present data on the prevalence of unregulated substance use in Canada. In addition, as my study pertains to harm reduction – which acknowledges that not all substance use is problematic, and that systemic factors impact harms experienced – I will delve into the benefits and harms of substance use, and social factors that impact harms experienced, with a focus on the impact of prohibitionist policies and the COVID-19 pandemic, which are social factors of particular relevance in the current socio-political landscape. I will present harm reduction as an approach to reducing substance use harms and delineate its key principles. I will also speak to the historical origins of harm reduction, as well as current efforts of managing substance use from a regulatory perspective (i.e., how the 4 Although I adopt the term "unregulated substance use," when discussing the literature, I also use the term "substance use" when speaking about substance use more broadly (inclusive of the use of substances that are not prohibited or criminalized) and/or in relation to how particular authors take up the term. 7 government takes up and manages substance use), including harm reduction, in the context of Vancouver, Canada. Such context is relevant in a research study that aims to explore facilitators and barriers to harm reduction implementation in EDs as it provides the necessary historical and socio-political grounding upon which implementation efforts take place in my specific research study. Following, I will speak to harm reduction implementation in the context of health care provision and their demonstrated benefits, including implementation in acute care. As the existing literature pertaining to harm reduction implementation in Canada is limited, I will additionally speak to interventions that have taken place, and reported on, in other developed countries, including the US and Australia. Lastly, I will explore the literature concerning harm reduction interventions that exist in EDs and contextual factors that influence implementation, resulting in the identification of a knowledge gap and providing rationale for the research study. The Spectrum of Substance Use Substance use involves the consumption of psychoactive substances that affect a person's perception, mood, behaviours, and sensations of pain and pleasure (Canadian Public Health Association, 2014; CATIE, 2022a). In Canada, psychoactive substances are managed through various regulatory approaches, ranging from commercialization (e.g., tobacco), state control (e.g., alcohol), prescription (e.g., pharmaceutical drugs), to prohibition and criminalization (e.g., heroin, cocaine) (Canadian Public Health Association, 2014), with the use of the last group constituting unregulated substance use. Substance use can be understood to occur along a spectrum or continuum, ranging from beneficial use (e.g., use that has positive effects for the person), through to non-problematic use (e.g., use that has negligible effects), problematic use (e.g., use that may have negative effects), and chronic dependence (e.g., use that has become 8 compulsive despite negative effects) (Figure 1) (Canadian Public Health Association, 2014; CATIE. 2022a). It is important to note that many people experience benefits from the use of psychoactive substances, and that between 70% to 90% of people who use unregulated substances do not experience problems as a result of their use. However, a small percentage (between 10 to 30%) do experience problematic use or chronic dependence (CATIE, 2022a). Additionally, people can experience benefits from psychoactive substance use regardless of where they are on the spectrum, and people’s relationship with substances can change over time and in response to the circumstances of their lives (CATIE, 2022a). Although psychoactive substances are managed through various regulatory approaches in Canada, for the purpose of this study, I focused specifically on psychoactive substances that are prohibited and criminalized, which hereafter I refer to as the use of unregulated substances. Figure 1 The Spectrum of Substance Use Note. From A New Approach to Managing Illegal Psychoactive Substances in Canada by the Canadian Public Health Association (2014), from 9 https://www.cpha.ca/sites/default/files/assets/policy/ips_2014-05-15_e.pdf. Copyright 2014 by the Canadian Public Health Association. The Prevalence of Unregulated Substance Use in Canada Given the impact of prohibition and criminalization on people’s willingness to self-disclose substance use, as well as limited strategies that aim to capture prevalence, it is often difficult to determine actual prevalence of unregulated substance use. Of the available data, findings from the 2019 Canadian Alcohol and Drug Survey (CADS) reported a prevalence of past-year use of at least one unregulated substance (e.g., cocaine or crack, speed or methamphetamines, ecstasy, hallucinogens, heroin, salvia) at 3%, or 1.1 million Canadians (Government of Canada, 2023). Overall, past-year use was similar among males (4%) and females (3%), and was notably higher among young adults aged 20 to 24 (14%) in comparison to youth aged 15 to 19 (3%), and adults aged 25 and older (3%) (Government of Canada, 2023). It should also be noted the CADS was completed via an electronic questionnaire, or alternatively, over the phone, and as such, people who did not have access to a computer or the telephone at the time of the study – socially disadvantaged populations5 – may be systematically excluded (Government of Canada, 2023). The Benefits and Harms of Substance Use The notable prevalence of substance use may be in part due to various benefits offered by these substances, which can include increased alertness, pain relief, relief of stress and anxiety, 5 Socially disadvantaged populations refer to population groups who are "subject to social exclusion or deprivation for reasons such as low socioeconomic status, ethnicity, age, gender, mental ill health, or similar" (Rogers, 2003, p. 141). The notion of socially disadvantaged population is relevant for this work as people who use unregulated substances are often simultaneously socially disadvantaged, in that they may be subject to social exclusion, stigma, and discrimination, as well as social deprivation in the form of poverty, housing insecurity, etc. 10 facilitation of social interaction, and enjoyment/pleasure (Canadian Public Health Association, 2014). At the same time however, unregulated substance use is associated with a significant number of harms, including infectious and chronic diseases, exacerbation of existing physical or mental ailments, dependence and addiction, financial hardship, as well as injury, toxicity, and death (Canadian Public Health Association, 2014). Also, unregulated substance use is highly stigmatized and can lead to social exclusion, as well as greater susceptibility for violence, harassment, and public shaming (International Network for People Who Use Drugs, 2014). In addition, stigma can act as a barrier to public service provision due to concerns about discriminatory interaction with service providers, where people who use substances are assumed to be violent and manipulative and are not seen as deserving of care (International Network for People Who Use Drugs, 2014). Lastly, stigma can impede access to housing and employment opportunities due to the perception that people are incapable and compromised due to their substance use, which is then leveraged to justify actions such as the forfeit of tenancy rights and the termination of employment (International Network for People Who Use Drugs, 2014). Social Factors that Impact Substance Use Harms It is known that unregulated substances use occurs within a larger sociopolitical context, and that social conditions such as prohibition, criminalization, housing insecurity, poverty, and gender-based violence, among other social inequities, all affect people’s vulnerability to substance use harms, and their capacity to mitigate and manage substance use harms (Bungay et al., 2010; El-Bassel et al., 2014; Seear et al., 2012; Yamamoto et al., 2019). Yamamoto et al. (2019) in their study to compare outcomes related to unregulated opioid use (i.e., risk of overdose and opioid-related ED visits/hospital admissions) between people who use unregulated opioids and simultaneously experience homelessness, versus individuals who use unregulated 11 opioids and are housed, found that the former group were at an increased risk of experiencing an overdose event. People with no fixed address were also more likely to experience repeat overdoses (British Columbia Centre for Disease Control, 2017). Moreover, Bungay et al. (2010) reported that due to immense poverty, women who use crack cocaine may resort to using makeshift equipment, such as Brillo® pads as filters and broken car antennas as push sticks, leading to burns and cuts to their lips and fingers. Finally, unequal gender-based power relations can impact substance use harms experienced, where women may rely on their male partner to acquire and administer unregulated substances, thereby having limited control over injection practices and frequency (El-Bassel et al., 2014; Morris et al., 2014; Roberts et al., 2010; Seear et al., 2012; Socías et al., 2016). Refusal to share substance use equipment may be seen as a sign of distrust and betrayal, with the potential to lead to violence (El-Bassel et al., 2014; Seear et al., 2012). Prohibitionist Policies as a Social Factor that Impacts Substance Use Harms A prime example of the impact of social factors on substance use harms experienced pertains to prohibitionist drug policies. To this end, it is well-established that many of the harms attributed to unregulated substance use are not due to the substances themselves, but due to their prohibition, which has the goals of reducing the demand for unregulated substances by disrupting their production, supply, and distribution, and employing law enforcement to ascertain and punish people who use (Buxton et al., 2008). Prohibition creates black markets that make available highly concentrated substances, and substances that have a high degree of impurity and may be toxic (Buxton et al., 2008; Emerson & Haden, 2009). As such, prohibitionist policies directly contribute to the considerable variation in the potency of substances available within the unregulated drug supply, thereby increasing the risk for overdose and preventable death (British 12 Columbia Centre for Disease Control, 2021). Currently, the impact of prohibitionist policies is evident in the devastating and ongoing drug toxicity crisis (British Columbia Office of the Provincial Health Officer, 2019). Across Canada, between January 2016 and December 2023, there was a total of 44,592 apparent opioid toxicity deaths, of which, 8,049 occurred in 2023, with the majority (87%) of deaths occurring in the provinces of BC, Alberta, and Ontario (Government of Canada, 2024). Comparatively, opioid toxicity mortality has been more stable in other provinces, such as Nova Scotia (Schleihauf et al., 2018). It has been proposed that several factors may contribute to inter-provincial discrepancies, including differences in the toxicity of the drug supply – characterized by a prominence of fentanyl, in prescribing and dispensing practices, as well as in demographic distribution related to age and gender (Gibbs et al., 2023). Within the BC context, where this study was situated, the Provincial Health Officer of BC declared a public health emergency in response to the rise in overdose deaths in the province in April of 2016 (Province of British Columbia, 2016). Most recently, there were 2,511 suspected unregulated drug deaths in 2023 in BC, compared to 2,383 in 2022 (British Columbia Coroners Service, 2024). The ongoing crisis is characterized by the increasing proportion of deaths in which fentanyl and its analogues were detected. In 2023, fentanyl and its analogues were detected in 83% of suspected unregulated drug deaths in BCs (British Columbia Coroners Service, 2024). Benzodiazepines are also increasingly being detected in the drug supply, which can similarly increase overdose risk (British Columbia Coroners Service, 2024). The COVID-19 Pandemic as a Social Factor that Impacts Substance Use Harms The COVID-19 pandemic was an additional social factor that impacted substance use harms, and further exacerbated the impacts of the drug toxicity crisis (Bennet et al., 2022; Imtiaz et al., 2021; Nguyen & Buxton, 2021). This impact was palpable especially during the 13 pandemic’s early stages. Due to physical distancing and social isolation measures implemented in response to the pandemic, people use unregulated substances were forced to use alone, which led to an increase in overdose events as bystanders were no longer available to respond in the case of an overdose (Henry et al., 2020; Khatri & Perrone, 2020; Nguyen & Buxton, 2021; Rodda et al., 2020; Schlosser & Harris, 2020). The pandemic also had an impact on people's ability to access substance use related services, treatments, and resources, including harm reduction, supervised consumption, withdrawal management, opioid agonist treatment, outreach, and peer support (Dunlop et al., 2020; MacKinnon et al. 2020; Nguyen & Buxton, 2021; Sun et al., 2020). Lastly, border closures and travel restrictions resulted an increasingly toxic and erratic supply of unregulated substances, contributing to the frequency of overdose events (Kang et al., 2020; Khatri & Perrone, 2020; Nguyen & Buxton, 2021; Ostrach et al., 2020; Wakeman et al., 2020). In the context of BC, where this study was situated, a second public health emergency was declared in the province in response to the pandemic in March of 2022 (Province of British Columbia, 2020). Harm Reduction as an Approach and its Key Principles As noted above, harm reduction is an approach to substance use that focuses on supporting people to reduce the harms associated rather than demanding abstinence (CATIE, 2022b; National Harm Reduction Coalition, 2020; Riley & O’Hare, 2000). As such, harm reduction does not expect the eradication of unregulated substance from our world. Rather, it is an approach that includes recognition that substance use encompasses a continuum – ranging from chronic dependence to total abstinence – and that for the majority of people, substance use is not problematic (CATIE, 2022b; National Harm Reduction Coalition, 2020). Harm reduction as a public health approach serves to challenge the notion that the use of unregulated substances 14 is inherently harmful, instead directing our attention to the types of social forces that marginalize and discriminate against people who use unregulated substances, such as prohibition and criminalization, as the primary causes of substance use harms (CATIE, 2022b). Moreover, harm reduction recognizes that systemic factors including poverty, class, racism, social isolation, histories of trauma, sex-based discrimination, among other social inequities can affect people's vulnerability to, and capacity for, managing and navigating substance use harms (National Harm Reduction Coalition, 2020). The principles of harm reduction include an approach to unregulated substance use that accepts people who use unregulated substances as they are, and meets them where they are in the context of their own lives (CATIE, 2022b; Harm Reduction International, 2022). Meeting people where they are involves upholding the rights of people to self-determine, and supporting them to meet their self-identified needs and priorities without judgment. Harm reduction does not employ paternalistic or coercive approaches, nor try to impose needs or priorities that individuals have not identified themselves (CATIE, 2022b). Rather, harm reduction affirms people who use unregulated substances as the primary agents of reducing harms, and strives to empower them to engage in strategies that meet their conditions of use (National Harm Reduction Coalition, 2020). As such, priority is given to the most pressing need as identified by the person, which is seen as an incremental gain (Riley & O’Hare, 2000). Harm reduction is grounded in principles of human rights and social justice (CATIE, 2022b; Harm Reduction International, 2022; National Harm Reduction Coalition, 2020). That is, substance use does not infer that people forfeit their basic human rights (Harm Reduction International, 2022; National Harm Reduction Coalition, 2020). Harm reduction focuses on treating people who use unregulated substances with compassion, and upholding their rights to 15 dignity and respect (CATIE, 2022b; Harm Reduction International, 2022; Riley & O’Hare, 2000). Harm reduction also involves attending to discrimination and exclusion from available services based on substance use, race, gender identify, sexual orientation, choice of work, or economic status (CATIE, 2022b; Harm Reduction International, 2022). Harm reduction assists people to meet their self-identified priorities through the provision of low- or no-barrier services that do not require them to meet stringent criteria (e.g., abstinence, sobriety, or having access to government identification) (CATIE, 2022b; National Harm Reduction Coalition, 2020). Harm reduction exemplifies a commitment to evidence as it is informed by a robust body of knowledge that demonstrates its practicality, feasibility, effectiveness, safety, and cost-effectiveness across diverse care settings (CATIE, 2022b; Harm Reduction International, 2022; Riley & O’Hare, 2000). Harm reduction additionally acknowledges people who use unregulated substances and those with a history of substance use as experts in harm reduction, and elicits their meaningful engagement in designing, implementing, and evaluating programs and policies that aim to meet their needs (CATIE, 2022b; Harm Reduction International, 2022; National Harm Reduction Coalition, 2020). Lastly, harm reduction is adaptive, with the goal of being responsive to people's changing needs as well as the changing harms that they experience (CATIE, 2022b). The Historical Origins of Harm Reduction Although harm reduction began as a grassroots movement led by people who use substances and their allies (Roe, 2005), in the context of publicly funded health and social systems, the origins of harm reduction can be traced to the United Kingdom, the Netherlands, and North America (O’Hare, 2007; Pates & Riley, 2012). In the early 1980s, the United Kingdom experienced a notable surge in the use of heroin. In response to the threat of HIV 16 transmission through the sharing of contaminated injection equipment, the UK trialed a new approach to unregulated substance use that had the aim of reducing substance use harms, as opposed to reducing substance use itself. This later became known as the Merseyside model of harm reduction (O’Hare, 2007). The Merseyside model encompassed a range of interventions, including the distribution of clean injection equipment, the prescription of methadone treatment, and the provision of housing and employment services. Additionally, the model engaged outreach workers work within community settings to meet people who use unregulated substances within their community and raise awareness about available services (O’Hare, 2007; Riley & O’Hare, 2000). The Merseyside model had the support of law enforcement, who did not place these services under observation, and referred individuals they arrested to available services (O’Hare, 2007; Riley & O’Hare, 2000). The model proved to be tremendously successful – service uptake was rapid and included many who had never had contact with existing services, and it has been noted that these interventions directly contributed to HIV not reaching epidemic levels in Merseyside (O’Hare, 2007). In the late 1970s in the Netherlands, very few people who use unregulated substances were being reached by abstinence based programming, which was proving to be ineffective in reducing substance use (Buning et al.,1986). In response, the city of Amsterdam revised its stance toward unregulated substance use toward a more pragmatic and non-moralistic approach. This new approach was based on the notion that “if it is impossible to cure drug addiction, one should at least try to create a situation that greatly reduces the risk that the addict harms himself or his environment” (Buning et al.,1986, p. 1435). Like the Merseyside model, this novel approach involved establishing contact with the target population through street outreach, providing medical care to individuals arrested by law enforcement, attending to those admitted to 17 hospitals, and facilitating access to low threshold methadone treatment (Buning et al., 2086). In addition, Amsterdam took measures to prevent the spread of HIV, including a publicity campaign to inform people who use unregulated substances as well as service providers about the risk for HIV and AIDS, the distribution of condoms to people who use and are simultaneously involved in sex work, and an exchange system for sterile injection equipment (Buning et al., 1986; Riley & O’Hare, 2000). By 1985, it was estimated that 60-80 percent of people who use unregulated substances in the city were in contact with the “helping system” (Buning et al., 1986). These efforts were also aligned with those of law enforcement, who focused their resources on prosecuting drug traffickers as opposed to ascertaining and punishing people who use (Riley & O’Hare, 2000). In the North America context, methadone maintenance programs have been available in Canada since the late 1950s, and in the US since the early 1960s (Pates & Riley, 2012; Riley & O’Hare, 2000). In the years following the beginning of World War II, Western Canada saw a rise in opioid addiction (Fischer, 2000). There was extensive debate at the time between those who understood addiction to be a criminal behaviour that required punishment, and people who believed addiction to be a medical condition that required treatment. Among discussions of the latter perspective, proposals for opioid maintenance treatment surfaced in the 1950s, which involved supplying people with their drug of choice with the goal of reducing the negative impacts of opioid addiction, instead of what was considered ‘coercing’ people to undergo treatment (Fischer, 2000). Accordingly, in 1958, Dr. Robert Halliday, an Addiction Medicine Physician based in Vancouver, Canada, conducted a “small controlled experiment” to investigate the use of methadone in the management of short-term opioid withdrawal, which was eventually transformed to a “prolonged withdrawal” program (Fischer, 2000). This type of treatment was 18 formalized in 1963, and involved providing methadone coupled with psychosocial support, thus defining the foundations for current methadone maintenance treatment – a first in Canada and in the world (Fischer, 2000). Since the late 1980s, and in Canada specifically, harm reduction has been taken up in various ways across the country, particularly within urban settings, such as in Vancouver, Toronto, and Montreal (Canadian Drug Policy Coalition, 2024; City of Toronto Public Health, 2015). In BC, where this study is situated, the first needle exchange program was established in Vancouver in 1989. This was followed by the establishment of the Vancouver Area Network of Drug Users (VANDU) in 1997 (British Columbia Centre for Disease Control, 2012; Canadian Drug Policy Coalition, 2024). In 2001, Vancouver endorsed harm reduction as a component of a Four Pillars approach to unregulated substance use, with the goals of improving public health (e.g., reducing disease transmission and overdose deaths) and public order (e.g., reducing the impact of organized crime and the open drug scene) (MacPherson, 2001). Namely, the Four Pillars are harm reduction, prevention, treatment, and enforcement, where each pillar interacts with and supports the other pillars (MacPherson, 2001). Harm reduction, as one of the pillars, focused on decreasing the negative impacts of unregulated substance use for individuals and communities (MacPherson, 2001). In 2002, the Dr. Peter Centre6 in Vancouver began providing supervised injection services, which was followed shortly by the opening of the first sanctioned supervised injection site in North America, Insite, in Vancouver in 2003 (British Columbia Centre for Disease Control, 2012; Canadian Drug Policy Coalition, 2024). In 2005 and in 2011, respectively, two separate heroin-assisted treatment trials (the NAOMI and SALOME trials) 6 The Dr. Peter Centre is a 24-hour care residence that provides specialized nursing care for adults living with HIV and complex comorbidities, including mental illness and problematic substance use (HealthLink BC, 2024a). 19 began enrolment in Canada. As of 2017, the Crosstown Clinic7 in Vancouver has operated North America's only heroin-assisted treatment program (British Columbia Centre for Disease Control, 2012; Canadian Drug Policy Coalition, 2024). Harm Reduction Interventions Available in the Health Care Context8 Applied to the health care context, harm reduction takes the form of many interventions, practices, programs, and services, including providing people who use unregulated substances with safe and appropriate drug use equipment and take-home naloxone kits, supervised consumption, and oral and injectable opioid agonist treatment (Eydt, 2021; Gowing et al., 2017; Kerr et al., 2017; Lee & Buxton, 2017; Lightfoot et al., 2009; Malchy et al., 2011; Mattick et al., 2014; Strike & Miskovic, 2018). The distribution of drug use equipment includes the distribution of supplies for injection and inhalation use (Ivsins et al., 2011; Malchy et al., 2011; Strike & Miskovic, 2018). In needle and syringe programs, people who use unregulated substances are provided with sterile injection equipment (e.g., syringe, needle, sterile water), and their used equipment is collected for disposal (Strike & Miskovic, 2018; Fernandes et al., 2017). When situated as a public health intervention, the primary aims of distributing sterile injection (or other route of use) equipment are reportedly to decrease the incidence of HIV and HCV, and to discourage and provide an alternative to the practice of needle sharing (Fernandes et al., 2017). These programs also provide services such as safer use education, bleach distribution, as well as referrals to substance use treatment programs and other health and social services (Fernandes et al., 2017). These programs are available in 7 The Crosstown Clinic provides a range of services for people struggling with problematic substance use, including, but not limited to, substance use treatment, referrals for housing, and legal assistance (HealthLink BC, 2024b). 8 The health care context encompasses services with the primary goal of promoting and improve health, such as through reducing infectious disease transmission, overdose deaths / events, and experiences of substance use withdrawal. 20 various delivery formats, including fixed, mobile, satellite (i.e. community agencies that provide services on behalf of the parent site), and home visits (Strike et al., 2002), and have been shown to reduce HIV transmission, HCV infection, and the sharing of injection equipment (Aspinall et al., 2014; Fernandes et al., 2017; Turner at al., 2011). There are also programs that distribute safer crack smoking equipment, including borosilicate glass stems, rubber mouthpieces, brass screens (Ivsins et al., 2011; Malchy et al., 2011). These programs have made safer crack smoking equipment more accessible (Ivsins et al., 2011; Malchy et al., 2011), and have led to a decreased need to share crack smoking equipment, and to use broken or makeshift equipment, to engage in sex work or petty crime to purchase equipment, as well as reduced verbal arguments and physical violence with others who use crack cocaine (Ivsins et al., 2011). There are been very limited reports of the distribution of drug use equipment in the acute care health care context. A 2022 study by Perera et al. (2022) reported that in the context of an urban, safety net hospital based in the US, a harm reduction program was implemented, which involved the provision of drug use equipment including sterile syringes, cookers, alcohol swabs, borosilicate pipes, rubber mouth pieces, fentanyl test strips, coupled with safer use and overdose prevention education. This study elaborated on the process of implementation, which involved partnering with a community organization (who provided the drug use equipment for distribution and training), engaging leadership to obtain support, and operationalizing a workflow (Perera et al., 2022). Similarly, a study by Brooks et al. (2019) reports on the implementation of a needle and syringe program that was offered through an Addiction Medicine Consultation Service for patients who were admitted to a large, urban acute care hospital based in Edmonton, Canada. Study findings note that, of over 1900 Addiction Medicine Consultation Service intakes, 31% (n=597) reported injecting drugs, and of that, just over half (56%, n=334) were offered syringes, and the rate of 21 patient acceptance was low (37%, n=124), warranting further investigation around best practices related to inpatient needle and syringe programming (Brooks et al., 2019). The distribution of take-home naloxone kits is another current harm reduction intervention. Naloxone is an opioid antagonist agent that blocks the effects of opioid medications, thereby capable of reversing an opioid overdose while also helping to re-establish return of consciousness and independent breathing (Strang et al., 2019). Take-home naloxone programs typically involve the provision of a naloxone kit (including items such as naloxone ampoules, syringes, gloves, alcohol swabs, and a breathing mask), training in overdose awareness and emergency response, including naloxone administration (Lee & Buxton, 2017; McDonald & Strang, 2016; Strang et al., 2019; Williams et al., 2014). Take home naloxone programs have been found to reduce opioid overdose mortality and to have a low rate of adverse events including symptoms of opioid withdrawal, vomiting, agitation, and seizures (McDonald & Strang, 2016). Historically, naloxone was only available in health care facilities and administered by health care providers when evidence of overdose was observed. In 2016 however, in response to the ongoing drug toxicity crisis, Health Canada revised the listing for naloxone on the Prescription Drug List (PDL) to remove its prescription status for use outside hospital settings, rendering the medication more readily available (Government of Canada, 2016). These policy changes have enabled the proliferation of take-home naloxone across the country (Alberta Health Services, 2024; City of Toronto, n.d.; Toward the Heart, 2024). In the context of BC, where this study is situated, the British Columbia Centre for Disease Control's Take Home Naloxone program has been operational since 2012, and provides naloxone kits to over 2,200 sites, including hospitals, EDs, community pharmacies, corrections facilities, and First Nations sites (Toward the Heart, 2024). Since its inception, the program has distributed over 411,000 kits, 22 with more 157,000 kits reported as used to reverse an overdose (Toward the Heart, 2024). Several studies have reported on naloxone kit distribution programs in acute care settings, including programs based in Canada and in BC (Black et al., 2022; Drainoni et al. 2016; Jakubowski et al., 2019; Johnson et al., 2016; Kestler et al., 2017; Kestler et al., 2019a; Mullennix et al., 2020; Train et al., 2020). These programs tend to encompass similar elements, including the identification and screening of patients who could benefit from the intervention, coupled with the provision of overdose education and take-home naloxone kit distribution (Jakubowski et al., 2019; Train et al., 2020). Another type of harm reduction intervention that has gained increased popularity across the globe (albeit not in a uniform manner) is supervised consumption services. There are various types of supervised consumption services, which are often dependent on the route of use (e.g., injection, inhalation), and the setting in which supervision occurs (e.g., mobile or fixed site) (Jozaghi et al., 2014; Kerr et al., 2017; Mema et al., 2019). Supervised consumption services that focus on injection drug use offer equipment such as sterile needles, alcohol swabs, tourniquets, and filters, alongside a safe space to use, health care provider supervision, safer use education, primary nursing care, and referral to withdrawal management, substance use treatment programs, and other health and social services (Kerr et al., 2017; Lightfoot et al., 2009). There is an abundance of evidence to suggest that supervised injection services are effective in reducing infectious disease transmission, preventing overdose deaths, and improving referral to detoxification and substance use treatment programs (Lightfoot et al., 2009; Kerr et al., 2017; Kerr et al., 2005a; Marshall et al., 2011; Wood et al., 2007; Wood et al., 2006). Supervised injection services are beginning to emerge in the acute care setting (Dogherty et al., 2022; Dong et al., 2020), which similarly offer a safe place to use injection drugs, sterile supplies, health care 23 provider supervision, safer use education, and drug testing (Dogherty et al., 2022; Dong et al., 2020). Comparatively, supervised inhalation services are a fairly new intervention (Bourque et al., 2019; Jozaghi et al., 2014; Ontario HIV Treatment Network, 2022). With these services, people are provided with a clean environment within which they can inhale drugs, access to overdose response, a safer crack use kit, as well as referral to primary health care (Jozaghi et al., 2014). There is anecdotal evidence from the first regulated sanctioned inhalation site in North America – based in Lethbridge, Alberta, and operated by the community organization AIDS Outreach Community Harm Reduction Education Support (ARCHES) – that supervised inhalation services can help to prevent substance use overdose, and facilitate transition to less risky routes of substance use (Bourque et al., 2019). Supervised inhalation services also have the potential to offer benefits such as reducing harms associated with "rushed" smoking in public spaces, including minimizing exposure to violence that occurs in these spaces (Ontario HIV Treatment Network, 2022). Supervised inhalation services remain rare in the acute care setting (Ontario HIV Treatment Network, 2022). One example is Casey House, a subacute hospital based in Toronto, Canada, which provides supervised inhalation services, encompassing the provision of sterile equipment for inhalation use, health care supervision, safer use education, drug testing, as well as facilitating connections to relevant health and social services (Casey House, 2022). Despite the advent of services such as supervised inhalation, which may benefit people who use unregulated substances other than opioids, as a whole, there has been a pronounced focus on harm reduction as pertaining to unregulated opioid use. An example of this is the prescription of medication in the form of opioid agonist treatment, including methadone and buprenorphine. Methadone can be used to relieve withdrawal symptoms, and can also be used as 24 a maintenance treatment to help people remain in substance use treatment or to reduce their opioid use (Amato et al., 2013; Mattick et al., 2009). Methadone has been found been to be superior to placebo, and medications such as clonidine and lofexidine for detoxification purposes (Amato et al., 2013; Gowing et al., 2016). Methadone, as a maintenance treatment, has been found to reduce heroin use, and be more effective than placebo, detoxification, and wait-list controls at retaining people in substance use treatment (Mattick et al., 2009). A second type of opioid agonist treatment, buprenorphine, can also be used during drug detoxication and as a maintenance treatment (Gowing et al., 2017; Mattick et al., 2014). When used for detoxification, individuals on buprenorphine experience fewer side effects and experience withdrawal symptoms that are less severe compared to those on clonidine or lofexidine (Gowing et al., 2017). When used as a maintenance treatment, individuals on buprenorphine are more likely to stay in substance use treatment longer, and are more likely to complete treatment compared to people on clonidine or lofexidine (Gowing et al., 2017). Buprenorphine at any dose has been shown to retain people in substance use treatment better than placebo, while buprenorphine at high doses has been found to be effective at reducing opioid use compared with placebo (Mattick et al., 2014). Buprenorphine is also comparable to methadone at fixed doses in retaining people in substance use treatment and in reducing opioid use (Mattick et al., 2014). Opioid agonist treatment initiation is increasingly available in acute care settings in recent years (Choo & Wen, 2018; Im et al., 2020; Kestler et al., 2019b; Low et al., 2020; Snyder et al., 2021), and is typically prescribed by substance use specialist consultation services (Englander et al., 2017; Priest & McCarty, 2019; Nordeck et al., 2022; Trowbridge et al., 2017). In regards to buprenorphine, due to the potential for precipitated withdrawal (i.e. withdrawal symptoms brought on by opioid agonist treatment), buprenorphine must be initiated when the patient is undergoing withdrawal 25 (Low, 2020). Consequently, some acute care settings offer the option of buprenorphine to-go, encompassing take-home dosing and instructions for at-home initiation and follow up care (Kestler et al., 2019b; Low, 2020; Snyder et al., 2021). The initiation if opioid agonist treatment in the acute care setting has been associated with reduced rates of leaving without care completion, and reduced rates of readmission (Ti & Ti, 2015; Wang et al., 2020). Expanding on methadone and buprenorphine as treatment options for people who use unregulated substances, injectable opioid agonist treatment (iOAT) in the form of diacetylmorphine (medical heroin) and hydromorphone are beginning to emerge in Canada, although these interventions have been long available in the European context (Eydt, 2021; Glegg et al., 2022). iOAT is typically reserved for individuals for whom oral forms of OAT have not been beneficial (Ohlendorf et al., 2023). A number of clinical trials have demonstrated diacetylmorphine to be superior to methadone in terms of reducing unregulated opioid use and engagement in criminal activity, as well as improving treatment retention and overall health and social functioning (Ferri et al., 2011; Oviedo-Joekes et al., 2009; Strang et al., 2015). In addition, in the SALOME study (Study to Assess Long-term Opioid Medication Effectiveness), hydromorphone was compared to diacetylmorphine, and was found to be non-inferior to diacetylmorphine (Oviedo-Joekes et al., 2016). There is also preliminary evidence that iOAT programs offer a number of benefits, including decreased withdrawal symptoms and cravings, reductions in overdose risk, increased access to health and social services, improvements to health and welling, and improved social functioning and relationships (Ivsins et al., 2021; Kolla et al., 2021, Lew et al., 2022; Ranger et al., 2021). Furthermore, iOAT programs may impact substance use practices, including reducing frequency of use, and changing in a person's substance of choice and mode of consumption (Gagnon et al., 2023). Currently, over a dozen 26 iOAT programs across Canada offer hydromorphone as an iOAT, with the majority located in urban centres in British Columbia, Ontario, and Alberta (Eydt et al., 2021). Due to regulatory restrictions, diacetylmorphine is only available to a small number of individuals through Health Canada's Special Access Program (British Columbia Centre on Substance Use, 2021b; Government of Canada, 2022). As such, Crosstown Clinic, operated by Providence Health Care, remains the only clinic in Canada to provide diacetylmorphine (Eydt et al., 2021). The existing evidence related to iOAT implementation in the acute care setting remain at the level of case reports. For instance, Brar et al. (2021) conducted a retrospective chart review of patients for whom iOAT, in the form of hydromorphone, was provided during their hospitalization. Griffith et al. (2021) and Patricelli et al. (2023) similarly report on the use of hydromorphone as an iOAT in the acute care setting during pregnancy and in the postpartum period for expecting mothers. Harm Reduction Interventions that Attend to Social Context Aside from harm reduction interventions as described above, which have the primary purpose of facilitating behaviour changes that are deemed necessary to reduce substance use harms, other harm reduction attends to the impact of social inequities, such as poverty and housing insecurity, on harms experienced, as well as on people's capacity to mitigate harms. One such intervention is outreach services, which attempt to reach people who use unregulated substances who are hidden and “hard-to-reach" (Carmona et al., 2017; Guo & Slesnick, 2017; Jiao et al., 2022; Wagner et al., 2020). “Hard-to-reach” is a term used to describe population groups who are difficult to access or engage in health programming or research due to physical or geographical location or social and economic circumstances (Shaghaghi, Bhopal, & Sheikh, 2011). Although many outreach programs tend to focus on the distribution of drug use equipment, the provision of safer use education, and referral to services such as shelters and 27 substance use treatment (Carmona et al., 2017; Deering et al., 2011; Guo & Slenick, 2017; Malchy et al., 2011; Small et al., 2012; Strike & Miskovic, 2018; Wagner et al., 2020), some programs take a more expansive approach. For instance, a study describing the Community Care in Reach Program based in Boston, Massachusetts reported harm reduction outreach programming encompassed syringe exchange and collection, naloxone distribution and training, safer use education, drug residue testing, primary care (e.g., vaccinations, wound care, disease screening), opioid agonist treatments, as well as facilitating access to detoxification and pre- and post-exposure prophylaxis for HIV (Regis et al., 2020). Outreach can be provided by outreach workers and by peers (individuals who currently using substances, or have used substances in the past) (Deering et al., 2011; Jiao et al., 2022), and has been associated with reductions in the use of unregulated substances and in the sharing of substance use equipment, and increased needle disinfection and entry into substance use treatment (Coyle et al., 1998; Needle et al., 2005). A second harm reduction intervention which attends to the impact of social inequities on harms experienced, and on people's capacity to mitigate harms, takes the form of housing initiatives. Housing First programs prioritize the provision of permanent housing for people who use unregulated substances, as opposed to requiring people to demonstrate they are "housing ready" by staying abstinent from substance use to obtaining access to housing (Roggenbuck, 2022; Stefancic & Tsemberis, 2007). This low-threshold approach is in contrast to a treatment-first approach, which requires detoxification and sobriety before an individual is eligible for housing services (Padgett et al., 2007; Stergiopoulos et al., 2014). There is mounting evidence that Housing First programs improve housing stability and retention (Aubry et al., 2020; Cherner et al., 2017; Chung et al., 2018; Stergiopoulos et al., 2019), housing quality (Goering et al., 2014), access to needed services (Goering et al., 2014; Roggenbuck, 2022), quality of life and 28 community functioning (Aubry et al., 2016; Nelson et al., 2013; Goering et al., 2014), while reducing ED admissions and hospitalizations (Aubry et al., 2020; Chhabra et al., 2020; Goering et al., 2014; Verdouw & Habibis, 2018). A well-known Housing First initiative based in Canada is the Home/Chez Soi Project, which was a study that was implemented across five Canadian cities, demonstrating the effectiveness of Housing First programming (Goering et al., 2014). Harm Reduction Interventions in the ED As illustrated above, harm reduction can take the form of many interventions, practices, programs, and services. While harm reduction has been implemented in varied settings, the ED setting, as is the focus of this study, reportedly has predominantly included two interventions – take-home naloxone for people who have experienced an opioid overdose, or are deemed as at risk for an overdose (Black et al., 2022; Dora-Laskey et al., 2021; Drainoni et al., 2016; Dwyer et al., 2015; Funke et al., 2021; Gunn et al., 2018; Kestler et al., 2019a; Lacroix et al., 2018; Mullennix et al., 2020; Punches et al., 2020), and opioid agonist treatment, including treatment initiation and referral to ongoing care in the community – offering descriptions of how these interventions are implemented (Im et al., 2020; Kestler et al., 2019b; Low, 2020; Snyder et al., 2021). The distribution of naloxone by EDs has been described by several scholars, and involved implementation in academic urban hospitals, safety net hospital (i.e., a hospital that delivers care to uninsured and marginalized patients), inner city hospitals, as well as regional, rural, and community hospitals, all within the US, Canadian, and Australian contexts (Black et al., 2022; Drainoni et al. 2016; Dwyer et al., 2015; Funke et al. 2021; Kestler et al., 2019a; Mullennix et al., 2020; Punches et al., 2020). Intervention implementation largely encompassed the distribution of take-home naloxone kits along with the provision of overdose education and 29 training related to kit use (Black et al., 2022; Drainoni et al. 2016; Dwyer et al., 2015; Funke et al. 2021; Kestler et al., 2019a; Lacroix et al., 2018; Mullennix et al., 2020). Existing studies have described various aspects of take-home naloxone kit implementation in the ED, including the establishment of standing orders (i.e. ED staff can distribute naloxone kits without a physician’s order) and pre-determined order sets, the introduction of new policies and standardized discharge instructions, the creation of clinical guidelines and patient education materials, the use of best practice advisories in the form of electronic medical record alerts, the provision of clinician education, as well as considerations related to storage, labelling, as well as funding (Dora-Laskey et al., 2021; Drainoni et al. 2016; Dwyer et al., 2015; Funke et al. 2021; Mullennix et al., 2020). The provision of opioid agonist treatment in the ED setting has been described in the context of academic hospitals, inner city hospitals, and rural hospitals in the US and Canada (Choo & Wen, 2018; Im et al., 2020; Kestler et al., 2019b; Low, 2020; Snyder et al., 2021). Intervention implementation has encompassed the initiation of opioid agonist treatment followed by connecting patients to continuing treatment (Choo & Wen, 2018; Im et al., 2020; Kestler et al., 2019b; Low et al., 2020; Snyder et al., 2021). Existing studies have described various approaches to providing opioid agonist treatment in the ED. Some EDs accept patients in early stages of withdrawal, allowing them stay to reach a sufficient level of withdrawal to induce treatment. Other EDs initiate treatment in-house if the patient presents with an appropriate level of withdrawal, followed by rapid referral to outpatient care (Choo & Wen, 2018; Low, 2020). If the person does not present to the ED with an appropriate level of withdrawal, the ED may offer OAT to-go, involving a "starter pack" with instructions for at-home treatment initiation and follow up care (Kestler et al., 2019b; Low, 2020; Snyder et al., 2021). Still, some EDs utilize peer assisted follow up, whereby EDs have peers contact patients who were started on opioid 30 agonist treatment in the ED, or who were identified as potential candidates for opioid agonist treatment, to help with transition to outpatient care (Kestler et al., 2019b). Finally, the existing research has reported on the use of in dedicated substance use navigators to facilitate connections to outpatient care – who are responsible for arranging follow up appointments, securing transportation, and addressing socioeconomic barriers such as homelessness (Snyder et al., 2021). Contextual Factors that Influence ED Harm Reduction Implementation Research over the past decade has illustrated that numerous contextual factors – defined as key features of an environment that interact, influence, modify, or constrain intervention implementation and its effectiveness (Coles et al., 2017) – can shape harm reduction implementation in the ED. These include individual service providers, leadership, access to resources, organizational policies, and interdisciplinary and interagency working dynamics. Overall, only a handful of studies pertain to contextual factors that influence harm reduction implementation in the ED as experienced by health care providers (Drainoni et al., 2016; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). Additionally, these studies tend to take either a quantitative (Lacroix et al., 2018) or qualitative approach (Drainoni et al., 2016; Holland et al., 2019; Wiercigroch et al., 2021). One contextual factor that appears to influence ED harm reduction implementation in the ED is service provider knowledge related to the evidence base for harm reduction interventions, and training related to prescription, procedures for use, and how the intervention will be implemented (Drainoni et al., 2016; Holland et al., 2019; Lacroix et al., 2018). Due to inadequate knowledge and training, service providers may be unfamiliar with initiation dosing and consequent dose adjustments for harm reduction interventions such as opioid agonist treatment, 31 which may lead to a reluctance in prescribing such treatments, as service providers are concerned about inadvertently causing harm (Im et al., 2020). Service providers may also be unacquainted with how to assess for withdrawal, or are concerned about missing subtle presentations of withdrawal and contributing to precipitated withdrawal when initiating opioid agonist treatment (Wiercigroch et al., 2021). Lastly, service providers may be unmotivated to initiate opioid agonist treatment in the ED due to "delayed clinical gratification," defined as uncertainty about the impact and effectiveness of engaging patients in these interventions (Im et al., 2020, p. 266; Wiercigroch et al., 2021). Leadership, encompassing support from hospital administrators, a culture of acceptance for harm reduction interventions, and consistency with missions of the acute care institution also appear to influence harm reduction implementation in the ED (Cisewski et al., 2019; Drainoni et al., 2016; Dwyer et al., 2015). Additionally, access to resources including targeted electronic health record alerts (Drainoni et al., 2016; Marino et al., 2019), pre-established order sets that provided inclusion and exclusion criteria and dosing recommendations (Wiercigroch et al., 2021), and readily available educational materials for service providers – including treatment flowcharts, listings of community based services, and patient communication instructions – can also serve to support ED harm reduction implementation (Cisewski et al., 2019). Conversely, time constraints and competing demand on the part of staff were seen as barriers to harm reduction implementation in the ED, impeding critical tasks such as the identification of eligible patients and the initiation of harm reduction-related treatment (Drainoni et al., 2016; Dwyer et al., 2015; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). There is further evidence that organizational policies influence harm reduction implementation in the ED, which can include the availability of established guidelines and 32 protocols, service provider consultation in policy development, and ambiguity with identifying eligible patients (Drainoni et al., 2016; Holland et al., 2019). Lastly, interdisciplinary and interagency working dynamics can influence ED harm reduction implementation. To this end, interdisciplinary dynamics encompass the availability of physician champions and mentorship from senior colleagues (Wiercigroch et al., 2021), clearly delineated roles and responsibilities (Drainoni et al., 2016), and support from allied health professionals, in particular, pharmacists and social workers (Cisewski et al., 2019; Drainoni, 2016; Lacroix, 2018), while interagency dynamics include the lack of timely access to community based services for follow-up (Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021), the establishment of effective mechanisms for transitioning to community-based supports (Cisewski et al., 2019), and the ability to receive feedback about attendance of outpatient services upon discharge (Wiercigroch et al., 2021). Current Knowledge Gaps and Rationale for Study As noted above, harm reduction interventions are an important element of care provision for people who use unregulated substances. However, of the available literature on harm reduction implementation in EDs, and contextual factors that may impact implementation, there appears to be a notable paucity of research related to the experiences of health care providers including how and if they implement harm reduction interventions in the ED and the factors influencing such practices (Drainoni et al., 2016; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). As health care providers are the very individuals who will be implementing these interventions, a knowledge gap pertaining to what they experience as facilitators and barriers to harm reduction implementation is highly concerning, and may impede the effective implementation of harm reduction in ED settings. 33 Additionally, while existing investigations that take either a quantitative or qualitative approach can offer a picture of the types of factors that may impact harm reduction implementation in the ED, what is needed are studies that leverage a mixed methods approach, which would allow for greater breadth and depth of understanding in capturing the complex interplay between various facilitators and barriers. Furthermore, much of the available research pertains to the US context (Devries et al., 2019; Dwyer et al., 2015; Hurt et al., 2020; Moore et al., 2021; Mullennix et al., 2020; Papp et al., 2019; Prach et al., 2019; Samuels et al., 2021; Snyder et al., 2021), with very few studies originating from other jurisdictions (Holland et al., 2019; Kestler et al., 2017; Kestler et al., 2019a; Low, 2020; Wiercigroch et al., 2021). As such, this dissertation uses a mixed methods approach to data collection to examine how harm reduction interventions are implemented in a specific case of one Canadian ED, and contextual factors that staff experience as facilitator and barriers to harm reduction implementation. As EDs serve as essential pathways for people who use unregulated substances to access public sector services, and staff are ideally positioned to offer harm reduction interventions, this knowledge is needed as an initial step to generating effective strategies to inform harm reduction implementation in Canadian EDs. Outline of Subsequent Dissertation Chapters Prior to detailing the research study, it is important to note that this dissertation is manuscript-based. As such, following this initial chapter, which provides the background and context needed to situate the research problem, and present an overview of the current state of knowledge, in Chapter 2, I speak to theoretical tenets that serve to inform this work, the study design, data collection and analysis, and considerations related to research rigour and ethics. 34 These initial chapters are followed by three manuscript-based findings chapters (Chapters 3, 4, and 5 respectively) that encompass core findings of this work. Each of these chapters are in the form of a standalone academic manuscript. In Chapter 3, I present study findings related to how the ED is organized to provide harm reduction, identifying facilitators and barriers in light of interactions between system elements. As this chapter has been published, I include the citation for the published manuscript as a footnote in Chapter 3. In Chapter 4, I examine how ED staff engage in harm reduction, and present factors that may influence their capacity to engage in harm reduction practice. In Chapter 5, I present the findings related to staff experiences and perceptions of violence towards them in the context of caring for people who use unregulated substances. While my dissertation study did not set out to specifically examine violence, this issue was repeatedly raised during all qualitative interviews with the ED staff and leaders I conducted. As these interviews unfolded, I listened and probed about their experiences and in my analysis, noted that many participants spoke about their own or other staff's assumptions concerning people who use unregulated substances as dangerous and/or potential perpetuators of violence. Given the rising evidence of staff experiences of violence as an important issue, I was compelled to analyze how and why issues of violence towards staff stood out strongly in the data. Moreover, findings about staff perceptions of and experiences with violence are inherently relevant to harm reduction as a health care intervention. As relayed by Jiao (2019), harm reduction not only encompasses technical solutions, or "interventions that decontextualized and have the primary purpose of facilitating behavioural changes" (pp. 1-2), such as the provision of opioid agonist treatment or take-home naloxone kits. Harm reduction is simultaneously a contextualized social practice that is concerned with, and proactively attends, to the structural context as contributing to harm (Jiao, 2019). An ED environment where people who use 35 unregulated substances are positioned as potential perpetrators of violence, and as dangerous, has the potential to contribute to and perpetuate harm by impinging on the ability of ED staff to engage in care provision. As such, staff perspectives of patient violence in the context of care provision for people who use unregulated substances is a topic that requires consideration in a study pertaining to harm reduction provision in the ED. Thus, in Chapter 5 of this dissertation, I examine ED staff perspectives of patient violence in the context of care provision for people who use unregulated substances, including when and why violence occurs, how staff navigate the potential for violence, the impact of their care choices on patient care, and factors that may shape their approach. Chapter 6 is the final chapter of this dissertation, where I offer a fulsome discussion of study findings as presented in all Findings chapters in light of previous work in the field, highlighting key contributions. I also speak to the building of research partnerships and knowledge mobilization, and offer recommendations as related to policy, education, practice, leadership, and research. 36 Chapter 2: Methods In this chapter, I situate myself as a researcher and speak to the various theoretical tenets that serve to inform this dissertation study. Subsequently I present the study design, an overview of the study site, and how different sources of data were collected and analyzed. Lastly, I address research rigour and considerations related to research ethics. Situating Myself as a Researcher My interest in conducting research related to harm reduction provision in the ED arose from my experiences as an ED Psychiatric Liaison Nurse (PLN). In my role as a PLN, I saw that many patients who had mental health diagnoses also faced substance use challenges, and that due to a lack of harm reduction provision in the acute care setting, people left without having their care completed and lost their chance to obtain the mental health care that they needed. Additionally, I witnessed that people who use unregulated substances returned to the ED repeatedly as they were leaving without having their health care needs met. I decided to tackle the issue of harm reduction provision in the ED. Feeling limited in my ability to affect change as a nurse working on the frontlines, I completed Master of Health Administration studies, where I began to understand that the health care system is incredibly complex, and that various factors are at play, including the knowledge and skills of staff, human and infrastructural supports, and safety concerns. Furthermore, realizing that changes to existing programs and practices require evidence, but there was a lack of research pertaining to harm reduction provision in the ED, I began to seek opportunities to gain researcher training. I enrolled in PhD studies and focused my research on harm reduction provision in the ED, encompassing contextual factors that impact provision, with the goal of improving ED care for people who use unregulated substances. 37 The COVID-19 Context Before detailing the methods used, it is important to situate the research activities within the COVID-19 pandemic context and its relevance for recruitment and data collection strategies. Due to university and health authority restrictions placed on research activities during this time of crisis, I was only permitted to conduct interviews with staff and clinical leaders remotely. Although I would have preferred to be more immersed in the ED space, and to connect with ED staff in-person to share more about the study and to engage in recruitment efforts, I was unable to do so. Consequently, I was unable to fully embed myself in the context of the ED environment, nor to be present with staff “in the moment” when conducting recruitment and data collection. A second implication of conducting research during the COVID era was that data collection was limited to a single site, thereby impeding the possibility for cross-site comparison. Although focusing on a single site allowed me to study harm reduction in-depth, and to consider site-specific context and nuances, I recognize that there are limitations to a single site related to the transferability of knowledge. For instance, study findings may not be fully applicable to acute care institutions that do not have comparable organizational missions or values, nor access to the same range of substance specialist services. Nonetheless, as the need for harm reduction in the ED setting is universal, I believe that findings arising from this study are useful for other organizations that have the goal of initiating and/or improving harm reduction implementation. Theoretical Positioning Complexity Adaptive Systems This dissertation study is informed by complexity science, which is concerned with the study of complex phenomena – animate or inanimate systems that are composed of numerous interacting parts whose structure or behaviour is difficult to understand or predict (Casti, 1997). 38 Examples of complex phenomena are evident in both the physical and social worlds, such as bodily processes, ecologies of nature, economics, and politics (Dodder & Dare, 2000). A complexity science perspective has been applied to a wide range of fields of study, including engineering, economics, management, health, and education (The Health Foundation, 2010). A complexity science orientation requires attending to the ED as a complex adaptive systems (CAS). A CAS approach is a way of thinking about systems that challenges linear assumptions of cause and effect. Rather, systems are understood as comprised of dynamic processes within which interactions and relationships between parts of the system simultaneously influence and are shaped by the system (The Health Foundation, 2010). A CAS approach focuses on the emergence9 of system structures and behaviours as a function of patterns of interaction among system agents (McDaniel & Driebe, 2001; Widmer et al., 2018). Within a CAS, the characteristics of a system are understood to arise from the characteristics of its agents and their interactions, but are not reducible to these characteristics (McDaniel & Driebe, 2001). One also cannot determine the structures and behaviours of the system by summing the behaviours of its parts (McDaniel & Driebe, 2001). Instead, there are positive and negative feedback loops within the CAS, where the behaviour of one system agent can feedback on itself and influence the behaviour of other system agents (McDaniel & Driebe, 2001). As a result of these feedback loops, the system engages in self-organization as new system structures and behaviours emerge (McDaniel & Driebe, 2001). In recent years, there has been increasing understanding that, when implementing health care interventions, one must not attribute implementation challenges to parts of the system that are deemed "broken" (Dekker, 2010). Instead, factors that impact 9 Emergence refers to the process by which properties or behaviours of a system become visible by "surprise," as they are unable to be explained nor predicted through knowledge or analysis of the system's constituent parts (Casti, 1997). 39 implementation should be identified in light of how system agents interact (Widmer et al., 2018). Health care intervention research that adopts a CAS approach has the potential to offer the benefits of confronting taken-for-granted assumptions, and gaining a comprehensive and nuanced understanding of forces that affect change (The Health Foundation, 2010). In the context of a research study that examines harm reduction implementation in the ED, the application of a CAS lens can illuminate new possibilities for systemic change, and contribute to the formulation of tailored and effective strategies to improve the delivery of care. Critical Perspectives This study is also informed by critical perspectives, which is concerned with “issues of power and justice and the ways that the economy, matters of race, class, and gender, ideologies, discourses, education, religion, and other social institutions, and cultural dynamics interact to construct a social system” (Kincheloe & McLaren, 2011, p. 288). A critical lens assumes the pervasiveness of unequal power relations and oppressive structures within the fabric of society, showing a commitment to illuminating how such structural features create and restrain opportunity for certain social groups (Kincheloe & McLaren, 2011). In doing so, a critical perspective allows for the illumination of the "winners and losers in particular social arrangements and the processes by which such power plays operate" (Kincheloe & McLaren, 2011, p. 288). A critical lens additionally has the goal of emancipation from oppressive societal structures – by revealing forces that restrict people's autonomy and human agency, and prevent them from being able to make decisions that affect their lives (Kincheloe & McLaren, 2011). Lastly, a critical perspective supports efforts of emancipation by shifting understandings beyond descriptions of “what is” happening to “why this is and what can be done about it” (Cook, 2005, p. 132). 40 By adopting critical perspectives in this work, I am making the explicit assumption that the ED, as an essential component of the social fabric, simultaneously creates and restrains opportunity for people who use unregulated substances to access appropriate and equitable services. As such, concomitantly drawing on a CAS approach enabled a comprehensive and nuanced understanding of the type of forces that may facilitate and hinder systemic change and transformation – an understanding that is critical in supporting future efforts of emancipation. Despite drawing on CAS as a theory, I draw on critical perspectives, as opposed to critical theory. This distinction is important because critical theory refers to a family of theories (e.g., feminist theory, critical race theory, decolonial theory) that have the shared aim of exposing and critiquing oppressive structures, as well as restitution and emancipation from these structures (Tyson, 2015). While this study draws on the shared tenets and perspectives that critical theories subscribe to, it does not draw on a particular "theory." I draw on critical perspectives to inform how I define harm reduction as part of the delivery of appropriate and equitable care for people who use unregulated substances. Harm Reduction This study is informed by understandings of harm reduction as a technical solution and as a contextualized social practice. In my previous work (Jiao, 2019), I positioned harm reduction as a technical solution when it involves "interventions that decontextualized and have the primary purpose of facilitating behavioural changes that are deemed necessary to reduce the harms associated with [unregulated substance] use" (pp. 1-2), encompassing interventions such as take-home naloxone kits and opioid agonist treatment. To position harm reduction as a technical solution neglects the social conditions that exacerbate and perpetuate substance use harms, and does not account for the impact of social, economic, and political context on the 41 capacity of people to reduce those harms (Jiao, 2019). Harm reduction as a contextualized social practice, on the other hand, refers to "interventions that are nuanced and situated within the contextualized […] lifeworld of PWUD [people who use drugs]" (Jiao, 2019, p. 2). These interventions bear in mind, and proactively attend to, the impact of broader, socio-structural factors (including poverty and housing insecurity) on harms experienced, and on people's capacity to manage and mitigate harms. Understandings of harm reduction not only as a technical solution, but also as a contextualized social practice were informed by critical perspectives. By conceptualizing harm reduction as a contextualized social practice, I acknowledge that socio-economic factors, such as poverty and housing insecurity, are social conditions whereby power operates, and constitute oppressive structures that restrict people's human agency to make decisions that affect their lives, including their ability to promote and maintain their health and wellbeing. Harm reduction as contextualized social practice additionally has the goal of emancipation from oppressive societal structures by attending to their impact on harms experienced and on people's capacity to manage and mitigate these harms. In summary, the integration of the three theoretical orientations allowed a comprehensive and nuanced examination of ED harm reduction implementation in a way that elucidates facilitator and barriers in light of interactions and relationships between diverse agents of the system. The goal of such an examination is to illuminate how the ED, as an essential element of the social fabric, simultaneously creates and restrains opportunity for people who use unregulated substances to access needed services, paving the way for efforts of emancipation and redressing oppression. 42 Study Design This study utilized a case study design, which Yin (2018) defines as an inquiry of an empirical nature that examines the phenomenon of interest in depth and within its real-life context. Case study design is often used when the phenomenon of interest is too complex, context-bound, or context-sensitive to be studied in any other way (Ragin, 2015). The logic of case studies is configurational, where different parts of the case must be understood in relation to one another and in terms of the whole, and where parts of the case only have integrity and coherence when considered together (Ragin, 2015), thus an appropriate approach for a study informed by CAS theory. When employing case study methodology, it is important to define one’s case, which involves determining the unit of analysis, and asking what is it that one wants to analyze (Baxter & Jack, 2008). For the purpose of this study, the unit of analysis is at the level of the hospital department, and the SPH ED is the case. In keeping with the need to understand the complexity of the case, including the types of system agents and their interrelationships, a mixed methods approach to data collection was employed (see section on "Data Collection" in this chapter). Overview of the Case – the Study Site The case used in this study was the Emergency Department of St. Paul’s Hospital (SPH). Situated within the Providence Health Care health authority, SPH is an acute care, teaching, and research hospital located in Vancouver, Canada. Providence Health Care is a Catholic health authority committed to care delivery that is aligned with the Christian principles of promoting healing, well-being, and dignity – principles which have their origins in the healing mission of Jesus Christ (Providence Health Care, 2024). SPH serves a patient population disproportionately impacted by health and social inequities, including people who use unregulated substances, 43 people who experience homelessness, and people living with a diagnosis of HIV (Providence Health Care, 2019a). In 2015-2016, there were more than 500,000 visits to the hospital, comprising over 174,000 unique patients (Providence Health Care, 2016). Of the EDs that serve the city of Vancouver, the SPH ED is the closest to a geographical neighbourhood known as the Downtown Eastside (DTES). The DTES is community renowned for poverty, violence, problematic drug use and community activism. Within this community, many residents experience intersecting health and social inequities including poverty, housing insecurity, interpersonal violence, intergenerational trauma, and racism and colonialism (Downtown Eastside Women’s Centre, 2022). Challenges related to unregulated substance use are also a reality in the lives of many who live in the DTES (City of Vancouver, 2013). In 2021, the highest rate of drug toxicity deaths in the province of British Columbia (49.5 per 100,000) was in the Vancouver Coastal Health Authority (VCH), a region which encompasses the DTES (Ministry of Public Safety & Solicitor General, 2022). As a Catholic health care organization, Providence Health Care, and by extension, SPH, is committed to "a deep respect for the intrinsic value and dignity of every human being," and to caring for "all people, from all background and faiths, especially society's most vulnerable" (Providence Health Care, 2024, para. 4). In keeping with this mission, the hospital strives provide excellent and compassionate care to all of its patient population, inclusive of people who use unregulated substances. In fact, SPH is in many ways a pioneer in the provision of care for people who use unregulated substances. The hospital is known for its expertise in harm reduction provision, including the development of a comprehensive set of harm reduction policies, and the implementation of various harm reduction interventions, including opioid agonist treatment and take-home naloxone kits (Kestler et al., 2019a; Kestler et al., 2019b). The hospital is also home 44 to a number of substance use specialist services, including an Addiction Medicine Consult Team, a Rapid Access Addiction Clinic, and an Overdose Prevention Site (Braithwaite et al., 2020; Dogherty et al., 2022). The ED at SPH is one of the busiest EDs in the province – from 2015 to 2016, there were more than 84,000 visits to the ED (Catholic Health Alliance of Canada, 2012; Providence Health, 2016; Providence Health Care, 2019c). Due to its geographical proximity to the DTES, the SPH ED plays a substantial role in responding to the ongoing drug toxicity crisis, seeing the highest number of overdoses of any ED in the province – amounting to almost 10 times more than other EDs in the VCH region (Vancouver Coastal Health, 2018; Vancouver Coastal Health, 2019). Gaining Entry My introduction to the SPH ED was facilitated by research partnerships between my supervisor Dr. Bungay and the staff and leadership at SPH. During my PhD studies, the SPH ED was one of three sites that participated in an unrelated study concerned with interventions to foster staff capacity for equity-oriented health care. Dr. Bungay served as a Co-PI and the site lead for SPH in that study and I had the chance to work with the SPH staff participating in that study in my role as research coordinator for approximately two years. Drawing on those established relationships, Dr. Bungay formally introduced me to leaders in administration and knowledge translation at SPH – Cindy Elliott, the ED Program Director, and Aggie Black, the Director of Health Services and Clinical Research and Knowledge Translation at Providence Health Care. We set up a meeting with the leaders to share more about my dissertation study and to explore their interest and request support to engage with the staff in the ED for my study. In the meeting that followed, I introduced my study and my proposed data sources, and spoke to why the research is needed and why SPH was an appropriate case for this work. The leaders 45 showed immense interest in the research topic, which was (and continues to be) extremely relevant given the ED's vicinity to the DTES, and SPH's rich history of advocating for the interest of people who use unregulated substances. The leaders were thus very committed to seeing this project go forward; the outcomes of which for recruitment and engagement are detailed in the section on "Data Collection" that follows. Data Collection As noted previously, this study employs a mixed method approach to data collection, involving the collection of both quantitative and qualitative data (Johnson, Onwuegbuzie, & Turner, 2007). Specifically, the study employs a convergent approach, which involves collecting quantitative and qualitative data concurrently, analyzing the data separately, and comparing results to look for points of convergence or divergence, with the goal of generating well-substantiated conclusions (Creswell & Creswell, 2018; Creswell & Plano Clark, 2018). A mixed methods approach, when coupled with a paradigmatic stance informed by critical perspectives, allows for the generation of “more complete and full portraits of our social world through the use of multiple perspectives and lenses” (Somekh & Lewin, 2005, p. 275). There were three specific approaches to data collection in the present study, including semi-structured interviews with ED staff and clinical leadership; an online, self-administered staff survey; and text documents in the form of organizational policies, all of which were collected concurrently. The purpose of the staff survey was to capture the context in which ED staff provide care for people who use unregulated substances and harm reduction interventions, including current harm reduction programs and practices that exist in the ED, education received by staff through school and through the workplace, staff attitudes toward caring for people who use unregulated substances, as well as staff-perceived factors that may impact harm reduction 46 provision (See section on "Data Source 1: Staff Surveys" below for a description of survey items and variables of interest. See Appendix A for the staff survey in its entirety). The purpose of interviews with ED staff was to explore how, as system agents, they engaged with harm reduction as well as their interactions with other agents in their attempts to provide this care. Interviews specifically explored the types of harm reduction interventions in their practice and the contextual features of the CAS that facilitated or created barriers for harm reduction implementation. Clinical leaders’ interviews were also included to develop a more nuanced understanding of their perspectives related to policy, programming, and implementation of harm reduction interventions, with the goal of capturing further nuance of the context in which harm reduction practice occurred (See section on "Data Source 2: Interviews with Staff and Clinical Leaders" below for discussion related to the interview guides, sampling, and recruitment. See Appendices B and D for the interview guide for staff and clinical leaders, respectively). The purpose of collecting text documents in the form or organizational policies was to obtain information related to how the ED should function with regards to harm reduction provision, encompassing the roles, responsibilities, and availability of system agents that are involved in the delivery of harm reduction interventions, as well as how these system agents are expected to interact with one another to support harm reduction provision (See section on "Data Source 3: Organizational Policies" below for more details about the collection of organizational policies). All data were collected between April to November, 2021, the details of which are provided in the subsequent sections. 47 Data Source 1: Staff Surveys A total of 99 ED staff members (nurses and physicians) participated in the staff survey. The survey consisted of 66 items, which captured participant characteristics, staff attitudes toward caring for people who use unregulated substances, education received through school and through the workplace, harm reduction programs and practices that exist in the ED, and factors that may impact harm reduction implementation. Questions 15 to 36 of the staff survey is composed of the 22-item Drug and Drug Problems Perception Questionnaire (DDPPQ), which is a standardized scale that measures care providers’ attitudes towards patients using unregulated substances (Watson et al., 2003). The DDPPQ consists of six subscales: Role adequacy; Role legitimacy; Role support; Task specific self-esteem; Work satisfaction; and Motivation, and uses a 7-point Likert response ranging from "strongly agree" to "strongly disagree" (Watson et al., 2003) (See section on "Quantitative Rigour" in this chapter for more information related to psychometric properties of the DDPPQ, including estimates of internal consistency). All other questions of the staff survey were researcher generated drawing from our collective experience in the area of harm reduction and literature concerned with harm reduction provider practices (see Appendix A for the survey). Inclusion criteria. Inclusion criteria for the staff survey were nurses and physicians who provide direct patient care in the SPH ED. Recruitment. A multi-pronged approach was used to recruit nurses and physicians to complete the survey. Clinical nursing leaders distributed recruitment materials (see Appendix H for Letter of Initial Contact) to nursing staff via staff email. Physician champions identified by clinical leadership further distributed materials tailored specifically to their physician colleagues. Additionally, recruitment posters were placed in the ED staff room where staff regularly took 48 their breaks. Chapter 4 of this dissertation, which examines how nurses and physicians in the ED engage in harm reduction and delineates the types of factors that may influence the capacity of staff to engage in harm reduction practice, draws specifically on data from the staff survey. Data Source 2: Interviews with Staff and Clinical Leaders A total of 20 individual interviews were conducted. Fifteen of these interviews were with staff, and 5 with clinical leaders. Of the interviews with staff, 10 were with Registered Nurses, 4 were with Staff Physicians, and 1 was with a Resident Physician. Interviews questions focused on the types of system agents that are involved in the delivery of opioid specific harm reduction in the ED, how system agents interact to support harm reduction provision, and facilitators and barriers in light of those interactions. Interviews with staff ranged from 45 to 75 minutes in length. Inclusion criteria. Inclusion criteria for the interviews with staff were nurses and physicians who provide direct patient care in the SPH ED. Recruitment. At the end of the staff survey, survey participants were asked if they would be interested in participating in an interview to further explore harm reduction in the SPH ED, and if so, to click on a separate link to leave their contact information. As the interviews with staff unfolded, the need for interviews with clinical leaders as system agents influencing harm reduction implementation was identified. As such, 5 interviews were conducted with leaders with responsibilities associated with harm reduction implementation at the level of Providence Health Care, with the goal of capturing greater context. These interviews focused on clinical leaders' perspectives of policy, programming, and implementation of opioid specific harm reduction interventions. Interviews with leaders ranged from 55 to 80 minutes in length. The sampling of clinical leaders was purposive, whereby leaders were 49 recruited for their insights and experience in their respective roles, with the goal of understanding diverse perspectives (Thorne, 2008). Recruitment. Recruitment for the interviews with clinical leadership was in the form of personalized invitations sent via email. All Findings chapters of this dissertation (Chapters 3, 4, and 5) draw on data from interviews with ED staff and clinical leaders. Chapter 3 examine how the ED is organized to provide harm reduction, and identify facilitators and barriers in light of interactions between system elements. Chapter 4 examines how ED staff engage in harm reduction and delineates the contextual factors that may influence the capacity of staff to engage in harm reduction practice. Chapter 5 explores ED staff perspectives of patient violence in the context of care provision for people who use unregulated substances, including when and why violence occurs, how staff navigate the potential for violence, factors shaping their approach, and impact on patient care. Data Source 3: Organizational Policies Organizational policies were gathered from the Providence Health Care Shared Health Organizations Portal (SHOP) website (http://shop.healthcarebc.ca/). Policies were deemed relevant if they: (1) were official and issued by Providence Health Care or SPH; (2) addressed harm reduction in some way (i.e. conceptually, or as interventions, programming, or practices); (3) were either a stand-alone policy pertaining to harm reduction, or address harm reduction as part of a policy on caring for people who use unregulated substances. Only policies that are in effect were included. In total, nine policies were gathered. Chapter 3 of this dissertation, which examines how the ED is organized to provide harm reduction, and identifies facilitators and barriers in light of interactions between system elements, draws on data from organizational policies. 50 Data Analysis Drawing on a combination of the above data sources, I arrived at three separate analyses, which allowed me to 1) examine into how the ED is organized to provide harm reduction in light of how system agents interact, 2) examine how staff engage in harm reduction practice and contextual factors that influence their capacity to do so, and 3) explore staff perspectives of patient violence in the context of care provision for people who use unregulated substances, including when and why violence occurs, how staff navigate the potential for violence, factors shaping their approach, and impact on patient care. The data analysis approaches utilized in each of the three analyses are detailed below. Analysis 1 The objective of Analysis 1 was to examine how the ED is organized to provide harm reduction, and identify facilitators and barriers in light of interactions between system elements. For this analysis, I drew on interview data with ED staff and clinical leaders, as well as organizational policies. Interview data were analyzed using a reflexive thematic analysis (RTA) approach (Braun & Clarke, 2006), informed by the theory of complex adaptive systems (McDaniel & Driebe, 2001; Widmer et al., 2018). As per the RTA approach, we did not use a fixed codebook. Rather, coding was iterative, where codes evolved as more interviews were reviewed. As part of this process, a number of the initial codes were deleted, renamed, split, and / or combined. These refinements allowed for the gradual development of themes as meaning-based patterns, facilitating a fulsome interpretation of the data (Braun & Clarke, 2019). In generating codes used, we considered the types of system agents involved in opioid specific harm reduction, how 51 these agents interact to provide harm reduction, and how their patterns of interaction can lead to the emergence of systemic facilitators and barriers. NVivo™ 12 was used to code the interviews. The theory of complex adaptive systems informed the analysis of organizational policies. Policy documents were reviewed to extract information pertaining to the roles, responsibilities, and availability of system agents involved in the provision of opioid specific harm reduction, and how these agents are expected to interact with one another to support harm reduction provision. To generate analytical themes, we engaged in data triangulation, whereby information extracted from policy documents was compared to information provided by staff and clinical leaders to look for points of convergence and divergence. Both data sources contributed to descriptions of the types of system agents involved, and how interactions between system agents can support harm reduction provision. The interview data further enabled a nuanced analysis of how patterns of interaction among system agents led to the emergence of systemic facilitators and barriers. Considerations of how the two data sources interface helped to shape the analysis. To formulate analytical themes, we asked questions such as: Which system agents are involved in the provision of opioid specific harm reduction? What are the required interactions between system agents to support harm reduction provision? What are the facilitators and barriers associated with these interactions, and how do they impact the delivery of care? (Please see the analytic approach detailed in the Methods section of the manuscript in Chapter 3). Analysis 2 The objective of Analysis 2 was to examine how ED staff (nurses and physicians) engage in harm reduction in the ED, and to delineate contextual factors that may influence the capacity of staff to engage in harm reduction practice, culminating in the identification of facilitators and 52 barriers. For this analysis, I drew on data from the staff survey and interview data with ED staff and clinical leaders. Survey data were uploaded to SPSS™ 27 for analysis. Descriptive statistics (e.g., frequencies) were generated for variables associated with participants' demographics and work experience characteristics. Frequencies were also generated for variables associated with the beliefs that staff held about people who use unregulated substances, staff perceptions of the availability of harm reduction interventions in the ED, factors staff perceive to influence ED harm reduction implementation, and education staff obtained through school and the workplace. SPSS™ was also used to calculate DDPPQ total scores, which were computed by summating the Likert response for each scale item, with lower scores denoting positive attitudes towards people who use unregulated substances and vice versa (Watson et al., 2003). Once the survey data was analysed, de-identified interview data were uploaded to NVivo™ 12 and analyzed using a reflexive thematic analysis (RTA) approach (Braun & Clarke, 2006). This analysis was informed by the theoretical construct of complex adaptive systems (McDaniel & Driebe, 2001; Widmer et al., 2018), as well as understandings of harm reduction as both a technical solution and a contextualized social practice as proposed by Jiao (2019). In accordance with the focus of the theory of complex adaptive systems on patterns of interaction between system agents (McDaniel & Driebe, 2001; Widmer et al., 2018), a coding scheme was constructed that reflected staff experiences of providing harm reduction in the ED, and the types of contextual factors that impact their ability to interact with colleagues, and with community-based service providers, to carry out their roles related to harm reduction. The final analysis involved integrating both quantitative and qualitative data to generate overarching analytical themes, thereby engaging in mixed analysis (Onwuegbuzie & Combs, 53 2015). Mixed analysis allows for data triangulation (i.e. the ability to compare qualitative findings with quantitative results), and complementarity (i.e. the ability to seek elaboration, illustration, enhancement, and clarification of findings generated via one data source with results generated via another data source) (Collins et al., 2006). In conducting mixed analysis, the two data sources were given approximately equal priority, and mixed analysis decisions were made iteratively (Onwuegbuzie & Combs, 2015). In formulating analytical themes, we asked questions such as: In the CAS that is the ED, how do nurses and physicians engage in harm reduction provision? What are staff-identified factors that may impact their capacity to engage in harm reduction practice? What contextual factors impact the capacity of staff to meet patient needs related to harm reduction? (Please see the analytic approach detailed in the Methods section of the manuscript in Chapter 4). Analysis 3 The objective of Analysis 3 was to examine ED staff perspectives of patient violence toward them in the context of care provision for people who use unregulated substances, including when and why violence occurs, how staff navigate the potential for violence, the impact of their care choices on patient care, and factors that may shape their approach. For this analysis, I drew on interview data with ED staff and clinical leaders. Consequent to the coding of interviews with staff and clinical leaders to support Analysis 1, data specific to staff experiences of patient violence were gathered under a dedicated code in NVivo™ 12. This data was then analyzed using reflexive thematic analysis (RTA) (Braun & Clarke, 2006), which was informed by the theory of complex adaptive systems. In carrying out RTA, we created sub-categories within the violence code that reflected how violence is talked about, defined, and taken up in the practice setting, moments in the 54 clinical encounter where it's being thought about and considered, and finally, how staff grappled with the potential for violence in their everyday work. This process resulted in a coding framework that reflected staff's experiences of patient violence in the ED, their understandings of when and why patient violence occurs in light of how patients and staff as system agents interact with one another and with system structures, and how staff navigate the potential for violence within this complex system. In formulating analytical themes, we asked questions such as: In the case of caring for people who use unregulated substances, how do staff experience patient violence toward them? What are scenarios where violence is perceived likely to occur? How do staff navigate the potential for patient-staff conflict, and what is the impact of these care decisions on the delivery of care? What types of factors shape how staff navigate the potential for patient-staff conflict? (Please see the analytic approach detailed in the Methods section of the manuscript in Chapter 5). Rigour Mixed Methods Rigour A number of potential threats to validity are inherent in using a mixed methods approach. First, the researcher must consider implications of having different samples, and different sample sizes (Creswell & Creswell, 2018; Creswell & Plano Clark, 2018). In this study, to counter the threat of having different samples, we tried to make the quantitative and qualitative samples as comparable as possible – a part of our qualitative sample (i.e., interviews with staff) is a subset of our quantitative sample (e.g., staff surveys). While we acknowledge the different requirements related to sample size taken in quantitative and qualitative approaches, different sample sizes are typical in a mixed methods approach, where quantitative and qualitative data are collected for different purposes (Creswell & Creswell, 2018; Creswell & Plano Clark, 2018). A second threat 55 to validity is related to the use of different concepts for the quantitative and qualitative components of a study, which may lead to findings that are incomparable and difficult to converge (Creswell & Creswell, 2018). To attend to this threat, we were careful to use the same concepts for the quantitative and qualitative components of the study. For instance, we conceptualize harm reduction in the same manner for both components – as a technical solution as well as a contextualized social practice (Jiao, 2019). Quantitative Rigour In quantitative research, validity means that meaningful inferences can be drawn from a sample to a population, and that study findings are generalizable (Giddings & Grant, 2009). To facilitate validity in the quantitative component of this research, we worked to ensure measurement validity, where the data collection instrument used should reliably measure the content it was intended to measure in a consistent manner (Giddings & Grant, 2009). The validity of a data collection instrument can be established through face validity, which is when a researcher concludes that, on the face of it, the questions asked are relevant and reflect the topic of interest (Giddings & Grant, 2009). For this study, face validity was established through piloting the data collection instrument (i.e. staff survey) among three nurse peers of the researcher to gauge clarity and acceptability, who also offered feedback for revisions. The validity of a data collection instrument can also be established through content validity, which requires experts in the field to come to a consensus that the instrument “can be trusted as representative of the content […] [it was] intended to measure” (Giddings & Grant, 2009, p. 124). For this study, content validity was established through having members of the supervisory committee, who all have both clinical and research expertise pertaining to harm reduction in health care settings, review, provide feedback for, and approve of the data collection instrument 56 (Eckhardt & DeVon, 2017). Finally, as Questions 15 to 36 of the staff survey comprise of the DDPPQ (Watson et al., 2003), there is a need for psychometric evidence that supports the DDPPQ's reliability in the form of internal consistency (Eckhardt & DeVon, 2017; Giddings & Grant, 2009). As noted above, the DDPPQ was developed to measure health care providers’ attitudes towards patients using unregulated substances, and consists of six subscales: Role adequacy; Role legitimacy; Role support; Task specific self-esteem; Work satisfaction; and Motivation. It uses a 7-point Likert response ranging from "strongly agree" to "strongly disagree" (Watson et al., 2003). A number of studies have provided estimates of the internal consistency of the DDPPQ, with a Cronbach's α of 0.92 for the scale as a whole (Williams et al., 2020), and Cronbach's α ranging from 0.734 and 0.955 for the various subscales (Kelly et al., 2018; Knopf-Amelung et al., 2018). For the purpose of this study, we adapted the wording and language of the DDPPQ to minimize stigma and to reflect current understandings of unregulated substance use (such as changing the language of "drug user" to "people who use unregulated substances," and "drug problems" to "harms associated with unregulated drug use"). We calculated Cronbach’s α for the study sample to be 0.857 for the scale as a whole. Qualitative Rigour In qualitative research, validity is established when accounts given by the participant and the interpretations of the researcher work together to produce credible findings that are trustworthy (Giddings & Grant, 2009). Validity in the qualitative component of this research was facilitated in a number of ways. First, we employed triangulation through the use of more than one qualitative data source (i.e., interviews and policy documents), and through engaging with more than one participant group (i.e. nurses, physicians, and clinical leaders). Triangulation can contribute to validity through offering comprehensiveness in the data collected, and facilitate the 57 convergence of patterns within the data (Giddings & Grant, 2009). Second, we addressed validity through attending to auditability (Giddings & Grant, 2009). To this end, we provided detailed accounts of the data analysis process. For instance, we discussed the types of considerations that led to the generating of codes used, and the types of questions we asked in formulating analytical themes. An added benefit of providing such detailed accounts is that consumers of research have sufficient information to determine whether study findings are applicable in other, similar settings, thereby increasing transferability and relevance (Eckhardt & DeVon, 2017; Giddings & Grant, 2009). Furthermore, trustworthiness is of utmost importance when conducting qualitative research. This is because the researcher’s prior experiences and assumptions, and the theoretical and methodological choices they make, can shape data collection and analysis (Giddings & Grant, 2009). As such, there is a need to ensure the integrity and credibility of the researcher (Eckhardt & DeVon, 2017; Giddings & Grant, 2009). To facilitate trustworthiness, I engaged in self-reflexivity by giving thought to the ways in which my own experiences and prior assumptions, as well as the theoretical and methodological positioning of the research, shape data collection and analysis (Giddings & Grant, 2009). Throughout the research process, these moments of self-reflection were often shared and explored with my supervisor in the context of student meetings. Finally, in interpretative research, it is essential to illustrate how theoretical components of the research impact how the research is conducted (Giddings & Grant, 2009). To this end, we justify our methodological choice of using a case study approach, which is highly compatible with the theoretical construct of complex adaptive systems. We also explicate how a convergent, mixed methods approach is suited to complexity theory, while simultaneously satisfying the need for triangulation as required by a case study approach (Eckhardt & DeVon, 2017). We additionally provide descriptions of how research decisions were made – not only 58 related to the study sample, but also how theoretical underpinnings shaped all aspects of data collection and analysis, contributing to the overall credibility of study findings. Ethics I obtained approval for this research from the University of British Columbia (UBC) Behavioural Research Ethics Board (BREB), Certificate of Approval no. H19-02470. As the staff survey was available online, I incorporated a consent cover letter prior to the survey content, which conveyed to the participant that all responses are anonymous. At the end of the staff survey, I asked the participant if they would like to be contacted for an in-depth interview. Working with the list of survey participants who indicated interest in participating in an interview, I then reached out to them to arrange for a time to meet via Zoom. I sent the participant the interview consent and the interview guide via email one week prior to the scheduled interview. When the participant and I met, we reviewed consent, and prior to starting, I obtained permission to record the interview. I also reminded the participant that they can refuse to answer any question that I pose, ask for the recording device to be turned off, and withdraw their participation at any time. I also reassured the participant that their name will not be associated with the information collected, and no identifying information will be included in any resulting publications or presentations. Many participants in the staff interviews spoke to difficult or traumatic experiences such as witnessing patient suffering on an ongoing basis, feeling limited in their ability to make a difference, feeling burnout, as well as patient violence toward them. Although I created a safe, non-judgmental space for participants to share these experiences, I did not intentionally probe into details related to these experiences. Additionally, I asked the participant if they would like to take a break when discussing these topics, and made sure to ensure their emotional safety prior to 59 ending the interview. I also prepared mental health resources that participants could connect with for support, but this was not needed. All electronic files resulting from the research, including interview transcripts and audio recordings are encrypted and stored in a secure server based in Canada. Data will be retained for five years and subsequently destroyed. In this chapter, I addressed theoretical tenets that serve to inform this dissertation study, outlined the study design and approaches to data collection and analysis, and presented considerations related to research rigour and ethics. This chapter is followed by three manuscript-based findings chapters (Chapters 3, 4, and 5) that form the core findings of this study. In the chapter that follows (Chapter 3), I examine how the ED is organized as a complex adaptive system to provide harm reduction, identifying facilitators and barriers in light of interactions between system elements. 60 Chapter 3: How an Emergency Department is Organized to Provide Opioid-Specific Harm Reduction and Facilitators and Barriers to Harm Reduction Implementation: A Systems Perspective Chapter 3 is the first findings chapter of this dissertation, and examines how the ED is organized as a complex adaptive system to provide harm reduction, identifying facilitators and barriers in light of interactions between system elements. The chapter is written in manuscript style and its contents have been published with the following citation: Jiao, S., Bungay, V., Jenkins, E., & Gagnon, M. (2023). How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: A systems perspective. Harm Reduction Journal, 20, 139. https://doi.org/10.1186/s12954-023-00871-1 Introduction In April 2016, a public health emergency was declared in British Columbia, Canada in response to an alarming rise in substance related overdoses and deaths. These occurrences were attributable to a highly toxic drug supply characterized by unregulated opioids, such as fentanyl (Ministry of Public Safety & Solicitor General, 2022; Province of British Columbia, 2016). In March 2020, a second public health emergency was declared in the province in response to the novel coronavirus (COVID-19) pandemic (Province of British Columbia, 2020). The pandemic further exacerbated the impact of the drug toxicity crisis and led to an increase in overdose events and deaths (Canadian Centre on Substance Use and Addiction, 2020; Legislative Assembly of British Columbia, 2022). The impact of the pandemic was palpable especially in its early stages. Whereas prior to the pandemic, people were discouraged from using alone as a safety measure, this was stymied by physical distancing measures implemented in response to 61 COVID-19 (Schlosser & Harris, 2020). In addition, the pandemic had an impact on people’s ability to access harm reduction services such as supervised consumption sites and withdrawal services (Canadian Centre on Substance Use and Addiction, 2020; Legislative Assembly of British Columbia, 2022). Between January and December 2021, which included the time period for data collection, there were 2,232 substance related deaths – the highest number ever recorded in a year, and representing a 26 percent increase from 2020, where fentanyl was detected in 86 percent of all substance related deaths (Ministry of Public Safety & Solicitor General, 2022). The drug toxicity crisis and the compounding impact of the pandemic do not affect all people who use unregulated opioids equally. Social and systemic inequities create conditions by which people who live in poverty, Indigenous people, and people who are unstably housed are disproportionally affected (British Columbia Centre for Disease Control, 2017; Lavalley et al., 2018; Thompson et al., 2020b). Against the backdrop of dual public health emergencies, there is an urgent need for harm reduction interventions to be scaled up across all health and social care settings (Greer et al., 2021; McNeil et al., 2016; Pauly et al., 2017; Sander et al., 2016; Syme et al., 2011; Wallace et al., 2018). Harm reduction is “a philosophy and a particular set of principles that inform policies, programs and practices that aim to reduce the negative health, social, and legal impacts associated with drug use, drug policies, and drug laws” (CATIE, 2022b, para. 2; Harm Reduction International, 2022). Harm reduction acknowledges that many harms associated with the use of unregulated substances – substances that are prohibited and criminalized in the Canadian context – can be attributed to systemic factors that marginalize, stigmatize, and oppress people who use substances including prohibition and criminalization (CATIE, 2022b). Harm reduction began as a grassroots initiative led by people who use substances (Roe, 2005), and the approach has been 62 taken up in health care settings to help decrease the harms related to unregulated opioid use. Examples of harm reduction in health care settings include the provision of naloxone kits, the distribution of safer injection supplies, supervised consumption services, drug checking, safer supply prescribing, and opioid agonist treatment (Amato et al., 2013; Black et al., 2022; Ferri et al., 2011; Ferri et al., 2013; Ivsins et al., 2020; Karamouzian et al., 2018; Kerr et al., 2017; Strike & Miskovic, 2018). These interventions have demonstrated benefits, including reducing infectious disease transmission, overdose deaths, substance use practices that lead to harms, as well as enhancing therapeutic relationships and increasing referral to services (Fernandes et al., 2017; Lightfoot et al., 2009; Marshall et al., 2011; McDonald & Strang, 2016). To date, many such interventions have occurred in community settings under the scope of public health and primary care (Marshall et al., 2011; Strike & Miskovic, 2018; Syme et al., 2011). There is currently a burgeoning of harm reduction interventions in the acute care setting, and in particular, interventions designed for people who use unregulated opioids. Harm reduction interventions are especially needed in this setting because people who use unregulated substances are more likely to rely on hospital-based services for their acute and chronic medical needs compared to the general population, and may resort to the hospital as a means to obtain primary care (Artenie et al., 2015; Lennox et al., 2021). In addition, the hospital has simultaneously been described as a “critical touchpoint” for people who use unregulated substances to access the health care system, as well as a “risk environment,” whereby factors such as abstinence-only policies and inadequate withdrawal management can intersect to contribute to an increased risk for substance use related harms (Lennox et al., 2021; McNeil et al., 2014). 63 A number of acute care-based harm reduction interventions applicable to unregulated opioid use have been proposed and documented in the Canadian context, including making available addiction consultation services and inpatient supervised consumption services, providing opioid agonist treatment and take-home naloxone kits, distributing safer use supplies, as well as facilitating referrals to relevant community supports (Dogherty et al., 2022; Lennox et al., 2021; Kestler et al., 2019a; Kestler et al., 2019b; Koh et al., 2020; Sharma et al., 2017). Implementation of those harm reduction interventions in the context of emergency departments (EDs) hold particular promise. The ED is a source of both urgent and primary care for people who use unregulated substances, who often resort to the ED due to gaps in primary care and appropriate wraparound services in the community setting (Fairbairn et al., 2012; Parashar et al., 2014). In addition, an alarming 5.5 percent of individuals treated for non-fatal opioid overdose in EDs die within one year of their visit, of whom, 20.5 percent die within the first month (Weiner et al., 2020). The ED thus services as a critical point of contact, offering opportunities to deliver potentially life-saving interventions, such as take-home naloxone kits, induction of opioid agonist treatment, as well as referrals for ongoing care (Hawk et al., 2021; Moe et al., 2021). Available research on ED implementation of harm reduction interventions specific to people who use unregulated opioids is scarce. While many interventions are possible, the existing literature and clinical practice focuses predominantly on two interventions: take-home naloxone for people who have either experienced an opioid overdose, or are deemed as at risk for an overdose; and opioid agonist treatment, including treatment induction and referral to ongoing care in the community (Black et al., 2022; Dora-Laskey et al., 2021; Langabeer et al., 2020; Low, 2020; Mullennix et al., 2020; Snyder et al., 2021). Several studies address contextual factors that may influence ED implementation of harm reduction interventions, including factors 64 at the service provider level, such as staff knowledge and attitudes (Drainoni et al., 2016; Holland et al., 2019; Lacroix et al., 2018), and factors at the policy level, such as policies for identifying eligible patients (Drainoni et al., 2016; Holland et al., 2019). Additional factors identified are at the level of infrastructural support, such as having targeted electronic medical record systems alerts (Drainoni et al., 2016), and at the level of interdisciplinary / interagency engagement, such as having support from the hospital pharmacy, or mechanisms for transitioning to community-based services (Cisewski et al., 2019). Overall, the existing literature tends to offer descriptions of how a single harm reduction intervention was developed, implemented, and evaluated, without explorations into how the ED is organized as a system to provide harm reduction interventions. Furthermore, challenges to implementation are often attributed to parts of the system that are deemed ‘broken’ (Dekker, 2010), as opposed to articulating facilitators and barriers to implementation considering how these parts interact (Widmer et al., 2018). A systems perspective offers a unique and helpful lens to study harm reduction intervention implementation in the ED. There is a growing literature conceptualizing health care organizations, including EDs, as systems to acknowledge and appropriately attend to their multiple, interdependent, and interacting elements (Widmer et al., 2018). Consequently, interventions that aim to tackle challenges within health care organizations require an understanding of how the system is organized as a whole, and must also account for how various elements of the system interact with one another (Widmer et al., 2018). Conceptualizing the ED in this way allows for examination of how it is organized to provide harm reduction, while also enabling the identification of facilitators and barriers to implementation considering interactions between elements of the system. This type of understanding is urgently needed and can 65 contribute to the formulation of tailored strategies – grounded in evidence – to better leverage opportunities for impactful implementation of harm reduction interventions in the ED. Purpose Using the ED at St. Paul’s Hospital in Vancouver, Canada as a case study, the purpose of this paper is to respond to this evidence gap. This paper has three objectives: 1. To describe the elements of the ED, as a system, involved in the organization and delivery of opioid specific harm reduction 2. To describe the required interactions between various elements of the system to support harm reduction implementation 3. To describe the facilitators and barriers to harm reduction implementation associated with these interactions and their potential impact on the delivery of care To our knowledge, there is no published research in the Canadian context that adopts a systems perspective to examine how the ED is organized to provide harm reduction interventions, nor identifies facilitators and barriers to implementation in light of interactions between system elements. Conducting such an analysis has implications for the development and implementation of ED-based harm reduction, with the potential to reduce the harms that are associated with unregulated opioid use. Theoretical Framework To address these research objectives, this study is guided by the theory of complex adaptive systems (CAS). A CAS approach considers systems, such as the ED, as a whole entity, and directs a focus on the emergence of system structures and behaviours as a function of patterns of interaction among system agents (McDaniel & Driebe, 2001; Widmer et al., 2018). Within a CAS framework, characteristics of a system are understood to arise from the 66 characteristics of its agents and their interactions, yet they are not reducible to these characteristics (McDaniel & Driebe, 2001). In addition, one is unable to determine structures and behaviours of the system by observing the properties of constituent parts nor summing their behaviours (McDaniel & Driebe, 2001). Instead, a CAS has both positive and negative feedback loops, whereby the effect of any one agent’s activity can feedback on itself, as well as influence the activity of others (McDaniel & Driebe, 2001). The system engages in self-organization through the emergence of new structures and behaviours as a result of these feedback loops (McDaniel & Driebe, 2001). Thus, the characteristics that a CAS displays are not externally imposed, and are rather a function of patterns of interaction among its agents (McDaniel & Driebe, 2001). Although an agent’s range of interaction may be short, their range of influence is often wide (McDaniel & Driebe, 2001). Furthermore, interactions among system agents are nonlinear, where inputs are not proportional to outputs and small changes can lead to big effects. Although interactions among system agents often follow and are constrained by simple rules, complex behaviour can emerge in the system (McDaniel & Driebe, 2001). Please see Figure 2 for an illustration of the components of a CAS. 67 Figure 2 Simple Representation of the Components of a CAS Note. Adapted from Evidence Scan: Complex Adaptive Systems by The Health Foundation (2010), from https://www.health.org.uk/sites/default/files/ComplexAdaptiveSystems.pdf. Copyright 2010 by The Health Foundation. The framing of complex adaptive systems has been utilized to study health care organizations in a number of ways, including to examine the roles and interrelationships within the healthcare workforce, to provide insight on how to manage health services, and to facilitate organizational development, change, and reform (Brown, 2006; Cepoiu-Martin & Bischak, 2018; Chaffee et al., 2007; Chen et al., 2007; Edgren, 2008; Horvat & Filipovic, 2018; Lindstrom, 2003; Minas, 2005; Nesse at al., 2010; The Health Foundation, 2010). Most often however, CAS thinking has been applied to explore health service delivery, where this approach has been used Emergence of structures / behaviours of the system Patterns of interaction as a result of feedback loops Interactions between diverse agents of the system 68 to explore an array of topics, including clinical complexity, patient trajectories, clinical decision making, and health care teams (Allred et al., 2005; Bandini et al., 2018; de Bock et al., 2018; Kuziemsky, 2016; Martin et al., 2011; Pype et al., 2018; The Health Foundation, 2010). Although there has been previous work that has noted the need to study EDs as complex adaptive systems (Camorlinga & Camorlinga, 2016; Petrie & Comber, 2019; Widmer et al., 2018), there has been very limited empirical research that conceptualizes EDs as CAS. Of note, in a study by Nugus et al. (2010), the authors examine how emergency clinicians manage dynamic boundaries between the ED and other hospital departments and organizations in striving to integrate care and meet the patient’s needs. Similarly, there has been a dearth of research that embraces EDs as complex adaptive systems in examining facilitators and barriers of implementing harm reduction interventions. As research that adopts the lens of CAS has the potential to offer numerous benefits, including delineating patterns of interactions between system agents, and gaining a more comprehensive understanding of forces that affect change (The Health Foundation, 2010), an analysis of how the ED is organized as a CAS to provide harm reduction interventions has the potential to contribute to the formulation of tailored, nuanced, and effective strategies to improve harm reduction implementation in the ED. Methods Research Design This paper draws on interview and policy data that were collected as part of the dissertation work of the first author (S. J.), which utilized a case study design to examine how harm reduction interventions for unregulated opioid use are implemented in the context of an ED in British Columbia, Canada, and to delineate the contextual factors that may influence harm 69 reduction implementation. Case study methodology allows for an in-depth investigation into numerous dimensions of complex phenomena (Crowe et al., 2011), such as those evident within complex systems like the ED. It is often used when the phenomenon of interest is too complex, context-bound, or context-sensitive to be studied in other ways (Ragin, 2015). Through drawing on various sources of data (e.g., interviews, surveys, text documents, etc.) to capture multiple facets of a phenomena (Yin, 2018), case study methodology allows for an examination of system elements at play, including the unique configuration of factors that serve as system facilitators or barriers, while also enabling those interrelationships to be considered in other similar systems. Case study methodology is compatible with the theoretical framework of CAS because, in both, systems are conceptualized as constituted by various elements. While systems theory is concerned with how interactions among system elements shape how systems self-organize, case study methodology is appropriate for examining systems as cases that have configurational arrangements that require parts to be understood in relation to one another and in terms of the coherent whole. Setting The case selected for this analysis is the ED at St. Paul’s Hospital (SPH) located in Vancouver, Canada. SPH is an acute care hospital that serves a client population disproportionately impacted by health and social inequities, including people who use unregulated substances, people who experience homelessness, and people living with a diagnosis of HIV (Providence Health Care, 2019a). In 2015-2016, there were more than 500,000 visits to SPH, comprising over 174,000 unique patients (Providence Health Care, 2016). SPH is known internationally for its expertise in harm reduction, including the development of a comprehensive set of harm reduction policies and the implementing of various harm reduction interventions. 70 SPH is also home to an in-house Addiction Medicine Consult Team, an onsite Rapid Access Addiction Clinic, and the second inpatient supervised consumption site in Canada (Braithwaite et al., 2020; Dogherty et al., 2022). The ED at SPH opened in 1962 and is one of the busiest EDs in the province of BC (Catholic Health Alliance of Canada, 2012; Providence Health Care, 2019c). In 2015-2016, there were more than 84,000 visits to the SPH ED (Providence Health, 2016). The ED serves a patient population with a high prevalence of people who use unregulated substances, and is, in many ways, a pioneer in the Canadian context in the provision of care for substance use, offering interventions such as take-home naloxone kits and access to a low barrier to-go Suboxone® program (Kestler et al., 2019a; Kestler et al., 2019b; Providence Health Care, 2018). Of all EDs that serve the city of Vancouver, the SPH ED is the closest to a geographical area known as the Downtown Eastside (DTES). The DTES is an area where residents experience a multitude of intersecting systemic inequities including extreme poverty, precarious housing, interpersonal violence, intergenerational trauma, as well as ongoing racism and colonialism (Downtown Eastside Women’s Centre, 2022). Substance use challenges are prevalent in the lives of many DTES residents (City of Vancouver, 2013). In 2021, the highest rate of drug toxicity deaths in the province (49.5 per 100,000) was in the Vancouver Coastal Health Authority, a region which encompasses the DTES (Ministry of Public Safety & Solicitor General, 2022). Due to its geographical proximity to the DTES, SPH has played a critical role in responding to the drug toxicity crisis, with its ED seeing the highest number of substance-related overdose of any ED in the province, and almost 10 times more than other hospitals in the Vancouver Coastal Health region (Vancouver Coastal Health, 2018; Vancouver Coastal Health, 2019). 71 Data Collection Data collection included individual interviews and document review, which were collected concurrently. We conducted a total of 20 in-depth interviews for this present study, with 15 of these being with ED nurses and physicians. Interviews used a semi-structured interview guide, and questions focused on the types of system agents that are involved in the delivery of opioid specific harm reduction in the ED, how system agents interact to support harm reduction implementation, and facilitators and barriers to implementation in light of these interactions as well as their impact on care provision. Inclusion criteria required participants be nurses (Registered Nurse and Registered Psychiatric Nurses) or physicians (staff physicians and resident physicians) who provide direct patient care. Interview recruitment occurred by asking survey participants of the dissertation study to identify if they would be willing to participate in a subsequent interview. The 10 nurse participants all held Registered Nurse designations. Physician participants included four staff physicians and one resident physician. Although demographic data were not collected systematically,10 eight interview participants noted their length of work in the SPH ED. They reported various levels of experience in the ED environment, ranging from 6 months to 12 years. As data collection unfolded, it was apparent that clinical leadership was a critical aspect of harm reduction intervention planning and implementation. Thus, we conducted five additional interviews with key clinical leaders with responsibilities associated with harm reduction interventions at the broader level of Providence Health Care. These interviews focused on their perspectives of policy, programming, and implementation of opioid specific harm reduction interventions. Sampling of the clinical leaders was purposive, whereby participants were 10 While demographic data was collected as part of the staff survey, this data was not linked to staff interviews in order to protect the confidentiality of study participants. 72 recruited for their experience in various roles, with the goal of capturing and understanding different angles and perspectives (Thorne, 2008). Clinical leaders who took part in the leadership interviews assumed various roles in the organization. For reasons of confidentiality, no details are provided as to their specific roles. All interview participants were offered a cash honorarium of $30 CAD. All interviews were audio recorded after obtaining consent from the participant. Data collection also included the identification and review of text documents in the form of organizational policies (n=9). Policies provide details pertaining to how the ED should function, encompassing information related to the roles, responsibilities, and availability of various system agents who are involved in the delivery of opioid specific harm reduction. Policies also addressed how these agents are expected to interact with one another to support harm reduction implementation. Policies were gathered from the Providence Health Care Shared Health Organizations Portal (SHOP) website. ED specific or organizational policies that addressed patients’ use of unregulated substances or harm reduction interventions were included. In total, nine organizational policies were gathered. (See Table 1 for policy title and purpose.). Table 1 Included Organizational Policies and Their Purpose Policy # Name Purpose 1 Harm reduction and managing substance use – Acute care (Providence Health Care, 2021c) To describe the organizational approach to managing substance use and implementing harm reduction interventions in the acute care setting 73 Policy # Name Purpose 2 Philosophy of care for patients and residents who use substances (Providence Health Care, 2020c) To articulate a philosophy of care for people who use substances that aligns with the organization’s vision and mission 3 Violence prevention in the workplace (Providence Health Care, 2019f) To describe the organizational approach in the prevention of workplace violence, and to delineate the roles of relevant parties (e.g., leadership, staff, and occupational health and safety) 4 Injectable opioid agonist treatment (iOAT11) for opioid user disorder and IV fentanyl for withdrawal management (Providence Health Care, 2022) To outline the protocols associated with the provision of iOAT and intravenous fentanyl 5 Dispensing take home naloxone kits to clients at risk of opioid overdose (adults and youth) (Providence Health Care, 2021b) To outline the protocol associated with the provision of take-home naloxone (THN) kits 6 Methadone for opioid use disorder (Providence Health Care, 2021d) To outline the protocol associated with the provision of methadone 11 iOAT (intravenous opioid agonist treatment) involves replacing unregulated opioids with prescribed opioid medications in injectable form. Examples include hydromorphone and diacetylmorphine (Providence Health Care, 2022). 74 Policy # Name Purpose 7 Buprenorphine / naloxone (Suboxone®) for opioid use disorder (Providence Health Care, 2020b) To outline the protocol associated with the provision of Suboxone® 8 Buprenorphine / naloxone ‘(Suboxone®) to-go’ patient kits for induction outside of hospital setting (Providence Health Care, 2021a) To outline the protocol associated with the provision of to-go Suboxone® kits 9 Overdose Prevention Site (OPS) at St. Paul’s Hospital: Operating procedures (Providence Health Care, 2021e) To outline operating procedures for the in-hospital OPS Approval for this research was obtained from the University of British Columbia (UBC) Behavioural Research Ethics Board (BREB). Data Analysis Audio recorded interviews were transcribed and all identifying information was removed. Interview data were analyzed using a reflexive thematic analysis (RTA) approach (Braun & Clarke, 2006), and informed by the theory of complex adaptive systems (McDaniel & Driebe, 2001). As per the RTA approach, coding was an iterative process, where we did not employ a fixed codebook at the onset. Rather, codes evolved as more interviews were reviewed. In generating the codes used, we considered the types of system agents who are involved in opioid specific harm reduction, how system agents interact to support implementation, and how patterns 75 of interaction can lead to the emergence of systemic facilitators and barriers to implementation. As part of this process, a number of initial codes were deleted, renamed, split, and/or combined (Braun & Clarke, 2019). These refinements allowed for the gradual development of themes as meaning-based patterns and facilitated a fulsome interpretation of the data (Braun & Clarke, 2019). NVivo™ Version 12 was used in coding the interviews. The theory of complex adaptive systems also informed the analysis of policy documents, which were reviewed to extract information pertaining to the roles, responsibilities, and availability of system agents involved in the delivery of opioid specific harm reduction, as well as how these agents are expected to interact with one another to support harm reduction implementation. To attend to triangulation, information extracted from policy documents was compared to the information provided by clinical leaders and ED staff to assess the extent to which the two were congruent, and whether there is alignment or disconnection. Both data sources contributed to descriptions of the types of system agents who are involved in the delivery of opioid specific harm reduction, as well as how interactions between system agents can support harm reduction implementation. The interviews with clinical leaders and ED staff further enabled a nuanced analysis of how patterns of interaction among system agents led to the emergence of systemic facilitators and barriers to implementation, including the potential impact for the delivery of care. Considerations of how the two data sources interface with one another ultimately helped to shape the resulting analysis as well as the presentation of study findings. Findings Our analysis showed that, in the context of the SPH ED, an array of system agents interact in ways that enable the provision of harm reduction interventions, including substance 76 use specialist services (e.g., the Addictions Medicine Physician, the Addiction Assessment Nurse, and the Overdose Prevention Site) and non-specialist providers (e.g., the Emergency Nurse and the Emergency Physician). (See Table 2 for detailed descriptions of system agents and their roles. See Figure 3 for a system map of the ED outlining the various interactions between system agents). At the same time, limited access to specialized providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, creates tensions in the system that hinder harm reduction provision, where system agents are unable to work in synergistic ways to accommodate the 24 hour/day service delivery model of the ED. Following, we detail how access to specialist providers intersects with issues of control, reliance, and safety to influence the provision of three harm reduction interventions: opioid agonist treatment, supervised consumption, and withdrawal management, including the resulting implications for patients. While the types of harm reduction interventions and the factors influencing their provision are addressed separately for this analysis, we acknowledge the complex interplay between these interventions and influential factors, where one factor may influence the provision of multiple interventions, or the implications of one factor for the provision of one intervention may lead to the need for a second, different intervention. Table 2 Diverse Agents of the ED System agent Role Substance use specialist services Addictions Medicine Physician The Addictions Medicine Physician is responsible for assessing the patient concerning their unregulated substance use, 77 System agent Role including the severity of any presenting substance use disorders and stage of change, and establishing connections to treatment (Providence Health Care, 2020a). They also treat withdrawal, cravings, and pain with the goal of enabling the treatment of the patient’s admitting diagnosis (Providence Health Care, 2020c; Providence Health Care, 2020a). The Addictions Medicine Physician is available seven day a week, and are on-site from 8 am and 5 pm, and available by phone from 5 pm to 8 am (Providence Health Care, 2021c). Addictions Assessment Nurse (AAN) Addiction Assessment Nurses (AANs) work in the ED and have expertise in care provision for people who use unregulated substances. They can assist with various aspects of care, including liaising with the Addictions Medicine Physician, obtaining information from community health providers, connecting patients to appropriate substance use related services in the community, helping to facilitate access to the in-hospital OPS, and 78 System agent Role providing mentorship and support to ED staff. They are available seven days a week from 8 am to 6 pm. Rapid Access Addiction Clinic (RAAC) The RAAC is an outpatient clinic that is located within the hospital that provides short-term treatment for people with substance use specific health concerns and connects people to care providers in the community for long term management (Providence Health Care, 2021c). The clinic facilitates connections to a variety of health and social services such as detoxification, counselling, housing, and financial aid (Providence Health Care, 2021f). It is open seven days a week from 9 am to 4 pm (Providence Health Care, 2021c). The clinic accepts referrals from the ED and inpatient units, community providers, and patient self-referrals (Providence Health Care, 2019b; Providence Health Care, 2021f). It has a mandate to see referred patients within a 24-48 hour window, and walk-ins are seen on a 79 System agent Role first come, first served basis until capacity is reached for the day (Providence Health Care, 2019b; Providence Health Care, 2019d). Overdose Prevention Site (OPS) Registered patients of the hospital, including ED patients, have access to the in-hospital OPS (Providence Health Care, 2021c). At the OPS, patients can use their personal supply of injection drugs and subsequently return to the ED to continue their care. The OPS is staffed by nurses who are responsible for overdose prevention and response, and harm reduction education and supply distribution, including take-home naloxone kits and safer use supplies (Providence Health Care, 2021c). The OPS is open from 10 am to 8 pm seven days a week (Providence Health Care, 2021c; Providence Health Care, 2021e). Non-specialist providers Emergency Nurse The Emergency Nurse's role is expansive. For the purpose of this paper, which pertains to care provision for people who use unregulated substances, the Emergency Nurse is 80 System agent Role responsible for ensuring that the patient’s substance use related needs are met through advocating for any necessary interventions on their behalf, providing treatments / interventions ordered, assessing effectiveness, providing patient education, and helping to coordinate all aspects of care provision related to substance use, both within the ED and through substance use specialist services that exist outside of the ED environment. Emergency Physician The Emergency Physician's role is expansive. For the purpose of this paper, which pertains to care provision for people who use unregulated substances, the Emergency Physician is responsible for ensuring that the patient’s admitting diagnosis is attended to, and that any needs related to substance use are also addressed, either through their own efforts or through referral to substance use specialist services, such as the Addictions Medicine Physician, the Addictions 81 System agent Role Assessment Nurse (AAN), and the Rapid Access Addiction Clinic (RAAC). Figure 3 System Map of the ED Note. This system map illustrates how various agents of the system are engaged within the context of different harm reduction interventions in the ED (OAT, withdrawal management, and supervised consumption). Its intention is not to capture the relationships between system agents. Opioid Agonist Treatment: The Interplay of Access and Control For some who use unregulated opioids, their goal may be to access opioid agonist treatment (OAT), which works by replacing an unregulated opioid with prescribed opioid 82 medications. OAT is a harm reduction intervention that can help to prevent withdrawal and reduce cravings. It can also offer a safer alternative to unregulated opioid use, which is vital in light of the ongoing drug toxicity crisis (British Columbia Ministry of Mental Health and Addictions, 2021).12 The SPH ED offers a number of options for OAT, including diacetylmorphine and hydromorphone as iOAT, and methadone, Suboxone® (Providence Health Care, 2020b; Providence Health Care, 2021a; Providence Health Care, 2021d; Providence Health Care, 2022), and Kadian® as oral OAT. An array of system agents, including both substance use specialists and non-specialists, interact with one another to enable the provision of OAT, as illustrated in Figure 3. Of which, the Addictions Medicine Physician – a substance use specialist – plays a most critical role. If a patient presents to the ED and is interested in OAT, the Emergency Physician can make a referral to the Addictions Medicine Physician, who can assess the patient and order the most appropriate form of treatment (Providence Health Care, 2020b; Providence Health Care, 2021a; Providence Health Care, 2021d; Providence Health Care, 2022).13 A referral can also be made to the Addictions Assessment Nurse, who can assess the patient and subsequently liaise with the Addiction Medicine Physician to obtain orders for OAT. While the Addictions Medicine Physician as a specialist service enables the provision of OAT, it simultaneously controls provision. This is because, for most types of OAT, with the exception of Suboxone®, the involvement of the Addictions Medicine Physician is mandatory – either the Addictions Medicine Physician has to order the treatment, or the Emergency Physician 12 We acknowledge that OAT is both a long-term treatment for people who wish to abstain from unregulated opioid use, as well as a harm reduction intervention that offers overdose protection and withdrawal management while people continue to engage in use. For the purpose of this paper, we focus on OAT as a harm reduction intervention. 13 We acknowledge that the mandatory engagement of addiction specialists in the provision of OAT (with the exception of Suboxone®) is a SPH specific practice, and that this may not be the case for other acute care settings. 83 needs to consult with the Addictions Medicine Physician prior to ordering OAT (Providence Health Care, 2020b; Providence Health Care, 2021a; Providence Health Care, 2021d; Providence Health Care, 2022). Pharmacy, I don’t think will release Kadian® [slow release oral morphine] to us unless we speak to the Addictions Physician on call... Last time I tried to do it, there was that extra piece, and I think methadone as well had the same issue. So when I tried to give methadone for a patient who required their evening dose, the pharmacy refused to release it without a conversation with Addictions. – ED staff Despite the extent of control that the Addictions Medicine Physician has over the provision of OAT, there are several limitations on access to this specialist service – in terms of which types of ED staff can make the specialist referral, when different types of staff can access the specialist service, and when it would be appropriate to contact the service afterhours. First, referrals must come from the Most Responsible Physician (the medical service under which the patient is admitted in the hospital, which in the ED setting, is often the Emergency Physician), the Addictions Assessment Nurse, or the Clinical Nurse Leader (Providence Health Care, 2021c). That is, the Emergency Nurse, who has the most direct contact and engagement with the patient is not able to make such a referral and must go through other care providers. We [Emergency Nurses] can’t call Addictions, the MRP [Most Responsible Physician] has to be the person that calls Addictions. So we don’t call Addictions. That’s just what is. That is directed from our on-call list, it’s just not allowed for us to call. If it was the ERP [Emergency Physician] or if they were admitted under CTU or GI [other medical services under which a patient can be admitted], those people would have to call. – ED staff Second, once a patient has been referred to the Addictions Medicine Physician, the Emergency Nurse has direct access to (and can call) the Addiction Medicine Physician only during the daytime hours of 8 am to 5 pm. Only the Emergency Physician has direct access to the Addictions Medicine Physician outside of these hours (Providence Health Care, 2021c). 84 Third, there are limitations on when it would be appropriate to contact the Addictions Medicine Physician afterhours. The Emergency Physician can contact the specialist service for guidance on new patients, or “when the clinical team has attempted all available strategies and substance use issues are still unmanaged” (Providence Health Care, 2021c, p. 6). The Emergency Nurse can advocate for such contact for issues including but not limited to: uncontrolled opioid withdrawal, and order clarification for medications ordered by the specialist service (“try to call before 2200 [10 pm]” and “ideally for orders that cannot wait until the following morning to be clarified”) (Providence Health Care, 2021c, p. 6). Policy dictates that the Emergency Nurse is also not to advocate for contact for pain management, with the stated assumption in the policy that pain may indicate an acute medical issue. Instead, if the patient is experiencing new onset or worsening pain, they are to ask the Emergency Physician to assess, who can then address the pain or contact the afterhours Addictions Medicine Physician if they deem there is a need to do so (Providence Health Care, 2021c). It is perhaps, in part, due to these various limitations that there is a great discrepancy in how staff in the ED speak about afterhours access to the Addictions Medicine Physician. While some ED staff are certain that this specialist service is available 24 hours a day, others have voiced that this has not been their experience. That is, although in theory the Addictions Medicine Physician is available around the clock, this may not be the case in practice. These discrepancies are highlighted through participants who report conflicting experiences in practice. For example, one participant shared: Addictions is always available by phone... If the patient requires Kadian® at eight o’clock at night, we would call them, they’d call back, we’d get approval of the Kadian® and the Kadian® comes up from pharmacy and the patient gets their drug. – ED staff 85 And yet, another participant had quite a different experience when trying to access the Addictions Medicine Physician, stating: The Addictions team [is] not [available] around the clock. Our Addictions Nurse is there until maybe like five or six, and sometimes the Addictions Medicine team is around that time as well, but sometimes the plan of care of patients in our department [is] "Addictions to see in the morning” or “Addictions Nurse to see in the morning,” so overnight they are not accessible. – ED staff The interplay between specialist control over OAT provision and access to these same specialists can create tensions in the system that hinder ED staff ability to comprehensively and consistently provide this specific harm reduction service to patients. If, for instance, a patient attends the ED after 5 pm and is interested in OAT, they will not be able to see the Addictions Medicine Physician. Instead, at the point of discharge, they will be referred to an outpatient service, such as the in-house Rapid Access Addiction Clinic (RAAC), to initiate OAT. However, the RAAC is also not available at all hours of the day (9 am to 4 pm). After the RAAC is closed, the Emergency Nurse can provide the patient with a brochure about the clinic. The provision of a brochure to people who are simultaneously navigating competing life priorities, such as securing food or shelter, or managing withdrawal, is insufficient. This is because these competing needs render the patient less likely to return to attend the RAAC on a different day. ED staff members speak to how the patient’s visit to the ED is a window of opportunity to facilitate access to OAT, and how due to limited access to specialist services such as the Addictions Medicine Physician and the RAAC, these opportunities are missed: What is really unfortunate is people that come in the middle of the night... There is no Addictions doc and RAAC is not open... We can tell them to go in the morning but they never do because there is a very small window. – ED staff If RAAC is closed, which is two-thirds of the time at least, you would say “here is a pamphlet and I encourage you to go to RAAC in the morning.” That obviously is just so much less of a closed loop. I think the chances of us getting them is just so much lower, but I do that all the time because that is just our reality. – ED staff 86 Withdrawal Management: The Interplay of Access and Reliance People who use unregulated opioids are at significant risk for withdrawal while accessing care due to factors such as prolonged wait times, abstinence-based policies, and the inadequate recognition and management of withdrawal needs (Horner et al., 2019; McNeil et al., 2014; Monks et al., 2013; Strike at al., 2020). Untreated opioid withdrawal is extremely uncomfortable and distressing for the patient, and is associated with the use of unregulated opioids and a high risk of overdose deaths after discharge from the ED (Herring et al., 2019). There is further evidence that unmanaged withdrawal can lead to the patient leaving without having their care completed (Chan Carusone et al., 2019; McNeil et al., 2014; Simon et al., 2020). Withdrawal management is a harm reduction intervention available in the SPH ED (Figure 3). When people attend the ED and are undergoing opioid withdrawal, or are at risk for withdrawal, the Emergency Physician has the authority to order the treatments required, which is typically an opioid medication, such as hydromorphone or morphine. However, as a non-specialist provider, the Emergency Physician may not feel that they have the expertise required, or they may not be comfortable ordering the doses needed, as conveyed by study participants below: So sometimes the dosing is unclear, so if somebody is on 1000 [mg] of Kadian® a day, it is difficult for, because the amounts are way out of what we’re used to, what we’re comfortable with in terms of dosing of narcotics, and so when we’re giving and trying to translate into how much Dilaudid does this patient need to stop their acute withdrawal. – ED staff I have a ton of experience with this patient population but I would still say that I probably don’t give sufficient doses... I wouldn’t say I’m not comfortable with, I’m not worried about that I’m going to overdose these patients... It’s just that I perhaps don’t appreciate what frequency of dosing and how large the dosing sometimes needs to be. So I’m certainly happy to make an effort, but I would bet that I often undershoot. – ED staff 87 Participants also spoke to how the patient’s clinical complexity related to active opioid use, acute illness, and the ever-changing drug supply, can further complicate withdrawal management: I would say the most worrying part is when you’re giving those high doses and the patient is using as well, just because then you have no real gauge of how much they’ve actually had. What is harder is... when the patient is really sick and you’re trying to also handle their withdrawal needs, so it’s hard to tell the clinical picture from that, they’re delirious and tachycardic, restless, agitated, but drowsy, and it’s hard to gauge if you should be giving more or less opioids. – ED staff I couldn’t have even fathomed that there would be an additional thing [benzodiazepines] that would be in the drug supply to make life harder... So it is an added factor... What we can give you to meet your needs in respect to your withdrawal and your pain, if you just used a whole bunch of fentanyl, which is what you’re used to, but unknowingly you’ve also used a bunch of benzodiazepines... It makes it a lot harder if you don’t know exactly what is on board. – ED staff Consequently, the Emergency Physician may need to rely on their specialist colleagues for withdrawal management, which can be facilitated through interactions with several types of specialist providers, as presented in Figure 3. Below, an ED staff member speaks to the option of referring to the Addictions Medicine Physician, who can assess the patient and order the treatments required: I think lots of people [Emergency Physicians] will call the Addictions team [to assist with withdrawal management] and some people are comfortable to give what tends to be an arbitrary dose [of medication for withdrawal management]. – ED staff The Emergency Physician can also refer to the Addictions Assessment Nurse, who can assess the patient and share results of their assessment with the Addictions Medicine Physician, who can order the required treatments. Alternatively, the Addictions Assessment Nurse can make a treatment recommendation to the Emergency Physician, as shared by the following participant: They’re [the Addictions Assessment Nurses] very attuned to figuring out what the patient’s history is, what’s appropriate for this patient, their dosing levels based on what they’re getting prescribed on paper but also what their substance use is in real life. And then helping to advocate for that... The AANs are recognized as experts in this area, and so they advocate and they make a recommendation to say, the Emergency physician, that 88 is often received very well and they trust that advice, and they’ll actually usually act on it. – Clinical leader Although the Emergency Physician may rely on specialist providers in managing opioid withdrawal, as noted previously, the Addictions Medicine Physician is, in effect, available from 8 am to 5 pm. Additionally, the Addictions Assessment Nurse is available from 8 am to 6 pm. The reliance of non-specialist providers on specialist services, when coupled with limited access to these same services, can translate to increased patient suffering and distress as a result of the patient’s withdrawal needs not being adequately met, which was the experience of the participant below: I always find it very helpful if it’s daytime, it’s 10 am, and I call Addictions and they come down... It is incredibly helpful to have that support. Afterhours, that is really tricky and I’m sure those patients get suboptimal care. – ED staff While during the day, the Addictions Assessment Nurse may be able to advise the Emergency Physician as to what would be an appropriate dose for withdrawal management, the Emergency Nurse may not have the same expertise to do so afterhours: If an Emergency Nurse tries to advocate for, “we need to something for their withdrawal,” and the doctor says, “well, what do you want to give them?” “Well I don’t know. I don’t know what they need. That’s not my area of expertise.” – Clinical leader Implications for the patient are substantial, include using at the bedside, in the patient bathrooms, or using outside, thereby posing a risk for unwitnessed overdose. Patients may also be forced to leave without completing the necessary care for the urgent health issue that necessitated their ED visit. An ED staff member speaks to the implications of not having access to the Addictions Medicine Physician afterhours: If it’s afterhours, they don’t have Addictions to call, so I think it gets much less, done much more poorly then. I think what ends up happening is people leaving against medical advice [without having their care completed] because they’re in withdrawal and they’re not getting that, and that’s a big problem. I think that is a very, very real phenomenon. Very common. – ED staff 89 Supervised Consumption: Interplay of Access and Safety The use of unregulated substances by patients, including opioids, is not permitted in the ED and policy states that this rule is due to safety concerns related to unwitnessed overdose (Providence Health Care, 2021c), which, as noted earlier, is amplified in the current toxic drug supply crisis, especially related to the use of unregulated opioids such as fentanyl (Ministry of Public Safety & Solicitor General, 2022). However, given patients' expertise in what substances are most appropriate for them (CATIE, 2022a), they may wish or need to use their own unregulated opioids while attending to care. The ED acknowledges the reality of these circumstances and consequently provides a harm reduction intervention, the Overdose Prevention Site (OPS), to enable in-hospital substance use (Figure 3). The OPS is a safe space to inject substances under the supervision of nurses who are able to respond in the event of an emergency (Providence Health Care, 2021c; Providence Health Care, 2021e). A clinical leader speaks to the role of the OPS to prevent unwitnessed overdose and promote safety: Keep our patients safe, give them a safe place to go and use... so that patients aren’t using at their bedsides, patients aren’t using in stairwells and nooks and crannies, and overdosing. – Clinical leader A number of system agents are involved in facilitating access to the OPS (Figure 3). ED staff are to let patients know about the availability of the OPS and patients can attend the OPS as long as their clinical condition allows them to do so. A clinical leader elaborates on the approach taken by ED staff: Respectfully telling them [the patient], "you’re not to use in the bathroom, in the bed, it’s not safe due to risk of overdose, it’s just not safe." So, we direct patients to the OPS if they are able to go there. – Clinical leader 90 The Addictions Assessment Nurse (AAN) can help ED staff make decisions about whether a patient is clinically appropriate to attend the OPS. A participant speaks to this aspect of the Addictions Assessment Nurse role: The AAN can use their clinical judgement on whether or not someone should go up to the OPS at that time. Sometimes there are other sort of interventions that we can use to keep them in the department and depending on how much they need to stay there versus how safe it is for them to leave. It is really important to have that person with the clinical knowledge to support those decisions. – Clinical leader In addition, as the patient’s absence from the ED while attending the OPS may impact care provision, the Addictions Assessment Nurse can liaise with OPS staff to provide an estimated time for the patient’s return to the ED to resume care. The role of the Addictions Assessment Nurse as a liaison between the ED and the OPS is noted by a clinical leader: Any time that there are patients in ED who are looking to use substances, the AAN is sort of that bridge to getting someone from ED up to the OPS. They’re able to liaise with both teams and that way, if somebody is leaving ED, the staff in ED know that that patient is looked after, they know that they’re gone to the OPS, they know there is somebody they can call with an ETA on when that person is coming back. – Clinical leader Although the OPS may be the only option for patients who wish to use opioids in a safe manner while they are accessing care, this specialist service is only available from 8 am to 6 pm. An ED staff member speaks to their experience of having limited access to the OPS: Unfortunately, the Overdose Prevention Site is not as accessible as it was, it was never open 24 hours so everything that happens at night, you’re going to be dealing with that. – ED staff The interplay between concerns related to safety and limited access to a specialist service that is meant to serve as a workaround solution has profound implications for the patient. When the OPS is not available, the patient may defy organizational policy and use in the immediate ED environment. They often resort to using in isolated areas, such as at the bedside or in the patient bathrooms in order to avoid detection by ED staff, posing a risk for unwitnessed overdose. 91 Although the use of unregulated substances by patients, is not permitted, if a patient was found to be using in the immediate ED environment, they are not automatically discharged, or denied access to care. Instead, ED staff are to assess for safety and respectfully remind the patient that they are expected not to use in the department as it is unsafe (Providence Health Care, 2021c). They are to let the patient know about the availability of the in-hospital OPS. They are also to inform the Addiction Medicine Physician about the in-hospital substance use to see about ways that the health care team can work with the patient to better manage their needs, such as through offering medications for withdrawal management, or options for OAT (Providence Health Care, 2021c), although the availability of these options may be affected by issues related to control and reliance as noted previously. Despite the options available, however, the patient may not be interested. Prohibited from their own unregulated opioids, some patients may leave the ED and ultimately not receive the care that they need. Below, an ED staff member and a clinical leader speak to employing various strategies to support patients to complete care, and how this is not always possible. I straight away offer anything that’s already ordered PRN, to help with the withdrawal symptoms or pain, and then if we have already given as much as we have been able to, I’ll say "I can call the Addictions team and see if we can get you something more," and sometimes that might work for a short amount of time, but if they are very adamant, we can’t hold them. We can either say there is a safe injection site, because I always try to get out of them why they want to leave and what is their reasoning. Sometimes I ask straight up, "do you want to use?"... Just trying to understand exactly what their needs are and try to meet them, which you can’t always do. – ED staff Other patients may continue the use of unregulated substances in the ED environment. If substance use is ongoing, especially when there are "unsafe behaviours" that may jeopardize the safety of others, such as open flames, uncapped needles, unregulated substances left attended, or verbal or physical aggression (Providence Health Care, 2021c), the health care team may initiate a Behavioural Support Plan with the patient, which conveys that if the patient does not stop the 92 behaviour in question, they may be forcibly discharged and lose their bed (Providence Health Care, 2019f). Similar to aforementioned barriers to harm reduction provision, this scenario also decreases the likelihood of the patient receiving care. A clinical leader speaks to how the ED manages unregulated substance use that is deemed unsafe – an approach that is also reflected through organizational policy (Providence Health Care, 2019f; Providence Health Care, 2020c). If substance use is ongoing, especially if it’s in a unsafe manner, then we’ll start to think about a care plan for the patient and if the behaviour is unsafe, then we can look at what’s called a Behaviour Support Plan… It will say "this is the unsafe behaviour," it’s almost like a contract with the patient, "here is what is unsafe, here is what we’ll do instead" and then "if I don’t stop doing this unsafe behaviour then I might be discharged," sometimes that’s the outcome. – Clinical leader Discussion Using the ED at St. Paul's Hospital in Vancouver, BC as a case study, this paper examines, through a systems lens, how a Canadian ED is organized to provide harm reduction interventions in an unregulated opioid use context, and identifies facilitators and barriers to harm reduction provision in light of interactions among various agents and elements of the system. Study findings demonstrate that diverse system agents, including substance use specialist services and non-specialist services, interact with one another to enable the provision of a number of harm reduction interventions, including opioid agonist treatment, supervised consumption, and withdrawal management. Existing studies report on the benefit of having substance use specialist services available in the acute care setting in enabling an array of harm reduction interventions including withdrawal management, safe opioid prescribing, naloxone prescription, the induction of opioid agonist treatment (Englander et al., 2019; Priest & McCarty, 2019; Perera et al., 2022). However, these studies do not adopt a systems perspective, nor address how specialist services facilitate harm reduction provision in light of interactions with other system agents. To assess the role of a system agent in contributing to system success or 93 failure without considering its various interrelationships can lead to the formulation of strategies that are ineffective and produce unintended consequences or suboptimal outcomes (Dekker, 2010; Widmer et al., 2018). Findings also highlight the resounding impacts of limited access to the substance use specialist services, especially the Addictions Medicine Physician and the Overdose Prevention Site. Although the ED has the potential to make harm reduction interventions such as OAT induction and withdrawal management available at all hours of the day, limited access to substance use specialist services can mean that this potential varies throughout the day, and the system is unable to support harm reduction provision in a way that is consistent with the around-the-clock service delivery model that is associated with the ED. Previous literature that describe substance use specialist services that operate in the acute care setting have similarly reported that access to these services is limited, especially on the weekend, where care providers have voiced frustration that patients who were admitted or discharged over the weekend were not receiving life-saving substance use related services (Priest & McCarty, 2019). Even among specialist services that were available to provide in-person consults on the weekend, this was tasked to trainees (Priest & McCarty). Given the immense benefits of having access to substance use specialist services, availability that is not congruent with the operating hours for settings like the ED is problematic. There is little reason that, while the ED care delivery model recognizes that people's health care needs occur at all hours of the day, the same recognition does not apply to serious, substance use related needs, such as withdrawal management and overdose prevention. This concern is significant, especially in light of evidence that more than half of referrals to acute care-based substance use specialist services originate from the ED (Braithwaite et al., 2020). 94 While the existing research only point to a lack of staffing resources as a reason for limited access to Addictions consultation services (Priest & McCarty, 2019), our study draws attention to the impact of organizational policy on access – policies that prohibit the Emergency Nurse from advocating for contact with the afterhours Addictions Medicine Physician for concerns related to pain management, and from having direct access the Addictions Medicine Physician afterhours. Unspoken in these restrictions is the assumption that nurses are unable to assess patients independently or appropriately – an assumption that is not supported by the scope of practice for nurses in this province (British Columbia College of Nurses & Midwives, 2022). These restrictions speak to hierarchical relations of power as applied to nurses and physicians in determining patient needs, and consequent to such restrictions, nurses are underutilized and unable to practice to their full professional scope, contributing to missed opportunities for harm reduction provision. Aside from explicit restrictions imposed by organizational policies, there are also implicit restrictions, as evidenced by a discrepancy between the Addictions Medicine Physician's hours of availability in theory versus in practice. Findings in this paper illustrate the need for a more nuanced understanding of what is shaping such discrepancies, and how ED staff are experiencing and navigating them. Findings also underscore the impact of specialist control on the provision of harm reduction, where, with the exception of Suboxone®, all types of OAT can only be ordered by the Addictions Medicine Physician. Previously to 2018, physicians in Canada were required to obtain an exemption under Section 56(1) of the Controlled Drugs and Substances Act prior to prescribing or providing methadone. As a response to the drug toxicity crisis, and in an effort to increase access to OAT, this requirement was removed in May 2018 (Government of Canada, 2018). Furthermore, a Provincial Opioid Addiction Treatment Support Program (POATSP) has 95 been available to all physicians in BC since 2017, which, upon program completion, allows physicians to prescribe the full range of OAT and iOAT options, including methadone, Suboxone®, Kadian®, and injectable hydromorphone and diacetylmorphine (British Columbia Centre on Substance Use, 2021a). While these changes relay the message that harm reduction should not be limited to the practice of specialists, this perspective has not been reflected in hospital policies, potentially jeopardizing the capacity of the ED to provide OAT as a harm reduction intervention. While it would be naïve to assume that organizational policy is the only barrier to non-specialist prescription and provision of OAT, there is nevertheless the need to re-examine the possibility of policy changes in keeping with regulation reform (prescribing), while, at the same time, exploring additional barriers, such as a lack of education or training, or concerns related to patient safety. In the system that is the SPH ED, multiple barriers to harm reduction implementation relate to restrictions placed on the Emergency Physician's scope of practice, such as those pertaining to the ordering of OAT, thereby hindering the ability of the Emergency Physician to provide the full scope of harm reduction interventions. It is clear that there is prevailing, hegemonic discourse that care provision for people who use unregulated substances is a highly specialized practice – a discourse that is also reflected through how organizational policies were constructed. Harm reduction, however, began as a grassroots movement instigated by people who use unregulated substances and their allies (Roe, 2005), and was never intended to be constrained to the realm of experts. Yet, harm reduction has been co-opted into the biomedical paradigm, which privileges the knowledge of "experts" and the need for specialization (Jiao, 2019). It is worth considering why the ED is reinforcing the need for expertise and specialization when this type of discourse is impeding harm reduction provision. There is also a need to inquire 96 into how Emergency Physicians are experiencing, and taking up policies, that restrict their scope of practice, and how they situate themselves in the conceptual tension of harm reduction as a technical solution versus a contextualized social practice (Jiao, 2019). Finally, study findings underscore that appropriate harm reduction interventions not only helps to prevent unwitnessed overdose, and increase access to safer opioid alternatives, but can ultimately supports patients to complete their care in the ED. There is an abundance of evidence that people who use unregulated substances may leave the acute care setting without completing care due to factors such as unmanaged withdrawal and ongoing cravings to use substances (McCreaddie et al. 2010; McNeil et al., 2014; Monks et al., 2013; Simon et al., 2020; Ti et al., 2015). By making available harm reduction interventions, such as supervised consumption and withdrawal management, the ED can attend to these needs and support patients to complete care. Conversely, ongoing substance use in the immediate ED environment, especially if there are related safety concerns, can jeopardize care completion, whereby the patient may be asked to participate in behaviour contracting, which may eventually lead to forcible discharge. Previous research in the Canadian context has similarly reported on the use of behavioural contracting and threats of / actual discharge to enforce expectations of abstinence in the acute care setting (Strike et al., 2020). These authors found that, due to a lack of institutional policy, care providers took vastly different approaches when they encountered active substance use, including "turning a blind eye," providing a safer opioid alternative, discharging the patient, and encouraging the patient to use outside and return (Strike et al., 2020). In contrast, our study found that care providers made earnest attempts to help the patient meet needs related to substance use, such as though offering OAT, managing opioid withdrawal, and inviting the patient to attend / 97 facilitating access to the OPS, prior to resorting to the use of behavioural contracting, or forcible discharge. Limitations There are several limitations to this study. First, due to the self-selection of qualitative interview participants, it is possible that study findings represent the insights and experiences of ED staff who are more accepting of harm reduction as a practice, and more willing to engage in harm reduction implementation. Second, in alignment with our theoretical framework of complex adaptive systems, we tried to capture the perspectives of various system agents, including Emergency Nurses, Emergency Physicians, and clinical leaders. We did not include occupational groups such as social workers or security personnel who work in the ED given that Emergency Nurses, Physicians, and clinical leaders are most directly involved in the implementation of harm reduction in the acute care context. The strength of this approach is that we were able to attain a nuanced understanding of the perspectives of those who are in a position to implement, or affect the implementation of harm reduction. However, we were unable to include Addictions Medicine Physicians in our study sample. There is a need for a larger scale examination of harm reduction implementation in the ED that considers the perspectives and experiences of all stakeholders, including patient perspectives. Third, despite the use of case study methodology, which supports the generation of highly contextual findings, we believe that our study findings hold relevance for other EDs in the province and across the country, regardless of their current stage of harm reduction implementation. For EDs that have harm reduction interventions that are underway, study findings can provide opportunities for further optimization through illustrating the need and importance of attending to interrelationships between system agents. For EDs that have limited engagement in harm reduction provision to 98 date, but are looking into the possibility of future implementation, study findings can similarly provide valuable guidance. Conclusion In the advent of an ongoing drug toxicity crisis related to the use of unregulated opioids in Canada, there is an urgent need to expand harm reduction approaches across all service provision settings, especially in the ED, which serves as a critical point of connection for people who use unregulated substances to the health care system. Existing research on harm reduction implementation in the ED context is scarce, and often offers descriptions of how a single harm reduction interventions was developed, implemented, or evaluated. In contrast, the present study delves into how the ED is organized as a system to provide harm reduction interventions, and identifies facilitators and barriers to implementation in light of interactions between diverse system agents, while considering the interplay between access, control, reliance, and safety. The findings of this study are novel and unique, and have the potential to contribute to the formulation of effective strategies to improve harm reduction implementation in the ED. 99 Chapter 4: Harm Reduction in the Emergency Department: How Staff Provide Harm Reduction and Contextual Factors that Impact Their Capacity to Engage in Harm Reduction Practice Chapter 4 is the second findings chapter of this dissertation. Building on findings of Chapter 3 (the first findings chapter), this chapter examines how ED staff engage in harm reduction, and present factors that may influence their capacity to engage in harm reduction practice. Similar to Chapter 3, this chapter is also written in manuscript style. Introduction Harm reduction is a philosophy and a corresponding set of principles that inform programs, policies, and practices that aim to reduce the negative health, social, and legal impacts associated with drug use, drug policies, and drug law (CATIE, 2022; Harm Reduction International, 2022). Harm reduction as an approach has been taken up in health care in various ways, including take-home naloxone kits, safer use supplies, supervised consumption services, drug checking, safer supply prescribing, and opioid agonist treatment (Amato et al., 2013; Black et al., 2022; Ferri et al., 2011; Ferri et al., 2013; Ivsins et al., 2020; Karamouzian et al., 2018; Kerr et al., 2017; Strike & Miskovic, 2018). These interventions have demonstrated tremendous benefit, including reducing infectious disease transmission, overdose deaths, substance use practices that lead to harms; enhancing therapeutic relationships; and increasing referrals to community-based supports (Fernandes et al., 2017; Lightfoot et al., 2009; Marshall et al., 2011; McDonald & Strang, 2016). Despite these benefits, harm reduction interventions have not been fully implemented in the full range of health care settings where people who could benefit attend to care. 100 The Emergency Department (ED) is a particularly important setting where harm reduction interventions could provide crucial and timely support. It is well substantiated that barriers to appropriate and timely primary care can delay care seeking and/or make the ED the only source of possible health care (Hope et al., 2015; Kerr et al., 2005b). Such barriers include for example, inflexible community health schedules, transportation costs, fear of experiencing stigma, and the normalization of pain (Lewer et al., 2020; Neale et al., 2007; Summers et al., 2018). Previous studies have reported that people who use unregulated substances visit the ED at a rate that is 4.8 times that of the general population (Mayer et al., 2023). Furthermore, when people who use unregulated substances present to the ED and are treated for non-fatal overdose, 5.5% die within one year of their visit, of whom, 20.5% die within the first month (Weiner et al. 2020). The ED is thus a critical point of connection, offering opportunities to deliver life-saving interventions, such as take-home naloxone kits, opioid agonist treatment, as well as referrals for ongoing care (Hawk et al., 2021; Moe et al., 2021). The extant research concerning harm reduction in EDs has focused on two distinct interventions – take-home naloxone kits and opioid agonist treatment – offering descriptions of how these interventions are implemented, and contextual factors that may influence implementation (Cao et al., 2020; Dwyer et al., 2015; Gunn et al., 2018; Holland et al., 2019; Im et al., 2020; Kestler et al., 2019a; Kestler et al., 2019b; Lacroix et al., 2018; Wiercigroch et al., 2021). Findings from these investigations focus on discrete elements of the ED, such as service provider knowledge, access to resources, and organizational policies, as influencing harm reduction implementation. However, there is growing evidence that attributing implementation challenges to parts of the system that are deemed "broken" without considering their various interrelationships (Dekker, 2010) can lead to the formulation of strategies that produce 101 unintended consequences and suboptimal outcomes (Dekker, 2010; Widmer et al., 2018). Counter to these approaches, a study by Jiao et al. (2023) (see Chapter 3) draws on central tenets of complexity theory that considers a systems approach to studying how an ED is organized to provide harm reduction. These findings illustrate that facilitators and barriers to implementation are shaped by interactions between policy and programming system elements (i.e., organizational policies that pertain to caring for people who use unregulated substances, the availability of substance use specialist services). Building upon these findings, this chapter expands on these understandings to explore, through a complexity lens, how staff engage in harm reduction practice in the ED, including potential facilitators and barriers to engagement at the point of care. As nurses and physicians are the primary groups providing care to people who use unregulated substances in EDs, and are ideally situated to implement harm reduction interventions in their practice (Canadian Nurses Association, Canadian Association of Nurses in HIV/AIDS Care, & Harm Reduction Nurses Association, 2018; British Columbia Nurses' Union, 2011; Doctors of British Columbia, 2021), there is a need to understand how these two groups of providers experience harm reduction provision in the ED. In this study, we examined how nurses and physicians engage in harm reduction in the ED, as well as their perspectives about the factors that may influence their capacity to engage in harm reduction practice, including potential facilitators and barriers (Cisewski et al., 2019; Drainoni et al., 2016; Dwyer et al., 2015; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). Purpose Statement and Research Questions Positioning the ED as a CAS, the purpose of this paper is to examine how nurses and physicians engage in harm reduction in the ED, and to delineate contextual factors that may 102 influence the capacity of staff to engage in harm reduction practice, culminating in the identification of facilitators and barriers. The specific research questions were: 1) In a CAS that is the ED, how do nurses and physicians as system agents engage in harm reduction provision? 2) What are provider-identified factors that may impact their capacity to engage in harm reduction practice? Emergency Departments, Harm Reduction, and Complexity Theory It is well substantiated that health care practice is situated within complex adaptive systems (CASs) that influence practice (Allred et al., 2005; de Bock et al., 2018; Kuziemsky, 2016; Nugus et al., 2010). Within a CAS framework, systems such as the ED are considered whole entities, and structures and behaviours of the system are understood to emerge from characteristics of system agents (i.e., "diverse actors […] that interact with common and competing goals") and their interactions (Jiao et al., 2023; McDaniel & Driebe, 2001; Swanson et al., 2012; Widmer et al., 2018, p. 630). Yet it is not possible to determine characteristics of the system by observing the properties of its constituent parts nor summing behaviours (McDaniel & Driebe, 2001). In recent years, there has been an increasing consensus that interventions that aim to tackle complex challenges within the health care system must cease to attribute challenges to implementation to specific parts of the system (Dekker, 2010). Instead, facilitators and barriers to implementation must be considered in light of how various elements of the system interact with one another (Widmer et al., 2018). Previously (Jiao et al., 2023), we examined how an ED as a CAS is organized to provide harm reduction. We found that substance use specialists (also known as addiction medicine specialists) and non-specialists, as system agents, interacted in ways that enable harm reduction provision in the ED. However, limited access to specialist providers, in combination with 103 specialist control, the reliance of non-specialists on specialist services, and safety concerns, created systemic tensions that hindered harm reduction provision. Contrary to this approach, previous investigations of contextual factors that impact the capacity of providers to engage in ED-based harm reduction practice do not adopt a complexity lens. Instead, they propose influential factors that place blame on certain parts of the system that are deemed "broken" (Dekker, 2010), including those at the service provider level; at the administrative, infrastructural, and logistical levels; at the policy level; and at the levels of interdisciplinary and interagency support. Factors reported to influence harm reduction practice at the service provider level include knowledge related to the evidence base for harm reduction, and training related to prescription, procedures for use, and implementation (Drainoni et al., 2016; Holland et al., 2019; Lacroix et al., 2018). Factors at the administrative level include support from hospital administrators, a culture of acceptance for harm reduction interventions, and consistency with missions of the acute care institution (Cisewski et al., 2019; Drainoni et al., 2016; Dwyer et al., 2015). Factors at the infrastructural level include targeted electronic health record alerts and pre-established order sets (Drainoni et al., 2016; Wiercigroch et al., 2021), while factors at the logistical level include time constraints and competing demands (Drainoni et al., 2016; Dwyer et al., 2015; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). At the policy level, the availability of guidelines and protocols, service provider consultation in policy development, and ambiguity with identifying eligible patients, influences harm reduction practices (Drainoni et al., 2016; Holland et al., 2019). Lastly, factors at the level of interdisciplinary support include the availability of physician champions and mentorship, clearly delineated roles and responsibilities, and allied health support (Cisewski et al., 2019; Drainoni, 2016; Lacroix, 2018; Wiercigroch et 104 al., 2021), while factors at the level of interagency support include timely access to community based services, and effective mechanisms for transitioning care to the community (Cisewski et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021). In the present study, we drew on central tenets of complexity theory to situate our examination into how ED nurses and physicians engage in harm reduction practice, including their perspectives on potential facilitators and barriers. Findings of this study have the potential to improve providers' ability to engage in ED-based harm reduction practice, and to support the effective implementation of harm reduction interventions in EDs and other similar care settings. Methods Research Design This paper draws on staff survey and interview data collected as part of my dissertation work, which examined implementation of harm reduction interventions for unregulated opioid use in an ED in British Columbia, Canada, and associated barriers and facilitators for implementation. The study employed a case study design, and was informed by theoretical tenets of complex adaptive systems (McDaniel & Driebe, 2001) (see Chapter 2 for an overview of the design and methods for this dissertation). Setting The study case was the St. Paul’s Hospital (SPH) ED, located in Vancouver, BC, Canada; an urban hospital that serves a patient population disproportionately impacted by health and social inequities. The hospital is known internationally for its providers' expertise in harm reduction, including the implementation of various harm reduction interventions and the development of comprehensive harm reduction policies, the full details of which are published elsewhere (Jiao et al., 2023). The SPH ED is one of the busiest EDs in the province of BC and 105 provides services to a large proportion of people who use unregulated substances and experience related health and social inequities (Providence Health Care, 2019a). There were more than 84,000 visits to the SPH ED in 2015-2016 (Providence Health Care, 2016). Data Collection Data collection included an online, self-administered staff survey (n=99) and one-on-one semi structured interviews (n=20) conducted by the lead investigator (SJ). Staff surveys took place from April to July, 2021, and survey recruitment included the distribution of recruitment emails to ED staff by clinical leadership, and the placement of recruitment posters in the ED staff room. The 66-item survey included research team generated items to capture demographic characteristics, work and educational experiences, and current harm reduction practices. The survey also included the 22-item Drug and Drug Problems Perception Questionnaire (DDPPQ), which was developed to measure care providers’ attitudes towards patients using unregulated substances (Watson et al., 2003). The scale consists of six subscales: Role adequacy; Role legitimacy; Role support; Task specific self-esteem; Work satisfaction; and Motivation (Watson et al., 2003). It uses a 7-point Likert response ranging from "Strongly agree" to "Strongly disagree" (Watson et al., 2003). Previous studies provide estimates of the reliability and validity of the DDPPQ, with a Cronbach's α of 0.92 for the scale as a whole (Williams et al., 2020), and Cronbach's α ranging from 0.734 and 0.955 for the various subscales (Kelly et al., 2018; Knopf-Amelung et al., 2018). For the purpose of this study, we adapted the wording and language of the DDPPQ to minimize stigma and to reflect current understandings of substance use (such as changing the language of "drug user" to "people who use unregulated substances," and "drug problems" to "harms associated with unregulated drug use"). We calculated Cronbach’s α for the study sample to be 0.857 for the scale as a whole. 106 Staff interviews took place from May to June, 2021. Participants were recruited via a question included in the staff survey which asked if the person would be interested in an in-depth interview to further discuss harm reduction implementation in the ED. Interviews were conducted with 10 staff (n=5 physicians and n=10 nurses) and ranged from 45 to 75 minutes in length. These interviews were semi-structured, and focused on how agents of the system interact with one another to support harm reduction implementation, as well as facilitators and barriers to implementation in light of these interactions. The interview guide was informed by contextual factors deemed to influence harm reduction in the ED as identified by a review of the existing literature, and allowed for the capturing of detailed knowledge pertaining to items of the staff survey. As data were collected, the need for key informant interviews with clinical leaders as agents influencing harm reduction implementation was identified. Thus, 5 additional interviews were completed with clinical leaders responsible for harm reduction implementation within the health authority. Interviews with leadership took place in November, 2021 and ranged from 55 to 80 minutes in length. Recruitment for interviews with leadership was in the form of personal email communications. These interviews focused on leaders' perspectives on policy, programming, and implementation of harm reduction interventions. Full details of interviews conducted are published elsewhere (Jiao et al., 2023). All interviews were audio recorded after obtaining permission from the participant and subsequently transcribed. The two strands of data (staff surveys and interviews) were collected concurrently. Approval for this research was obtained from the University of British Columbia (UBC) Behavioural Research Ethics Board (BREB), Certificate of Approval no. H19-02470. 107 Data Analysis Staff survey data were uploaded to SPSS™ 27 for analysis. Descriptive statistics (e.g., frequencies) were generated for specific variables associated with participants' demographics and work experience characteristics. Frequencies were also generated for variables associated with the types of beliefs that staff held about people who use unregulated substances, staff perceptions of the availability of harm reduction interventions in the SPH ED, factors staff perceive to influence ED harm reduction implementation, and education staff obtained through school and the workplace. SPSS™ was also used to calculate DDPPQ total scores, which were calculated by summating the Likert response for each scale item, with lower scores denoting positive attitudes towards people who use unregulated substances and vice versa (Watson et al., 2003). Once the survey data was analysed, de-identified interview data were uploaded to NVivo™ 12 for review and analysis. For this analysis, we utilized reflexive thematic analysis (Braun & Clarke, 2006; Braun & Clarke, 2019), and drew upon the theoretical construct of complex adaptive systems (McDaniel & Driebe, 2001; Widmer et al., 2018), which is concerned with the emergence of system structures and behaviours as a function of patterns of interaction between agents of the system (McDaniel & Driebe, 2001; Widmer et al., 2018). We also adopted understandings of harm reduction as both a technical solution and as a contextualized social practice as proposed by Jiao (2019). As per Jiao (2019), harm reduction as a technical solution refers to "interventions that decontextualized and have the primary purpose of facilitating behavioural changes that are deemed necessary to reduce the harms associated with [unregulated substance] use" (pp. 1-2), encompassing interventions such as take-home naloxone kits and opioid agonist treatment. Harm reduction as a social practice, on the other hand, refers to "interventions that are nuanced and situated within the contextualized […] lifeworld of PWUD 108 [people who use drugs]" (Jiao, 2019, p. 2). These interventions consider and attend to the impact of broader, socio-structural factors (i.e., poverty, housing insecurity, etc.) on harms experienced related to unregulated substance use, and people's capacity to manage and mitigate those harms. As the theory of complex adaptive systems directs a focus on patterns of interaction between system agents (McDaniel & Driebe, 2001; Widmer et al., 2018), we generated a thematic coding scheme that reflected staff's experiences of providing harm reduction in the ED, and the types of contextual factors that impact their capacity to interact with colleagues and community-based service providers to carry out their roles related to harm reduction provision. The final analysis involved integrating both quantitative and qualitative data to generate overarching analytical themes, thereby engaging in mixed analysis (Onwuegbuzie & Combs, 2015). Mixed analysis offers the benefits of triangulation (i.e. the ability to compare qualitative findings with quantitative results) and complementarity (i.e. the ability to seek elaboration, illustration, enhancement, and clarification of findings generated via one data source with results generated via another data source) (Collins et al., 2006). In conducting mixed analysis, we gave the two data sources approximately equal priority, and made mixed analysis decisions iteratively (Onwuegbuzie & Combs, 2015). In determining analytical themes for the mixed analysis, we asked questions such as: In the CAS that is the ED, how do nurses and physicians engage in harm reduction provision? What are staff-identified factors that may impact their capacity to engage in harm reduction practice? What contextual factors impacted the capacity of staff to meet patient needs related to harm reduction? Findings The analysis of the SPH ED as a case for harm reduction implementation illustrated there were an array of influential factors within the system that facilitate or hinder the capacity of 109 nursing and physician staff to implement the full range of harm reduction interventions available in the ED and in the hospital more broadly. In the sections that follow, I first present the study's participants (SPH ED staff) and the context in which they provide care for people who use unregulated substances including harm reduction interventions. Following, I present the three interrelated analytic themes of teamwork, preparedness, and connections that illustrate the elements of the ED as a complex adaptive system that influence harm reduction implementation. Participants A total of 99 participants completed the staff survey. Demographic and employment characteristics for the staff survey are detailed in Table 3. Overall, the sample included almost equivalent numbers of nurses and physicians, and most participants held regular employment staff positions. Experience levels varied with 55.6% (n=55) of survey participants having worked in their respective profession for six or more years, and 49.5% (n=49) of participants with similar career time practicing in an ED setting. Table 3 Staff Survey: Participant Characteristics and Length of Work (n=99) Participant characteristic n (%) Self-identified gender (n=98) Woman 61 (61.6) Man 37 (37.4) Age (n=91) Mean (SD) 38.7 (10.9) Range 25-67 110 Participant characteristic n (%) Occupation (n=98) Nurse 51 (52.0) Physician 47 (48.0) Employment status Regular a 89 (89.9) Casual b 6 (6.1) Temporary c 4 (4.0) Length of time in occupation ≤ 5 years 44 (44.4) ≥ 6 years 55 (55.6) Length of time in ED practice ≤ 5 years 50 (50.5) ≥ 6 years 49 (49.5) Length of time in current ED ≤ 5 years 59 (59.6) ≥ 6 years 40 (40.4) a "Regular" refers to permanent employment in a full-time or part-time position. b "Casual" refers to employment on an on-call basis without holding a full time or part time position. c "Temporary" refers to employment in a full-time or part-time position but only until the staff member who holds the permanent position returns from leave. 111 Harm Reduction in Context The SPH ED has a longstanding history of providing care for patients who use unregulated substances. The hospital is home to the second in-hospital overdose prevention site in Canada, and has played, and continues to play, a tremendous role in responding to the ongoing drug toxicity crisis. Consequently, staff regularly care for people who use unregulated substances and who simultaneously experience multiple, intersecting structural inequities including poverty, housing insecurity, gender-based violence, and histories of trauma. As one nurse noted: My experience with the population who uses drugs is basically on a daily basis. I would say about 75 percent of the population that I care for are people who use drugs of some sort. It is a huge part of job. – Emergency Nurse In caring for people who use unregulated substances, ED staff provide numerous harm reduction interventions to support patient safety, encompassing interventions that embrace harm reduction as a technical solution and as a social practice (Jiao, 2019). As a technical solution, staff provide three specific harm reduction interventions at the level of direct patient care, including opioid agonist treatment (OAT) initiation, take-home naloxone kits, and safer use supplies (such as sterile needles and alcohol swabs). As a social practice, staff aim to establish a continuum of care to support that patients continue to engage with care upon their discharge from the ED and within their home settings and daily lives. To facilitate such, staff provide internal referrals to other hospital services as well as external referrals to community services (Table 4). Several wraparound programs and services (i.e., services that are based outside of the ED but have a role in supporting ED care provision) make harm reduction implementation possible in the ED, and numerous organizational policies outline the types of interactions between system agents that are required to support implementation (full details are discussed elsewhere, see Jiao et al., 2023). However, the mere existence of these structures does not translate to harm 112 reduction implementation in the ED. A necessary condition for implementation is that staff are aware of these interventions. For the most part, staff are aware of the types of harm reduction interventions that are available within their department. They are also cognizant of the option for referral to a variety of internal and external substance use and harm reduction services (Table 4). Table 4 Staff Perceptions of the Availability of Harm Reduction Interventions Harm reduction intervention n (%) Provided by ED staff Opioid agonist treatment initiation (n=96) Yes 85 (88.5) No 7 (7.3) Don't know 4 (4.2) Take-home naloxone kits (n=96) Yes 90 (93.8) No 3 (3.1) Don't know 3 (3.1) Harm reduction supplies (n=96) Yes 42 (43.8) No 41 (42.7) Don't know 13 (13.5) 113 Harm reduction intervention n (%) Internal referral Social work (n=96) Yes 83 (86.5) No 9 (9.4) Don't know 4 (4.2) External referral Opioid agonist treatment services (n=96) Yes 92 (95.8) No 3 (3.1) Don't know 1 (1.0) Harm reduction supply services (n=95) Yes 78 (82.1) No 5 (5.3) Don't know 12 (12.6) In addition to awareness of existing harm reduction interventions, staff also acknowledged the impact of stigma and discrimination on the care experiences of people who use unregulated substances, including harm reduction provision. Many staff did not subscribe to prejudicial discourse about this patient population and held fairly positive attitudes about caring for people who use unregulated substances. Results of the staff survey illustrate that staff's average total score on the DDPPQ was 61.8 (Table 6). The distribution of DDPPQ total scores was asymmetric with a skew towards the lower end indicating positive attitudes. There exists, 114 however, an extent of variation, ranging from extremely positive attitudes to comparatively more negative attitudes. Staff were also cognizant that stigma and discrimination are fundamental to the experience of people who use unregulated substances when accessing health care, and that these experiences can have profound implications for attendance to care (Table 5). These beliefs were echoed in interviews with staff: I think the biggest thing for people of that population [people who use unregulated substances] is that they just feel like they can’t access healthcare the same way that people who don’t use, do... They felt disrespected, they felt judged... so that is a huge barrier for people. – Emergency Nurse Table 5 Beliefs About People Who Use Unregulated Substances (n=99) Variable n (%) They are among the most frequent attendees of EDs Strongly agree / agree 79 (79.8) Neutral 11 (11.1) Disagree / strongly disagree 9 (9.1) They have complex social and health needs Strongly agree / agree 99 (100.0) There is an inadequacy of community-based public sector services for this particular group Strongly agree / agree 73 (73.7) Neutral 10 (10.1) Disagree / strongly disagree 16 (16.2) 115 Variable n (%) They experience significant stigma and discrimination in the health care system, in hospitals, and in EDs Strongly agree / agree 75 (75.8) Neutral 14 (14.1) Disagree / strongly disagree 10 (10.1) These experiences of stigma and discrimination can impact their access and attendance to care (n=98) Strongly agree / agree 88 (89.8) Neutral 6 (6.1) Disagree / strongly disagree 4 (4.1) Table 6 Results from the Drug and Drug Problems Perception Questionnaire (DDPPQ) (n=99) Variable Mean (SD) Range DDPPQ total score (n=94) 61.8 (15.2) 25-100 Individual scale items of the DDPPQ When working with people who use unregulated substances, if I felt the need to, I could easily find someone with whom I could discuss any personal difficulties that I might encounter. (n=98) 3.07 (1.501) 1-7 116 Variable Mean (SD) Range If I felt the need I could easily find someone who would be able to help me formulate the best approach to a person who uses unregulated substances. (n=98) 2.86 (1.478) 1-7 I feel I have a working knowledge of unregulated substances and the harms that are associated with their use. 1.90 (0.953) 1-5 I feel I know enough about the causes of harms that are associated with unregulated substance use to carry out my role when working with people who use these substances. 2.03 (1.044) 1-7 I feel I know enough about the physical effects of unregulated substance use to carry out my role when working with people who use these substances. 2.12 (1.013) 1-5 I feel I know enough about the psychological effects of unregulated substances to carry out my role when working with people who use these substances. 2.38 (1.131) 1-7 I feel I know enough about factors which put people at risk of developing harms that are associated with unregulated substance use to carry out my role when working with these individuals. 2.35 (1.072) 1-6 I feel I know how to counsel people who use unregulated substances over the long term. 3.83 (1.340) 1-7 I feel I can appropriately advise my patients about unregulated substances and their effects. 3.08 (1.209) 1-6 117 Note. For each item of the DDPPQ, respondents were asked to rate their level of agreement with a statement about caring for people who use unregulated substances. There were seven possible responses to each item on a scale of "Strongly agree" (which as given a score of 1) to "Strongly disagree" (which was given a score of 7). Item-specific mean scores and standard deviations were calculated using these numerical scores, where a score of 4 represented a neutral attitude, and a score of less than or more than 4 represented positive and negative attitudes respectively. Working in an institution that provides care for people who use unregulated substances on a daily basis, ED staff are committed to care provision for this patient population, and have a desire to provide harm reduction as a part of quality patient care. Staff are additionally knowledgeable about the types of harm reduction interventions available in their practice setting and cognizant of the existence and the impact of stigma and discrimination. Overall, staff feel positive about caring for this particular group of patients. In the ensuing analytic themes, we present the types of factors that staff experience as influencing their capacity to engage in harm reduction provision – teamwork, preparedness, and connections, and how these factors shape harm reduction provision in the ED, as well as their impact for the delivery of care. Theme 1: Teamwork Teamwork, defined as being able to draw on the knowledge, experience, and expertise of, and to work collaboratively with, inter and intradisciplinary colleagues to support care provision, was central to shaping harm reduction provision in the ED. Collaboration, consultation, role clarity, and the attitudes of team members towards caring for people who use unregulated substances were particularly important factors shaping harm reduction implementation (see Table 7). 118 Staff noted specifically, that teamwork can facilitate harm reduction provision by helping to improve intervention provision timeliness. Providing missed doses of opioid agonist treatment (OAT) for example, was defined as a “time-consuming” intervention because staff must first obtain confirmation about the patient's dose and whether that treatment has been provided from system agents external to the ED – the person's community dispensary. However, teamwork and collaboration among system agents who are internal to the ED were seen to improve the timeliness of OAT provision, as explained by an Emergency Physician below: I would have the [in-house] pharmacist and the Addictions Nurse chase it up. So they would have to then contact the [patient's community] pharmacy and find out whether the patient had received the dose. We can check on PharmaNet [provincial prescription medication tracking system], and then have some idea of it, but it is never completely sure on PharmaNet. Sometimes they’ll [the community pharmacy] reverse it if the patient hasn’t picked it up, but they don’t always do that. So it can be difficult to tell from that, so we need the corollary. – Emergency Physician Teamwork also facilitated harm reduction provision in the ED by allowing system agents to draw on the knowledge, experience, and expertise of one another in arriving at the most appropriate approach to care inclusive of preventing and managing opioid withdrawal. Clinical policies note that staff can provide the patient with doses of opioid medications that are comparable to the amount of unregulated opioids they use in the community setting (Providence Health Care, 2021c). Staff, however, noted that they may be hesitant to provide this intervention as the doses required are often over and above the therapeutic range for people without histories of opioid use. In such cases, staff reported that inter-colleague consultation was effective to assist their comfort and confidence in providing sufficient opioid doses as part of withdrawal management. Staff also relayed that, overall, when they needed help in formulating the best approach to caring for people who use unregulated substances, they were able to rely on their colleagues for support 119 (n=98, M = 2.86, SD = 1.478) (Table 6). Below, an Emergency Nurse speaks to how system agents consult, and draw on the expertise of one another to facilitate withdrawal management: I usually discuss it with another nurse every time. Even, because I’ve given the high dose hydromorphone, like 150 mg of IV hydromorphone that they give at [an outpatient clinic], I’ve given that before in the emerg and I’m not comfortable with it, but I’ll doublecheck it with the doctor and discuss it with another nurse and then I’ll give it. – Emergency Nurse Lastly, teamwork among system agents can help to ensure that a harm reduction intervention is offered through leveraging shared responsibility. Within this ED, while certain interventions, such as the provision of OAT, can only be initiated by one type of system agent (physicians), other interventions, such as distribution of take-home naloxone kits, can be initiated by multiple types of system agents (physicians and nurses). In the case of the latter, such overlapping duties can serve as what staff described as a "safety net" to ensure that the intervention is offered to the patient; the assumption being that if one type of system agent does not offer the intervention, another will. One type of system agent can also prompt the other, as explained by ED staff below: Physicians will order it [take-home naloxone kits], but we [nurses] don’t obviously need an order. We can just give it to them [the patient] but it’s nice to see that the physician has ordered it because they’ve acknowledged that they need it… and then it will definitely get done. I feel like it maybe gets missed if it is not ordered… so it’s nice if the physicians order it because it kind of prompts us too. – Emergency Nurse In the same way that ED staff experienced teamwork to facilitate their engagement in harm reduction provision, they found a lack of teamwork to hinder harm reduction provision. This was especially evident when there was a muddying of roles between occupational groups, and when staff encountered attitudes and assumptions on the part of their colleagues that were incongruent with the harm reduction approach and discriminatory towards people who use unregulated substances. 120 Within the context of role clarity, more than 60% (n=59) of survey participants reported that occupational role clarity impacted harm reduction implementation in the ED (Table 7). For the most part, system agents were acutely aware of their roles related to harm reduction. They also reported that, if needed, they could find a colleague who could help them clarify their professional responsibilities (n=98, M = 2.88, SD = 1.494) (Table 6). Role clarity, however, quickly became muddled when there were overlapping duties between occupational groups. That is, despite the benefits of shared responsibility, staff reported adverse implications of shared responsibility in the form of the passing of responsibility from one occupational group to another, which they saw as contributing inconsistences in harm reduction practice. As noted by one physician: I think it [the responsibility to offer naloxone kits] should be shared. But part of the problem is if you make it a shared responsibility and it is not one person’s responsible, then nobody does it. So maybe it’s maybe easier to have a designated person... I think it’s inconsistent because it’s not one person’s responsibility and so everyone assumes the other person is doing it. – Emergency Physician Work culture concerning acceptance of harm reduction as an appropriate intervention was also relevant for harm reduction (see Table 7). In particular, negative attitudes held by some staff that were discriminatory towards people who use unregulated substances and negated harm reduction, had a profound impact on interdisciplinary collaboration and diminished the capacity of ED colleagues to provide harm reduction interventions. Assumptions that perpetuated stereotypes about the dishonesty of patients who use unregulated substances were particularly problematic as noted in the excerpt below: They’re [the patient is] starting to go into withdrawal and they manage with high doses of hydromorphone and you ask the doctor... and they’ll be like "oh give them Tylenol or Advil." You’re like "I get it" but also, I get the sense that, at least one of the doctors has said [they don't] want us to perpetuate the system of people coming in for minor things when they can’t get the down [heroin] that they need on the street, and so now they’re 121 coming in with other concerns in the hopes of getting hydromorphone. That was [the physician's] concern. – Emergency Nurse Table 7 Factors Perceived to Influence Harm Reduction Implementation Variable n (%) Interdisciplinary collaboration and support (n=95) Crucial / quite a bit 80 (84.2) Somewhat 9 (9.5) A little / not at all 6 (6.4) Occupational role clarity (n=96) Crucial / quite a bit 59 (61.5) Somewhat 26 (27.1) A little / not at all 11 (11.4) Leadership support (n=95) Crucial / quite a bit 74 (77.9) Somewhat 15 (15.8) A little / not at all 6 (6.3) Culture of harm reduction acceptance (n=95) Crucial / quite a bit 81 (85.2) Somewhat 8 (8.4) A little / not at all 6 (6.3) 122 Variable n (%) Electronic medical record alerts (n=94) Crucial / quite a bit 64 (68.1) Somewhat 18 (19.1) A little / not at all 12 (12.8) Training in prescribing / administering opioid agonist treatment (n=96) Crucial / quite a bit 72 (75.0) Somewhat 17 (17.7) A little / not at all 7 (7.3) Training in using / teaching patients how to use a naloxone kit (n=96) Crucial / quite a bit 60 (62.6) Somewhat 23 (24.0) A little / not at all 13 (13.6) Training in using / teaching patients how to use harm reduction supplies (n=96) Crucial / quite a bit 57 (59.4) Somewhat 25 (26.0) A little / not at all 14 (14.6) Information on the evidence base for harm reduction (n=96) Crucial / quite a bit 61 (63.5) Somewhat 25 (26.0) A little / not at all 10 (10.4) 123 Variable n (%) Information on community-based service providers (n=93) Crucial / quite a bit 65 (69.9) Somewhat 21 (22.6) A little / not at all 7 (7.6) Policies around transferring care to the community (n=94) Crucial / quite a bit 74 (78.7) Somewhat 14 (14.9) A little / not at all 6 (6.4) Overall, it was evident that teamwork was a significant factor that shaped ED harm reduction provision. While staff experienced teamwork to facilitate provision in various ways, such as through leveraging delegation and shared responsibility, and allowing staff to draw on the knowledge and experience of one another, a lack of teamwork also had profound implications, especially when roles were ambiguous between occupational groups, and when colleagues held attitudes or assumptions that were incongruent with the harm reduction approach. Theme 2: Preparedness Preparedness was a salient factor that influenced staff’s capacity to engage in harm reduction provision. Preparedness referred to having the knowledge and skills required to carry out their respective roles to their full scope of practice when implementing harm reduction. Education was a fundamental part of preparedness. 124 Overall, staff reported they did not feel prepared to provide harm reduction as part of their patient care: a situation influenced by a dearth of education to assume these roles (see Table 8). Almost 70% (n=67) reported never receiving any education in their entry to practice schooling concerning care for patients using unregulated substances (Table 8). Consequently, the workplace was central hub for staff to obtain such education, with 70% (n=68) reporting having received such education in the workplace. Harm reduction education was available through a variety of formats, including in-service education offered by nurse educators during work hours, online modules, and lectures from Addiction Medicine Physicians. They [the department offered] did these little coffee things, it was pre-COVID and you could come and have a cup of coffee and they would go through these boards and teach you about how to do the COWS [Clinical Opiate Withdrawal Scale] and how to look for precipitated withdrawal and the whole process of learning and educating about Suboxone® starts, and then there was an online Learning Hub. – Emergency Nurse Ad hoc education also occurred when seeking guidance from agents specializing in addiction care, such as from Addiction Assessment Nurses as noted below: If we need help figuring out what we’re going to do for induction, if we are doing a Suboxone® induction, they [the Addictions Assessment Nurse] can certainly assist us with regards to the framework of that. They are also a good education piece for nursing and for physicians with regards to how much medication should we give this guy to bridge and that comfort level of giving that medication, so you have somebody else who is saying "yes, it is okay to give that." – Emergency Physician 125 Table 8 Education Through Formal Schooling and the Workplace Variable n (%) Education received through school Caring for people who use unregulated substances (n=96) Yes 29 (30.2) No 53 (55.2) Don’t know / remember 14 (14.6) Prescribe or administer opioid agonist treatment (n=29) Yes 21 (72.4) No 7 (24.1) Don’t know / remember 1 (3.4) Use a naloxone kit (n=29) Yes 18 (62.1) No 10 (34.5) Don’t know / remember 1 (3.4) Engage in overdose prevention conversations (n=29) Yes 18 (62.1) No 7 (24.1) Don’t know / remember 4 (13.8) 126 Variable n (%) Use harm reduction supplies (n=29) Yes 16 (55.2) No 11 (37.9) Don’t know / remember 2 (6.9) Education received through the workplace Caring for people who use unregulated substances (n=96) Yes 68 (70.8) No 24 (25.0) Don’t know / remember 4 (4.2) Prescribe or administer opioid agonist treatment (n=68) Yes 60 (88.2) No 6 (8.8) Don’t know / remember 2 (2.9) Use a naloxone kit (n=68) Yes 54 (79.4) No 11 (16.2) Don’t know / remember 3 (4.4) Engage in overdose prevention conversations (n=68) Yes 34 (50.0) No 26 (38.2) Don’t know / remember 8 (11.8) 127 Variable n (%) Use harm reduction supplies (n=68) Yes 35 (51.5) No 26 (38.2) Don’t know / remember 7 (10.3) There was also inconsistency in the type of education received (Table 8). Opioid agonist treatment (88.2%, n=60) was the most common type of education received, with less people receiving education on harm reduction supplies as a source of intervention (Table 8). Staff spoke at length about variations in education noting that inconsistency in the availability of workplace education greatly influenced the uptake of education and type received. Uptake was described as complex, noting that educational content and formats often failed to consider the complexity among system agents’ work schedules or availability, as noted below: One thing that I was not able to attend due to scheduling problems was [physician] from the Psychiatry Department actually hosted three sessions for emergency department staff, which from my understanding were sessions to talk about work in the emergency department at St. Paul’s [Hospital] and some of the challenges and to learn a little bit about trauma and all that kind of stuff. That was my general understanding, that it was kind of a safe place for people to gather and talk about some of their experiences and learn other’s experiences, or patient experiences. That was offered. I would have loved to go but I was unable to go. – Emergency Physician Additionally, variation in financial incentivization and the optional versus mandatory nature of education were described as barriers to accessibility. As one nurse noted: It’s not mandatory [Suboxone® modules]. There is an online thing on Learning Hub [online platform for staff education]. It was incentivized previously where there was a draw or something if you completed the course, but it is voluntary. – Emergency Nurse Staff further added that, when they did receive workplace harm reduction education, these opportunities were often limited to the point of "onboarding" (when staff were first hired for their 128 job), and not consistently available on a regular or ongoing basis. Although they appreciate the educational material covered, and understand their roles related to harm reduction provision upon completion of the education, the concern about “forgetting” what was learned was frequently expressed. Overall, staff saw a lack of education as undermining their preparedness and limiting the scope of care provision in the ED. The impact of insufficient education played out in unique ways associated with staff's role as physicians or nurses. Physicians specifically spoke to how education gaps affected their comfort level in prescribing harm reduction treatments and the impact for patient care. I’m not as comfortable with methadone induction in the emergency department. It is not something I’ve done or learned about before. I’ve read about how to do it, or in a clinic setting, but no. Often people I see come in after overdosing, pretty significant overdoses, so starting something that might make them more sleepy, or have respiratory depression and things like that, I think is a limiting factor as well. – Emergency Physician Physicians also voiced that a lack of education affected their ability to arrive at appropriate dosing for harm reduction related medications, which, in turn, impacted their ability to meet the patient's care needs. Determinations of the correct dosage proved to be especially difficult in light of complex patient needs, such as when the patient requires withdrawal management in addition to OAT and/or pain management. I struggle, for instance, not just meeting their [the patient's] needs in terms of withdrawal but then figuring out how to meet their needs in terms of withdrawal and then additionally provide them with proper pain control for whatever the new issue is that is bringing them. If somebody is on X amount of Kadian® [a type of OAT], I have no idea how to even start treating the pain that they have for their terrible cellulitis or osteomyelitis or whatever it is that they have. I can’t even fathom what am I going to give you that is going to do anything on top of these doses that you’re getting, so I think that is really tricky as well. It is not because we don’t want to, it’s because [we] don’t know how to address it. – Emergency Physician 129 For nurses, the lack of educational opportunities impacted their ability to determine when to administer harm reduction treatments and to respond when treatment complications arose. For instance, uncertainty concerning use of the Clinical Opiate Withdrawal Scale (COWS) – a tool used to rate signs and symptoms of opioid withdrawal and to monitor symptoms over time was a serious concern. A COWS score is used to determine the severity of one's withdrawal and can influence clinical decisions such as when to induce Suboxone® (a type of OAT). Suboxone® should only be induced when the patient is in withdrawal, otherwise the person risks experiencing precipitated withdrawal (i.e. withdrawal symptoms brought on by OAT). Below, Emergency Nurses speak to how a lack of education affected their ability to provide Suboxone® at the most clinically appropriate time and to prevent and manage potential complications. Some people still don’t really, they’re not super comfortable with administration [of Suboxone®] and they don’t know to take a COWS score prior and that the patient has to be at a certain point [of withdrawal to induce the treatment]. – Emergency Nurse I think the biggest thing that we’re not great on is if we’re getting into precipitated withdrawal, what do we do as nurses. How do we make sure [patients do not experience precipitated withdrawal], you can do the best you can in terms of your scoring. – Emergency Nurse Inconsistent and unavailable education also influenced nurses' ability to administer as needed (PRN) medications, which consequently negatively affected their ability to meet the patient's harm reduction care needs. Without education concerning the timing, dosing, and purpose of PRN methadone for example, patients are left to experience greater withdrawal and limited pain management (Hemmons et al., 2019). Similarly, insufficient knowledge about the interrelationships between opioid dosage and patients’ tolerance associated with a history of unregulated opioid use, left nurses uncomfortable with PRN dosages and contributed to hesitancy to provide this important intervention. 130 They’ll [Emergency Nurse] be like "oh, the patient is in withdrawal" or like really uncomfortable and they had methadone, but then you’re like "oh, but they had three PRNs and they weren’t given over night," but now it’s the morning shift and it is too late to do much with the PRNs because you know the bigger dose is coming... I remember an Addictions doctor had said to me, "we do 30 [mg] because that’s the basic safe starting dose and then you PRN it, so that if we come in tomorrow and we’ve used the PRNs, we know we can comfortably increase it to X, and to [continue with] PRNs until we raise it to the right amount."... Oh, so it’s not just about a breakthrough medication, it is actually about trying to titrate the right amount. – Emergency Nurse Ultimately, inconsistent and unavailable education further impacted the ability of nurses to advocate for patients’ harm reduction needs. Nurses explained that, with inadequate education, they were limited to passively passing information onto physicians, and may not be able to advocate fully on the patient's behalf. Having received the corresponding education however, allowed them to have proactive discussions with physicians to arrive at the most appropriate care for the patient. Like safe supply, it all started happening in the community and I feel like emerg was never really part of that and so it’s one of those things, I just don’t really know what to do. I hate those things... I don’t really know how much are people getting every day, how do they get it, where do they get it, is it a daily dispensed thing, do people ingest it, do they crush it and inject it, like I don’t know any of the stuff about it. I feel like I’m very sort of in the dark about how that goes, so it’s hard for me to really proactively be a good advocate and nurse, I guess, when it comes specifically to that kind of stuff, other than to just make sure the doctor knows what is going on. – Emergency Nurse As a whole, staff of the ED described education as critical in being prepared to carry out their roles as related to harm reduction. However, many did not receive the corresponding education, either through entry to practice education, or through educational opportunities offered through their workplace. Although specific implications for practice varied for nurses and physicians due to differences in professional scope (i.e., prescription vs. administration) – what remained constant was the profound impact of unavailable and inconsistent education on staff's capacity to carry out their roles as system agents and to meet their patient's care needs. 131 Theme 3: Connections In addition to teamwork and education as influential factors for staff's capacity to carry out their roles when implementing harm reduction, another crucial consideration relates to support that staff receive to help patients make connections to community-based services and resources. ED staff identified that people who use unregulated substances have complex social and health needs (Table 5). Staff acknowledged the socio-structural context of people's lives and viewed substance use as occurring against a backdrop of intersecting factors including chronic illness, mental health challenges, poverty, housing insecurity, racism, and trauma. Staff recognized the compounding nature of such factors and noted how, collectively, they contributed to a person's unique social location in respect to their substance use and harms experienced. Patients who struggle with addictions issues, usually they have pretty significant trauma histories or mental health issues, or they’re marginalized for other reasons, whether it be poverty or their ethnicity, or maybe generational trauma from being an Indigenous person in Canada.14 The patients are extraordinarily complex in many, many ways, and often we get a very small window into their lives, usually on their worst day, in the emergency department. – Emergency Physician In recognizing the interrelated complexity between substance use harms and the structural disadvantages that exacerbate the potential for harms, staff embraced harm reduction as both a technical solution and a social practice (Jiao, 2019). Staff saw their role as not only resting at the level of direct patient care, but also as helping people make valued connections to available and appropriate community-based services and resources to support that people continue to engage with care. Staff saw connection making as essential to providing comprehensive harm reduction care, and recognized the limitations of solely offering interventions that subscribe to harm reduction as a technical solution. 12 We recognize that intergenerational trauma is not limited to Indigenous peoples. However, the unique features of colonization, inclusive of the destruction of family and heritage, are key structural drivers of intergenerational trauma for Indigenous peoples. 132 This person [patient] wants to get off the drugs, he wants to get on Suboxone®, or methadone, but he has no place to live. I think that makes you press harder and get the social worker to focus on finding housing because we have an opportunity here but it’s going to fail if they don’t have housing, so "can you please help us find something?" – Emergency Physician Overall, staff struggled to carry out their role in helping their patients make the necessary connections to community-based services and resources. Staff spoke about how, in order to facilitate such connections, they must manage multiple layers of systemic complexity and navigate a series of barriers – a situation influenced by intersecting issues of competing work demands, the limited availability of interdisciplinary support, as well as uncertainty related to available community-based services and resources. The first barrier conveyed by staff relates to competing demands on their time and the resultant non-prioritization of connection making as a part of care delivery. The nature of the ED is such that nursing staff are simultaneously caring for four or more patients, while physicians may be involved in the care of up to 20 patients. As such, ED staff must constantly prioritize competing demands on their time. Notably, when caring for people who use unregulated substances, although nurses and physicians acknowledge the importance of helping to establish community-based connections, this aspect of care was not described as a standard part of their work, but rather, as something superfluous that staff could address if there was time. Many staff expressed concerns about the time required to engage with patients related to making community-based substance use and harm reduction connections, and reported that they may not have time in their workday to have a prolonged interaction with patients related to these needs. I want to say in an ideal world that [helping the patient make community-based connections] should be part of our role. Some days you just don’t have time to go the bathroom, so it’s like anything extra might be not wanted. – Emergency Nurse 133 Accepting that many ED staff do not consider connection making as a regular part of their work, yet striving to enact harm reduction as a social practice, the system creates workarounds through leveraging interdisciplinarity in helping patients make these valued connections. Interdisciplinary support is available through the Rapid Access Addiction Clinic (RAAC) – an outpatient clinic staffed by physicians, nurses, social workers, and peers. The clinic is located on hospital grounds and facilitates connections to an array of community-based supports – with the intention of offloading such responsibilities from ED service providers. Additionally, ED-based social work services are available to help patients connect to community-based supports, such as housing, income assistance, and outreach services (Table 4). One of the main purposes RAAC was set up was to support the ED... There is such volumes and such high demand, a lot of the addictions patients that came into emerg... [The clinic was] set up to help decant emerg and help offload some of the pressure on the emerg department... I think it definitely alleviated a lot of the burden on the emerg department. – Clinical Leader The staff were acutely aware of the availability of interdisciplinary support in enacting harm reduction as a social practice in the ED, and consistently drew on these supports. As noted in Table 4 for instance, over 80% (n=78) of staff reported that the ED facilitates community-based connections for patients, and many spoke about how, instead of referring directly to community-based services and resources, they relied on referral to other agents of the acute care institution. Staff shared that oftentimes, they prefer to refer to the RAAC as opposed to ED-based social work services, whom they saw as overwhelmed and inundated with requests. Staff also believed that RAAC staff may be able to dedicate more time to addressing the patient's interrelated and complex needs and can better attend to continuity of care. I don’t refer to community supports. I refer to RAAC [the Rapid Access Addiction Centre]. That is the umbrella under which people can access those types of services, or have that office liaise with community services in order to try to make things happen on that level... In terms of any kind of direct referral service from an emergency RN to a 134 community-based support network, no, that it is not a thing. We refer to the resources available within St. Paul’s [Hospital] and then from there, that would be their stepping stone towards accessing other outside services. – Emergency Nurse In light of staff's reliance on interdisciplinary support for connection making, the second barrier relates to the limited availability of such supports. The RAAC as a system agent and as interdisciplinary support was not available for the entire 24 period in which the ED operates. Afterhours (from 4 pm to 9 am), ED staff were left on their own with regards to making valued connections for patients – a capacity that solely depended on their personal knowledge of available and appropriate community-based supports. Staff described having very limited understanding of available and appropriate community-based services and resources or the mechanism for referral, contributing to the third and final barrier to connection making. Those who had some understanding noted that what they knew came from prior experience working as a care provider in the community context. I am one of the people who doesn’t have a good understanding of just which community health centre or OAT provider would be appropriate for this patient. I don’t have a good map in my mind of what are the clinics. The only one I really know well is the Connections Clinic and that is from working at the [other workplace]... so I do direct people there, people who don’t have doctors. If they do have a doctor, if I happen to know their provider, I’ll direct them there, but if they have no doctor but they live Downtown Eastside, I’ll direct them to DCHC [Downtown Community Health Centre], or sometimes Three Bridges [Clinic], just because I know that they provide OAT. But I think not everybody knows that. – Emergency Physician Discussion Positioning ED care provision as situated within a complex adaptive system, this paper examines nurse and physician perspectives on the implementation of harm reduction in the ED, the types of factors staff experience as influencing their capacity to engage in harm reduction practice, and how these factors shape harm reduction in practice. Findings of this study illustrate that for ED staff to engage in harm reduction practice, and to carry out their roles as system 135 agents related to harm reduction provision, they must be sufficiently prepared through receiving the appropriate education and training, be able to leverage the benefits afforded by working collaboratively with their colleagues, and be supported in helping patients make connections for ongoing care. Although existing studies have reported on the impact of education and training, and of interdisciplinary and interagency support on harm reduction practice in the ED, these studies do not adopt a systems perspective (Cisewski et al., 2019; Drainoni et al., 2016; Im et al., 2020; Lacroix, 2018; Wiercigroch et al., 2021). In fact, many such studies lack an overt statement of theoretical underpinnings (Khan et al., 2022; Holland et al., 2019; Im et al., 2020), or draw on theoretical frameworks that attribute facilitators and barriers to implementation to a single element of the system (Calcaterra et al., 2022). A number of studies leverage theoretical frameworks that allow for the delineation of influential factors across multiple system elements (Drainoni et al., 2016; Collins et al., 2021). However, they do not attend to the emergence of system structures and behaviours as a function of patterns of interaction among agents of the system (McDaniel & Driebe, 2001; Widmer et al., 2018). To attribute implementation challenges to parts of the system without considering their interactions can lead implementation strategies that produce unintended consequences and suboptimal outcomes (Dekker, 2010; Widmer et al., 2018). In contrast, what this study offers is a careful consideration of interrelationships between parts of the system, leading to a comprehensive understanding of forces that affect change (The Health Foundation, 2010), and the formulation of effective and nuanced implementation strategies. Through adopting a systems perspective, this study offers novel insights about contextual factors that impact the capacity of ED staff to engage in harm reduction practice – not only in light of not only how system agents act, but also how they interact. For instance, pertaining to 136 the contextual factor of teamwork – which is concerned with how system agents work together – study findings underscore that while shared responsibility, and overlapping duties between different occupational groups, have the intended purpose of improving the consistency of which harm reduction interventions are offered, it can paradoxically contribute to inconsistencies in harm reduction practice. To this end, the existing literature has reported on the passing of responsibility between occupational groups including physicians, nurses, social workers, and pharmacists when responsibilities related to harm reduction provision in the ED were shared, to which staff provide a number of justifications – insufficient time in their work day, the presence of other occupational groups at the point of discharge, and inconsistencies with their scope of practice (Drainoni et al., 2016; Holland et al., 2019). Drainoni et al. (2016) encapsulates the inherent irony of shared responsibility, and note that while shared responsibility has its merits – where everyone can provide harm reduction, it can also lead to scenarios where harm reduction is nobody's responsibility. These findings, coupled with those of this study, suggest a need to concurrently leverage the benefits of shared responsibility while also being wary of its shortcomings. Hence, system agents must work together to ensure that shared responsibility translates to additional opportunities for harm reduction, and does not instead, serve as justification for inaction, nor lead to lost opportunities for harm reduction practice. A second contextual factor influencing the capacity of staff to engage in harm reduction practice is consistent and available education. Findings of this study that many nurses and physicians did not receive substance use education within their entry to practice education is aligned with previous research. For example, in a survey of Canadian nursing students, 43% reported that they had received between 1 to 5 hours of substance use education in their program to date, while for 20%, this subject was not broached at all (Gagnon et al., 2020). Overall, 137 students expressed that they do not feel prepared nor knowledgeable to provide care to people who use unregulated substances. Gagnon et al. (2020) also found that although students report having been introduced to harm reduction as a philosophy of care, they may not be offered concrete ways of implementing harm reduction, nor learn the knowledge required to translate harm reduction into practice. Insufficient exposure to substance use education is similarly an issue for entry to practice medical school education (Miller et al., 2001; Kothari et al., 2011; Rasyidi et al., 2012; Ratycz et al., 2018). A study by Wakeman et al. (2013) notes that 27% of internal medicine residents report not receiving any substance use education in their entry to practice education, and 62% report feeling unprepared to provide treatment for substance use. Furthermore, the existing substance use education tends to focus on relaying biomedical knowledge, with limited attention to the practical skills and attitudes that are necessary in caring for patients in the clinical setting (Ram & Chisolm, 2016). Given findings of this study, which elucidate how the oversight of education as an important contextual factor can have a myriad of detrimental consequences for harm reduction practice, it is of critical importance that substance use education is integrated into entry to practice nursing and medical education – a task that is decades long overdue (Finnell et al., 2018). These measures will help to ensure that nurses and physicians of the future will possess the practical knowledge and skills required to feel adequately prepared to engage in harm reduction practice to their full professional scope. While research based in Ireland, the UK, and the Netherlands report on the inconsistent provision of substance use education at both "pre-qualifying" (prior to practice) and "post-qualifying" (after assuming practice) levels (Clancy et al., 2019), the present study details the problem of inconsistent and unavailable workplace-based education pertaining to harm reduction in the Canadian context. Participants of the study identified various factors they believe to 138 contribute to such inconsistencies, such as a lack of consideration for variation among staff work schedules, which appear to be novel. Furthermore, study findings bolster those of previous research that inconsistent and unavailable education has profound and grave implications for service provider preparedness in carrying out their roles as system agents as related to harm reduction provision, including impacts on staff's ability to prescribe harm reduction related treatments and to determine when to administer such treatments (Collins et al., 2021; Dwyer et al., 2015; Funke et al., 2021; Im et al., 2020; Wiercigroch et al., 2021; Winetsky et al., 2017). The impact of inconsistent and unavailable education on staff's ability to administer PRN medications, and to advocate on behalf of the patient's needs appear to be unique. Given such findings, it must be stressed that simply offering staff education is not enough. Instead, health care institutions must ensure that education for staff is consistently accessible so that staff are prepared to carry out their respective roles as system agents when implementing harm reduction. Lastly, a third contextual factor that impacts the capacity of ED staff to engage in harm reduction practice is staff's ability to facilitate connections with community-based services and resources. A key finding of this study is that ED providers did not see helping patients to establish community-based connections to be a standard part of their work, but as something extra they could address if they had time. This finding echoes existing literature which reports that ED staff found harm reduction, as a whole, to be time-consuming and interruptive to their workflow. This type of discourse was palpable across many harm reduction interventions, including take-home naloxone distribution and education (Black et al., 2022; Drainoni et al., 2016; Dwyer et al., 2015; Gunn et al., 2018; Holland et al., 2019; Lacroix et al., 2018), opioid agonist treatment (Lowenstein et al., 2019; Wiercigroch et al., 2021), and withdrawal management (Wiercigroch et al., 2021). Overall, staff felt that there was inadequate time in the 139 clinical encounter for harm reduction provision due to the need to balance other clinical responsibilities. This type of discourse was particularly evident in the case of OAT as harm reduction intervention – where staff reported insufficient time for relationship building for the purpose of identifying eligible patients, to wait for patients to reach an appropriate clinical state for induction, and finally, for treatment induction and subsequent monitoring (Im et al., 2020; Wiercigroch et al., 2021). To address these concerns, previous authors have recommended that ED based harm reduction be mindful of time pressures and competing priorities inherent in the ED (Black et al., 2022). It has also been proposed that EDs should employ dedicated staff to identify eligible patients for harm reduction, provide patient education, and establish outpatient follow up (Im et al., 2020). What is blatantly absent in these discussions, and urgently needed, is a critical examination as to why harm reduction, is not understood to be a standard part of ED practice, and why staff do not prioritize this facet of care – a topic worthy of investigation through future work in this field. Finally, while the existing research identifies interagency support as a factor that impacts harm reduction practice in ED, this body of work tends to focus on the insufficient capacity of community-based resources. Winetsky et al. (2017), for instance, report that community-based OAT providers are limited their capacity to accept patients who had their treatment initiated in the acute care setting, and this was a barrier to inpatient treatment induction. Previous research also highlights issues with siloing within the system, where care providers in the ED may face hurdles in referring patients in a timely manner due to disconnects between acute and community based care, as well as a lack of functioning referral mechanisms that can be accessed by ED staff (Duber et al., 2018). Findings of this study, however, offer a different perspective and speak to interagency support in terms of staff's personal knowledge of available and appropriate 140 community-based resources – an issue that impacts staff's ability to facilitate interrelationships and interactions with system agents external to the ED. We were not able to locate other studies that speak to a lack of knowledge related to community-based supports and their referral processes as a barrier to connection making, and, as such, these findings appear to be innovative. Future efforts to help patients make valued connections should attend to staff knowledge related to community-based supports – and consequently, staff's ability to interact with other system agents to carry out their respective roles, in addition to considerations of insufficient program capacity and dysfunctional referral mechanisms (Duber et al., 2018; Fanucchi & Lofwall, 2016; Winetsky et al., 2017). Limitations The strengths of this study include its mixed methods approach, which allows for the integration of both quantitative and qualitative data in a mixed analysis, with the potential to generate rich, detailed, and nuanced findings. Additionally, the study draws on complexity theory to offer facilitators and barriers to engaging in harm reduction practice from the perspective of ED providers who are best positioned to implement harm reduction interventions in their practice. At the same time however, we must acknowledge a number of limitations to the present study. First, due to self-selection bias, we may be more likely to capture the perspectives of staff who are more accepting of harm reduction as an approach, and are more open to providing harm reduction interventions. Second, this study focuses on the perspectives of staff who are most directly involved in ED based harm reduction provision – nurses and physicians. However, there is a need for future research that examines factors that influence harm reduction practice from the perspective of a broader range of stakeholders, including Addiction Medicine Physicians, social workers, and security personnel. Lastly, although this study delves into staff 141 perspectives of engaging in harm reduction practice in the context of a single ED, and presents highly contextualized and nuanced findings, we believe these findings may hold relevance for, and may be useful in, supporting harm reduction provision in other EDs and similar care settings. Conclusion Given the many demonstrated benefits of harm reduction as an approach, there is a need for the implementation of harm reduction interventions across all health and social care settings where people who use unregulated substances attend to care. In the context of EDs, the perspectives of health care providers such as nurses and physicians are particularly relevant as these groups are most directly involved, and ideally positioned, to provide harm reduction in this setting. This study delves into ED nurses' and physicians' experiences of harm reduction provision, and identifies three interrelated factors as shaping staff's ability to engage in harm reduction practice – teamwork, preparedness, and connections. Considerations related to these salient factors have the potential to inform and support current and future harm reduction implementation efforts in the context of EDs and across other health and social care settings. 142 Chapter 5: Emergency Department Staff Perspectives of Violence Towards Them: The Disconnect and Divide Between Patients, Staff, and Organizational Structures of the ED Chapter 5 is the third findings chapter of this dissertation, and is written in manuscript style. Unlike the previous two manuscripts that focused specifically on harm reduction, this manuscript attends to the issue of patient violence toward staff in the context of people who use unregulated substances. To this, we are not stating that people who use unregulated substances are violent, but rather that the potential for, and experiences of violence, were commonly discussed in interviews with staff, with the potential to impact the way that staff care for people who use unregulated substances. As such, the issue of violence warranted further analysis. Introduction The Emergency Department (ED) is a source of both urgent and primary care for people who use unregulated substances and are simultaneously marginalized through inequitable circumstances such as poverty, housing insecurity, racism, and ableism, and other forms of stigma and discrimination (Cederbaum et al., 2014; Kendall et al., 2017). ED use among this population is directly associated with existing gaps and inadequacies in primary care and wraparound health and social services (e.g., shelters and housing) in the community setting (Fairbairn et al., 2012; Parashar et al., 2014). Despite serving as a critical entry point for care (Mayer et al., 2023; Rajab et al., 2023), many people who use unregulated substances attend to care in the ED only when all other options have been exhausted (Hawk et al., 2022; Rajab et al., 2023). This is because their ED care experiences are frequently poor associated with complex factors, including, but not limited to long wait times, poor withdrawal and pain management, delayed, incomplete, or inappropriate care, and experiences of discriminatory differential 143 treatment and neglect (Chan Carusone et al., 2019; Henderson et al., 2008; Mayer et al., 2023; McNeil et al., 2014; Summers et al., 2018). Much research has sought to examine why poor care occurs, with findings illustrating a myriad of factors, including acts of stigmatization by staff (Jackson et al., 2014; Henderson et al., 2008; Paterson et al., 2013), staff knowledge deficits concerning the complex needs of patient who use unregulated substances coupled with a lack of around-the-clock substance use specialist support (Jiao et al., 2023; Mayer et al., 2023; Paterson et al., 2013; see Chapter 4 for further details). Even still, other factors that contribute to poor care include outdated organizational policies and procedures to foster optimal care, and paternalistic ideologies and assumptions about the agency of individuals and / or their ability to manage their own health (Jiao et al., 2023; McNeil et al., 2014). As the body of evidence concerning health care among people who use unregulated substances continues to grow, some researchers have focused this discussion on the association between substance use and patient violence toward staff as a factor influencing their care experience. In these studies, service providers often described people who use unregulated substances as a "challenging" population to work with, associating them with notions of violence, aggression, unpredictability, and conflict (Ford, 2011; Henderson et al., 2008). This type of understanding has led to portrayals of substance use as a predisposing factor to violence (Crilly et al., 2004; James et al., 2006; Knott et al., 2005), thereby conflating substance use with violence. Such research has often overlooked however, the complexity of the ED care experience, including organizational structures of the ED, and variations in staff practices with people who use unregulated substances as contributing to the potential for violence / poor care. As whole, there has been a paucity of research examining how organizational structures of the 144 ED impact care provision for people who use unregulated substances, especially as related to patient violence (see Jackson et al., 2014; Paterson et al., 2013). Organizational structures are important because they influence the context in which care provision occurs, the ability of staff to make decisions, as well as the types of supports that staff receive. Within my research focused on harm reduction implementation in the ED, staff repeatedly talked about the potential for, and experiences of, patient violence, often describing people who use unregulated substances as potential perpetuators of violence. Staff perceptions of and experiences with violence are inherently relevant to harm reduction implementation because they impact staff's ability to provide care for people who use unregulated substances, of which harm reduction is an important element. Additionally, as I will discuss in the Findings section of this chapter, the context of use (i.e., substance use in ED bathrooms) is highly relevant in how patient violence was perceived and experienced. In this paper, we draw on interview data resulting from my dissertation study (interviews with ED nurses and physicians) and embark on a deeper analysis of staff perspectives of patient violence. In this, we are concerned with staff perspectives of when and why violence occurs, how staff navigate the potential for violence, the impact of their care choices on patient care, and factors that may shape their approach. This knowledge is urgently needed as patient violence toward ED staff is an increasingly pressing concern (Anderson et al., 2010; Ashton et al., 2018; Taylor & Rew, 2019). Findings from the study have the potential to contribute to understandings of patient violence in the ED in the context of care provision for people who use unregulated substances, and to inform future strategies that help staff navigate the potential for violence, with the goal of improving patient care inclusive of harm reduction provision. 145 Methods Research Design The study employed a case study design, and was informed by the theory of complex adaptive systems (McDaniel & Driebe, 2001; Widmer et al., 2018). Extensive details for that study are published elsewhere (Jiao et al., 2023) and detailed in Chapters 2 and 3 of this dissertation. For the purpose of this paper, we focus on interview data pertaining to ED staff's experiences of patient violence that have not been previously described. Setting The study case for this analysis is the ED at St. Paul’s Hospital (SPH). SPH is located in Vancouver, Canada and is an acute care hospital serving a client population disproportionately impacted by health and social inequities, including people who use unregulated substances, people who experience homelessness, and people living with a diagnosis of HIV (Providence Health Care, 2019a). SPH is known internationally for the implementation of an array of harm reduction programs (e.g., Addiction Medicine Consult Team, Rapid Access Addiction Clinic, Overdose Prevention Site) and interventions (e.g., take-home naloxone kits, to-go Suboxone®) (Braithwaite et al., 2020; Dogherty et al., 2022; Kestler et al., 2019a; Kestler et al., 2019b; Providence Health Care, 2019b), as well as the development of comprehensive harm reduction policies, the full details of which are published elsewhere (Jiao et al., 2023). The SPH ED opened in 1962 and is one of the busiest EDs in BC (Catholic Health Alliance of Canada, 2012; Providence Health Care, 2019c). In 2015-2016, there were more than 84,000 visits to the SPH ED (Providence Health, 2016). 146 Data Collection Data collection included in-depth, semi-structured interviews with interdisciplinary ED staff, including nurses (n=10), physicians (n=5), and clinical leaders responsible for harm reduction policy and implementation (n = 5). Interviews were conducted via Zoom and were audio-recorded, transcribed verbatim and checked for accuracy. Interviews with ED staff focused on how they, as agents of the ED system, interact with other system agents to support harm reduction implementation. Interviews with clinical leaders focused on their perspectives of policy, programming, and implementation of opioid specific harm reduction interventions. Consent was obtained verbally and all participants received $30 CAD in appreciation of their time. Ethics approval for this research was obtained from the University of British Columbia (UBC) Behavioural Research Ethics Board (BREB), Certificate of Approval #H19-02470. Data Analysis For my dissertation study, transcribed data were uploaded to NVivo™ 12 to facilitate data management. A coding scheme was established, taking into consideration the types of system agents that are involved in opioid specific harm reduction in the ED, how system agents interact to support implementation, and how patterns of interaction can lead to the emergence of systemic facilitators and barriers to implementation. Resultantly, data were organized into 32 codes, such as Addiction Medicine Physician, Addiction Assessment Nurse, Rapid Access Addiction Clinic (RAAC), Overdose Prevention Site (OPS), opioid agonist treatment (OAT), take-home naloxone, withdrawal management, teamwork, staff education, policies, space, and discharge and referral. Although the purpose of my dissertation study was not to examine patient violence in the ED, staff spoke at length about the potential for patient violence toward staff by patients who use 147 unregulated substances and the relevance of violence for patient care. In the experiences relayed by ED staff, it was apparent that many grappled with the potential for patient violence and specifically associated this with caring for people who use unregulated substances. Staff reported a range of experiences including their own direct experiences of violence (e.g., being hit or sworn at by patients) and/or witnessing violence by patients towards other staff. As such, a dedicated code was created to encompass these experiences. Data from the dedicated code on "violence" were analyzed using reflexive thematic analysis (RTA) (Braun & Clarke, 2006), which was informed by the theory of complex adaptive systems (McDaniel & Driebe, 2001; Widmer et al., 2018). As per the RTA approach, coding of the data was an iterative process whereby new codes emerged and evolved as more data were reviewed. As such, a number of initial codes were deleted, renamed, split, and / or combined (Braun & Clarke, 2019). This process allowed for the gradual development of themes as meaning-based patterns, and facilitated a fulsome interpretation of the data (Braun & Clarke, 2019). In carrying out RTA, we created sub-categories within the violence code that reflected how violence was talked about, defined, and taken up in the practice setting, moments in the clinical encounter where it is being thought about and considered, and how staff grappled with the potential for violence in their day-to-day work. This process resulted in the construction of a coding scheme that reflected not only staff's experiences of patient violence in the ED, but also their understandings of when and why patient violence occurs in light of how patients and staff as system agents interact with one another and with system structures, as well as how staff navigate the potential for violence within this complex system. Finally, in formulating analytical themes, we asked questions such as: In the case of caring for people who use unregulated 148 substances, how do staff experience patient violence toward them? What are scenarios where violence is perceived likely to occur? How do staff navigate the potential for patient-staff conflict, and what is the impact of these care decisions on the delivery of care? What factors may shape how staff navigate the potential for patient-staff conflict? Findings As stated earlier, a total of 20 individuals took part in one-to-one interviews that informed the present analysis, with 15 of interviews being with ED staff (i.e.,10 nurses and 5 physicians). All 10 nurse participants held Registered Nurse designations. Physician participants included four staff physicians and one resident physician. Nine women and six men participated in the interviews, of which, eight spoke to their length of work in the SPH ED, which ranged from 6 months to 12 years. Five additional interviews were conducted with clinical leaders with responsibilities associated with harm reduction implementation at the broader organizational level of Providence Health Care.15 Overall, ED staff described by patient violence toward them to be a "common" occurrence, and a significant concern that affected patient care. Staff reported not only experiencing and witnessing patient violence, but also fearing the potential for violence. Albeit recognition that patient violence occurs with many patient populations irrespective of substance use, staff emphasized that violence was a particular concern among this patient group. Staff described patient violence as taking many forms, including verbal (e.g., swearing, issuing threats, yelling, screaming) and physical violence (e.g., hitting, kicking, throwing objects such as beverages, brandishing weapons such as used needles). Staff described experiences of 15 The clinical leaders who participated in leadership interviews assumed various roles in the organization. For reasons of confidentiality, no details are provided as to their specific roles. 149 patient violence as “challenging,” and as contributing to a work environment that was "unsustainable." Staff also spoke about the impact that patient violence had for them, particularly given what they described as ongoing and continuous violence by patients in their ED. Exposure to violence specifically led to feelings of frustration, fatigue, and burnout, which in turn, they described ultimately impacted their ability to provide their best care as exemplified in the following excerpt: I think that that takes a lot of patience to not take that [patient violence] personally and to let that go. It is just complicated because you really want to help people and support them when they need you in the hospital, and then when they call you something and it’s hard to continue to provide your best care. – ED Nurse Despite the frequent occurrence of patient violence, ED staff underscored that it is not that they, nor patients, intend for violence to occur. Rather, they understood the potential for violence in light of how patients and staff as system agents interact with one another, and with structures of the system that negatively impact patients’ experiences of care and limit staff’s ability to provide holistic care. Specifically, staff attributed the potential for patient violence to a disconnect between what patients need and what they can offer – a disconnect that is situated within constraints produced by structures of the system. Consequent to this disconnect, patients felt disregarded or unheard in the context of attending to care, and patient violence is a consequence of these experiences. Sometimes people want more than our emergency department can offer... A really common one [patient request] is people wanting a bed to lay down in and rest, so sometimes it’s as simple as "I want to lay down" and we say "I cannot help you do that."... Code Whites [Emergency code for "aggression" in the hospital] or violence, whether that’s physical or verbal, that usually just has to do with the fact that that person [the patient] feels they’re in a crisis and they’re not being heard and they’re not being respected, or their needs are not met. – ED Nurse 150 Staff specifically identified two distinctive points in the ED care trajectory where a disconnect between what patients need and what they can offer created conditions that contribute to staff-patient conflict, with the potential to escalate to patient violence – at the point of discharge, and when patients use substances in ED bathrooms. In the sections that follow, through delving into these two distinctive points, we examine why patient violence occurs in light of how patients and staff as system agents interact with one another and with structures of the system. We additionally present varied perspectives and approaches taken by staff to navigate the potential for patient-staff conflict, speak to the impact of these care choices on patient care, and relay factors that may shape staff's approach. Theme 1: Timing and Reasons for Patient Violence Staff described discharge as the “single most volatile point” in the ED care trajectory where such a disconnect is likely to occur, with the potential for staff-patient conflict and patient violence. Staff explained that, for some patients, experiences of homelessness coupled with limited access to emergency shelters meant that they were faced with discharge to the street upon care completion. Staff discussed how weather and season further complicates discharge, particularly when patients were being discharged during rainy and colder seasons. With the lack of appropriate and accessible shelter, staff noted that they believed patients viewed the ED as a temporary shelter, thereby contributing to their refusal to leave the ED when care was completed as noted in the following excerpts: Certainly in the winter months when it is colder and it’s raining out, you do have more of these requests [to stay in the ED after care completion] and you have more of these people who are shelter seeking, and also because of COVID, because the limited capacity of shelters and the way the shelters operate nowadays, the population has only grown and resources have been down to half in some places, and some places have closed entirely. – ED Nurse The emergency department is a safe environment and there is shelter. It’s comfortable in 151 comparison to what they [patients] are being discharged to. I have to sympathize with that situation – that is obviously a pretty awful situation where the emergency department is the most comfortable place that you have access to. – ED Physician However, patients' need for shelter clashes directly with the mandate of the ED as a system structure, which, as understood by staff, is to provide emergency care while minimizing wait times. As such, staff strive to ensure that patients are seen in an efficient manner, and expect patients to leave the department as soon as care is complete. Below, staff speak to how a disconnect between what patients need (to seek shelter), and what staff can offer them as dictated by the mandate of the ED, created conditions that contribute to staff-patient conflict and scenarios of violence. There are patients that can become extremely angry and violent because you’re trying to tell them that they have to leave because the hospital is not a shelter and it’s not a place that they can just hang out for the night. They don’t understand where you’re coming from because what they see is like an empty waiting room and why can’t they just hang out there for a little bit. – ED Nurse It is unfortunately an emergency department where you have to maintain the flow, see patients rapidly and keeping things moving. I have seen patients respond quite violently [when their request to seek shelter in the ED is denied], often with verbal aggression more than physical aggression. – ED Physician To this end, staff cautioned that such a disconnect is not limited to people who use unregulated substances, emphasizing that the potential for patient-staff conflict is related to inequitable circumstances that people experience, such as poverty and homelessness, rather than substance use, and that they are at a loss to address these issues within the ED mandate. As noted previously, staff also identified a second point in the ED care trajectory where a disconnect between patients, staff, and structures of the system is likely to manifest, with the potential for staff-patient conflict and patient violence – when patients engage in substance use in ED bathrooms. As per organizational policy, the use of unregulated substances is not permitted in the immediate ED environment (Providence Health Care, 2021c). Cognizant that patients may 152 experience symptoms of withdrawal while attending to care, the hospital makes available an Overdose Prevention Site (OPS) dedicated to supervised consumption. However, this service is only available from 8 am to 6 pm. The hospital additionally offers substance use withdrawal management services. However, because Emergency Physician often rely on their Addiction Medicine colleagues to offer appropriate management for withdrawal, and the latter are inconsistently available after 5 pm and overnight, withdrawal management may similarly be unavailable at all times of the day (see Jiao et al., 2023). These structures of the system – organizational policy coupled with service availability contributed to conditions where what patients need and what staff can provide are incommensurate. People have this certain standard [threshold] they need to meet [when using substances] to have their [withdrawal] symptoms controlled, or their pain managed. When they come into hospital they don’t have access to that. We don’t allow people to use in our department. – ED Nurse Consequently, patients resorted to using substances in ED bathrooms to manage their withdrawal, and to avoid detection by staff. However, if a patient is perceived as “taking too long” in the bathroom, or refuses to open the door – and staff suspect substance use – they noted being concerned about the potential for overdose and their ability to respond in a timely manner. Moreover, as the bathroom is a shared space, staff also had to navigate that other patients and visitors need access to the bathroom. Participants discussed many responses to use in the bathroom, including eviction of the patient from the bathroom. This eviction regularly involved the assistance of security personnel, contributing to potential scenarios of violence. This disconnect between what patients need (withdrawal management), and what staff can offer them as dictated by structures of the ED and staff responses to patients' use in the bathroom, were seen as directly creating conditions that contribute to patient-staff conflict and scenarios of violence as noted below: 153 [When patients resort to using substances in the ED bathroom], you cannot spend two hours in the bathroom. It’s a shared space. We have had situations where a patient used [substances] in the bathroom, refused to come out. [The person was] approached by security, and [the person] was wielding a used needle almost as a weapon, and it is a weapon, a used dirty needle. – ED Physician Theme 2: Navigating Conflict and Implications for Care With the potential for violence noted at two key time points in the care trajectory, it was apparent that there were substantial variations in how staff navigated these situations. Such variations were influenced by organizational policies as well as individual staff anxiety, previous experiences of violence, and preparedness to manage and navigate conflict that could occur. ED staff were cognizant of the potential disconnect between what patients need (shelter) and what they can offer in the context of system constraints at the point of discharge. Some staff tried to minimize the potential for patient-staff conflict by meeting the needs of patients to the best of their ability. They did so by taking a trauma and violence informed approach that allowed for control, choice, and empowerment on the part of the patient. Having a trauma informed lens and giving them [the patient] choice... Just trying to give them a little bit more, a sense of control, because I feel like they lack that so often. I try to make them feel empowered. – ED Nurse In some instances, staff described “leniency” as an approach to navigate conflict associated with the discharge trajectory. For instance, although it is not within their power to increase the availability of community-based shelter spaces, staff were sensitive to power imbalances inherent in the patient-staff relationship. “Leniency” was a practice of allowing the patient to stay for a while if the department is not busy. Additionally, staff were proactive and resourceful in trying to meet the socio-structural needs of patients. Some provided the patient with a means of transportation through referring the person to a volunteer-based driver program, or to the ED 154 social worker to obtain a voucher for cab services. Others offered sandwiches and juice to-go, and facilitated access to donated clothing and shoes, as described by an ED Nurse below: If somebody [patient] is just being slow to get out [of the department after they have been discharged] and it is the middle of the night, then maybe there is a way to sort of let them sit in the waiting room for another hour or two until the sun comes up and it’s a little bit warmer. Or maybe it is just a matter of getting them some extra food, some extra sandwiches, some extra whatever, getting them a to-go bag together to just make it a little bit less unbearable. We have a clothing donation locker we can look into. If you have an extra couple of minutes, sometimes you can run down there and if you’re lucky maybe you do find them a nice, a jacket or something like that that is going to help things along a little bit better. – ED Nurse However, there remained varied perspectives, and inconsistencies, in the approaches taken by staff and in the care choices that they made. While some took a trauma and violence informed approach and tried to meet the needs of patients to the best of their ability, others reportedly do not agree with nor condone strategies such as allowing the patient to stay after care completion, or offering food to-go – deeming these actions as “superfluous” and in contradiction to the ED mandate. If you offer your patients two sandwiches, if you say "yes" to them more than once, you’re being frowned upon [by colleagues]. They’re like "we don’t have time for this. They’re [the patient and their presenting concern] fixed. Time to go." – ED Nurse They [colleagues] see me keeping them [the patient] a bit longer in the bed [after the person has been discharged from care], they’re like "no, you don’t." They know that if it’s my patient, I have full control over my care and practice, but I still get a lot of criticism. – ED Nurse As such, some staff were described as choosing to forcibly discharge the patient – a process that often involves the escort of security personnel. Ending the patient care encounter on a note of strife and discord left little opportunity for the provision of discharge planning. The following excerpts highlight what this forcible removal entails, illustrating both a lack of dignity for patients and limited discharge planning, particularly for overdose prevention. 155 They [the patient] don’t want to go, they’re described [by staff] as malingering, and it’s like "well, just call security and they have to go." If the patient refuses to get changed out of hospital clothes, it’s like "okay, we’ll put your stuff in a bag and you get walked out." – ED Nurse Sometimes they [the patient] leave super violently where you know you’re not going to toss them a Narcan [take-home naloxone] kit as they’re being carried out by security. – ED Nurse As with the refusal of discharge, staff similarly had varied responses to substance use in the ED bathroom. Notably, in these scenarios, staff are offered a degree of support by other organizational policy, which acknowledges the prohibition of substances use in the care environment as potentially problematic (Providence Health Care, 2021c). According to this policy, although substance use is prohibited, if a person was found to be using substances in the care environment, the person is not automatically discharged or denied access to care. Instead, ED staff are expected to ensure the person's safety, offer the option of attending the in-hospital Overdose Prevention Site (OPS), and facilitate connections to substance use specialists for withdrawal management (Providence Health Care, 2021c). Below, staff speak to how, when faced with scenarios of substance use in ED bathrooms, they tried to allow for control, choice, and empowerment on the part of the patient – an approach that aligns with this organizational policy. If they’ve [the patient] used [substances] but they’re at baseline and their resp [respiration] rate is fine, then I typically see it treated as "oh okay, we’re going to get rid of the contaminated supplies and get you all set up again here in the waiting room, and keep an eye on you," or "we’ll bring you into a back area to keep an eye on you and make sure that you’re not about to suffer from acute respiratory depression or anything like that."... I’ve never seen hostility towards the patients, which is always reassuring. I’ve always seen it as being "let’s try and provide the best care possible for this patient." – ED Nurse As long as they [the patient] haven’t overdosed, I would probably bring them back to where they were before... I would put them somewhere where we at least have a sat probe [measure of oxygen status] on them and we can watch them... Our Addiction Assessment Nurses, I think most people [staff] would probably have one of those two [Addiction 156 Assessment Nurses] come and at least have a chat with them [the patient] and see if there are any resources that they’re missing that they might need when it comes to their addiction. I probably would try and tell them [the patient] not to use in the bathroom... Now that I’m thinking of the third floor [the OPS] as more of an alternative, that might be a really good time for that to come up as an option. – ED Nurse Again, there remains a degree of variation in the individual practice of staff and the care choices that they make. While some tried to avoid a punitive approach to substance use in ED bathrooms, and did their best to meet the needs of patients while working within system constraints, for others, the disobedience of the department's prohibitionist policy automatically translates to involuntary discharge from services of the ED, and consequently the denial of care. Theme 3: Factors Shaping the Approaches of Staff As illustrated above, when faced with the potential for patient-staff conflict in the clinical space, arising from a disconnect between what patients need and what staff can offer, the responses of staff were constrained by structures of the system. At the same time, however, the approaches taken by staff were ultimately individualized. To this end, study participants spoke to a number of factors that shape how ED staff navigate the potential for patient-staff conflict – thereby contributing to variations seen in practice, including hypervigilance and fear, expectations around teamwork, and a lack of training related to violence prevention. In the subsequent discussion of this theme, we detail these variations. The fear of violence, especially the threat of physical altercation and injury, was extremely disconcerting for staff. This was especially the case for staff who had previously experienced violence – either through the workplace, or in the context of their personal lives. Fears associated with the potential for future violence, notably contributed to some staff being hypervigilant in identifying the potential for violence. Simultaneously, patients with complex histories of violence and other adversities such as poverty, homelessness, and discrimination 157 were recognized by some of the staff to be particularly guarded and reactive. Consequently, staff hypervigilance contributed to identifying patients' defensive behaviours as what they perceived as violence further escalated the situation – thereby contributing to violence as a type of self-fulfilled prophecy. Below, a clinical leader provides an example of this interrelationship between hypervigilance, escalation and the potential for violence: A nurse […] told the person [the patient] who started to make his fix [prepare own supply of substances to use] "hey, don’t use so much this time, because last time you used too much and you went on the nod [to be in a semi-conscious state]." He [the patient] was instantly defensive, and right away I could say this could escalate to a Code White [violent incident]. She [the nurse] has no idea, and she doesn’t know that there is no point in arguing this with him. He was like "that is bullshit, I would never do that, I hate it when people go on the nod. How could you fucking say that to me?" Then he started swearing. I intervened, but I thought to myself she was going to keep arguing this point with him, and he was going to keep defending himself. As somebody who has spent so much time in prison, on the streets, surviving, a normal response for him is not a normal response for people that are housed and secure. If you hear his swear words and you interpret that as violence, and you react even bigger and then you both get louder together. I see it happen all the time. I see people [staff] get into that power struggle and then it escalates and they’re confirmed right, "I knew that guy was going to be trouble, and look, now he’s calling me this name and that name." – Clinical leader Furthermore, when staff identified the potential for violence, due to fear, they called upon and involved security personnel as soon as possible. Regrettably, security involvement paradoxically contributed to the likelihood for violence as this action can "up the ante" for the patient. That is – the patient may be triggered by the presence of security, especially if they have had previous experiences of trauma, or have had negative encounters with power and authority. Triggers are situation, places, people, sensations, feelings, or thoughts that can cause a person to experience of a traumatic event of the past as if it was reoccurring in the present (Substance Abuse and Mental Health Services Administration, 2014). People who have experienced trauma, loss, or hardship may be more likely to be affected by new traumatic events – for instance, being accosted by security personnel – which can lead to intense reactions, including anger, fear, and 158 helplessness (United States Department of Veterans Affairs, 2023). Given established interconnections between experiences of trauma, substance use, and homelessness (Greene at al., 2023; Padgett et al., 2006), triggers are an especially pertinent consideration. Below, staff speak to how early engagement of security personnel can concurrently provide them with a sense of safety and contribute to scenarios of violence. I think sometimes it is because people don’t know enough, they’re not experienced enough, or they’ve just had some really bad experiences, so they get security for times when they don’t [need it]. And of course, seeing security, that automatically ups the tension level, if you’re a patient and somebody shows up with security right away. – ED Nurse Still, even if staff deem that their colleagues may have "jumped the gun" in involving security personnel, it was evident that they are not often comfortable in offering inter-colleague feedback. Staff explained that, in the clinical space, if the primary nurse for a patient decides to involve security personnel, other team members have very strong reservations about intervening. This is because, as is the case for many health care settings, staff are expected to follow a team-based approach (i.e., to work in unison and to support each other's efforts): Nobody [staff member] is going to be questioned if they kick someone [the patient] out with security, [the patient] who is using drugs in the bathroom. Nobody is going to say [to the patient] "you can do this too [such as attending the OPS] and stay [to complete your care]." Nobody is going to do that. It’s like done and gone. – ED Nurse Staff were also hesitant to offer feedback because health care providers, including nurses and physicians, have expectations of autonomous practice, which refers to the authority they have to act according to their professional judgement, including making decisions about "client care activities that they are educated, competent, and authorized to make" (British Columbia College of Nurses and Midwives, 2023a, para. 2). Below, staff speak to their hesitancy to engage in professional dialogue in light of expectations related to autonomous practice. 159 It is challenging in nursing. Everybody has their own practice. There isn’t a black and white right answer to things. It is a competitive environment almost. People feel competitive with each other to an extent... It is easy for people to take things personally and there is nothing in it for me in offering that feedback to them... Everybody does their own thing. Everybody’s got their own practice, and for the most part, people don’t critique each other or offer feedback. – ED Nurse Hesitancy to offer inter-colleague feedback on a one-to-one level is further compounded by a perceived lack of safe spaces for feedback on the organizational level. In particular, staff voiced a need for more "on the ground" observation and coaching from leadership to support that they receive feedback in real-time – both in the moment and immediately after a violent incident has occurred. I feel like more presence, observation from leadership can help see and change things... In other professions, you've got management on the floor observing and coaching and offering feedback... I think unless you can offer specific feedback at the time it’s happening, it really becomes generic if people can detach from it and not take it to heart because it’s not specific enough. – ED Nurse Finally, clinical leaders noted that when staff identify the potential for violence, they resorted to involving security simply because that is what staff were taught. That is, as part of workplace training, staff are not taught how to prevent violence, or how to navigate the potential for patient violence. Rather, they are taught how to respond after a violence incident has occurred. Below, clinical leaders underscore the need for training initiatives that truly address violence prevention, especially through a trauma informed lens. None of this [workplace education] is preventing violence, like not a single thing is actually going to prevent violence. You’re teaching people how to do a Code White. You’re teaching people how to use security. That is not prevention. – Clinical leader Discussion Using the ED at SPH as a case study, this paper examines ED staff perspectives of patient violence toward them in the context of care provision for people who use unregulated substances. Findings of the study illustrate how disconnects between what patient needs and 160 what staff can offer them created conditions that contribute to staff-patient conflict and scenarios of violence – disconnects situated within constraints produced by structures of the ED and hospital system. This paper additionally presents the varied perspectives of and individualized approaches taken by staff to navigate the potential for patient violence, relaying factors that may shape their practice. Of the extant literature that addresses patient violence in the ED, a very small number of studies acknowledge that violence may arise from unmet patient needs (Jackson et al., 2014; Morken et al., 2015), or when there is a "mismatch between patient expectations and the reality of services offered" (Morken et al., 2015, p. 3). Conversely, the vast majority of studies have tended to focus on identifying "predisposing factors" to violence. For instance, Knott et al. (2005) have reported predisposing factors to violence in the ED at the level of the patient, including previous history of violence or psychiatric illness, or being under the influence of alcohol or unregulated substances. Other studies have focused on predisposing factors at the level of the service provider, such as years of work experience, working alone, or working in "gatekeeping positions" (Ferri et al., 2020; Kowalenko et al., 2005; Morken et al., 2015). Moreover, a number of studies have outlined predisposing factors at the level of the organization, such as lengthy wait times, the slow response of security services, and unsupportive feedback given by management (Hou et al., 2022; James et al., 2006; Morken et al., 2015). However, extant studies do not address when and why patient violence occurs in light of how patients and staff as system agents interact with one another and with structures of the system. As such, the findings of our study appear to be novel and unique. One area of considerable importance is our findings that demonstrated tremendous variation in how ED staff navigate the potential for patient-staff conflict, and propose fear as a 161 factor that impacts how staff identify the potential for violence and how they respond – manifesting in hypervigilance and early engagement of security personnel. In comparison, previous studies have tended to focus on how staff identify the potential for violence through observable behaviours of the patient, such as staring, or lack of eye contact; tone or volume of voice; anxiety; mumbling or slurring or incoherence; and pacing or agitation – constituting the acronym STAMP (Luck et al., 2007). Additionally, researchers have alluded to factors that may shape how staff respond to violence, which include degree of personalization (e.g., whether staff perceive the violence to be directed at their personhood), presence of mitigating factors (such as psychiatric illness, intoxication or withdrawal from substance use, head injury, or anxiety in the context of recent traumatic events, and perceived degree of responsibility for requiring ED services), and reason for ED presentation (e.g., "legitimate" presentations versus "inappropriate" self-referrals) (Luck et al., 2008). Given that experiences of fear are prevalent among ED staff (Sachdeva et al., 2019) – 26% of ED nurses "never" or "seldom" feel safe at work (Gates et al., 2006), findings of the present study that fear is a factor that impacts how staff identify the potential for violence and how they respond are noteworthy, and should be considered in the formulation of future strategies to address violence in the ED. Our study findings also suggest that expectations of teamwork is a factor that shapes how staff navigate the potential for patient-staff conflict, resulting in low comfort and willingness of staff to engage in professional dialogue with one another. The existing literature has similarly reported that health care providers have reservations about providing feedback to their colleagues – although these studies have tended to pertain to "speaking up" in the context of patient safety issues and preventing harm (Lee et al., 2021; Okuyama et al., 2014). These extant studies have highlighted a multitude of factors that contribute to hesitancy in offering inter-colleague 162 feedback, including collectivist cultures where "the maintenance of harmonious working relationships is more valued than expressing one's ideas" (Lee et al., 2021, p. 1059), concerns of appearing incompetent, fear of reprisal, and various hierarchies of power, including seniority-based hierarchy, age-based seniority, as well as gender and profession based power differentials (Lee et al., 2021; Okuyama et al., 2014). While findings of this study echo previous research that expectations of teamwork are a deterrent to "speaking up," finding related to autonomous practice appear to be innovative, as is the impact of unwillingness to provide inter-colleague feedback on how staff navigate the potential for patient-staff conflict within the context of the ED. Furthermore, it has been well established that inter-colleague feedback is critical for the professional development of health care providers – for instance, an annual requirement for license renewal for nurses in the province of BC is that they gather feedback from their peers, which then serves as the basis for their professional development plan (British Columbia College of Nurses and Midwives, 2023b). It is thus essential that clinical leadership create safe spaces, and facilitate opportunities, for inter-colleague feedback. Relatedly, there is the need for ongoing "on the ground" mentorship and coaching from clinical leadership to support that staff learn, and are adequately prepared to navigate the potential for patient-staff conflict in a trauma-informed way. Our study further identified a lack of violence prevention training – as opposed to violence response training – as a factor that shapes how staff respond when faced with the potential for patient-staff conflict. Consequently, there is the need for training that truly addresses how to prevent violence through a trauma-informed lens. In the context of BC, staff who work in the ED are expected to undertake the Provincial Violence Prevention Curriculum (Providence Health Care, 2019e), which is currently being updated as part of a broader 163 provincial initiative to establish a new relational security model (Government of British Columbia, 2022). This model is informed by principles of trauma informed practice, and strives to integrate "knowledge of how people are affected by trauma into procedures, practices, and services to create a safer environment for staff and patients" (Government of British Columbia, 2022, para. 4; SWITCH British Columbia, 2023). These changes strive to ensure that patients feel safe, and are not retraumatized or triggered by their care, and are based on the understanding that "when people feel safe, they are far less likely to behave aggressively" (Government of British Columbia, 2022, para. 21-22). To remain faithful to the principles of trauma informed care, violence prevention training should incorporate awareness of the types of adaptations that people make in order to cope and survive in the face of historical and ongoing violence. That is, people who have had experiences of trauma may be in "survival mode" – a state characterized by a heightened sense of awareness and stress – which means that they may be constantly on guard and ready to react (Ford & Courtois, 2020). Furthermore, there is a need for organizational policies and processes that allow for and support staff to offer meaningful choices and consider them collaboratively with patients (Wathen & Varcoe, 2021). Limitations There are a number of limitations to the present study. First, the study reports on staff perspectives of patient violence in the ED of an acute care institution with a longstanding commitment to providing quality care to populations disadvantaged by health and social inequities. The unique client population served by this institution, and its vision to provide exceptional care that driven by compassion and social justice, may have implications for points in the care trajectory where patient violence is perceived likely to occur, how staff navigate the potential for patient-staff conflict, as well as the types of factors that may shape the care choices 164 that staff make. As such, findings of this study may not be directly applicable to care settings that do not have similar organizational missions or mandates. Despite this limitation however, we believe our study findings hold relevance for other EDs, and can offer valuable insight into understanding patient violence in this practice setting. Second, the present study centres on the experiences of ED nurses and physicians, and clinical leaders. Investigations in the future should additionally consider the perspectives of other types of ED staff, in particular, the perspectives of security personnel. Finally, there are perspectives that would see actions of staff such as security escorted discharge and forcibly removing someone from the bathroom as acts of violence against patients. While the present study is situated from the perspective of ED staff, and is specific to staff experiences, there is a pending need for future work that frames violence in the ED as structurally embedded and experienced by both staff and patients. This future work should further challenge the conceptualization of patient violence as a one-way phenomenon (i.e., patient perpetuating violence against staff), and instead, explore violence as a product of the complex interplay between structural, clinical, and cultural dimensions of the ED experience. Conclusion Although EDs serve as critical entry points for care for people who use unregulated substances, the ED care experiences of this patient population tend to be poor. The extant literature speaks to a number of factors that shape ED care provision for people who use unregulated substances, including care provider stigmatization, insufficient staff education, a lack of substance use specialist support, and discriminatory organizational policies. Researchers have additionally pointed to patient violence as a factor influencing the care experience. These understandings have tended to portray substance use as a predisposing factor to violence, thereby conflating substance use and violence, without consideration of organizational structures of the 165 ED, and variations in staff practices, as contributing to poor care and / or the potential for violence. The positioning of people who use unregulated substances as potential perpetrators of violence, and as dangerous, has the potential to contribute to harm by impinging on the ability of staff to provide care. As such, there is a need to examine staff perspectives of patient violence in the context of care provision for people who use unregulated substances in a study pertaining to harm reduction provision in the ED. In filling this research gap, this study identified, through the lens of staff, points in the ED care trajectory where patient violence is likely to occur, illustrating a disconnect between what patient needs and what staff can offer them created conditions that contribute to scenarios of patient violence – a disconnect that is situated within constraints produced by structures of the system. Study findings further detailed the varied perspectives of and approaches taken by staff to navigate the potential for patient-staff conflict, while also outlining factors that may shape their practice and care choices. These findings are significant and noteworthy, and have the potential to inform and support current and future efforts of addressing patient violence in the ED, with the end goal of improving patient care for people who use unregulated substances, inclusive of harm reduction provision. Study findings may also offer important guidance for clinical education, supports made available to staff related to patient violence, organizational policy reform, and future research endeavours. 166 Chapter 6: Discussion In this final Chapter, I offer a fulsome discussion of the cross-cutting study findings in light of previous work, highlighting key contributions. I also speak to the building of research partnerships and knowledge mobilization, and offer recommendations related to policy, education, practice, leadership, and research. Chapter Summaries In Chapter 1, I provided the background and context needed to situate the research problem. I presented harm reduction as an approach to reducing the harms associated with unregulated substance use, and established the need for harm reduction implementation in the ED context. I then provided a brief summary of the existing research on harm reduction in EDs, culminating in the identification of a knowledge gap – harm reduction implementation in Canadian EDs, and contextual factors that staff experience as facilitators and barriers to implementation – leading to the delineation of the research purpose and questions. I also presented a comprehensive overview of the current state of knowledge related to the topic of investigation. In Chapter 2, I situated myself as a researcher, noted the impacts of undertaking research during the COVID era, and spoke to the theoretical tenets that serve to inform my dissertation study, including complex adaptive systems and critical perspectives. I presented the study design and an overview of the study site, including gaining permission for entry. I spoke to the study's three data sources, including semi-structured interviews with staff and clinical leadership, a self-administered staff survey, and text documents in the form of organizational policies. I detailed the purpose and the analytical procedures associated with each of the study's three separate analyses. Lastly, I addressed considerations related to research rigour and ethics. 167 Chapter 3 is the first findings chapter presented in manuscript format. In Chapter 3, I focused on how the ED is organized as a complex adaptive system to provide harm reduction, identifying facilitators and barriers in light of interactions between system elements. Study findings demonstrated that an array of system agents, including substance use specialists and non-specialists, interact in ways that enable harm reduction provision, including opioid agonist treatment, supervised consumption, and withdrawal management. At the same time, limited access to substance use specialists, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created systemic tensions that hinder harm reduction provision with profound implications for the delivery of care. Chapter 4 is the second findings chapter and builds on the findings of Chapter 3. Continuing to position the ED as a complex adaptive system, this chapter examined how ED staff, in particular nurses and physicians, engage in harm reduction in the ED, and delineated contextual factors that may influence their capacity to engage in harm reduction practice. Findings demonstrated that contextual factors that shape the capacity of staff to engage in harm reduction practice include adequate preparation through receiving the necessary education and training, opportunities to leverage benefits afforded by working collaboratively with colleagues, and support in helping patients establish connections for ongoing care. Chapter 5 is the final findings chapter and where I explored ED staff perspectives of patient violence in the context of care provision for people who use unregulated substances. In this chapter, I examined when and why violence occurs, how staff navigate the potential for violence, factors shaping their approach, as well as impacts on patient care. Study findings demonstrated that disconnects between what patients need and what staff can offer created conditions that contribute to staff-patient conflict and scenarios of violence – disconnects that are 168 situated within constrains produced by structures of the system. In navigating the potential for staff-patient conflict, there was significant variation in the approaches taken by staff, with different implications for care. The care choices of staff were shaped by a number of factors, including fear and hypervigilance, expectations around teamwork and autonomous practice, as well as a lack of training related to violence prevention. In conducting the research that resulted in the three findings chapters, I was able to establish a most rewarding and collaborative relationship with the research site (i.e., my partner organization). In the section that follows, I speak to how, together with my partner organization, we navigated the research relationship, including engagement in activities of knowledge mobilization. Research Relationships and Knowledge Mobilization I was extremely fortunate to work with a research site, and with clinical leaders, who are very committed to this area of work. We also engaged as partners throughout the entire research process. We convened to determine appropriate timing for recruitment and data collection activities; taking into consideration the operational needs of the research site (i.e., what the organization needs to conduct its day-to-day work, and how to minimize disruption due to activities of research). We arrived at the decision to expand the scope of the study to encompass interviews with clinical leaders with the intention of capturing diversity and the greater context (such as considerations related to program availability and organizational policy). I was also introduced to clinical nurse leaders and educators, and physician champions, who contributed to strategies for recruitment and helping with recruitment on-the-ground. After the completion of data collection activities, as a continuance of this research relationship, and to support ongoing organizational initiatives to improve care, my supervisor and I met with clinical leaders to share 169 back some of the preliminary data from the staff survey. This sharing was in the form of a slideshow encompassing data related to participant characteristics, staff attitudes, workplace education, and staff perceptions of harm reduction interventions available in the ED. Furthermore, we created a formal, citable infographic with this data to share with the SPH ED Opioid Use Disorder Quality Improvement Group, with a caveat that the data presented are preliminary, and have not been integrated with findings from other data sources (see Appendix F). Lastly, clinical leaders showed a particular interest in the topic of patient violence toward staff, which was the inspiration for the third findings chapter on staff perspectives of patient violence in the context of care provision for people who use unregulated substances, including when and why violence occurs, how staff navigate the potential for violence, factors shaping their approach, and impact on patient care. Overall, through working with my partner organization, I gained an understanding of several key considerations related to navigating the research relationship, including conducting research that is relevant for the organization, being sensitive to, respecting, and catering to organizational needs, leveraging introductions and nurturing new connections, and lastly, the importance of respect, authenticity, and reciprocity. Key Contributions Study findings illustrated how, in the context of an ED where staff regularly care for people who use unregulated substances, staff engaged in harm reduction as a technical solution through facilitating access to opioid agonist treatment, withdrawal management, and supervised consumption, while also supporting patients to complete care through attending to their harm reduction needs. Staff additionally engaged in harm reduction as a contextualized social practice by helping their patients make valued community-based connections to support that they continue to engage with care after discharge from the ED. Comparatively, previous studies have 170 tended to have a narrow view of harm reduction that is limited to harm reduction as a technical solution, comprising of interventions such as opioid agonist treatment and take-home naloxone kits (e.g., Cisewski et al., 2019; Drainoni et al., 2016; Im et al., 2020; Lacroix, 2018; Wiercigroch et al., 2021). Although a number of studies have addressed how ED staff help their patients to make valued connections to available and appropriate community-based services and resources, these studies do not position connection making as harm reduction practice. For instance, studies have reported that staff employ strategies such as leveraging inpatient addiction consultation services to facilitate community-based connections, referring to rapid access “bridge” clinics that assist with follow up until such time that care provision can be assumed by long-term community-based care providers, and referring to community-based harm reduction specialists who are come into the hospital to facilitate post discharge linkages to care (Duber et al., 2018; Hu et al., 2019; Hyshka et al., 2019; Khan et al.; 2022; Salvalaggio et al., 2022; Thompson et al., 2020a; Trowbridge et al., 2017; Wakeman et al., 2017; Wiercigroch et al., 2021). By limiting harm reduction to a technical solution, interventions remain decontextualized, and with primary purpose of facilitating behaviour change (Harris, 2016; Jiao, 2019). While important, there is a simultaneous oversight of the need to address the impacts of contextualized socio-structural factors such as stigma, poverty, housing insecurity, and violence on harms experienced, and on people's capacity to mitigate harms (Bungay et al., 2010; Galea & Vlahov, 2002; Lang et al., 2013; Pauly, 2008). Previous work on ED care provision for people who use unregulated substances has emphasized how staff attitudes shape care provision. For instance, Henderson et al. (2008) reported that care providers believe that people who use unregulated substances do not take responsibility related to their health, and therefore do not attend appointments, follow through 171 with referrals, or take medications. This type of discourse contributed to care providers de-prioritizing the needs of these patients, and instead, offering resources to those they deem more likely to follow through with recommendations. Furthermore, service providers assumed that people who use unregulated substances are "drug seeking," especially when they present to the ED repeatedly or voice generalized pain (Henderson et al., 2008), which in turn impacted the triage process, whereby these patients had their concerns brushed aside or they were assigned lower priority (Paterson et al., 2013). In contrast to previously reported implications of discriminatory attitudes on care provision, findings of our study illustrated that staff are committed to care provision for people who unregulated substances and strive to do their best, but must work within various restraints of the system. While discriminatory attitudes and practices do exist, they do not negate barriers inherent in how the system is set up to provide care, inclusive of harm reduction and supporting people to complete their care journeys. A number of existing studies have illustrated how factors at different levels of the system can impact harm reduction provision in the of ED, including factors at the service provider level (Drainoni et al., 2016; Holland et al., 2019; Lacroix et al., 2018), the administrative, infrastructural, and logistical levels (Cisewski et al., 2019; Drainoni et al., 2016; Dwyer et al., 2015; Holland et al., 2019; Im et al., 2020; Lacroix et al., 2018; Wiercigroch et al., 2021), the policy level (Drainoni et al., 2016; Holland et al., 2019), and at the level of interdisciplinary and interagency support (Cisewski et al., 2019; Drainoni, 2016; Im et al., 2020; Lacroix, 2018; Wiercigroch et al., 2021). While these studies contribute to our understanding of the types of factors that can impact harm reduction implementation, they often overlook the complexity of the system including system agent interactions. As conveyed in Chapter 3 of this dissertation, by positioning the ED as a CAS, and accounting for how system agents interact with one another, 172 study findings may lead to more fulsome recommendations to enhance harm reduction as an element of care. Our unique contributions demonstrated the importance of understanding how system agents interact to carry out their respective roles related to harm reduction provision. For example, limited hours of operation for specialist services, when paired with specialist control, non-specialist reliance, and concerns related to safety, were seen to directly limit harm reduction provision. Study findings further explicated how inconsistent access to staff education, and unsupportive institutional policies and structures, are inadequate in supporting staff to interact with patients, ED colleagues, and community-based service providers to carry out their roles. A system perspective thus allowed for the unpacking of potential intersections and interrelationships when identifying influential factors, and can contribute to recommendations that are tailored, effective, and nuanced (Widmer et al., 2018). Across the three findings chapters, what is notable is that substance use harms in the context of the ED have little to do with substance use itself, but are rather imposed by inequities embedded in the structures and policies of acute care institutions. In many ways, the acute care institution acts as a microcosm that is reflective of larger society, where substance use harms also have little to do with substance use, and are rather imposed by societal structures such as laws that criminalize substance use, and which result in the amplification of substance use harms (Canadian Drug Policy Coalition, 2021; Canadian Public Health Association, 2014). Previous studies have illustrated how laws that criminalize substance use intersect with multiple social inequities, such as gender inequality, poverty, and colonialism to produce "everyday violence" (Boyd, 2020; Boyd et al., 2018; Bungay et al., 2010). For instance, to avoid the possibility of law enforcement seizing safer use supplies, people did not carry supplies on their bodies, contributing to the practice of equipment sharing (Bungay et al., 2010). Additionally, although 173 many would prefer to use substances in the home environment, they were limited by circumstances such as poverty and homelessness. Consequently, they were forced to use in the outside environment, where there is greater potential for violence (Bungay et al., 2010). People also tried to avoid being seen while using substances, which, coupled with a lack of access to mobile phones, meant that they were unable to make use of safety networks that were only available to them in person (Bungay et al., 2010). These understandings of oppressive structures as pervasive, and as ubiquitous regardless of setting prompt a need to account for the impact of structural inequities in all aspects of service planning – both within the context of the EDs and acute care institutions, and at higher levels of policy making as well as political decision making. Our study findings also established that people who use unregulated substances are cognizant of what they need to mitigate substance use harms while attending to care in the ED, and are proactive in trying to prevent those harms. In the context of ED care provision, patients who use unregulated substances were noted to be acutely aware of the extremely distressing experience of withdrawal. These experiences were seen to contribute to unregulated substance use in patient bathrooms, which allowed patients to avoid withdrawal while simultaneously hiding from staff to avoid detection, thereby preserving their access to care. These understandings further support calls for a shift from stigmatizing beliefs that people who use unregulated substances are irresponsible and passive in the promotion of their health and wellbeing (see Henderson et al., 2008). There is an urgent need to acknowledge people as experts related to mitigating substance use harms, and a need for staff to work collaboratively with people to reduce harms experienced in the context of care provision (Canadian HIV/AIDS Legal Network, 2005). For instance, staff can inquire into what works for the person in their own experience related to reducing harms, followed by a concerted effort to explore possible options 174 in the care setting. These conversations however, require the support of organizational structures and policies that offer more options for patients and staff, while also permitting an extent of flexibility so that staff can provide care that aligns with the specific needs of the person. Furthermore, previous studies have identified substance use to be a predisposing factor for patient violence toward ED staff, thereby conflating people who use substances with violence (see Crilly et al., 2004; James et al., 2006; Knott et al., 2005). For instance, Knott et al. (2005) investigated the characteristics of patients who were involved in unarmed threats in an Australian ED, citing substance use as a contributing factor to these incidents. Contrary to findings of previous studies that portrayed substance use as a predisposing factor for violence, findings of this study demonstrate that it is not substance use that contributes to patient violence. Rather, structures of the system – including the ED mandate, organizational policy, and service availability – contribute to a mismatch between what people who use unregulated substances need and what staff can offer, culminating in patient-staff conflict and the potential for violent encounters. These understandings of why patient violence occurs in the context of ED care provision help to shift the blame away from people who use unregulated substances as inherently violent, and as intentional perpetuators of violence. They also underscore a need to direct our attention to how patients experience the care provided, and how the system can better attend to their needs, as opposed to labelling certain population groups as the locus of the problem. Lastly, these findings help to humanize both patients and staff by de-pathologizing their behaviours, including staff's hypervigilance in detecting the potential for violence, and patients' intensified reactions, by taking into consideration that both patients and staff may have personal histories of trauma and violence, and may also have had past negative encounters in the clinical space. 175 Recommendations Grounded in study findings, this section speaks to recommendations across policy, education, practice, leadership, and research, with the recognition that many interrelationships exist between these categories. For instance, in the event of changing policies, there would be a need for clinical leaders to provide teaching, and to support staff to understand what it means to put new policies into practice. Following policy implementation, it is also possible to engage staff in conducting a policy evaluation to assess policy appropriateness and effectiveness. Lastly, as a number of recommendations from the study have already been outlined in each of the preceding findings chapters, this section focuses on overarching themes across all findings chapters, and speaks to recommendations from study findings as a whole. Policy Findings of this study illuminated how organizational policies influence and shape harm reduction provision in the ED in various ways. In light of study findings that organizational policies that subscribe to notions of specialized practice and hierarchical relations of power and restrict the ability of staff to practice to their full professional scope related to harm reduction, there is an urgent need to re-examine these policies with the intent of determining how care can best be delivered around the clock, and to support staff to work to their full scope of practice. Study findings also highlighted how organizational policies that prohibit unregulated substance use in the care environment hinder the ability of staff to support patients to complete care. Correspondingly, there is a need to improve the availability of harm reduction interventions that aim to counteract the impact of such policies, including withdrawal management and supervised consumption, while also considering alternatives to prohibitionist policies, such as episodic overdose prevention services (eOPS) – referring to care provider witnessed 176 consumption of unregulated substances for the purpose of preventing or responding to overdose (British Columbia Centre for Disease Control, 2023). Lastly, while previous studies have noted how prohibitionist policies render the care environment a "risk environment" for people who use unregulated substances by amplifying substance use harms and impeding the completion of care (McNeil et al., 2014), findings of this study add that these policies also contribute to staff-patient conflict and scenarios of violence. In addition to policies that dissuade a punitive approach to unregulated substance use in the care environment, organizations can support staff to navigate the potential for staff-patient conflict through the provision of trauma and violence informed care by establishing policies that allow for flexibility, collaboration, and connection when caring for and working with patients. Policies should also support the actions of staff to empower patients by giving choice and a sense of control whenever this is possible (Wathen & Varcoe, 2021) – for instance, policies that normalize staff's attempts in meeting the socio-structural needs of patients upon discharge, such as through the provision of food and wound care supplies. Education As evidenced by findings of this study, almost 70% of staff (i.e. physicians and nurses) reported never receiving education in their entry to practice schooling concerning caring for patients using unregulated substances. Given that people who use unregulated substances may require care for a number of reasons including overdose, other concerns related to substance use (e.g., endocarditis, cellulitis), as well as concerns not directly related to substance use (e.g., psychiatric diagnoses, injury) (Canadian Public Health Association, 2014; Winetsky et al., 2017), it is both alarming and disturbing that caring for people who use unregulated substances is not a standard component of entry-to-practice education for care providers (Gagnon et al., 2020; 177 Wakeman et al., 2013). There is an urgent need for care provider education to encompass caring for people who use unregulated substances, inclusive of the provision of harm reduction. Education endeavours must not only introduce harm reduction as a philosophy, but rather, offer concrete ways of translating harm reduction into practice (Gagnon et al., 2020), by covering practical topics such as OAT prescription, administering PRN opioid medication, recognizing signs and symptoms of withdrawal, and using the Clinical Opiate Withdrawal Scale (COWS). Furthermore, while the provision of entry to practice education is essential, it is insufficient on its own. Workplaces must continue to support staff in gaining the skills that they need by offering education opportunities that are consistently accessible. Over and above staff education pertaining to harm reduction as a technical solution, there is a need for education that address available and appropriate community-based services and their referral processes so staff can be prepared to engage in harm reduction as a contextualized social practice. Namely, through helping people make valued community-based connections, staff can facilitate access to important socio-structural resources such as financial aid and shelters/housing, which can, in turn, support people to not only mitigate harms but also to continue to engage with care. Lastly, there is a need for staff education that encompasses the provision of trauma and violence informed care. In particular, educators should underscore the impacts of histories of trauma and violence on how patients and staff may react and interact within the context of a potentially violent encounter. Practice and Leadership Study findings demonstrated considerable variation in how ED staff engage in harm reduction practice. Much of this variation appears to be attributable to unsupportive organizational policies and inconsistent access to staff education, which hampered the ability of 178 staff to interact with one another in carrying out their roles related to harm reduction (see recommendations related to policy and education above). Study findings additionally spoke to inconsistency in the practice of staff related to how they grapple with and navigate patient violence, and proposed the need for inter-collegial feedback to support that staff engage with trauma and violence informed care. To this end, there is a need for clinical leaders to convey a message that embracing teamwork and autonomous practice does not mean that staff are unable to give feedback – in fact, it is their ethical imperative to support care provision that is equitable and socially just (Canadian Nurses Association, 2017). Leadership can additionally invite staff to explore how they take up the notion of teamwork, and support staff to engage in discussion / to provide feedback related to points of tension they experience when navigating patient violence. While it is important for staff to be able to give and receive feedback, and to engage in discussions about practice, it is also imperative that staff be mentored on how such discussions can or should occur. For example, as demonstrated by Hardavella et al. (2017), feedback in the context of health care provision should be given in a timely and private (i.e. one-to-one) manner, and focus on one's actions as opposed to the person themselves. Those on the receiving end of feedback, on the other hand, are cautioned to pause and think before responding, avoid jumping to conclusions, and ask for clarification if this is necessary (Hardavella et al., 2017). Lastly, study findings conveyed the need for more "on the ground" mentorship and coaching from leadership pertaining to the provision of trauma and violence informed care. This will require clinical leaders to seek and to leverage teachable moments in the clinical space to demonstrate how to be mindful of potential histories of violence and trauma and their effects; foster connection and trust through taking a non-judgmental approach; provide meaningful choices and consider them collaboratively with patients; and work with patients to identify their strengths 179 while also supporting them to build capacity (Wathen & Varcoe, 2021). Through working with ED staff "in the moment" and the provision of ongoing mentorship and coaching, staff can learn not only the principles of trauma and violence informed care, but more importantly, how to model trauma and violence informed care in their everyday practice. Research A number of directions for future research arise from this work. First, greater sensitivity to different occupational groups (nurses versus physicians), and studying their unique perspectives, versus as an aggregate, would be important and beneficial for future research. This is because differences in roles and responsibilities, occupational drivers and cultures, as well as frequency of interactions with patients, may have implications for harm reduction provision. There is also a need for studies that explore how staff experience organizational policies that restrict their scope of practice related to harm reduction provision, including how they take up these policies. Such studies could benefit from qualitative approaches that include interviews with staff and leaders and a policy analysis. There is also a need for research that examines both the processes and impacts associated with discrepancies related to the availability of substance use specialist services. Such studies are essential to determine both the effects for staff practices and overall patient care outcomes, as well as to generate recommendations for enhanced services availability around-the-clock. Additionally, there is a need for studies that investigate the interconnections between constraints produced by system structures and the provision of trauma and violence informed care inclusive of the variety of settings where patients attend to care. For instance, a mixed methods study inclusive of patients, staff, leadership, and community organizations that explores how structures of the system produce constraints, how community- 180 based service providers navigate these constraints, and factors shaping their approach, including barriers to the provision of trauma and violence informed care. Our study findings demonstrated that connection making to additional resources is not understood to be a standard part of ED practice. Given that EDs are essential pathways to further health and social service connections for people who use unregulated substances (Mayer at al., 2023), there is need to examine why connection making is not prioritized. These examinations can begin with an investigation of how the availability of specialist services impacts the ability of ED staff to independently facilitate these connections. This could take the form of a retrospective chart review that examines when, how, and by whom referrals to community-based services are made. Furthermore, previous researchers (e.g., Slemon et al., 2023) have illustrated how prevailing discourses – for instance, related to the mandate of the ED to uphold patient flow, can preclude equity-promoting practices, such as attending to patients' socio-structural needs, which is deemed to fall outside of staff's scope of work. There is a need to examine if similar discourses operate to hinder staff engagement in connection making. Lastly, despite studies that have examined the perspectives of people who use unregulated substances related to factors that may impact care provision, including harm reduction (Hawk et al., 2022; Hyshka et al., 2019; Kosteniuk et al., 2021; Mayer et al., 2023), there is a need to integrate patient perspectives in the design of harm reduction interventions, and organizational policies, that better meet their needs. Embracing patient as partners in research, and the meaningful engagement of peers, will require capacity building and empowerment inclusive of the potential for peer-facilitated data collection and collaborative data analysis, and adopting a strength-based approach to generating outputs from the research (Greer et al., 2018). 181 Conclusion Harm reduction interventions are urgently needed throughout all settings where people who could benefit from them attend to care, especially in the context of EDs. The present study identified facilitators and barriers to ED-based harm reduction in light of interactions between system agents, highlighting systemic tensions that hinder the ability of staff to carry out their roles related to harm reduction. Staff additionally lacked the necessary education and training, and were insufficiently supported to facilitate connections for ongoing care. Study findings further stressed that, in the context of ED care provision for people who use unregulated substances, patient violence toward staff is often a consequence of a disconnect between what patients need and what staff can offer – a disconnect situated within constraints produced by structures of the system, necessitating the provision of trauma and violence informed care. Study recommendations spoke to the need for far-reaching change – as related to organizational policy, improving access to staff education and specialist support, and increased mentorship and professional dialogue. Future studies can build on this work by continuing to explore knowledge gaps related to problematic institutional structures that hinder care provision, inclusive of harm reduction, and must engage the organizations, and the people they work with (including patients, staff, and clinical leaders) as true partners in this important endeavour. 182 References Alberta Health Services. (2024). Community-based naloxone program: Harm reduction services. https://www.albertahealthservices.ca/info/page13663.aspx Allred, C. A., Burns, B. J., & Phillips, S. D. (2005). The assertive community treatment team as a complex dynamic system of care. Administration and Policy in Mental Health and Mental Health Services Research, 32(3), 211-220. https://doi.org/10.1007/s10488-004-0841-6 Amato, L., Davoli, M., Minozzi, S., Ferroni, E., Ali, R., & Ferri, M. (2013). Methadone at tapered doses for the management of opioid withdrawal. Cochrane Database of Systematic Reviews, 2, Art. No.: CD003409. https://doi.org/10.1002/14651858.CD003409.pub4. Anderson, L., FitzGerald, M., & Luck, L. (2010). An integrative literature review of interventions to reduce violence against emergency department nurses. Journal of Clinical Nursing, 19(17-18), 2520-2530. https://doi.org/10.1111/j.1365-2702.2009.03144.x Artenie, A. A., Jutras-Aswad, D., Roy, É., Zang, G., Bamvita, J. -., Lévesque, A., & Bruneau, J. (2015). Visits to primary care physicians among persons who inject drugs at high risk of hepatitis C virus infection: Room for improvement. Journal of Viral Hepatitis, 22(10), 792-799. https://doi.org/10.1111/jvh.12393 Ashton, R. A., Morris, L., & Smith, I. (2018). A qualitative meta-synthesis of emergency department staff experiences of violence and aggression. International Emergency Nursing, 39, 13-19. https://doi.org/10.1016/j.ienj.2017.12.004 Aspinall, E. J., Nambiar, D., Goldberg, D. J., Hickman, M., Weir, A., Van Velzen, E., Palmateer, N., Doyle, J. S., Hellard, M. E., & Hutchinson, S. J. (2014). Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject 183 drugs: A systematic review and meta-analysis. International Journal of Epidemiology, 43(1), 235–248. https://doi.org/10.1093/ije/dyt243 Aubry, T. (2020) Analysis of Housing First as a practical and policy relevant intervention: The current state of knowledge and future directions for research. European Journal of Homelessness, 14(1), 13-26. Aubry, T., Goering, P., Veldhuizen, S., Adair, C. E., Bourque, J., Distasio, J., Latimer, E., Stergiopoulos, V., Somers, J., Streiner, D. L., & Tsemberis, S. (2016). A multiple-city RCT of Housing First with assertive community treatment for homeless Canadians with serious mental illness. Psychiatric Services, 67(3), 275–281. https://doi.org/10.1176/appi.ps.201400587 Bandini, F., Guidi, S., Blaszczyk, S., Fumarulo, A., Pierini, M., Pratesi, P., Spolveri, S., Padeletti, M., Petrone, P., Zoppi, P., & Landini, G. (2018). Complexity in internal medicine wards: A novel screening method and implications for management. Journal of Evaluation in Clinical Practice, 24(1), 285-292. https://doi.org/10.1111/jep.12875 Baxter, P., & Jack, S. (2008). Qualitative case study methodology: Study design and implementation for novice researchers. Qualitative Report, 13(4), 544-559. https://doi.org/10.46743/2160-3715/2008.1573 Bennett, A. S., Townsend, T., & Elliott, L. (2022). The COVID-19 pandemic and the health of people who use illicit opioids in New York City, the first 12 months. International Journal on Drug Policy, 101, 103554. https://doi.org/10.1016/j.drugpo.2021.103554 Black, E., Monds, L. A., Chan, B., Brett, J., Hutton, J. E., Acheson, L., Penm, J., Harding, S., Strumpman, D., Demirkol, A., & Lintzeris, N. (2022). Overdose and take-home naloxone in emergency settings: A pilot study examining feasibility of delivering brief interventions 184 addressing overdose prevention with 'take-home naloxone' in emergency departments. Emergency Medicine Australasia, 34(4), 509–518. https://doi.org/10.1111/1742-6723.13925 Bourque, S., Pijl, E. M., Mason, E., Manning, J., & Motz, T. (2019). Supervised inhalation is an important part of supervised consumption services. Canadian Journal of Public Health, 110(2), 210–215. https://doi.org/10.17269/s41997-019-00180-w Boyd, J., Collins, A. B., Mayer, S., Maher, L., Kerr, T., & McNeil, R. (2018). Gendered violence and overdose prevention sites: A rapid ethnographic study during an overdose epidemic in Vancouver, Canada. Addiction, 113(12), 2261-2270. https://doi.org/10.1111/add.14417 Boyd, J., Lavalley, J., Czechaczek, S., Mayer, S., Kerr, T., Maher, L., & McNeil, R. (2020). “Bed bugs and beyond”: An ethnographic analysis of North America's first women-only supervised drug consumption site. International Journal of Drug Policy, 78, 102733. https://doi.org/10.1016/j.drugpo.2020.102733 Braithwaite, V., Ti, L., Fairbairn, N., Ahamad, K., McLean, M., Harrison, S., Wood, E., & Nolan, S. (2021). Building a hospital-based addiction medicine consultation service in Vancouver, Canada: The path taken and lessons learned. Addiction, 116(7), 1892-1900. https://doi.org/10.1111/add.15383 Brar, R., Fairbairn, N., Colizza, K., Ryan, A., & Nolan, S. (2021). Hospital initiated injectable opioid agonist therapy for the treatment of severe opioid use disorder: A case series. Journal of Addiction Medicine, 15(2), 163–166. https://doi.org/10.1097/ADM.0000000000000713 Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa 185 Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597. https://doi.org/10.1080/2159676X.2019.1628806 British Columbia Centre for Disease Control (2017, March 17). The BC public health opioid overdose emergency: March 2017 update. http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/Public%20Surveillance%20Report_2017_03_17.pdf British Columbia Centre for Disease Control (2018, December 4). The history of harm reduction: International & provincial (BC) perspectives. https://towardtheheart.com/assets/uploads/1543964080U2ZlytEqTdNhpYTwYuAVivwVEA1gODYD2px5sKs.pdf British Columbia Centre for Disease Control. (2021, March 31). Dual public health emergencies: Overdose in BC during COVID-19. http://www.bccdc.ca/resource-gallery/Documents/Statistics%20and%20Research/Statistics%20and%20Reports/Overdose/2021.04.16_Infographic_OD%20Dashboard.pdf British Columbia Centre for Disease Control. (2023). Provincial episodic overdose prevention service (eOPS protocol). http://www.bccdc.ca/Documents/EpisodicOPSProtocolGuidelines_FINAL%202023.pdf British Columbia Centre on Substance Use (2021a). BCCSU annual education report 2020/2021. https://www.bccsu.ca/wp-content/uploads/2021/07/Annual-BCCSU-Education-Report-2020-21.pdf 186 British Columbia Centre on Substance Use. (2021b, July). Guidance for injectable opioid agonist treatment for opioid use disorder. https://www.bccsu.ca/wp-content/uploads/2021/07/BC_iOAT_Guideline.pdf British Columbia College of Nurses and Midwives (2022, November). Registered Nurses – Scope of practice: Standards, limits, conditions. https://www.bccnm.ca/Documents/standards_practice/rn/RN_ScopeofPractice.pdf British Columbia College of Nurses and Midwives. (2023a). Acting within autonomous scope of practice. https://www.bccnm.ca/RN/learning/scope/awas/Pages/Default.aspx British Columbia College of Nurses and Midwives. (2023b). Feedback. https://www.bccnm.ca/RN/QA/annual/feedback/Pages/Default.aspx British Columbia Coroners Service (2024, January 24). Unregulated drug deaths in B.C. (to Dec. 31, 2023). https://app.powerbi.com/view?r=eyJrIjoiMmIzN2UyYTItNmM0Yi00MGZhLWI1NDUtOTRhZGNjYTBhZDJlIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9 British Columbia Ministry of Mental Health and Addictions. (2021, July 15). Access to prescribed safer supply in British Columbia: Policy direction. https://www2.gov.bc.ca/assets/gov/overdose-awareness/prescribed_safer_supply_in_bc.pdf British Columbia Nurses' Union. (2011, November). Position statement: Harm reduction. https://www.bcnu.org/AboutBcnu/Documents/position-statement-harm-reduction.pdf British Columbia Office of the Provincial Health Officer. (2019). Stopping the harm: Decriminalization of people who use drugs in BC. 187 https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/special-reports/stopping-the-harm-report.pdf Brooks, H. L., O'Brien, D. C., Salvalaggio, G., Dong, K., & Hyshka, E. (2019). Uptake into a bedside needle and syringe program for acute care inpatients who inject drugs. Drug and Alcohol Review, 38(4), 423–427. https://doi.org/10.1111/dar.12930 Brown, C. A. (2006). The application of complex adaptive systems theory to clinical practice in rehabilitation. Disability and Rehabilitation, 28(9), 587-593. https://doi.org/10.1080/00222930500219175 Bungay, V., Johnson, J. K., Varcoe, C., & Boyd, S. (2010). Women’s health and use of crack cocaine in context: Structure and ‘everyday’ violence. International Journal of Drug Policy, 21(4), 321-329. https://doi.org/10.1016/j.drugpo.2009.12.008 Buning, E. C., Coutinho, R. A., van Brussel, G. H. A., van Santen, G. W., & van Zadelhoff, A. W. (1986). Preventing AIDS in drug addicts in Amsterdam. Lancet, 327(8495), 1435. https://doi:10.1016/S0140-6736(86)91570-9 Buxton, J. A., & Haden, M., & Mathias, R. (2008). The control and regulation of currently illegal drugs. In K. Heggenhougen & S. Quah (Eds.), International encyclopedia of public health (Volume 2, pp. 7-16). Academic Press. Calcaterra, S. L., Lockhart, S., Callister, C., Hoover, K., & Binswanger, I. A. (2022). Opioid use disorder treatment initiation and continuation: A qualitative study of patients who received addiction consultation and hospital-based providers. Journal of General Internal Medicine, 37(11), 2786-2794. https://doi.org/10.1007/s11606-021-07305-3 188 Camorlinga, P., & Camorlinga, S. (2016). Leading the emergency department as a complex adaptive system. In J. P. Sturmberg (Ed.), The value of systems and complexity sciences for healthcare (pp. 205-216). Springer. https://doi.org/10.1007/978-3-319-26221-5_17 Canadian Centre on Substance Use and Addiction. (2020). Impacts of the COVID-19 pandemic on people who use substances: What we heard. https://www.ccsa.ca/sites/default/files/2020-07/CCSA-COVID-19-Impacts-on-People-Who-Use-Substances-Report-2020-en.pdf Canadian Drug Policy Coalition. (2021). Decriminalization done right: A right-based approach for drug policy. https://www.drugpolicy.ca/wp-content/uploads/2021/12/EN-PTL-Decrim.pdf Canadian Drug Policy Coalition. (2024). History of drug policy in Canada. https://drugpolicy.ca/about/history/ Canadian HIV/AIDS Legal Network. (2005). "Nothing about us without us" – Greater, meaningful involvement of people who use illegal drugs: A public health, ethical, and human rights imperative. http://www.hivlegalnetwork.ca/site/wp-content/uploads/2013/04/Greater+Involvement+-+Bklt+-+Drug+Policy+-+ENG.pdf Canadian Nurses Association. (2017). Code of ethics for Registered Nurses. https://cna.informz.ca/cna/data/images/Code_of_Ethics_2017_Edition_Secure_Interactive.pdf Canadian Nurses Association, Canadian Association of Nurses in HIV/AIDS Care, & Harm Reduction Nurses Association. (2018, March). Joint position statement: Harm reduction and substance use. https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/2f975e7e-4a40-45ca-863c- 189 5ebf0a138d5e/UploadedImages/documents/Joint_Position_Statement_Harm_Reduction_and_Substance_Use.pdf Canadian Public Health Association. (2014, May). A new approach to managing illegal psychoactive substances in Canada. https://www.cpha.ca/sites/default/files/assets/policy/cannabis_submission_e.pdf Cao, S. S., Dunham, S. I., & Simpson, S. A. (2020). Prescribing buprenorphine for opioid use disorders in the ED: A review of best practices, barriers, and future directions. Open Access Emergency Medicine, 12, 261-274. https://doi.org/10.2147/OAEM.S267416 Carmona, J., Slesnick, N., Guo, X., Murnan, A., & Brakenhoff, B. (2017). Predictors of outreach meetings among substance using homeless youth. Community Mental Health Journal, 53(1), 62–71. https://doi.org/10.1007/s10597-015-9919-8 Casey House (2022, November 16). Casey House opens first indoor supervised inhalation space for substance use. https://caseyhouse.ca/commentary/casey-house-opens-first-indoor-supervised-inhalation-space-for-substance-use/ Casti, J. L. (1997). Would-be-worlds: How simulation is changing the frontiers of science. Wiley. Catholic Health Alliance of Canada. (2012, June). St. Paul's Hospital: A proud tradition of compassionate care. https://www.chac.ca/documents/57/Vancouver_St_Pauls_100th.pdf CATIE. (2022a). Unit 1: Setting a foundation for harm reduction. Framing substance use. Harm reduction fundamentals: A toolkit for service providers. https://elearning.catie.ca/HRTOOLKIT/unit1/content/#/lessons/_c8EqeHD_LruT4nWfTi7REAbJ9_wuxad 190 CATIE. (2022b). Unit 2: Harm reduction principles and practices. What is harm reduction? Harm reduction fundamentals: A toolkit for service providers. https://elearning.catie.ca/HRTOOLKIT/unit2/content/#/lessons/sGlrFs517B6OlQ2pnE4gl0NgZHHOewvC Cederbaum, J. A., Guerrero, E. G., Mitchell, K. R., & Kim, T. (2014). Utilization of emergency and hospital services among individuals in substance abuse treatment. Substance Abuse Treatment, Prevention, and Policy, 9, 16. https://doi.org/10.1186/1747-597X-9-16 Cepoiu-Martin, M., & Bischak, D. P. (2018). Policy choices in dementia care – An exploratory analysis of the Alberta continuing care system (ACCS) using system dynamics. Journal of Evaluation in Clinical Practice, 24(1), 278-284. https://doi.org/10.1111/jep.12790 Chaffee, M. W., & McNeill, M. M. (2007). A model of nursing as a complex adaptive system. Nursing Outlook, 55(5), 232-241. https://doi.org/10.1016/j.outlook.2007.04.003 Chan Carusone, S., Guta, A., Robinson, S., Tan, D. H., Cooper, C., O'Leary, B., de Prinse, K., Cobb, G., Upshur, R., & Strike, C. (2019). "Maybe if I stop the drugs, then maybe they'd care?" – Hospital care experiences of people who use drugs. Harm Reduction Journal, 16, 16. https://doi.org/10.1186/s12954-019-0285-7 Chen, D. T., Werhane, P. H., & Mills, A. E. (2007). Role of organization ethics in critical care medicine. Critical Care Medicine, 35(Suppl. 2), S11-S17. https://doi.org/10.1097/01.CCM.0000252913.21741.35 Cherner, R. A., Aubry, T., Sylvestre, J., Boyd, R., & Pettey, D. (2017). Housing First for adults with problematic substance use. Journal of Dual Diagnosis, 13(3), 219–229. https://doi.org/10.1080/15504263.2017.1319586 191 Chhabra, M., Spector, E., Demuynck, S., Wiest, D., Buckley, L., & Shea, J. A. (2020). Assessing the relationship between housing and health among medically complex, chronically homeless individuals experiencing frequent hospital use in the United States. Health and Social Care in the Community, 28(1), 91–99. https://doi.org/10.1111/hsc.12843 Choo, S., & Wen, L. S. (2018). Baltimore citywide engagement of emergency departments to combat the opioid epidemic. American Journal of Public Health, 108(8), 1003-1005. https://doi.org/10.2105/AJPH.2018.304551 Chung, T. E., Gozdzik, A., Palma Lazgare, L. I., To, M. J., Aubry, T., Frankish, J., Hwang, S. W., & Stergiopoulos, V. (2018). Housing First for older homeless adults with mental illness: A subgroup analysis of the At Home / Chez Soi randomized controlled trial. International Journal of Geriatric Psychiatry, 33(1), 85–95. https://doi.org/10.1002/gps.4682 Cisewski, D. H., Santos, C., Koyfman, A., & Long, B. (2019). Approach to buprenorphine use for opioid withdrawal treatment in the emergency setting. American Journal of Emergency Medicine, 37(1), 143-150. https://doi.org/10.1016/j.ajem.2018.10.013 City of Toronto. (n.d.). Naloxone distribution. https://www.toronto.ca/community-people/health-wellness-care/health-programs-advice/naloxone-anti-overdose-medication/ City of Toronto Public Health (2015, September 22). The Works – 25 years of harm reduction services in Toronto. https://www.toronto.ca/legdocs/mmis/2015/hl/bgrd/backgroundfile-84078.pdf City of Vancouver (2013, November 7). Downtown Eastside: Local area profile 2013. https://vancouver.ca/files/cov/profile-dtes-local-area-2013.pdf 192 Clancy, C., Kelly, P., & Loth, C. (2019). State of the art in European addictions nursing: Perspectives from the United Kingdom, Ireland, and the Netherlands. Journal of Addictions Nursing, 30(3), 139-148. https://doi.org/10.1097/JAN.0000000000000293 Coles, E., Anderson, J., Maxwell, M., Harris, F. M., Gray, N. M., Milner, G., & MacGillivray, S. (2020). The influence of contextual factors on healthcare quality improvement initiatives: A realist review. Systematic Reviews, 9, 94. https://doi.org/10.1186/s13643-020-01344-3 Collins, A. B., Beaudoin, F. L., Samuels, E. A., Wightman, R., & Baird, J. (2021). Facilitators and barriers to post-overdose service delivery in Rhode Island emergency departments: A qualitative evaluation. Journal of Substance Abuse Treatment, 130, 108411. https://doi.org/10.1016/j.jsat.2021.108411 Collins, K. M. T., Onwuegbuzie, A. J., & Sutton, I. L. (2006). A model incorporating the rationale and purpose for conducting mixed-methods research in special education and beyond. Learning Disabilities, 4(1), 67-100. Cook, K. E. (2005). Using critical ethnography to explore issues in health promotion. Qualitative Health Research, 15(1), 129-138. https://doi.org/10.1177/1049732304267751 Coyle, S. L., Needle, R. H., & Normand, J. (1998). Outreach-based HIV prevention for injecting drug users: A review of published outcome data. Public Health Reports, 113(Suppl. 1), 19-30. Creswell, J. W., & Creswell, J. D. (2018). Research design: Qualitative, quantitative, and mixed methods approaches (5th ed.). SAGE Publications, Inc. Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). SAGE Publications, Inc. 193 Crilly, J., Chaboyer, W., & Creedy, D. (2004). Violence towards emergency department nurses by patients. Accident and Emergency Nursing, 12(2), 67-73. https://doi.org/10.1016/j.aaen.2003.11.003 Crowe, S., Cresswell, K., Robertson, A., Huby, G., Avery, A. J., & Sheikh, A. (2011). The case study approach. BMC Medical Research Methodology, 11, 100. https://doi.org/10.1186/1471-2288-11-100 de Bock, B. A., Willems, D. L., & Weinstein, H. C. (2018). Complexity perspectives on clinical decision making in an intensive care unit. Journal of Evaluation in Clinical Practice, 24(1), 308-313. https://doi.org/10.1111/jep.12794 Deering, K. N., Kerr, T., Tyndall, M. W., Montaner, J. S., Gibson, K., Irons, L., & Shannon, K. (2011). A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting. Drug and Alcohol Dependence, 113(1), 46–54. https://doi.org/10.1016/j.drugalcdep.2010.07.007 Dekker, S. W. A. (2010). We have Newton on a retainer: Reductionism when we need systems thinking. Joint Commission Journal on Quality and Patient Safety, 36(4), 147-149. https://doi.org/10.1016/S1553-7250(10)36024-7 Devries, J., Rafie, S., Ajayi, T. A., Kreshak, A., & Edmonds, K. P. (2019). Results of a naloxone screening quality-improvement project in an academic emergency department. Journal of Emergency Medicine, 56(4), 378–385. https://doi.org/10.1016/j.jemermed.2018.12.029 Doctors of British Columbia. (2021, June). Illicit drugs toxicity / overdose crisis. https://www.doctorsofbc.ca/file/30207/download?token=H94KWgaS 194 Dodder, R., & Dare, R. (2000, October 31). Complex adaptive systems and complexity theory: Inter-related knowledge domains. ESD.83: Research Seminar in Engineering Systems. Massachusetts Institute of Technology. https://web.mit.edu/esd.83/www/notebook/ComplexityKD.pdf Dogherty, E., Patterson, C., Gagnon, M., Harrison, S., Chase, J., Boerstler, J., Gibson, J., Gill, S., Nolan, S., & Ryan, A. (2022). Implementation of a nurse-led overdose prevention site in a hospital setting: Lessons learned from St. Paul's Hospital, Vancouver, Canada. Harm Reduction Journal, 19, 13. https://doi.org/10.1186/s12954-022-00596-7 Dong, K. A., Brouwer, J., Johnston, C., & Hyshka, E. (2020). Supervised consumption services for acute care hospital patients. CMAJ, 192(18), E476–E479. https://doi.org/10.1503/cmaj.191365 Dora-Laskey, A., Kellenberg, J., Dahlem, C. H., English, E., Gonzalez Walker, M., Brummett, C. M., & Kocher, K. E. (2022). Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose. Academic Emergency Medicine, 29(4), 442–455. https://doi.org/10.1111/acem.14435 Downtown Eastside Women's Centre. (2022). Our community. https://dewc.ca/about/community Drainoni, M. L., Koppelman, E. A., Feldman, J. A., Walley, A. Y., Mitchell, P. M., Ellison, J., & Bernstein, E. (2016). Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment. BMC Research Notes, 9, 465. https://doi.org/10.1186/s13104-016-2268-z Duber, H. C., Barata, I. A., Cioè-Peña, E., Liang, S. Y., Ketcham, E., Macias-Konstantopoulos, W., Ryan, S. A., Stavros, M., & Whiteside, L. K. (2018). Identification, management, and 195 transition of care for patients with opioid use disorder in the emergency department. Annals of Emergency Medicine, 72(4), 420-431. https://doi.org/10.1016/j.annemergmed.2018.04.007 Dunlop, A., Lokuge, B., Masters, D., Sequeira, M., Saul, P., Dunlop, G., Ryan, J., Hall, M., Ezard, N., Haber, P., Lintzeris, N., & Maher, L. (2020). Challenges in maintaining treatment services for people who use drugs during the COVID-19 pandemic. Harm Reduction Journal, 17, 26. https://doi.org/10.1186/s12954-020-00370-7 Dwyer, K., Walley, A. Y., Langlois, B. K., Mitchell, P. M., Nelson, K. P., Cromwell, J., & Bernstein, E. (2015). Opioid education and nasal naloxone rescue kits in the emergency department. Western Journal of Emergency Medicine, 16(3), 381–384. https://doi.org/10.5811/westjem.2015.2.24909 Eckhardt, A. L., & DeVon, H. A. (2017). The MIXED framework: A novel approach to evaluating mixed-methods rigor. Nursing Inquiry, 24(4), e12189. https://doi.org/10.1111/nin.12189 Edgren, L. (2007). The meaning of integrated care: A systems approach. International Journal of Integrated Care, 8(4), e68. El-Bassel, N., Shaw, S. A., Dasgupta, A., & Strathdee, S. A. (2014). People who inject drugs in intimate relationships: It takes two to combat HIV. Current HIV/AIDS Reports, 11, 45–51. https://doi.org/10.1007/s11904-013-0192-6 Emerson, B., & Haden, M. (2008). Public health and the harm reduction approach to illegal psychoactive substances. In K. Heggenhougen & S. Quah (Eds.), International encyclopedia of public health (Volume 6, pp. 169-183). Academic Press. 196 Englander, H., Weimer, M., Solotaroff, R., Nicolaidis, C., Chan, B., Velez, C., Noice, A., Hartnett, T., Blackburn, E., Barnes, P., & Korthuis, P. T. (2017). Planning and designing the Improving Addiction Care Team (IMPACT) for hospitalized adults with substance use disorder. Journal of Hospital Medicine, 12(5), 339–342. https://doi.org/10.12788/jhm.2736 Eydt, E., Glegg, S., Sutherland, C., Meador, K., Trew, M., Perreault, M., Goyer, M. È., Le Foll, B., Turnbull, J., & Fairbairn, N. (2021). Service delivery models for injectable opioid agonist treatment in Canada: 2 sequential environmental scans. CMAJ Open, 9(1), E115–E124. https://doi.org/10.9778/cmajo.20200021 Fairbairn, N., Milloy, M. J., Zhang, R., Lai, C., Grafstein, E., Kerr, T., & Wood, E. (2012). Emergency department utilization among a cohort of HIV-positive injecting drug users in a Canadian setting. Journal of Emergency Medicine, 43(2), 236-243. https://doi.org/10.1016/j.jemermed.2011.05.020 Fanucchi, L., & Lofwall, M. R. (2016). Putting parity into practice — Integrating opioid-use disorder treatment into the hospital setting. New England Journal of Medicine, 375(9), 811-813. https://doi.org/10.1056/NEJMp1606157 Fernandes, R. M., Cary, M., Duarte, G., Jesus, G., Alarcão, J., Torre, C., Costa, S., Costa, J., & Carneiro, A. V. (2017). Effectiveness of needle and syringe programmes in people who inject drugs – An overview of systematic reviews. BMC Public Health, 17, 309. https://doi.org/10.1186/s12889-017-4210-2 Ferri, M., Davoli, M., Perucci, C.A. (2011). Heroin maintenance for chronic heroin-dependent individuals. Cochrane Database of Systematic Reviews, 12, Art. No.: CD003410. https://doi.org/10.1002/14651858.CD003410.pub4. 197 Ferri, M., Minozzi, S., Bo, A., & Amato, L. (2013). Slow-release oral morphine as maintenance therapy for opioid dependence. Cochrane Database of Systematic Reviews, 6, Art. No.: CD009879. https://doi.org/10.1002/14651858.CD009879.pub2. Ferri, P., Stifani, S., Accoto, A., Bonetti, L., Rubbi, I., & Di Lorenzo, R. (2020). Violence against nurses in the triage area: A mixed-methods study. Journal of Emergency Nursing, 46(3), 384-397. https://doi.org/10.1016/j.jen.2020.02.013 Finnell, D. S., Savage, C. L., Hansen, B. R., Sanchez, M., White, K. M., Johnson, J. A., & Seale, J. P. (2018). Integrating substance use content in an “overcrowded” nursing curriculum. Nurse Educator, 43(3), 128-131. https://doi.org/10.1097/NNE.0000000000000438 Fischer, B. (2000). Prescriptions, power and politics: The turbulent history of methadone maintenance in Canada. Journal of Public Health Policy, 21(2), 187-210. https://doi:10.2307/3343343 Ford. (2011). Interpersonal challenges as a constraint on care: The experience of nurses' care of patients who use illicit drugs. Contemporary Nurse, 37(2), 241-252. https://doi.org/10.5172/conu.2011.37.2.241 Ford, J. D., & Courtois, C. A. (Eds.). (2020). Treating complex traumatic stress disorders in adults: Scientific foundations and therapeutic models (2nd ed.). The Guilford Press. Funke, M., Kaplan, M. C., Glover, H., Schramm-Sapyta, N., Muzyk, A., Mando-Vandrick, J., Gordee, A., Kuchibhatla, M., Sterrett, E., & Eucker, S. A. (2021). Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids. Joint Commission Journal on Quality and Patient Safety, 47(6), 364–375. https://doi.org/10.1016/j.jcjq.2021.03.002 198 Gagnon, M., Payne, A., Denis-Lalonde, D., Wilbur, K., & Pauly, B. (2020). Substance use education in Canadian nursing programs: A student survey. Journal of Nursing Education, 59(9), 510-513. https://doi.org/10.3928/01484834-20200817-06 Gagnon, M., Rudzinski, K., Guta, A., Schmidt, R. A., Kryszajtys, D. T., Kolla, G., & Strike, C. (2023). Impact of safer supply programs on injection practices: Client and provider experiences in Ontario, Canada. Harm Reduction Journal, 20, 81. https://doi.org/10.1186/s12954-023-00817-7 Galarneau, L. R., Hilburt, J., O'Neill, Z. R., Buxton, J. A., Scheuermeyer, F. X., Dong, K., Kaczorowski, J., Orkin, A. M., Barbic, S. P., Bath, M., Moe, J., Miles, I., Tobin, D., Grier, S., Garrod, E., & Kestler, A. (2021). Experiences of people with opioid use disorder during the COVID-19 pandemic: A qualitative study. PLOS One, 16(7), e0255396. https://doi.org/10.1371/journal.pone.0255396 Galea, S., & Vlahov, D. (2002). Social determinants and the health of drug users: Socioeconomic status, homelessness, and incarceration. Public Health Reports, 117(Suppl. 1), S135–S145. Gates, D. M., Ross, C. S., & McQueen, L. (2006). Violence against emergency department workers. Journal of Emergency Medicine, 31(3), 331-337. https://doi.org/10.1016/j.jemermed.2005.12.028 Gibbs, B., Workman, R., Kiefer, J., & Canlas, C. (2023, March). Canada’s health crisis: Profiling opioid addiction in Alberta & British Columbia. Report for the Stanford Network on Addiction Policy (SNAP). https://addictionpolicy.stanford.edu/sites/g/files/sbiybj25011/files/media/file/canadas-health-crisis-opioid-addiction-in-alberta-and-british-columbia-web-version-1.pdf 199 Giddings, L. S., & Grant, B. M. (2009). From rigour to trustworthiness: Validating mixed methods. In S. Andrew & E. J. Halcomb (Eds.), Mixed methods research for nursing and the health sciences (pp. 119-134). Blackwell Publishing Ltd. Glegg, S., McCrae, K., Kolla, G., Touesnard, N., Turnbull, J., Brothers, T. D., Brar, R., Sutherland, C., Le Foll, B., Sereda, A., Goyer, M. È., Rai, N., Bernstein, S., & Fairbairn, N. (2022). "COVID just kind of opened a can of whoop-ass": The rapid growth of safer supply prescribing during the pandemic documented through an environmental scan of addiction and harm reduction services in Canada. International Journal on Drug Policy, 106, 103742. https://doi.org/10.1016/j.drugpo.2022.103742 Goering, P., Veldhuizen, S., Watson, A., Adair, C., Kopp, B., Latimer, E., Nelson, G., MacNaughton, E., Streiner D., & Aubry, T. (2014) National final report: Cross-site At Home / Chez Soi project. Mental Health Commission of Canada. https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/mhcc_at_home_report_national_cross-site_eng_2_0.pdf Government of British Columbia. (2022, October 24). 320 protection services officers will support safer workplaces for health-care workers. https://news.gov.bc.ca/releases/2022HLTH0204-001579 Government of Canada. (2016, March 22). Notice: Prescription Drug List (PDL): Naloxone. https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/prescription-drug-list/notice-naloxone.html Government of Canada. (2018, March 26). The Honourable Ginette Petitpas Taylor, Minister of Health announces new measures to reduce barriers to treatment and $231 M to address the opioid crisis. https://www.canada.ca/en/health-canada/news/2018/03/the-honourable- 200 ginette-petitpas-taylor-minister-of-health-announces-new-measures-to-reduce-barriers-to-treatment-and-231-m-to-address-the-o.html Government of Canada. (2022, January 5). Regulations amending certain regulations relating to restricted drugs (Special Access Program): SOR/2021-271. https://www.gazette.gc.ca/rp-pr/p2/2022/2022-01-05/html/sor-dors271-eng.html Government of Canada. (2023, June 28). Canadian Alcohol and Drugs Survey (CADS): Summary of results for 2019. https://www.canada.ca/en/health-canada/services/canadian-alcohol-drugs-survey/2019-summary.html Government of Canada. (2024, June 28). Opioid- and stimulant-related harms in Canada. https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/ Gowing, L., Ali, R., White, J. M., & Mbewe, D. (2017). Buprenorphine for managing opioid withdrawal. Cochrane Database of Systematic Reviews, 2, Art. No.: CD002025. https://doi.org/10.1002/14651858.CD002025.pub5. Gowing, L., Farrell, M., Ali, R., & White, J. M. (2016). Alpha2-adrenergic agonists for the management of opioid withdrawal. Cochrane Database of Systematic Reviews, 5, Art. No.: CD002024. https://doi.org/10.1002/14651858.CD002024.pub5. Greene, A., Korchmaros, J. D., & Frank, F. (2023). Trauma experience among women who have substance use disorders and are homeless or near homeless. Community Mental Health Journal, 60, 233-243. https://doi.org/10.1007/s10597-023-01162-6 Greer, A., Buxton, J. A., Pauly, B., & Bungay, V. (2021). Organizational support for frontline harm reduction and systems navigation work among workers with living and lived experience: Qualitative findings from British Columbia, Canada. Harm Reduction Journal, 18, 60. https://doi.org/10.1186/s12954-021-00507-2 201 Greer, A. M., Amlani, A., Pauly, B., Burmeister, C., & Buxton, J. A. (2018). Participant, peer and PEEP: Considerations and strategies for involving people who have used illicit substances as assistants and advisors in research. BMC Public Health, 18, 834. https://doi.org/10.1186/s12889-018-5765-2 Griffiths, S., Campbell, D. M., Caudarella, A., Guimond, T., Lamba, W., Lurie, E., Nader, M., Sgro, M., & Turner, S. (2021). Use of injectable opioid agonist therapy in a in-patient setting for a pregnant patient with opioid use disorder: A case report. Journal of Addiction Medicine, 15(5), 435–438. https://doi.org/10.1097/ADM.0000000000000776 Gunn, A. H., Smothers, Z. P. W., Schramm-Sapyta, N., Freiermuth, C. E., MacEachern, M., & Muzyk, A. J. (2018). The emergency department as an opportunity for naloxone distribution. Western Journal of Emergency Medicine, 19(6), 1036–1042. https://doi.org/10.5811/westjem.2018.8.38829 Guo, X., & Slesnick, N. (2017). Reductions in hard drug use among homeless youth receiving a strength-based outreach intervention: Comparing the long-term effects of shelter linkage versus drop-in center linkage. Substance Use & Misuse, 52(7), 905–915. https://doi.org/10.1080/10826084.2016.1267219 Hardavella, G., Aamli-Gaagnat, A., Saad, N., Rousalova, I., & Sreter, K. B. (2017). How to give and receive feedback effectively. Breathe, 13(4), 327–333. https://doi.org/10.1183/20734735.009917 Harm Reduction International. (2022). What is harm reduction? https://hri.global/what-is-harm-reduction/ Harris, S. (2016). The social practice of harm reduction in Argentina: A ‘Latin’ kind of intervention. Human Organization, 75(1), 1-9. https://doi.org/10.17730/0018-7259-75.1.1 202 Hawk, K., Grau, L. E., Fiellin, D. A., Chawarski, M., O’Connor, P. G., Cirillo, N., Breen, C., D’Onofrio, G., & Bird, S. B. (2021). A qualitative study of emergency department patients who survived an opioid overdose: Perspectives on treatment and unmet needs. Academic Emergency Medicine, 28(5), 542-552. https://doi.org/10.1111/acem.14197 Hawk, K., McCormack, R., Edelman, E. J., Coupet, E., Toledo, N., Gauthier, P., Rotrosen, J., Chawarski, M., Martel, S., Owens, P., Pantalon, M. V., O’Connor, P., Whiteside, L. K., Cowan, E., Richardson, L. D., Lyons, M. S., Rothman, R., Marsch, L., Fiellin, D. A., & D’Onofrio, G. (2022). Perspectives about emergency department care encounters among adults with opioid use disorder. JAMA Network Open, 5, e2144955. https://doi.org/10.1001/jamanetworkopen.2021.44955 HealthCare Link BC (2024a). Program: Dr. Peter Centre Residence. https://find.healthlinkbc.ca/ResourceView2.aspx?org=53965&agencynum=17663850 HealthCare Link BC (2024b). Program: Providence Crosstown Clinic. https://find.healthlinkbc.ca/ResourceView2.aspx?org=53965&agencynum=17654767 Hemmons, P., Bach, P., Colizza, K., & Nolan, S. (2019). Initiation and rapid titration of methadone in an acute care setting for the treatment of opioid use disorder: A case report. Journal of Addiction Medicine, 13(5), 408-411. https://doi.org/10.1097/ADM.0000000000000507 Henderson, S., Stacey, C. L., & Dohan, D. (2008). Social stigma and the dilemmas of providing care to substance users in a safety-net emergency department. Journal of Health Care for the Poor and Underserved, 19(4), 1336-1349. https://doi.org/10.1353/hpu.0.0088 Henry, B. F., Mandavia, A. D., Paschen-Wolff, M. M., Hunt, T., Humensky, J. L., Wu, E., Pincus, H. A., Nunes, E. V., Levin, F. R., & El-Bassel, N. (2020). COVID-19, mental 203 health, and opioid use disorder: Old and new public health crises intertwine. Psychological Trauma, 12(Suppl. 1), S111–S112. https://doi.org/10.1037/tra0000660 Herring, A. A., Perrone, J., & Nelson, L. S. (2019). Managing opioid withdrawal in the emergency department with buprenorphine. Annals of Emergency Medicine, 73(5), 481-487. https://doi.org/10.1016/j.annemergmed.2018.11.032 Holland, T. J., Penm, J., Dinh, M., Aran, S., & Chaar, B. (2019). Emergency department physicians’ and pharmacists’ perspectives on take-home naloxone. Drug and Alcohol Review, 38(2), 169-176. https://doi.org/10.1111/dar.12894 Hope, V. D., Ncube, F., Parry, J. V., & Hickman, M. (2015). Healthcare seeking and hospital admissions by people who inject drugs in response to symptoms of injection site infections or injuries in three urban areas of England. Epidemiology and Infection, 143(1), 120-131. https://doi.org/10.1017/S0950268814000284 Horner, G., Daddona, J., Burke, D. J., Cullinane, J., Skeer, M., & Wurcel, A. G. (2019). "You're kind of at war with yourself as a nurse": Perspectives of inpatient nurses on treating people who present with a comorbid opioid use disorder. PLOS One, 14(10), e0224335. https://doi.org/10.1371/journal.pone.0224335.t001 Horvat, A., & Filipovic, J. (2018). Service quality and maturity of health care organizations through the lens of complexity leadership theory. Journal of Evaluation in Clinical Practice, 24(1), 301-307. https://doi.org/10.1111/jep.12789 Hou, Y., Corbally, M., & Timmins, F. (2022). Violence against nurses by patients and visitors in the emergency department: A concept analysis. Journal of Nursing Management, 30(6), 1688–1699. https://doi.org/10.1111/jonm.13721 204 Hu, T., Snider-Adler, M., Nijmeh, L., & Pyle, A. (2019). Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers. CJEM, 21(4), 492–498. https://doi.org/10.1017/cem.2019.24 Hurt, B. R., Hussain, A., Aledhaim, A., Moayedi, S., Schenkel, S. M., & Kim, H. K. (2020). Access and barriers to take-home naloxone use among emergency department patients with opioid misuse in Baltimore, Maryland, USA. Substance Use & Misuse, 55(13), 2237–2242. https://doi.org/10.1080/10826084.2020.1797811 Hyshka, E., Morris, H., Anderson-Baron, J., Nixon, L., Dong, K., & Salvalaggio, G. (2019). Patient perspectives on a harm reduction-oriented addiction medicine consultation team implemented in a large acute care hospital. Drug and Alcohol Dependence, 204, 107523. https://doi.org/10.1016/j.drugalcdep.2019.06.025 Im, D. D., Chary, A., Condella, A. L., Vongsachang, H., Carlson, L. C., Vogel, L., Martin, A., Kunzler, N., Weiner, S. G., & Samuels-Kalow, M. (2020). Emergency department clinicians' attitudes toward opioid use disorder and emergency department-initiated buprenorphine treatment: A mixed-methods study. Western Journal of Emergency Medicine, 21(2), 261–271. https://doi.org/10.5811/westjem.2019.11.44382 Imtiaz, S., Nafeh, F., Russell, C., Ali, F., Elton-Marshall, T., & Rehm, J. (2021). The impact of the novel coronavirus disease (COVID-19) pandemic on drug overdose-related deaths in the United States and Canada: A systematic review of observational studies and analysis of public health surveillance data. Substance Abuse Treatment, Prevention, and Policy, 16, 87. https://doi.org/10.1186/s13011-021-00423-5 205 International Network of People who Use Drugs. (2014). Stigmatizing people who use drugs. https://inpud.net/wp-content/uploads/2022/03/DUPI-Stigmatising_People_who_Use_Drugs.pdf Ivsins, A., Boyd, J., Mayer, S., Collins, A., Sutherland, C., Kerr, T., & McNeil, R. (2020). Barriers and facilitators to a novel low-barrier hydromorphone distribution program in Vancouver, Canada: A qualitative study. Drug and Alcohol Dependence, 216, 108202. https://doi.org/10.1016/j.drugalcdep.2020.108202 Ivsins, A., Boyd, J., Mayer, S., Collins, A., Sutherland, C., Kerr, T., & McNeil, R. (2021). "It's helped me a lot, just like to stay alive": A qualitative analysis of outcomes of a novel hydromorphone tablet distribution program in Vancouver, Canada. Journal of Urban Health, 98(1), 59–69. https://doi.org/10.1007/s11524-020-00489-9 Ivsins, A., Roth, E., Nakamura, N., Krajden, M., & Fischer, B. (2011). Uptake, benefits of and barriers to safer crack use kit (SCUK) distribution programmes in Victoria, Canada: A qualitative exploration. International Journal on Drug Policy, 22(4), 292–300. https://doi.org/10.1016/j.drugpo.2011.05.005 Jackson, L. A., McWilliam, S., Martin, F., Dingwell, J., Dykeman, M., Gahagan, J., & Karabanow, J. (2014). Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada. Drugs: Education, Prevention and Policy, 21(3), 244-253. https://doi.org/10.3109/09687637.2013.870534 Jakubowski, A., Pappas, A., Isaacsohn, L., Castillo, F., Masyukova, M., Silvera, R., Holaday, L., Rausch, E., Farooq, S., Veltri, K. T., Cunningham, C. O., & Bachhuber, M. A. (2019). Development and evaluation of a pilot overdose education and naloxone distribution 206 program for hospitalized general medical patients. Substance Abuse, 40(1), 61–65. https://doi.org/10.1080/08897077.2018.1518836 James, A., Madeley, R., & Dove, A. (2006). Violence and aggression in the emergency department. Emergency Medicine Journal, 23(6), 431-434. https://doi.org/10.1136/emj.2005.028621 Jiao, S. (2019). Harm reduction: Philosophical drivers of conceptual tensions and ways forward. Nursing Inquiry, 26(2), e12286. https://doi.org/10.1111/nin.12286 Jiao, S., Bungay, V., Jenkins, E., & Gagnon, M. (2023). How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: A systems perspective. Harm Reduction Journal, 20, 139. https://doi.org/10.1186/s12954-023-00871-1 Jiao, S., Slemon, A., Guta, A., & Bungay, V. (2022). Exploring the conceptualization, operationalization, implementation, and measurement of outreach in community settings with hard-to-reach and hidden populations: A scoping review. Social Science & Medicine, 309, 115232. https://doi.org/10.1016/j.socscimed.2022.115232 Johnson, R. B., Onwuegbuzie, A. J., & Turner, L. A. (2007). Toward a definition of mixed methods research. Journal of Mixed Methods Research, 1(2), 112-133. https://doi.org/10.1177/1558689806298224 Jozaghi, E., & Vancouver Area Network of Drug Users (2014). A cost-benefit/cost-effectiveness analysis of an unsanctioned supervised smoking facility in the Downtown Eastside of Vancouver, Canada. Harm Reduction Journal, 11, 30. https://doi.org/10.1186/1477-7517-11-30 207 Kang, S., Moon, J., Kang, H., Nam, H., Tak, S., & Cho, S. I. (2020). The evolving policy debate on border closure in Korea. Journal of Preventive Medicine and Public Health, 53(5), 302–306. https://doi.org/10.3961/jpmph.20.213 Karamouzian, M., Dohoo, C., Forsting, S., McNeil, R., Kerr, T., & Lysyshyn, M. (2018). Evaluation of a fentanyl drug checking service for clients of a supervised injection facility, Vancouver, Canada. Harm Reduction Journal, 15, 46. https://doi.org/10.1186/s12954-018-0252-8 Kelly, P., Gotham, H. J., Knopf-Amelung, S., Kohnle, K., & Kuofie, A. (2018). Distance versus on-site educational strategies for competency-based screening, brief intervention, and referral to treatment education. Journal of Addictions Nursing, 29(4), E1-E8. https://doi.org/10.1097/JAN.0000000000000247 Kendall, C. E., Boucher, L. M., Mark, A. E., Martin, A., Marshall, Z., Boyd, R., Oickle, P., Diliso, N., Pineau, D., Renaud, B., Rose, T., LeBlanc, S., Tyndall, M., Lee, O. M., & Bayoumi, A. M. (2017). A cohort study examining emergency department visits and hospital admissions among people who use drugs in Ottawa, Canada. Harm Reduction Journal, 14, 16. https://doi.org/10.1186/s12954-017-0143-4 Kerr, T., Mitra, S., Kennedy, M. C., & McNeil, R. (2017). Supervised injection facilities in Canada: Past, present, and future. Harm Reduction Journal, 14, 28. https://doi.org/10.1186/s12954-017-0154-1 Kerr, T., Tyndall, M., Li, K., Montaner, J., & Wood, E. (2005a). Safer injection facility use and syringe sharing in injection drug users. Lancet, 366(9482), 316-318. https://doi.org/10.1016/S0140-6736(05)66475-6 208 Kerr, T., Wood, E., Grafstein, E., Ishida, T., Shannon, K., Lai, C., Montaner, J., & Tyndall, M. W. (2005b). High rates of primary care and emergency department use among injection drug users in Vancouver. Journal of Public Health, 27(1), 62-66. https://doi.org/10.1093/pubmed/fdh189 Kestler, A., Buxton, J., Meckling, G., Giesler, A., Lee, M., Fuller, K., Quian, H., Marks, D., & Scheuermeyer, F. (2017). Factors associated with participation in an emergency department-based take-home naloxone program for at-risk opioid users. Annals of Emergency Medicine, 69(3), 340–346. https://doi.org/10.1016/j.annemergmed.2016.07.027 Kestler, A., Giesler, A., Buxton, J., Meckling, G., Lee, M., Hunte, G., Wilkins, J., Marks, D., & Scheuermeyer, F. (2019a). Yes, not now, or never: An analysis of reasons for refusing or accepting emergency department-based take-home naloxone. CJEM, 21(2), 226–234. https://doi.org/10.1017/cem.2018.368 Kestler, A., Wale, J., & Allan, M. (2019b). The time for emergency department opioid agonist therapy is now: "A BC perspective." CJEM, 21(4), 443–445. https://doi.org/10.1017/cem.2019.368 Khan, G. K., Harvey, L., Johnson, S., Long, P., Kimmel, S., Pierre, C., & Drainoni, M. (2022). Integration of a community-based harm reduction program into a safety net hospital: A qualitative study. Harm Reduction Journal, 19, 35. https://doi.org/10.1186/s12954-022-00622-8 Khatri, U. G., & Perrone, J. (2020). Opioid use disorder and COVID-19: Crashing of the crises. Journal of Addiction Medicine, 14(4), e6–e7. https://doi.org/10.1097/ADM.0000000000000684 209 Kincheloe J. L., & McLaren, P. (2011). Rethinking critical theory and qualitative research. In: K. Hayes, S. R. Steinberg, & K. Tobin (Eds.), Key works in critical pedagogy (pp. 285-326). Sense Publishers. Knopf-Amelung, S., Gotham, H., Kuofie, A., Young, P., Manney Stinson, R., Lynn, J., Barker, K., & Hildreth, J. (2018). Comparison of instructional methods for screening, brief intervention, and referral to treatment for substance use in nursing education. Nurse Educator, 43(3), 123-127. https://doi.org/10.1097/NNE.0000000000000439 Knott, J. C., Bennett, D., Rawet, J., & Taylor, D. M. (2005). Epidemiology of unarmed threats in the emergency department. Emergency Medicine Australasia, 17(4), 351-358. https://doi.org/10.1111/j.1742-6723.2005.00756.x Koh, J. J., Klaiman, M., Miles, I., Cook, J., Kumar, T., Sheikh, H., Dong, K., Orkin, A. M., Ali, S., & Shouldice, E. (2020). CAEP position statement: Emergency department management of people with opioid use disorder. Canadian Journal of Emergency Medicine, 22(6), 768-771. https://doi.org/10.1017/cem.2020.459 Kolla, G., Long, C., Perri, M., Bowra, A., & Penn, R. (2021). Safer opioid supply program: Preliminary report. London Intercommunity Health Centre. https://lihc.on.ca/wp-content/uploads/2022/01/2021-SOS-Evaluation-Full.pdf Kosteniuk, B., Salvalaggio, G., McNeil, R., Brooks, H. L., Dong, K., Twan, S., Brouwer, J., & Hyshka, E. (2021). "You don't have to squirrel away in a staircase": Patient motivations for attending a novel supervised drug consumption service in acute care. International Journal on Drug Policy, 96, 103275. https://doi.org/10.1016/j.drugpo.2021.103275 Kothari, D., Gourevitch, M. N., Lee, J. D., Grossman, E., Truncali, A., Ark, T. K., & Kalet, A. L. (2011). Undergraduate medical education in substance abuse: A review of the quality of 210 the literature. Academic Medicine, 86(1), 98-112. https://doi.org/10.1097/ACM.0b013e3181ff92cf Kowalenko, T., Walters, B. L., Khare, R. K., Compton, S. (2005). Workplace violence: A survey of emergency physicians in the state of Michigan. Annals of Emergency Medicine, 46(2), 142-147. https://doi.org/10.1016/j.annemergmed.2004.10.010 Kuziemsky C. (2016). Decision-making in healthcare as a complex adaptive system. Healthcare Management Forum, 29(1), 4-7. https://doi.org/10.1177/0840470415614842 Lacroix, L., Thurgur, L., Orkin, A. M., Perry, J. J., & Stiell, I. G. (2018). Emergency physicians' attitudes and perceived barriers to the implementation of take-home naloxone programs in Canadian emergency departments. Canadian Journal of Emergency Medicine, 20(1), 46-52. https://doi.org/10.1017/cem.2017.390 Lang, K., Neil, J., Wright, J., Dell, C. A., Berenbaum, S., & El-Aneed, A. (2013). Qualitative investigation of barriers to accessing care by people who inject drugs in Saskatoon, Canada: Perspectives of service providers. Substance Abuse Treatment, Prevention and Policy, 8, 35. https://doi.org/10.1186/1747-597X-8-35 Langabeer, J. R., Champagne-Langabeer, T., Yatsco, A. J., O'Neal, M. M., Cardenas-Turanzas, M., Prater, S., Luber, S., Stotts, A., Fadial, T., Khraish, G., Wang, H., Bobrow, B. J., & Chambers, K. A. (2021). Feasibility and outcomes from an integrated bridge treatment program for opioid use disorder. Journal of the American College of Emergency Physicians Open, 2(2), e12417. https://doi.org/10.1002/emp2.12417 Lavalley, J., Kastor, S., Valleriani, J., & McNeil, R. (2018). Reconciliation and Canada’s overdose crisis: Responding to the needs of Indigenous peoples. CMAJ, 190(50), E1466-E1467. https://doi.org/10.1503/cmaj.181093 211 Lee, J., & Buxton, J. (2017, August). Policy indicators report: Data to December 31st 2016. BC Harm Reduction Strategies and Services (HRSS) Committee. http://www.bccdc.ca/resource-gallery/Documents/2017%20HRSS%20Indicators%20Report%20final.pdf Lee, S. E., Choi, J., Lee, H., Sang, S., Lee, H., & Hong, H. C. (2021). Factors influencing nurses' willingness to speak up regarding patient safety in East Asia: A systematic review. Risk Management and Healthcare Policy, 14, 1053-1063. https://doi.org/10.2147/RMHP.S297349 Legislatively Assembly of British Columbia. (2022, November). Closing gaps, reducing barriers: Expanding the response to the toxic drug and overdose crisis. Select Standing Committee on Health. https://www.leg.bc.ca/content/CommitteeDocuments/42nd-parliament/3rd-session/health/report/SSC-Health-Report_42-3_2022-11-01_Final.pdf Lennox, R., Martin, L., Brimner, C., & O'Shea, T. (2021). Hospital policy as a harm reduction intervention for people who use drugs. International Journal of Drug Policy, 97, 103324. https://doi.org/10.1016/j.drugpo.2021.103324 Lew, B., Bodkin, C., Lennox, R., O'Shea, T., Wiwcharuk, G., & Turner, S. (2022). The impact of an integrated safer use space and safer supply program on non-fatal overdose among emergency shelter residents during a COVID-19 outbreak: A case study. Harm Reduction Journal, 19, 29. https://doi.org/10.1186/s12954-022-00614-8 Lewer, D., Freer, J., King, E., Larney, S., Degenhardt, L., Tweed, E. J., Hope, V. D., Harris, M., Millar, T., Hayward, A., Ciccarone, D., & Morley, K. I. (2020). Frequency of health-care utilization by adults who use illicit drugs: A systematic review and meta-analysis. Addiction, 115(6), 1011-1023. https://doi.org/10.1111/add.14892 212 Lightfoot, B., Panessa, C., Hayden, S., Thumath, M., Goldstone, I., & Pauly, B. (2009). Gaining Insite: Harm reduction in nursing practice. Canadian Nurse, 105(4), 19-22. Lindstrom, R. R. (2003). Evidence-based decision-making in healthcare: Exploring the issues through the lens of complex, adaptive systems theory. HealthcarePapers, 3(3), 29-35. https://doi.org/10.12927/hcpap..17127 Low, K. (2020). Initiating buprenorphine/naloxone for opioid use disorder in the emergency department. Canadian Journal of Emergency Nursing, 43(1), 12-22. https://doi.org/10.29173/cjen15 Lowenstein, M., Kilaru, A., Perrone, J., Hemmons, J., Abdel-Rahman, D., Meisel, Z. F., & Delgado, M. K. (2019). Barriers and facilitators for emergency department initiation of buprenorphine: A physician survey. American Journal of Emergency Medicine, 37(9), 1787-1790. https://doi.org/10.1016/j.ajem.2019.02.025 Luck, L., Jackson, D., & Usher, K. (2007). STAMP: Components of observable behaviour that indicate potential for patient violence in emergency departments. Journal of Advanced Nursing, 59(1), 11-19. https://doi.org/10.1111/j.1365-2648.2007.04308.x Luck, L., Jackson, D., & Usher, K. (2008). Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence. Journal of Clinical Nursing, 17(8), 1071-1078. https://doi.org/10.1111/j.1365-2702.2006.01870.x MacKinnon, L., Socías, M. E., & Bardwell, G. (2020). COVID-19 and overdose prevention: Challenges and opportunities for clinical practice in housing settings. Journal of Substance Abuse Treatment, 119, 108153. https://doi.org/10.1016/j.jsat.2020.108153 MacPherson, D. (2001, April 24). A framework for action: A four-pillar approach to drug problems in Vancouver (revised). 213 https://www.researchgate.net/profile/Donald_Macpherson2/publication/242480594_A_Four-Pillar_Approach_to_Drug_Problems_in_Vancouver/links/55ca4a3c08aeca747d69e597/A-Four-Pillar-Approach-to-Drug-Problems-in-Vancouver.pdf Malchy, L. A., Bungay, V., Johnson, J. L., & Buxton, J. (2011). Do crack smoking practices change with the introduction of safer crack kits? Canadian Journal of Public Health, 102(3), 188-192. https://doi.org/10.1007/BF03404893 Marino, R., Landau, A., Lynch, M., Callaway, C., & Suffoletto, B. (2019). Do electronic health record prompts increase take-home naloxone administration for emergency department patients after an opioid overdose? Addiction, 114(9), 1575–1581. https://doi.org/10.1111/add.14635 Marshall, B. D., Milloy, M., Wood, E., Montaner, J. S., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North America's first medically supervised safer injecting facility: A retrospective population-based study. Lancet, 377(9775), 1429-1437. https://doi.org/10.1016/S0140-6736(10)62353-7 Martin, C. M., Grady, D., Deaconking, S., McMahon, C., Zarabzadeh, A., & O'Shea, B. (2011). Complex adaptive chronic care - typologies of patient journey: A case study. Journal of Evaluation in Clinical Practice, 17(3), 520-524. https://doi.org/10.1111/j.1365-2753.2011.01670.x Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 3, Art. No.: CD002209. https://doi.org/10.1002/14651858.CD002209.pub2. 214 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2, Art. No.: CD002207. https://doi.org/10.1002/14651858.CD002207.pub4. Mayer, S., Langheimer, V., Nolan, S., Boyd, J., Small, W., & McNeil, R. (2023). Emergency department experiences of people who use drugs who left or were discharged from hospital against medical advice. PLOS One, 18(2), e0282215. https://doi.org/10.1371/journal.pone.0282215 McCreaddie, M., Lyons, I., Watt, D., Ewing, E., Croft, J., Smith, M., & Tocher, J. (2010). Routines and rituals: A grounded theory of the pain management of drug users in acute care settings. Journal of Clinical Nursing, 19(19-20), 2730-2740. https://doi.org/10.1111/j.1365-2702.2010.03284.x McDaniel, R. R., & Driebe, D. J. (2001). Complexity science and health care management. Advances in health care management (Volume 2, pp. 11-36). Emerald Group Publishing Limited. https://doi.org/10.1016/S1474-8231(01)02021-3 McDonald, R., & Strang, J. (2016). Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction, 111(7), 1177–1187. https://doi.org/10.1111/add.13326 McNeil, R., Kerr, T., Pauly, B., Wood, E., & Small, W. (2016). Advancing patient-centered care for structurally vulnerable drug-using populations: A qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals. Addiction, 111(4), 685-694. https://doi.org/10.1111/add.13214 215 McNeil, R., Small, W., Wood, E., & Kerr, T. (2014). Hospitals as a ‘risk environment’: An ethno-epidemiological study of voluntary and involuntary discharge from hospital against medical advice among people who inject drugs. Social Science & Medicine, 105, 59-66. https://doi.org/10.1016/j.socscimed.2014.01.010 Mema, S. C., Frosst, G., Bridgeman, J., Drake, H., Dolman, C., Lappalainen, L., & Corneil, T. (2019). Mobile supervised consumption services in rural British Columbia: Lessons learned. Harm Reduction Journal, 16, 4. https://doi.org/10.1186/s12954-018-0273-3 Miller, N. S., Sheppard, L. M., Colenda, C. C., & Magen, J. (2001). Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Academic Medicine, 76(5), 410-418. https://doi.org/10.1097/00001888-200105000-00007 Minas, H. (2005). Leadership for change in complex systems. Australasian Psychiatry, 13(1), 33-39. https://doi.org/10.1111/j.1440-1665.2004.02147.x Ministry of Public Safety & Solicitor General. (2022, August 16). Illicit drug toxicity deaths in BC: January 1, 2012 – June 30, 2022. https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf Moe, J., Chong, M., Zhao, B., Scheuermeyer, F. X., Purssell, R., & Slaunwhite, A. (2021). Death after emergency department visits for opioid overdose in British Columbia: A retrospective cohort analysis. CMAJ Open, 9(1), E242-E251. https://doi.org/10.9778/cmajo.20200169 Monks, R., Topping, A., & Newell, R. (2013). The dissonant care management of illicit drug users in medical wards, the views of nurses and patients: A grounded theory study. Journal of Advanced Nursing, 69(4), 935-946. https://doi.org/10.1111/j.1365-2648.2012.06088.x Moore, P. Q., Cheema, N., Celmins, L. E., Patel, A., Follman, S., Soni, H., Szwak, J. A., Pho, M. T., Carter, K., & Arora, V. M. (2021). Point-of-care naloxone distribution in the 216 emergency department: A pilot study. American Journal of Health-System Pharmacy, 78(4), 360–366. https://doi.org/10.1093/ajhp/zxaa409 Morken, T., Johansen, I. H., & Alsaker, K. (2015). Dealing with workplace violence in emergency primary health care: A focus group study. BMC Family Practice, 16, 51. https://doi.org/10.1186/s12875-015-0276-z Morris, M. D., Evans, J., Montgomery, M., Yu, M., Briceno, A., Page, K., & Hahn, J. A. (2014). Intimate injection partnerships are at elevated risk of high-risk injecting: A multi-level longitudinal study of HCV-serodiscordant injection partnerships in San Francisco, CA. PLOS One, 9(10), e109282. https://doi.org/10.1371/journal.pone.0109282 Mullennix, S. C., Iseler, J., Kwiatkowski, G. M., McCann-Spry, L., Skinner, J., Kuhl, N., VanDePol, E. K., & Poland, C. A. (2020). A clinical nurse specialist-led emergency department naloxone distribution program. Clinical Nurse Specialist, 34(3), 116–123. https://doi.org/10.1097/NUR.0000000000000515 Nambiar, D., Stoové, M., & Dietze, P. (2017). Frequent emergency department presentations among people who inject drugs: A record linkage study. International Journal of Drug Policy, 44, 115–120. https://doi.org/10.1016/j.drugpo.2017.03.010 National Harm Reduction Coalition. (2022). Principles of harm reduction. https://harmreduction.org/about-us/principles-of-harm-reduction/ Neale, J., Sheard, L., & Tompkins, C. N. E. (2007). Factors that help injecting drug users to access and benefit from services: A qualitative study. Substance Abuse Treatment, Prevention and Policy, 2, 31. https://doi.org/10.1186/1747-597X-2-31 Needle, R. H., Burrows, D., Friedman, S. R., Dorabjee, J., Touzé, G., Badrieva, L., Grund, J. C., Kumar, M. S., Nigro, L., Manning, G., & Latkin, C. (2005). Effectiveness of community- 217 based outreach in preventing HIV/AIDS among injecting drug users. International Journal of Drug Policy, 16(Suppl. 1), 45-57. https://doi.org/10.1016/j.drugpo.2005.02.009 Nelson, G., Macnaughton, E., Goering, P., Dudley, M., O'Campo, P., Patterson, M., Piat, M., Prévost, N., Strehlau, V., & Vallée, C. (2013). Planning a multi-site, complex intervention for homeless people with mental illness: The relationships between the national team and local sites in Canada's At Home / Chez Soi project. American Journal of Community Psychology, 51(3-4), 347–358. https://doi.org/10.1007/s10464-012-9554-2 Nesse, R. E., Kutcher, G., Wood, D., & Rummans, T. (2010). Framing change for high-value healthcare systems. Journal for Healthcare Quality, 32(1), 23-28. https://doi.org/10.1111/j.1945-1474.2009.00060.x Nguyen, T., & Buxton, J. A. (2021). Pathways between COVID-19 public health responses and increasing overdose risks: A rapid review and conceptual framework. International Journal on Drug Policy, 93, 103236. https://doi.org/10.1016/j.drugpo.2021.103236 Nordeck, C. D., Welsh, C., Schwartz, R. P., Mitchell, S. G., O'Grady, K. E., & Gryczynski, J. (2022). Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service. Drug and Alcohol Dependence Reports, 2, 100031. https://doi.org/10.1016/j.dadr.2022.100031 Nugus, P., Carroll, K., Hewett, D. G., Short, A., Forero, R., & Braithwaite, J. (2010). Integrated care in the emergency department: A complex adaptive systems perspective. Social Science & Medicine, 71(11), 1997-2004. https://doi.org/10.1016/j.socscimed.2010.08.013 O'Brien, D. C., Dabbs, D., Dong, K., Veugelers, P. J., & Hyshka, E. (2019). Patient characteristics associated with being offered take home naloxone in a busy, urban 218 emergency department: A retrospective chart review. BMC Health Services Research, 19, 632. https://doi.org/10.1186/s12913-019-4469-3 O’Hare, P. (2007). Merseyside, the first harm reduction conferences, and the early history of harm reduction. International Journal of Drug Policy, 18(2), 141-144. https://doi:10.1016/j.drugpo.2007.01.003 Ohlendorf, E., Perez-Correa, A., Riback, L., Ghiroli, M., Lopez-Castro, T., & Fox, A. D. (2023). Treatment history and interest in injectable opioid agonist treatment with hydromorphone among people who inject drugs. Journal of Addiction Medicine, 17(3), e148–e155. https://doi.org/10.1097/ADM.0000000000001093 Okuyama, A., Wagner, C., & Bijnen, B. (2014). Speaking up for patient safety by hospital-based health care professionals: A literature review. BMC Health Services Research, 14, 61. https://doi.org/10.1186/1472-6963-14-61 Ontario HIV Treatment Network (2022, July). A review of supervised inhalation services in Canada. Rapid Response Service. https://www.ohtn.on.ca/wp-content/uploads/2022/07/RR171_supervised-inhalation_July212022.pdf Onwuegbuzie A. J., & Combs, J. P. (2015). Emergent data analysis techniques in mixed methods research: A synthesis. In: A. Tashakkori & C. Teddlie (Eds.), SAGE handbook of mixed methods in social and behavioural research (2nd ed.) (pp. 1-51). SAGE Publications, Inc. Ostrach, B., Buer, L. M., Armbruster, S., Brown, H., Yochym, G., & Zaller, N. (2021). COVID-19 and rural harm reduction challenges in the US southern mountains. Journal of Rural Health, 37(1), 252–255. https://doi.org/10.1111/jrh.12499 219 Oviedo-Joekes, E., Brissette, S., Marsh, D. C., Lauzon, P., Guh, D., Anis, A., & Schechter, M. T. (2009). Diacetylmorphine versus methadone for the treatment of opioid addiction. New England Journal of Medicine, 361(8), 777–786. https://doi.org/10.1056/NEJMoa0810635 Oviedo-Joekes, E., Guh, D., Brissette, S., Marchand, K., MacDonald, S., Lock, K., Harrison, S., Janmohamed, A., Anis, A. H., Krausz, M., Marsh, D. C., & Schechter, M. T. (2016). Hydromorphone compared with diacetylmorphine for long-term opioid dependence: A randomized clinical trial. JAMA Psychiatry, 73(5), 447–455. https://doi.org/10.1001/jamapsychiatry.2016.0109 Padgett D. K. (2007). There's no place like (a) home: Ontological security among persons with serious mental illness in the United States. Social Science & Medicine, 64(9), 1925–1936. https://doi.org/10.1016/j.socscimed.2007.02.011 Padgett, D. K., Hawkins, R. L., Abrams, C., & Davis, A. (2006). In their own words: Trauma and substance abuse in the lives of formerly homeless women with serious mental illness. American Journal of Orthopsychiatry, 76(4), 461-467. https://doi.org/10.1037/1040.3590.76.4.461 Papp, J., Vallabhaneni, M., Morales, A., & Schrock, J. W. (2019). Take-home naloxone rescue kits following heroin overdose in the emergency department to prevent opioid overdose related repeat emergency department visits, hospitalization and death – A pilot study. BMC Health Services Research, 19, 957. https://doi.org/10.1186/s12913-019-4734-5 Parashar, S., Chan, K., Milan, D., Grafstein, E., Palmer, A. K., Rhodes, C., Montaner, J. S., & Hogg, R. S. (2014). The impact of unstable housing on emergency department use in a cohort of HIV-positive people in a Canadian setting. AIDS Care, 26(1), 53–64. https://doi.org/10.1080/09540121.2013.793281 220 Paterson, B., Hirsch, G., & Andres, K. (2013). Structural factors that promote stigmatization of drug users with hepatitis C in hospital emergency departments. International Journal of Drug Policy, 24(5), 471-478. Doi:10.1016/j.drugpo.2013.01.008 Pates, R., & Riley, D. (Eds.). (2012). Harm reduction in substance use and high-risk behaviour: International policy and practice. Addiction Press. Patricelli, C. J., Chai, J., Gordon, S., Gouin, I. J., Carter, N., Stewart, K., Paquette, V., Urbanoski, K., & Albert, A. (2023). Perinatal injectable opioid agonist therapy (iOAT) administration: A case series. Journal of Addiction Medicine, 17(4), 431–438. https://doi.org/10.1097/ADM.0000000000001152 Pauly, B. (2008). Shifting moral values to enhance access to health care: Harm reduction as a context for ethical nursing practice. International Journal of Drug Policy, 19(3), 195-204. https://doi:10.1016/j.drugpo.2008.02.009 Pauly, B., Wallace, B., & Barber, K. (2018). Turning a blind eye: Implementation of harm reduction in a transitional programme setting. Drugs: Education, Prevention & Policy, 25(1), 21-30. https://doi.org/10.1080/09687637.2017.1337081 Perera, R., Stephan, L., Appa, A., Giuliano, R., Hoffman, R., Lum, P., & Martin, M. (2022). Meeting people where they are: Implementing hospital-based substance use harm reduction. Harm Reduction Journal, 19, 14. https://doi.org/10.1186/s12954-022-00594-9 Petrie, D. A., & Comber, S. (2020). Emergency department access and flow: Complex systems need complex approaches. Journal of Evaluation in Clinical Practice, 26(5), 1552-1558. https://doi.org/10.1111/jep.13418 Prach, A., Clancy, A., LeBlanc, M., Thomasian, B. B., Kelley, M., Hogan, E., & Pawasauskas, J. (2019). Implementation and evaluation of an inpatient naloxone program in a community 221 teaching hospital. Research in Social and Administrative Pharmacy, 15(8), 1037–1042. https://doi.org/10.1016/j.sapharm.2018.10.004 Priest, K. C., & McCarty, D. (2019). Role of the hospital in the 21st century opioid overdose epidemic: The addiction medicine consult service. Journal of Addiction Medicine, 13(2), 104–112. https://doi.org/10.1097/ADM.0000000000000496 Providence Health Care. (2016, June 21). About St. Paul's Hospital. https://thenewstpauls.ca/app/uploads/2016/06/FS-About-St.-Pauls-21-June-2016.pdf Providence Health Care. (2018). Save a life in 60-minutes. http://annualreport2018.providencehealthcare.org/save-a-life-in-60-minutes/ Providence Health Care. (2019a). Our populations of emphasis. https://www.providencehealthcare.org/about-providence/who-we-serve/our-populations-emphasis Providence Health Care. (2019b). Rapid Access Addiction Clinic (RAAC). https://www.providencehealthcare.org/rapid-access-addiction-clinic-raac Providence Health Care. (2019c). St. Paul's Hospital: Emergency services. https://www.providencehealthcare.org/hospitals-residences/st-pauls-hospital/emergency-services Providence Health Care. (2019d). Substance use services: Research and treatment of complex mental illnesses and addictions. https://www.providencehealthcare.org/substance-use-services Providence Health Care. (2019e). Violence prevention. https://www.providencehealthcare.org/violenceprevention 222 Providence Health Care. (2019f, July 15). Violence prevention in the workplace. http://shop.healthcarebc.ca/phc/PHCPolicies/B-00-11-10196.pdf Providence Health Care. (2020a, November 20). Addiction medicine: Addiction Medicine Consult Team (AMCT) at St. Paul's Hospital. https://familymedicine.providencehealthcare.org/programs/addiction-medicine Providence Health Care. (2020b, December 22). Buprenorphine / naloxone (Suboxone®) for opioid use disorder. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-13-10183.pdf Providence Health Care. (2020c, May 6). Philosophy of care for patients and residents who use substances. http://shop.healthcarebc.ca/phc/PHCPolicies/B-00-11-10125.pdf Providence Health Care. (2021a, January 8). Buprenorphine / naloxone ‘(Suboxone®) to-go’ patient kits for induction outside of hospital setting. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-13-10232.pdf Providence Health Care. (2021b, October 5). Dispensing take home naloxone kits to clients at risk of opioid overdose (adults and youth). http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-13-10175.pdf Providence Health Care. (2021c, October 27). Harm reduction and managing substance use – Acute care. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-07-10096.pdf Providence Health Care. (2021d, April 29). Methadone for opioid use disorder. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-13-10180.pdf Providence Health Care. (2021e, June 16). Overdose Prevention Site (OPS) at St. Paul’s Hospital: Operating procedures. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-16-10044.pdf 223 Providence Health Care. (2021f, June 29). Rapid Access Addiction Clinic. https://www.providencehealthcare.org/sites/default/files/RAACBrochure_29_June_2021.pdf Providence Health Care. (2022, January 17). Injectable opioid agonist treatment (iOAT) for opioid user disorder and IV fentanyl for withdrawal management. http://shop.healthcarebc.ca/phc/PHCDSTs/B-00-12-10126.pdf Providence Health Care. (2024). Our mission. https://www.providencehealthcare.org/en/our-mission Province of British Columbia. (2016, April 14). Provincial health officer declares public health emergency. https://news.gov.bc.ca/releases/2016HLTH0026-000568 Province of British Columbia. (2020, March 18). Province declares state of emergency to support COVID-19 responses. https://news.gov.bc.ca/releases/2020PSSG0017-000511 Punches, B. E., Soliman, S., Freiermuth, C. E., Lane, B. H., & Lyons, M. S. (2020). Emergency nurse perceptions of naloxone distribution in the emergency department. Journal of Emergency Nursing, 46(5), 675–681.e1. https://doi.org/10.1016/j.jen.2020.05.006 Pype, P., Mertens, F., Helewaut, F., & Krystallidou, D. (2018). Healthcare teams as complex adaptive systems: Understanding team behaviour through team members' perception of interpersonal interaction. BMC Health Services Research, 18, 570. https://doi.org/10.1186/s12913-018-3392-3 Ragin, C. C. (2015). Case-oriented research. In J. D. Wright (Ed.), International encyclopedia of the social and behaviour sciences (2nd ed.) (pp. 187-193). Elsevier. Rajab, D., Fujioka, J. K., Walker, M., Bartels, S. A., MacKenzie, M., & Purkey, E. (2023). Emergency department care experiences among people who use substances: A qualitative 224 study. International Journal for Equity in Health, 22, 1-248. https://doi.org/10.1186/s12939-023-02050-x Ram, A., & Chisolm, M. S. (2016). The time is now: Improving substance abuse training in medical schools. Academic Psychiatry, 40(3), 454-460. https://doi.org/10.1007/s40596-015-0314-0 Ranger, C., Hobbs, H., Cameron, F., Stuart, H., McCall, J. Sullivan, G., Urbanoski, K., Slaunwhite, A., & Pauly, B. (2021). A practice brief: Implementing the Victoria SAFER Initiative. Canadian Institute for Substance Use Research, University of Victoria. https://www.uvic.ca/research/centres/cisur/assets/docs/colab/practice-brief-safer.pdf Rasyidi, E., Wilkins, J. N., & Danovitch, I. (2012). Training the next generation of providers in addiction medicine. Psychiatric Clinics of North America, 35(2), 461-480. https://doi.org/10.1016/j.psc.2012.04.001 Ratycz, M. C., Papadimos, T. J., & Vanderbilt, A. A. (2018). Addressing the growing opioid and heroin abuse epidemic: A call for medical school curricula. Medical Education Online, 23, 1466574. https://doi.org/10.1080/10872981.2018.1466574 Regis, C., Gaeta, J. M., Mackin, S., Baggett, T. P., Quinlan, J., & Taveras, E. M. (2020). Community care in reach: Mobilizing harm reduction and addiction treatment services for vulnerable populations. Frontiers in Public Health, 8, 501. https://doi.org/10.3389/fpubh.2020.00501 Riley, D., & O'Hare, P. (2000). Harm reduction: History, definition, and practice. In J. A. Inciardi & L. D. Harrison (Eds.), Harm reduction: National and international perspectives (pp. 1-26). SAGE Publications Ltd. 225 Roberts, A., Mathers, B., Degenhardt, L. (2010). Women who inject drugs: A review of their risks, experiences and needs. National Drug and Alcohol Research Centre (NDARC), University of New South Wales. https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Women%20who%20inject%20drugs.pdf Rodda, L. N., West, K. L., & LeSaint, K. T. (2020). Opioid overdose-related emergency department visits and accidental deaths during the COVID-19 pandemic. Journal of Urban Health, 97(6), 808–813. https://doi.org/10.1007/s11524-020-00486-y Roe, G. (2005). Harm reduction as paradigm: Is better than bad good enough? The origins of harm reduction. Critical Public Health, 15(3), 243-250. https://doi.org/10.1080/09581590500372188 Rogers, W. A. (2004). Evidence based medicine and justice: A framework for looking at the impact of EBM upon vulnerable or disadvantaged groups. Journal of Medical Ethics, 30(2), 141-145. https://doi.org/10.1136/jme.2003.007062 Roggenbuck, C. (2022, August). Housing First: An evidence review of implementation, effectiveness and outcomes. Australian Housing and Urban Research Institute Limited. https://www.ahuri.edu.au/sites/default/files/documents/2022-08/AHURI-Prof-Services-Housing-First-An-evidence-review-of-implementation-effectiveness-and-outcomes.pdf Sachdeva, S., Jamshed, N., Aggarwal, P., & Kashyap, S. (2019). Perception of workplace violence in the emergency department. Journal of Emergencies, Trauma and Shock, 12(3), 179-184. https://doi.org/10.4103/JETS.JETS_81_18 Salvalaggio, G., Dong, K. A., Hyshka, E., McCabe, C., Nixon, L., Rosychuk, R. J., Dmitrienko, K., Krajnak, J., Mrklas, K., & Wild, T. C. (2022). Impact of an addiction medicine consult 226 team intervention in a Canadian inner city hospital on acute care utilization: A pragmatic quasi-experimental study. Substance Abuse Treatment, Prevention, and Policy, 17, 20. https://doi.org/10.1186/s13011-022-00445-7 Samuels, E. A., Bernstein, S. L., Marshall, B. D. L., Krieger, M., Baird, J., & Mello, M. J. (2018). Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes. Journal of Substance Abuse Treatment, 94, 29–34. https://doi.org/10.1016/j.jsat.2018.07.013 Samuels, E. A., Wentz, A., McCormick, M., McDonald, J. V., Marshall, B. D. L., Friedman, C., Koziol, J., & Alexander-Scott, N. E. (2021). Rhode Island's opioid overdose hospital standards and emergency department naloxone distribution, behavioral counseling, and referral to treatment. Annals of Emergency Medicine, 78(1), 68–79. https://doi.org/10.1016/j.annemergmed.2021.02.004 Sander, G., Scandurra, A., Kamenska, A., MacNamara, C., Kalpaki, C., Bessa, C. F., Laso, G. N., Parisi, G., Varley, L., Wolny, M., Moudatsou, M., Pontes, N. H., Mannix-McNamara, P., Libianchi, S., & Antypas, T. (2016). Overview of harm reduction in prisons in seven European countries. Harm Reduction Journal, 13, 28. https://doi.org/10.1186/s12954-016-0118-x Schleihauf, E., Crabtree, K., Dohoo, C., Fleming, S., McPeake, H., & Bowes, M. (2018). Concurrent monitoring of opioid prescribing practices and opioid-related deaths: The context in Nova Scotia, Canada. Health Promotion and Chronic Disease Prevention in Canada: Research, Policy and Practice, 38(9), 334–338. https://doi.org/10.24095/hpcdp.38.9.05 227 Schlosser, A., & Harris, S. (2020). Care during COVID-19: Drug use, harm reduction, and intimacy during a global pandemic. International Journal of Drug Policy, 83, 102896. https://doi.org/10.1016/j.drugpo.2020.102896 Seear, K., Gray, R., Fraser, S., Treloar, C., Bryant, J., & Brener, L. (2012). Rethinking safety and fidelity: The role of love and intimacy in hepatitis C transmission and prevention. Health Sociology Review, 21(3), 272-286. https://doi.org/10.5172/hesr.2012.21.3.272 Shaghaghi, A., Bhopal, R. S., & Sheikh, A. (2011). Approaches to recruiting 'hard-to-reach' populations into re-search: A review of the literature. Health Promotion Perspectives, 1(2), 86–94. https://doi.org/10.5681/hpp.2011.009 Sharma, M., Lamba, W., Cauderella, A., Guimond, T. H., & Bayoumi, A. M. (2017). Harm reduction in hospitals. Harm Reduction Journal, 14, 32. https://doi.org/10.1186/s12954-017-0163-0 Small, W., Wood, E., Tobin, D., Rikley, J., Lapushinsky, D., & Kerr, T. (2012). The Injection Support Team: A peer-driven program to address unsafe injecting in a Canadian setting. Substance Use & Misuse, 47(5), 491–501. https://doi.org/10.3109/10826084.2012.644107 Simon, R., Snow, R., & Wakeman, S. (2020). Understanding why patients with substance use disorders leave the hospital against medical advice: A qualitative study. Substance Abuse, 41(4), 519-525. https://doi.org/10.1080/08897077.2019.1671942 Slemon, A., Bungay, V., Varcoe, C., & Blanchet Garneau, A. (2023). From subversion to hard-wiring equity: A discourse analysis of nurses' equity-promoting practices in emergency departments. Advances in Nursing Science, https://doi.org/10.1097/ANS.0000000000000517 228 Smye, V., Browne, A. J., Varcoe, C., & Josewski, V. (2011). Harm reduction, methadone maintenance treatment and the root causes of health and social inequities: An intersectional lens in the Canadian context. Harm reduction Journal, 8, 17. https://doi.org/10.1186/1477-7517-8-17 Snyder, H., Kalmin, M. M., Moulin, A., Campbell, A., Goodman-Meza, D., Padwa, H., Clayton, S., Speener, M., Shoptaw, S., & Herring, A. A. (2021). Rapid adoption of low-threshold buprenorphine treatment at California emergency departments participating in the CA Bridge Program. Annals of Emergency Medicine, 78(6), 759–772. https://doi.org/10.1016/j.annemergmed.2021.05.024 Socías, M. E., Koehoorn, M., & Shoveller, J. (2016). Gender inequalities in access to health care among adults living in British Columbia, Canada. Women's Health Issues, 26(1), 74–79. https://doi.org/10.1016/j.whi.2015.08.001 Somekh, B., & Lewin, C. (2005). Research methods in the social sciences. Sage. Stefancic, A., & Tsemberis, S. (2007). Housing First for long-term shelter dwellers with psychiatric disabilities in a suburban county: A four-year study of housing access and retention. Journal of Primary Prevention, 28(3-4), 265–279. https://doi.org/10.1007/s10935-007-0093-9 Stergiopoulos, V., Gozdzik, A., O'Campo, P., Holtby, A. R., Jeyaratnam, J., & Tsemberis, S. (2014). Housing First: Exploring participants' early support needs. BMC Health Services Research, 14, 167. https://doi.org/10.1186/1472-6963-14-167 Stergiopoulos, V., Mejia-Lancheros, C., Nisenbaum, R., Wang, R., Lachaud, J., O'Campo, P., & Hwang, S. W. (2019). Long-term effects of rent supplements and mental health support services on housing and health outcomes of homeless adults with mental illness: Extension 229 study of the At Home / Chez Soi randomised controlled trial. Lancet Psychiatry, 6(11), 915–925. https://doi.org/10.1016/S2215-0366(19)30371-2 Strang, J., Groshkova, T., Uchtenhagen, A., van den Brink, W., Haasen, C., Schechter, M. T., Lintzeris, N., Bell, J., Pirona, A., Oviedo-Joekes, E., Simon, R., & Metrebian, N. (2015). Heroin on trial: Systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction. British Journal of Psychiatry, 207(1), 5–14. https://doi.org/10.1192/bjp.bp.114.149195 Strang, J., McDonald, R., Campbell, G., Degenhardt, L., Nielsen, S., Ritter, A., & Dale, O. (2019). Take-home naloxone for the emergency interim management of opioid overdose: The public health application of an emergency medicine. Drugs, 79(13), 1395–1418. https://doi.org/10.1007/s40265-019-01154-5 Strike, C. J., Challacombe, L., Myers, T., & Millson, M. (2002). Needle exchange programs: Delivery and access issues. Canadian Journal of Public Health, 93(5), 339–343. https://doi.org/10.1007/BF03404565 Strike, C., & Miskovic, M. (2018). Scoping out the literature on mobile needle and syringe programs-review of service delivery and client characteristics, operation, utilization, referrals, and impact. Harm Reduction Journal, 15, 6. https://doi.org/10.1186/s12954-018-0212-3 Strike, C., Robinson, S., Guta, A., Tan, D. H., O'Leary, B., Cooper, C., Upshur, R., & Chan Carusone, S. (2020). Illicit drug use while admitted to hospital: Patient and health care provider perspectives. PLOS One, 15(3), e0229713. https://doi.org/10.1371/journal.pone.0229713 230 Substance Abuse and Mental Health Services Administration. (2014). Trauma-informed care in behavioral health services. Treatment improvement protocol (TIP) series 57. https://store.samhsa.gov/sites/default/files/sma14-4816.pdf Summers, P. J., Hellman, J. L., MacLean, M. R., Rees, V. W., & Wilkes, M. S. (2018). Negative experiences of pain and withdrawal create barriers to abscess care for people who inject heroin. A mixed methods analysis. Drug and Alcohol Dependence, 190, 200-208. https://doi.org/10.1016/j.drugalcdep.2018.06.010 Sun, Y., Bao, Y., Kosten, T., Strang, J., Shi, J., & Lu, L. (2020). Editorial: Challenges to opioid use disorders during COVID-19. American Journal on Addictions, 29(3), 174–175. https://doi.org/10.1111/ajad.13031 Swanson, R. C., Cattaneo, A., Bradley, E., Chunharas, S., Atun, R., Abbas, K. M., Katsaliaki, K., Mustafee, N., Mason Meier, B., & Best, A. (2012). Rethinking health systems strengthening: Key systems thinking tools and strategies for transformational change. Health Policy and Planning, 27, iv54–iv61. https://doi.org/10.1093/heapol/czs090 SWITCH British Columbia. (2023). Provincial Violence Prevention Curriculum (PVPC) refresh. https://switchbc.ca/programs/provincial-violence-prevention-curriculum-refresh/ Taylor, J. L., & Rew, L. (2011). A systematic review of the literature: Workplace violence in the emergency department. Journal of Clinical Nursing, 20(7-8), 1072-1085. https://doi.org/10.1111/j.1365-2702.2010.03342.x The Health Foundation. (2010, August). Evidence scan: Complex adaptive systems. https://www.health.org.uk/sites/default/files/ComplexAdaptiveSystems.pdf Thompson, H. M., Faig, W., VanKim, N. A., Sharma, B., Afshar, M., & Karnik, N. S. (2020a). Differences in length of stay and discharge destination among patients with substance use 231 disorders: The effect of Substance Use Intervention Team (SUIT) consultation service. PLOS One, 15(10), e0239761. https://doi.org/10.1371/journal.pone.0239761 Thompson, S., Bonnycastle, M., & Hill, S. (2020b, May). COVID-19, First Nations and poor housing: "Wash hands frequently" and "self-isolate" akin to "let them eat cake" in First Nations with overcrowded homes lacking piped water. Canadian Centre for Policy Alternatives Manitoba. https://policyalternatives.ca/sites/default/files/uploads/publications/Manitoba%20Office/2020/05/COVID%20FN%20Poor%20Housing.pdf Thorne, S. E. (2008). Interpretive description. Left Coast Press. Ti, L., Milloy, M., Buxton, J., McNeil, R., Dobrer, S., Hayashi, K., Wood, E., & Kerr, T. (2015). Factors associated with leaving hospital against medical advice among people who use illicit drugs in Vancouver, Canada. PLOS One, 10(10), e0141594. https://doi.org/10.1371/journal.pone.0141594 Ti, L., & Ti, L. (2015). Leaving the hospital against medical advice among people who use illicit drugs: A systematic review. American Journal of Public Health, 105(12), e53–e59. https://doi.org/10.2105/AJPH.2015.302885 Toward the Heart. (2024, January 16). THN in BC infograph. https://towardtheheart.com/thn-in-bc-infograph Train, M. K., Patel, N., Thapa, K., Pasho, M., & Acquisto, N. M. (2020). Dispensing a naloxone kit at hospital discharge: A retrospective QI project. American Journal of Nursing, 120(12), 48–52. https://doi.org/10.1097/01.NAJ.0000724248.74793.35 Trowbridge, P., Weinstein, Z. M., Kerensky, T., Roy, P., Regan, D., Samet, J. H., & Walley, A. Y. (2017). Addiction consultation services: Linking hospitalized patients to outpatient 232 addiction treatment. Journal of Substance Abuse Treatment, 79, 1–5. https://doi.org/10.1016/j.jsat.2017.05.007 Turner, K. M., Hutchinson, S., Vickerman, P., Hope, V., Craine, N., Palmateer, N., May, M., Taylor, A., De Angelis, D., Cameron, S., Parry, J., Lyons, M., Goldberg, D., Allen, E., & Hickman, M. (2011). The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: Pooling of UK evidence. Addiction, 106(11), 1978–1988. https://doi.org/10.1111/j.1360-0443.2011.03515.x Tyson, L. (2015). Critical theory today: A user-friendly guide (3rd ed.). Taylor & Francis. United States Department of Veterans Affairs. (2023, September 25). Trauma reminders: Triggers. https://www.ptsd.va.gov/understand/what/trauma_triggers.asp Vancouver Coastal Health. (2018). Response to the opioid overdose crisis in Vancouver Coastal Health. http://www.vch.ca/Documents/CMHO-report.pdf Vancouver Coastal Health. (2019, June 2). Pilot at St. Paul's Hospital gives overdose patients at-home treatment. http://www.vch.ca/about-us/news/pilot-at-st-pauls-hospital-gives-overdose-patients-at-home-treatment Verdouw, J., & Habibis, D. (2018). Housing First programs in congregate-site facilities: Can one size fit all? Housing Studies, 33(3), 386-407. https://doi.org/10.1080/02673037.2017.1346192 Wagner, K. D., Oman, R. F., Smith, K. P., Harding, R. W., Dawkins, A. D., Lu, M., Woodard, S., Berry, M. N., & Roget, N. A. (2020). "Another tool for the tool box? I'll take it!": Feasibility and acceptability of mobile recovery outreach teams (MROT) for opioid 233 overdose patients in the emergency room. Journal of Substance Abuse Treatment, 108, 95–103. https://doi.org/10.1016/j.jsat.2019.04.011 Wakeman, S. E., Green, T. C., & Rich, J. (2020). An overdose surge will compound the COVID-19 pandemic if urgent action is not taken. Nature Medicine, 26(6), 819–820. https://doi.org/10.1038/s41591-020-0898-0 Wakeman, S. E., Metlay, J. P., Chang, Y., Herman, G. E., & Rigotti, N. A. (2017). Inpatient addiction consultation for hospitalized patients increases post-discharge abstinence and reduces addiction severity. Journal of General Internal Medicine, 32(8), 909-916. https://doi.org/10.1007/s11606-017-4077-z Wallace, B., Barber, K., & Pauly, B. (2018). Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency. International Journal of Drug Policy, 53, 83-89. https://doi.org/10.1016/j.drugpo.2017.12.011 Wang, S. J., Wade, E., Towle, J., Hachey, T., Rioux, J., Samuels, O., Bonner, C., Kirkpatrick, C., O'Loughlin, S., & Foster, K. (2020). Effect of inpatient medication-assisted therapy on against-medical-advice discharge and readmission rates. American Journal of Medicine, 133(11), 1343–1349. https://doi.org/10.1016/j.amjmed.2020.04.025 Wathen, C.N. & Varcoe, C. (2021). Trauma and violence-informed care (TVIC): A tool for health and social service organizations and providers. https://equiphealthcare.ca/files/2021/05/GTV-EQUIP-Tool-TVIC-Spring2021.pdf Watson, H., Maclaren, W., Shaw, F., Nolan, A. (2003, July). Measuring staff attitudes to people with drug problems: The development of a tool. Scottish Executive Drug Misuse Research Programme. https://www.gov.scot/Publications/2003/08/17735/23454 234 Weiner, S. G., Baker, O., Bernson, D., & Schuur, J. D. (2020). One-year mortality of patients after emergency department treatment for nonfatal opioid overdose. Annals of Emergency Medicine, 75(1), 13–17. https://doi.org/10.1016/j.annemergmed.2019.04.020 Widmer, M. A., Swanson, R. C., Zink, B. J., & Pines, J. M. (2018). Complex systems thinking in emergency medicine: A novel paradigm for a rapidly changing and interconnected health care landscape. Journal of Evaluation in Clinical Practice, 24(3), 629-634. https://doi.org/10.1111/jep.12862 Wiercigroch, D., Hoyeck, P., Sheikh, H., & Hulme, J. (2021). A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department. BMC Emergency Medicine, 21, 48. https://doi.org/10.1186/s12873-021-00443-1 Williams, A. V., Marsden, J., & Strang, J. (2014). Training family members to manage heroin overdose and administer naloxone: Randomized trial of effects on knowledge and attitudes. Addiction, 109(2), 250–259. https://doi.org/10.1111/add.12360 Williams, K. T., Baron, K. A., Gee, J. P., & Chan, J. (2020). Educating students about opioid use disorder and treatments in the community using an educational video. Nurse Educator, 45(6), 326-330. https://doi.org/10.1097/NNE.0000000000000793 Winetsky, D., Weinrieb, R. M., & Perrone, J. (2018). Expanding treatment opportunities for hospitalized patients with opioid use disorders. Journal of Hospital Medicine, 13(1), 62-64. https://doi.org/10.12788/jhm.2861 Wood, E., Tyndall, M. W., Montaner, J. S., & Kerr, T. (2006). Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. CMAJ, 175(11), 1399-1404. https://doi.org/10.1503/cmaj.060863 235 Wood, E., Tyndall, M. W., Zhang, R., Montaner, J. S. G., & Kerr, T. (2007). Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 102(6), 916-919. https://doi.org/10.1111/j.1360-0443.2007.01818.x Yamamoto, A., Needleman, J., Gelberg, L., Kominski, G., Shoptaw, S., & Tsugawa, Y. (2019). Association between homelessness and opioid overdose and opioid-related hospital admissions/emergency department visits. Social Science & Medicine, 242, 112585. https://doi.org/10.1016/j.socscimed.2019.112585 Yin, R. K. (2018). Case study research and applications: Design and methods (6th ed.). SAGE Publications. 236 Appendices Appendix A: Staff Survey Survey: Harm Reduction in BC Emergency Departments (EDs) Title of Research Study: Harm Reduction in BC Emergency Departments (EDs) Principal investigator: Dr. Vicky Bungay, Professor, UBC School of Nursing Co-investigator: Sunny Jiao, PhD Candidate, UBC School of Nursing Co-investigator: Cindy Elliott, Program Director, St. Paul’s Hospital (SPH) Emergency Department As a physician or a nurse working in the St. Paul’s Hospital Emergency Department, you are invited to complete this survey. The survey asks questions about harm reduction interventions that exist in your ED and contextual factors that may impact the integration of harm reduction interventions in the ED, including service provider attitudes. If you work in other parts of the hospital or in the ED of another facility, please base your responses only on your work at the St. Paul’s Hospital Emergency Department. What we learn may help to generate recommendations to inform the integration of harm reduction interventions in Canadian EDs. You will not directly benefit from participating. Potential risks of taking part are minimal. Your participation is voluntary and your employment will not be affected. This information will not be used to evaluate your work performance. Information collected as part of this study is confidential. Your name will not be associated with the information collected in this study. Study findings will be published in academic journals and presented at academic conferences. Data without identifying information may be required to be made publicly available by funders and/or journals. Once the data is made public, you will not be able to withdraw your data. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. You can contact the Providence Health Care Research Institute at 604-682-2344 ext. 68366. - Please respond to the survey. The survey should take approximately 10 minutes. - Your responses will be anonymous. - At the end of the survey, you will have the chance to enter your name in a draw for one of three $100 Amazon gift cards. Thank you! 237 Do you consent to participate in the survey as described above? Yes No Survey: Harm Reduction in BC Emergency Departments Thank you for agreeing to participate in this survey. Your participation is voluntary and your responses are confidential. 1. In what year were you born? ___________ 2. How do you describe your gender? Woman Man Transgender woman / Trans woman Transgender man/ Trans man Non-binary Two-spirit Not listed (please specify): ___________ Prefer not to answer 3. What is your occupation? Registered Nurse (RN) Registered Psychiatric Nurse (RPN) Licensed Practical Nurse (LPN) Nurse Practitioner (NP) Staff physician Resident physician 4. How long have you been a nurse or physician? Less than 1 year 1 to 5 years 6 to 10 years More than 10 years 5. What is your employment status? Regular full-time Regular part-time Casual Temporary full-time Temporary part-time 238 6. How long have you worked in this ED? Less than 1 year 1 to 5 years 6 to 10 years More than 10 years 7. How long have you worked in emergency nursing or medicine? Less than 1 year 1 to 5 years 6 to 10 years More than 10 years 8. Do you care for people who are currently using illegal drugs such as heroin, cocaine or crack, methamphetamines, or hallucinogens? Yes No 9. If yes, what percentage of patients that you care for in a typical shift are people who are currently using illegal drugs? Please fill in a number between 1 to 100. % We are interested in how ED staff view the service needs of people who use illegal drugs and how these individuals attend to care. Please Indicate your level of agreement/disagreement with the following statements by placing a check mark (þ) in the applicable box: Strongly Agree Agree Neutral Disagree Strongly disagree 10. People who use illegal drugs are among the most frequent attendees of EDs 11. People who use illegal drugs have complex social and health needs 12. There is an inadequacy of community-based public sector services for people who use illegal drugs 239 13. People who use illegal drugs experience significant stigma and discrimination in the health care system, in hospitals, and in EDs 14. Experiences of stigma and discrimination can impact access and attendance to care for people who use illegal drugs We are interested in ED staff’s knowledge and attitudes toward working with people who use illegal drugs. To what extent do you agree or disagree with the following statements? Please place a check mark (þ) in the applicable box: Strongly agree Strongly disagree 1 2 3 4 5 6 7 15. I feel I have a working knowledge of illegal drugs and the harms that are associated with their use. 16. I feel I know enough about the causes of harms that are associated with illegal drug use to carry out my role when working with people who use illegal drugs. 17. I feel I know enough about the physical effects of illegal drug use to carry out my role when working with people who use illegal drugs. 18. I feel I know enough about the psychological effects of illegal drugs to carry out my role when working with people who use illegal drugs. 19. I feel I know enough about factors which put people at risk of developing harms that are associated with illegal drug use to carry out my role when working with these individuals. 20. I feel I know how to counsel people who use illegal drugs over the long term. 21. I feel I can appropriately advise my patients about illegal drugs and their effects. 22. I feel I have the right to ask patients questions about their illegal drug use when necessary. 23. I feel that my patients believe I have the right to ask them questions about illegal drug use when necessary. 240 We are interested in what types of harm reduction programming and practices may or may not currently exist in your ED. 37. Does your ED initiate patients on opioid agonist therapy (e.g., methadone, buprenorphine, etc.)? Yes No Don’t know 38. Does your ED refer patients to services that provide opioid agonist therapy in the community? Yes No Don’t know 39. Does your ED provide naloxone kits to patients upon discharge? Yes No Don’t know 24. I feel I have the right to ask a patient for any information that is relevant to their problematic drug use. 25. When working with people who use illegal drugs, if I felt the need to, I could easily find someone with whom I could discuss any personal difficulties that I might encounter. 26. When working with people who use illegal drugs, if I felt the need to, I could easily find someone who would help me clarify my professional responsibilities. 27. If I felt the need I could easily find someone who would be able to help me formulate the best approach to a person who uses illegal drugs. 28. I want to work with people who use illegal drugs. 29. I feel that there is little I can do to help people who use illegal drugs. 30. In general, I have less respect for people who use illegal drugs than for most other patients I work with. 31. I feel I do not have much to be proud of when working with people who use illegal drugs. 32. At times I feel I am no good at all with people who use illegal drugs. 33. On the whole, I am satisfied with the way I work with people who use illegal drugs. 34. In general, one can get satisfaction from working with people who use illegal drugs. 35. In general, it is rewarding to work with people who use illegal drugs. 36. In general, I feel I can understand people who use illegal drugs. 241 40. Does your ED provide harm reduction supplies to patients upon discharge (e.g., sterile needles, alcohol swabs, etc.)? Yes No Don’t know 41. Does your ED refer patients to services that provide harm reduction supplies in the community? Yes No Don’t know 42. Does your ED provide social work services that refer patients for income assistance/person with disabilities, housing, and outreach services? Yes No Don’t know 43. During nursing or medical school, did you receive education about how to care for people who use illegal opioids chronically/compulsively? Yes No Don’t know/don’t remember If you answered yes to the last question, did you receive education on the following topics? 44. How to prescribe/administer opioid agonist therapy Yes No Don’t know/don’t remember 45. How to use a naloxone kit Yes No Don’t know/don’t remember 46. How to engage in overdose prevention conversations Yes No Don’t know/don’t remember 47. How to use harm reduction supplies Yes No Don’t know/don’t remember 48. In the workplace, have you received in-service or continuing education about how to care for people who use illegal opioids chronically/compulsively? Yes No Don’t know/don’t remember If you answered yes to the last question, have you received in-service or continuing education on the following topics? 242 49. How to prescribe/administer opioid agonist therapy Yes No Don’t know/don’t remember 50. How to use a naloxone kit Yes No Don’t know/don’t remember 51. How to engage in overdose prevention conversations Yes No Don’t know/don’t remember 52. How to use harm reduction supplies Yes No Don’t know/don’t remember In some of the previous work, researchers have found that various factors may impact the integration of harm reduction programs and practices in EDs. Please indicate how much you think each of the following factors may impact the integration of harm reduction programs and practices in your ED. Please place a check mark (þ) in the applicable box for each factor that you think would apply. Not at all A little Somewhat Quite a bit Crucial 53. Training in prescribing/administering opioid agonist therapy 54. Training in using/teaching patients how to use a naloxone kit 55. Training in using/teaching patients how to use harm reduction supplies 56. Availability of patient education instructions 57. Availability of a list of harm reduction providers in the community 58. Clarity around the role of each occupational group in the provision of, or referral to, harm reduction services and programs 59. Information on the evidence base for harm reduction services and programs 60. Support from ED leadership/hospital administrators to provide, or refer to, harm reduction services and programs 61. Culture of acceptance in the ED about the provision of, or referral to, harm reduction services and programs 62. Interdisciplinary collaboration and support 63. Policies around identifying eligible patients 64. Policies around transferring care to the community 243 65. Electronic medical record alerts that suggest a patient may be appropriate for, or eligible for, harm reduction services and programs 66. Would you be interested in an interview to further explore harm reduction in your ED? Yes No If yes, what is the best way for us to contact you? Please go to this link: https:// [Please note that the information you provide through this link will not be connected to your survey responses.] Thank you for your time! If you would like to enter your name in a draw for one of three $100 Amazon gift cards, please go to this link: https:// [Please note that the information you provide through this link will not be connected to your survey responses and will be deleted once winners of the draw have been selected.] 244 Appendix B: Staff Interview Guide Interview Guide: Qualitative Interviews Introductory script: Thank you so much for taking the time to meet with me and for agreeing to this interview! Please note that there are no right or wrong answers to any of the questions I am asking. So when we talked through the consent process, I described how we are doing this research to better understand what harm reduction currently looks like in EDs across BC and also, the types of factors that may impact the integration of harm reduction services and practices in this setting. There is a lot of existing research out there on the experiences of people who use illegal opioids as patients of the ED, but I am interested in learning more about the perspectives and experience of staff. 1. To start, perhaps you could tell me a little bit about your experiences of caring for people who use illegal opioids who present to the ED. It might be helpful to start by describing a patient encounter. (Pay particular attention to how staff take up or describe this patient population). Probes: a. If the participant mentions the opioid crisis right away: Could you tell me a little bit about how the drug toxicity/overdose crisis is playing out in your ED? Followed by: We talked a lot about the opioid crisis and accidental overdose as a concern that may bring people who use illegal opioids to the ED. Could you describe for me what other types of concerns may bring people who use illegal opioids to your ED? b. If the participant does not mention the opioid crisis: It sounds like __________ is a health concern that may bring people who use illegal opioids to the ED. Could you describe for me what other types of concerns may bring these individuals to your ED? If the participant mentions the opioid crisis, follow probe a. If the participant does not mention the opioid crisis: We can’t deny that drug toxicity and accidental overdose are at an all-time high right now. How is that playing out in your ED? c. From what you shared, it sounds like caring for people who use illegal opioids in the ED setting can present various challenges (e.g., due to patients’ complex health and social needs, lack of resources and supports, confusion around policy, etc.) What type of strategies do you use to navigate these complexities? d. Have you always used these strategies? How did you know how to do that? Do other ED staff seem to use similar or different strategies? e. It seems to me that you have a great handle on things. What resources or supports have been helpful for you, or what has made things difficult for you? f. Is there anything you do that is unique or different when you care for people who use illegal opioids, as opposed to people who use other types of illegal drugs, or other patient populations? 245 g. How has the pandemic shaped, or has the pandemic changed anything for you in terms of how you engage with or care for people who use illegal opioids in your ED? 2. As you know, an array of harm reduction services and practices that pertain to illegal opioid use have been implemented in the community setting, including methadone, buprenorphine, naloxone kits, safe supply, and the distribution of sterile supplies. To your knowledge, in what ways (if any) does your ED implement harm reduction services or practices? What does harm reduction look like in your ED? I know we already talked a little bit about the overdose crisis, but I was wondering if you could describe for me what types of harm reduction approaches (for example, programs, policies, or practices) is your ED engaged with in response to this crisis? 3. Thanks for telling me about the types of harm reduction services and practices that are currently being implemented in your ED. You mentioned _______________, could you tell me a little more about what this service/practice looks like? 4. I am wondering if you could tell me more about your experiences of seeing the services or practices implemented in your ED. For example, do you think that the services or practices are carried out by staff in a consistency way? Why or why not? When these services or practices were first implemented in your ED, what sorts of support did you receive? For example, where there any policies or guidelines to help you? General probes: Service provider knowledge, preparation, confidence, and willingness Administrative, infrastructural, and logistical support Regulations, policies, and protocols Interdisciplinary, interdepartmental, and interagency support Specific probes: Training in prescribing/administering the intervention Training in using/teaching patients how to use the intervention Availability of patient education instructions Availability of a list of community providers Clarity around the role of each occupational group Information in the evidence base for the intervention Support from ED leadership/hospital administers Culture of acceptance of the intervention in the ED Interdisciplinary collaboration and support Policies around identifying eligible patients Policies around transferring care to the community Compatible electronic medical record alerts 246 5. There has been a lot of discussion these days about harm reduction and EDs, particularly in the current context of the ongoing opioid crisis. I was wondering if you would share with me your thoughts on the pros and cons, from your perspective, about EDs implementing harm reduction services or practices. What may these services or practices look like in this setting? What types of things do you think would need to be in place to allow for the implementation or integration of these services or practices in the ED? General probes: Service provider knowledge, preparation, confidence, and willingness Administrative, infrastructural, and logistical support Regulations, policies, and protocols Interdisciplinary, interdepartmental, and interagency support Specific probes: Training in prescribing/administering the intervention Training in using/teaching patients how to use the intervention Availability of patient education instructions Availability of a list of community providers Clarity around the role of each occupational group Information in the evidence base for the intervention Support from ED leadership/hospital administers Culture of acceptance of the intervention in the ED Interdisciplinary collaboration and support Policies around identifying eligible patients Policies around transferring care to the community Compatible electronic medical record alerts 6. I am also wondering if you could tell me a little bit about how staff prepare patients who use illegal opioids for discharge. 7. Do staff refer these individuals to agencies or services in the community that provide harm reduction services such as methadone, buprenorphine, naloxone, or sterile supplies? Is your unit engaged with any of the safe supply programming? Please tell me more about what this referral process may look like. In your opinion, what factors may impact referral to these outside agencies or services? General probes: Service provider knowledge, preparation, confidence, and willingness Administrative, infrastructural, and logistical support Regulations, policies, and protocols Interdisciplinary, interdepartmental, and interagency support Specific probes: Training in the available community-based services Training in how to refer patients to these services 247 Availability of a list of community providers Clarity around the role of each occupational group Information in the evidence base for the intervention Support from ED leadership/hospital administers Culture of acceptance of the intervention in the ED Interdisciplinary collaboration and support Policies around identifying eligible patients Policies around transferring care to the community Compatible electronic medical record alerts 8. Do you have any other thoughts or ideas about ED-based harm reduction services or practices that relate to illegal opioid use? Or factors that might impact the integration of these services or practices in this setting? 9. I know we focused primarily on illegal opioid use so far, but as you know, people use many other types of illegal drugs, such as methamphetamine and cocaine. Do you have any thoughts or ideas about ED-based harm reduction services or practices that pertain to illegal stimulant use? Or factors that may impact the integration of these services or practices? 10. Is there anything else we should know that may help to inform recommendations for the integration of harm reduction services and practices in the ED? Thank you for your time! 248 Appendix C: Staff Interview Consent Title: Harm Reduction in BC Emergency Departments (EDs) Consent Form: Interviews This consent form is for the interview component of the research study. Principal investigator: Dr. Vicky Bungay, Professor, UBC School of Nursing, Tel: __________ Co-investigator: Sunny Jiao, PhD Candidate, UBC School of Nursing, Tel: __________ Co-investigator: Cindy Elliott, Program Director, St. Paul’s Hospital (SPH) Emergency Department Funded by: Social Sciences and Humanities Research Council of Canada Invitation: You are being invited to participate in a research study. The goals of this study are to examine: a) what harm reduction currently looks like in BC EDs, and b) what factors may impact the integration of harm reduction interventions in this setting. This knowledge is needed as an initial step to generating recommendations to inform the integration of harm reduction interventions in EDs with the prospect of improving health service provision for people who use drugs. We invite you to participate in this study by completing a qualitative interview. To participate, you must be a physician or a nurse working in this ED. You must have a minimum of six months experience in providing direct patient care in this ED. You must also work either in a full-time capacity, or in a part-time or casual capacity for at least 8 to 12 hours per week. What participating means: If you agree to participate, you will complete an interview with the co-investigator Sunny Jiao. The interview involves questions related to your experiences of caring for people who may be experiencing problematic drug use, if and how harm reduction interventions are implemented in your ED, and what factors may influence the integration of these interventions in this setting. The interview will take approximately 45 minutes. As a token of appreciation, you will be provided with an honorarium of $30. The interview will take place online via Zoom and will be audio recorded with your permission. You can request to have the recording device turned off at any time. If you deny permission to record, permission will be obtained to take notes of core discussion points. Your participation is voluntary. You may decline participation, refuse to answer any questions, or withdraw your participation at any time. Whether you choose to participate or not will not affect your employment. Privacy and confidentiality: 249 Information collected as part of this study is confidential. Your name will not be associated with the information collected in this study. Only the principal and co-investigators will have access to the data. If you decide to stop participating, the information you have provided will be deleted. A summary of study findings will be made available to ED leadership via email for distribution to ED staff. Please also let the co-investigator know if you would like a copy of this summary sent to your email. This research is being conducted as part of graduate degree requirements for the co-investigator Sunny Jiao. Study findings will form part of a doctoral dissertation (which is a public document) and will be published in academic journals. Study findings will also be presented at academic conferences. No identifying information will be included in such publications or presentations. Data without identifying information may be required to be made publicly available by funders and/or publishing journals. Once the data is made public, you will not be able to withdraw your data. Electronic files including audio recordings will be encrypted and stored in a secure server based in Canada. Audio recordings will be transcribed, but any identifying information will be removed from the transcripts. All data will be retained for five years after the dissemination of study findings and subsequently destroyed. To help maintain your confidentiality and to ensure that the research data is being collected in a secure manner, please log into Zoom using only a nickname or a substitute name. You can turn off your camera and mute your microphone at any time. Potential benefits and risks: Taking part in this study will help us better understand what harm reduction looks like in Canadian EDs and what factors may influence the integration of harm reduction interventions in this setting. What we learn from this study may help to generate recommendations to inform the integration of harm reduction interventions in Canadian EDs. Potential risks of taking part in this research are minimal. Your participation is voluntary and your employment will not be affected. This information will not be used to evaluate your work performance. You will not directly benefit from participation in this study. Questions about this study: If you have questions about the study or your potential participation, please contact Sunny Jiao or Dr. Vicky Bungay via the contact information provided at the top of the first page of this form. Concerns about this study: 250 If you have concerns or complaint about your rights as a research participant and/or your experiences while participating in this study, please contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598. You can also call toll free at 1-877-822-8598 or email rsil@ors.ubc.ca. You can contact the Providence Health Care Research Institute at 604-682-2344 ext. 68366. This letter is for you to keep. For the Research Project: Harm Reduction in BC Emergency Departments Consent Your participation is this qualitative interview is voluntary. If you decide to participate and then change your mind, you are free to withdraw at any time without consequence. By signing this consent form, you agree to participate in the study described above. You have received a copy of this consent form for your own records. Signature of Participant Printed Name Date Signature of Co-Investigator Printed Name Date 251 Appendix D: Leadership Interview Guide Interview Guide: Leadership Interviews Some questions are for all clinical leaders while others are for specific leaders. Thank you so much __________ for agreeing to the interview! 1. To start things off, maybe you could tell me a little bit about how your organization or department takes up care provision for people who use drugs. How is substance use and/or people who use substances considered in the care? Probe: Are there different subgroups of people who use drugs and if so, how are these differences taken into consideration? 2. When staff are first oriented to the organization or department, what types of training or supports do they receive related to working with people who use drugs? Who provides this training? What does the training focus on? Are staff directed to any policies or guidelines? What types of services do addiction nurses provide? When addictions nurses are first oriented, what types of training or supports do they receive related to their work in the ED? Do you think their services are fully utilized by ED patients and staff? Why or why not? 3. Describe for me how well you think your emergency department provides health care to people who are using drugs. It may be helpful to discuss what is working well or perhaps not working well in your ED? Tell me more about why the care is the way it is? Probes: a. Withdrawal can be a real health issue for patients when they attend for care in an ED. Is managing withdrawal a common element of care in your ED? How are staff supported to help patients meet their withdrawal needs? What types of strategies are available? Do staff receive related education or training? Who and how often? Personnel or policy support? Is there a mechanism for quality assurance? b. I understand that the SPH ED provides people who use drugs with injectable opioid agonist therapy. This is a fairly new practice. How are ED staff prepared or supported to engage in this practice? Do they receive related education or training? Who and how often? Personnel or policy support? Is there a mechanism of quality assurance? c. Patients’ use of their own drugs sometimes occurs in health care such as in bathrooms or while in their bed. Are there policies or guidelines around how staff 252 should approach this situation, or is this more of the primary nurse’s call? How are staff supported to make these decisions? d. In instances where people leave the unit or leave hospital grounds to manage their withdrawal symptoms or cravings (either announced or unannounced to staff), are there policies or guidelines around how staff should approach this situation, or is it more of the primary nurse’s call in terms of what happens next? How are staff supported to make these decisions? 4. I’ve been doing interviews with staff and I have learned about the many harm reduction strategies that are available in the SPH ED. I want to zoom in on some of these strategies if that’s ok with you. I have a few strategy-specific questions. Probes: a. I understand that staff provide methadone and Suboxone®, and missed doses of safe supply. How are staff prepared or supported with these practices? Do they receive education or training? Who and how often? Personnel and policy support? Is there a mechanism of quality assurance? For the Suboxone® to-go program, how did that come to be? What did you need to put in place to enable that to happen? b. The provision of naloxone kits is another harm reduction intervention that has come up in the staff interviews. Again, I am wondering: How did that intervention come to be? What did you need to put in place to enable that to happen? How are staff prepared or supported with this practice? Do they receive education or training? Who and how often? Personnel or policy support? Is there a mechanism of quality assurance? c. I understand that the ED provides several types of specialist support for staff, including addictions nurses, AMCT, and the RAAC. How did these services come to be? How were decisions made around the types of services provided and hours of availability? What kinds of things were necessary to support that staff fully utilize these services? How was the purpose or scope of these services communicated? Are staff reminded to take advantage of these services? Is there a process of tracking or evaluation? What supports are put in place to support staff and patients when these services are unavailable? d. I wanted to touch on the OPS that is available at SPH. What can you tell me about how this service came to be? How were decisions made around the types of services provided and hours of availability? What kind of things were necessary to support that staff fully utilize these services? How was the purpose or scope of these services communicated? Are staff reminded to offer this option to patients while they’re waiting for or receiving care in the ED? Is there a process of tracking or evaluation? What supports are put in place to support staff and patients when the OPS is unavailable? 253 e. The last harm reduction intervention I wanted to touch on was the provision of harm reduction supplies. Does the SPH ED support the distribution of harm reduction supplies in terms of sterile needles, alcohol swabs, etc.? If so, how did this practice come to be? What did you need to put in place to enable that to happen? What kinds of things were necessary to support that staff fully engage in this practice? How was the availability of supplies for distribution communicated? Are staff reminded to engage in the practice? Any relevant policies or guidelines? Is there a process of tracking or evaluation? 5. I am wondering if we can touch on preparing people for discharge. Are ED staff expected to refer people who use drugs to harm reduction and/or social services in the community? Or would they refer to the RAAC? What supports are put in place to support staff and patients when the RAAC is unavailable? How do you see the role of RAAC versus the role of social work in this regard? Do ED staff receive education or have access to resources on available services in the community, the different eligibility criteria, and how to refer patients? I understand that ED staff can refer patients to the RAAC to facilitate connections to harm reduction and/or social services in the community. What types of services? How do you see the role of RAAC versus the role of social work in this regard? How are RAAC staff supported in learning about available services in the community, the different eligibility criteria, who has space, and how to refer patients? Do ED staff have access to the same learning opportunities? 6. Finally, what do you think are the pros and cons of the ED context offering harm reduction? Do you envision other harm reduction strategies being offered in the ED? What would need to be in place for these additional strategies to be actualized? Is there anything else that is currently “in the works” in terms of harm reduction programming or policies that pertain to the ED?’ 7. The purpose of this work is to generate recommendations for how to implement and improve harm reduction services in the SPH ED. Is there anything else you wanted to add? Thank you so much for your time and for sharing your insights! 254 Appendix E: Leadership Interview Consent Title: Harm Reduction in BC Emergency Departments (EDs) Consent Form: Leadership Interviews Principal investigator: Dr. Vicky Bungay, Professor, UBC School of Nursing, Tel: __________ Co-investigator: Sunny Jiao, PhD Candidate, UBC School of Nursing, Tel: __________ Co-investigator: Cindy Elliott, Program Director, St. Paul’s Hospital (SPH) Emergency Department Funded by: Social Sciences and Humanities Research Council of Canada Invitation: You are being invited to participate in a research study. The goals of this study are to examine: a) what harm reduction currently looks like in BC Emergency Departments (EDs), and b) what factors may impact the integration of harm reduction interventions in this setting. This knowledge is needed as an initial step to generating recommendations to inform the integration of harm reduction interventions in EDs with the prospect of improving health service provision for people who use drugs. We invite you to participate in this study by completing a qualitative interview. What participating means: If you agree to participate, you will complete an interview with the co-investigator Sunny Jiao. The interview involves questions related to the approach that your organization and/or department takes in regard to caring for people who may be experiencing problematic drug use, if and how harm reduction interventions are implemented, and what factors may influence the integration of these interventions. The interview will take approximately 45 minutes. As a token of appreciation, you will be provided with an honorarium of $30. The interview will take place online via Zoom and will be audio recorded with your permission. You can request to have the recording device turned off at any time. If you deny permission to record, permission will be obtained to take notes of core discussion points. Your participation is voluntary. You may decline participation, refuse to answer any questions, or withdraw your participation at any time. Whether you choose to participate or not will not affect your employment. Privacy and confidentiality: Information collected as part of this study is confidential. Your name will not be associated with the information collected in this study. Only the principal and co-investigators will have access to the data. If you decide to stop participating, the information you have provided will be deleted. 255 A summary of study findings will be made available to ED leadership via email for distribution to ED staff. This research is being conducted as part of graduate degree requirements for the co-investigator Sunny Jiao. Study findings will form part of a doctoral dissertation (which is a public document) and will be published in academic journals. Study findings will also be presented at academic conferences. No identifying information will be included in such publications or presentations. Data without identifying information may be required to be made publicly available by funders and/or publishing journals. Once the data is made public, you will not be able to withdraw your data. Electronic files including audio recordings will be encrypted and stored in a secure server based in Canada. Audio recordings will be transcribed, but any identifying information will be removed from the transcripts. All data will be retained for five years after the dissemination of study findings and subsequently destroyed. To help maintain your confidentiality and to ensure that the research data is being collected in a secure manner, please log into Zoom using only a nickname or a substitute name. You can turn off your camera and mute your microphone at any time. Potential benefits and risks: Taking part in this study will help us better understand what harm reduction looks like in Canadian EDs and what factors may influence the integration of harm reduction interventions in this setting. What we learn from this study may help to generate recommendations to inform the integration of harm reduction interventions in Canadian EDs. Potential risks of taking part in this research are minimal. Your participation is voluntary and your employment will not be affected. This information will not be used to evaluate your work performance. You will not directly benefit from participation in this study. Questions about this study: If you have questions about the study or your potential participation, please contact Sunny Jiao or Dr. Vicky Bungay via the contact information provided at the top of the first page of this form. Concerns about this study: If you have concerns or complaint about your rights as a research participant and/or your experiences while participating in this study, please contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598. You can also call toll free at 1-877-822-8598 or email rsil@ors.ubc.ca. You can contact the Providence Health Care Research Institute at 604-682-2344 ext. 68366. 256 This letter is for you to keep. For the Research Project: Harm Reduction in BC Emergency Departments Consent Your participation is this qualitative interview is voluntary. If you decide to participate and then change your mind, you are free to withdraw at any time without consequence. By signing this consent form, you agree to participate in the study described above. You have received a copy of this consent form for your own records. Signature of Participant Printed Name Date Signature of Co-Investigator Printed Name Date 257 Appendix F: SPH Infographic Sunny Jiao, PhD Candidate, UBC School of Nursing January 2022 Harm Reduction in BC Emergency Departments (EDs): Preliminary Findings from St. Paul’s Hospital Harm Reduction in BC EDs is a student-led research project that aims to examine if and how harm reduction interventions are implemented in BC EDs, and the contextual factors that may influence harm reduction implementation in this setting. As part of the project, a staff survey was conducted with nurses and physicians who work in the ED at St. Paul’s Hospital (SPH) in Vancouver, BC. This document outlines some of the preliminary findings from the survey for this research site. Section 1: Participant characteristics* The average age of survey participants was 38.65 years (n = 91, SD = 10.90). *A total of 102 staff members consented to the survey. Three staff members completed less than 40 percent of the survey and were thus excluded from the survey sample, resulting in a sample size of 99 staff members. Section 2: Staff attitudes Staff attitudes toward people who use illegal drugs were measured using the Drug and Drug Problems Perception Questionnaire (DDPPQ), for which, the minimum possible score is 22 and the maximum possible score is 154. Lower scores on the DDPPQ denote attitudes that are more positive. The average total score on the DDPPQ for the SPH ED staff who participated in the survey was 61.78, with a range of 25 to 100 (n = 94, SD = 15.23). Results showed that overall, the attitudes of staff toward people who use illegal drugs was positive, although there was some variation in staff responses and attitudes. 51471OCCUPAT ION Nurse Physician Did not specify(n = 99)61371SELF - IDENT IF I ED GENDER Woman Man Other (Did not specify)(n = 99)896 4EMPLOYMENT STATUS Regular Casual Temporary(n = 99)18253126 25 2815 15 13403427A s a nu r se/phys i c ianI n ED nu r s i ng o r med i c i neI n t he SPH EDLENGTH OF WORK< 1 Year 1 - 5 Years 6 - 10 Years > 10 Years(n = 99) 258 Sunny Jiao, PhD Candidate, UBC School of Nursing January 2022 Section 3: Workplace education Workplace education refers to education received by staff through the organization (e.g., Providence Health Care, SPH, or the ED), such as during their initial orientation or onboarding, as well as continuing education activities including in-services. Section 4: Next steps for ongoing analysis - A thematic analysis of the interview data with nurses, physicians, and leadership - An analysis of health policies, including organizational policies from PHC, regulatory policies, etc. - A manuscript that details the scope of harm reduction interventions and their interrelationships in the ED of an inner city hospital with a longstanding commitment to caring for people who use illegal drugs Section 5: How to use and cite this infographic - The data presented in this infographic are preliminary findings. They have not been integrated with findings from other data sources of the study (e.g., interviews with staff and leadership, health policies), are not a full representation of the contextual factors that may affect harm reduction implementation, and are unable to lead to formal recommendations on their own. - Jiao, S., Bungay, V., Jenkins, E., & Gagnon, M. (2022, January). Harm Reduction in BC Emergency Departments (EDs): Preliminary Findings from St. Paul’s Hospital [Infographic]. School of Nursing, University of British Columbia, Vancouver, Canada. - Copyright statement: This document is the work of the authors and is not to be reproduced without permission from the authors. 606 2Y E S N O D O N ’ T K N O W / R E M E M B E RHOW TO PRESCRIBE OR ADMINISTER OPIOID AGONIST THERAPY(n = 68)5411 3Y E S N O D O N ’ T K N O W / R E M E M B E RUSE A NALOXONE KIT(n = 68)68244H O W T O C A R E F O R P E O P L E W H O U S E I L L E G A L O P I O I D S C H R O N I C A L L Y / C O M P U L S I V E L Y *YesNoDon’t know / remember(n = 96)34268Y E S N O D O N ’ T K N O W / R E M E M B E RHOW TO ENGAGE IN OVERDOSE PREVENTION CONVERSATIONS(n = 68)35267Y E S N O D O N ’ T K N O W / R E M E M B E RHOW TO USE HARM REDUCTION SUPPL IES (n = 68)*Participants only responded to the questions on whether they received workplace education related to opioid agonist therapy, engaging in overdose conversations, naloxone kits, and harm reduction supplies if they answered “Yes” to the question on whether they received workplace education on how to care for people who use illegal opioids chronically or compulsively. 259 Appendix G: Letter of Initial Contact Dear St. Paul's Hospital Emergency Staff: As you know, our Emergency Department (ED) serves many vulnerable and marginalized populations, including people who use drugs, who among the most frequent attendees of EDs in Canada. Harm reduction is a public health approach to reducing the morbidity and mortality associated with drug use that focuses on tackling negative consequences rather than demanding abstinence. Harm reduction interventions have led to numerous benefits for people who use drugs, including reduced infectious disease transmission and overdose deaths, as well as improved referral to public sector services and enhanced therapeutic relationships. There is currently a gap in our knowledge about the scope of harm reduction interventions in Canadian EDs and factors that may impact the integration of harm reduction interventions in this setting. It is vital that we learn from EDs what current practice looks like if we are to be able to generate evidence-informed recommendations concerning harm reduction implementation in EDs. With the intention of filling this knowledge gap, Dr. Vicky Bungay from the UBC School of Nursing and her PhD student Sunny Jiao will be conducting a Harm Reduction in BC Emergency Departments survey, which asks about harm reduction interventions that currently exist in our ED and factors that may impact the integration of harm reduction interventions in the ED. The survey is open to physicians and nurses who work in our department. Vicky and Sunny are members of the EQUIP Emergency study that our department has been involved in. Vicky is a co-principal investigator of this larger study, and Sunny has served as the interim research site coordinator for the St. Paul’s Hospital ED since September of 2019. Although you will not benefit directly from the research, you have a chance to contribute to the improvement of health service provision for an important population we serve. I am asking that all of you consider participating. The survey takes approximately 10 minutes of your time. Survey participants will have a chance to win one of three $100 Amazon gift cards. In addition, Sunny will be interviewing a number of our physicians and nurses via Zoom at a future date. These interviews will take approximately 45 minutes and you will receive a $30 honorarium as a token of appreciation. Thank you for your time and consideration! If you have questions or concerns, please don’t hesitate to contact Sunny Jiao, PhD Candidate, at __________, or Dr. Vicky Bungay, Professor, at __________ If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. You can contact the Providence Health Care Research Institute at 604-682-2344 ext. 68366.
Thesis/Dissertation
eng
Nursing
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Bungay, Vicky
A case study exploration of harm reduction implementation and related barriers and facilitators in an emergency department in British Columbia, Canada
Text