in Hospital Settings for People who use(d) Illicit Drugs
CREATING CULTURALLY SAFE CARE
HEALTH CARE AND ILLICIT DRUG USE
People who use, previously used or are presumed to use,
illicit drugs face challenges getting good health care and
often have poorer health than the rest of the population.
The stigma and criminalization associated with illicit drug
use is increased for people living in poverty, impacting
health and acting as a barrier to accessing care.1 Negative
experiences in hospitals can lead people to avoid seeking
care and, if admitted, to leave before their care is complete.
Hospital nurses are critical to helping people access the
care they need, shaping patients’ hospital experiences,
and ensuring supports are in place when people leave
the hospital. However, there are few models or guidelines
to help nurses provide ethical, safe and appropriate care
when working with people who use(d) illicit drugs and face
poverty and homelessness.
The concept of cultural safety has been used to guide
nursing practice in ways that counteract the problems
of stigma, discrimination and inequitable access to care,
particularly when working with Indigenous peoples.2
Cultural safety has been endorsed by organizations
such as the Canadian Nurses Association (CNA), the
Canadian Association of Nurses in AIDS Care, the College
of Registered Nurses of British Columbia (CRNBC), the
Canadian Medical Association (CMA) and the Aboriginal
Nurses Association of Canada (ANAC). Nurses working at
Insite, a supervised injection site in Vancouver, Canada,
found cultural safety to be a helpful concept in working
respectfully with both Aboriginal and non-Aboriginal
Our goal was to generate knowledge about what cultural
safety looks like in acute care settings and how this
knowledge could improve the delivery of health care.
AUTHORS: Bernie Pauly RN, Ph.D, Jane McCall,
MN, Joanne Parker, MA, Cat McLaren, BA, Annette
J. Browne, RN, Ph.D, Ashley Mollison, MA
OUR RESEARCH QUESTIONS:
1. What is culturally safe care in acute care settings for
people who use(d) illicit drugs and face multiple social
2. How can nurses enhance delivery of culturally safe,
competent and ethical nursing care to people who identify
as currently or previously using illicit drugs?
OUR RESEARCH METHODS:
We conducted a qualitative, ethnographic study in a large acute
care hospital, exploring patients’ and nurses’ views on culturally
safe care and the role of the hospital environment in fostering
or limiting that care. We did in-depth individual interviews with
34 participants, including 15 patients (8 male, 6 female and 1
transgendered person), 12 nurses and 7 acute care managers
or educators. We also spent time (275 hours over 12 months)
on two dierent hospital units to observe nurses’ work with
patients, and studied the hospital’s organizational policies and
documents (e.g., philosophy of care, mission and mandate,
substance use policies).
People who use(d) illicit drugs and nurses were involved in
all stages of the research through two advisory committees:
one included nurses, and the other included ‘peers’ – from the
Society of Living Illicit Drug Users (SOLID), an organization
run by and for people who use(d) illicit drugs. We worked with
both advisory groups to develop interview questions, interpret
data, and develop and present the ndings. At the end of the
project, we hosted two policy forums to share ndings with
an expanded group of nurses, health care managers, peer-run
organizations that represent people who use(d) drugs.
WHAT IS CULTURALLY SAFE CARE?
Cultural safety is based on the principle that the people
receiving care decide what is safe or unsafe.4 Thus, there is a
shift of power from providers to recipients of care. Cultural
safety encourages nurses to a) learn how stereotyping,
discrimination and other assumptions operate in health care
settings, b) reect on hospital policies that negatively impact
BULLETIN #11 December 2013
2Centre for AddiCtions reseArCh of BC
patients, c) understand how social inequities shape patients’
access to health care, and d) convey unconditional acceptance
of patients regardless of their decisions or circumstances and,
e) treat patients with dignity and respect at all times.5 Below,
we highlight ve elements of culturally safe care for people
who use(d) illicit drugs. These elements emerged from our
understanding of cultural safety, the ndings of this research
and our collaboration with nurses and people who use(d) illicit
drugs, and are meant to help guide nurses’ practice.
1. Culturally safe care fosters engagement and
participation of people who have experience with
substance use and marginalization in shaping the
care they and their peers receive.
In hospital, people who use(d) illicit drugs often feel excluded
and judged. Patients in our study had experienced hospital care
that they described as disrespectful and lacking compassion. A
common fear expressed by patients – and reinforced by our peer
advisory – was that in hospital they would be judged, labelled
and blamed for their current health problems and drug use.
…I’ve seen the way they treat people when they’ve had
drugs: you’re a drug addict, you know, you’re considered a
drug addict. It’s like a label, you know, ‘drug addict’, and they
just discard you.
Patients described worries that they would be written o, not
listened to, or seen as undeserving of care. As a consequence,
they felt they would receive poorer quality care. It helped
patients to feel safer when nurses listened to and believed what
they said. We recommend that nurses, managers and others in
Actively listen to and acknowledge concerns expressed by
patients about their care.
Seek opportunities to learn from patients – about their lives,
their needs, their preferences, and their perspectives on
good hospital care.
Accommodate patients’ preferences for care, to the extent
Ensure that patients know their rights and what they can
expect when receiving health care.
Create and promote opportunities for sta to engage
in experiential learning in community settings, such as
harm reduction outreach, street nursing programs, and
community health clinics.
Involve people who use drugs and peer advocacy
organizations in the development and delivery of
education about hospital care for people who use(d) drugs.
2. Culturally safe care recognizes that people’s
health, health care, priorities and experiences are
inuenced by history and policies that criminalize
Canada’s history of criminalizing drug use and poverty has
fueled negative attitudes towards people who use(d) illicit
drugs. There is increasing recognition that current drug policies
can be a barrier to obtaining health care, and the establishment
of appropriate health care services.6, 7 In our study, patients
described feeling ‘under surveillance’ while they were in hospital.
Some patients indicated that if anything went wrong or missing
on the unit, they would be the rst ones accused, and some felt
under constant suspicion of drug use.
I just left; it was 11:00 at night, the guy is demanding a
urinalysis from me… I said ‘what for?’ He said ‘because
you’ve been going out for walks a lot’. I said ‘Because I’m
going out, I’m getting fresh air, that means that you’re
suspecting me for doing drugs?’
Even more concerning is that patients in this study told us they
were afraid to ask nurses or doctors for pain medication for fear
of being labelled as ‘drug seeking’.
If you’re in pain and you’re asking for pain medication, they’ll
doubt it… half the time they’ll think ‘oh, he just wants to get
high’ instead of ‘this guy is really hurting’.
3BULLETIN: cULTUraLLy safE carE
Nurses said that the hospital had a harm reduction philosophy
but hospital policies indicated zero tolerance for substance use.
Most nurses were unclear as to exactly what the harm reduction
policy said, or what they can or should do when they become
aware of active drug use. Nurses responded in various ways,
such as ignoring drug use, reporting it to their manager, or
trying to ensure patients’ safety.
I remember seeing [clean needles] in, like she had a little
makeup bag. I didn’t take them away. Because to me that’s
not, that’s not harm reduction at all. If I take them away, you
know, I might be putting her in a position where she’s got to
go and share with somebody else.
Only a few nurses mentioned promoting safer drug use, for
example, by providing supplies or education for safer use.
Hospital policies emphasizing zero tolerance of substance
use, and the lack of explicit harm reduction policies, leave
nurses caught between professional ethical commitments
to health promotion and ocial policies more aligned with
criminalization. To enhance culturally safe care, nurses, their
managers and health care leaders can:
Reect on their own attitudes and beliefs about illicit drug
use and people who use(d) illicit drugs. Consider how drug
policies have shaped these attitudes.
Recognize that people may feel under surveillance while in
hospital. Be sensitive to giving people space.
Ensure that the hospital environment is free of the threat of
Assess patients for pain and manage pain accordingly, rather
than assuming they are ‘drug-seeking’ based on their history.
Resist assuming that people using illicit drugs will not
require pain medication.
Ensure nurses have training in withdrawal management.
Expect to talk to patients about drug use as it relates to
their care. Ensure privacy, choose the right moment, explain
any specic concerns, and focus on health and safety –
avoid lectures or judgment.
Look at the existing evidence base showing the
eectiveness of harm reduction strategies.
Ensure that patients who use illicit drugs have access to
harm reduction supplies and services.
Ensure that patients who are ready to stop or reduce drug
use have access to detox, replacement therapies and other
Establish and clearly communicate harm reduction policies
to nurses and others.
Provide and promote opportunities for leaders and front-line
sta to question assumptions through open discussions of
drug policy, criminalization, marginalization and stigma.
3. Culturally safe care considers how past histories
of trauma and violence, layers of disadvantage
and stigma may affect patients’ ability to engage
with providers and care plans.
Some nurses said they know that people come to hospital feeling
distrustful and fearful of how they will be treated. Many were
aware that patients are sometimes treated poorly, disrespected
or dismissed, and do not always have their needs met.
I like to think everybody is the same, but I think people who
are more marginalized often times might have like more
abuse and trust issues. So I think you have to just work a little
bit extra hard at that.
4Centre for AddiCtions reseArCh of BC
Nurses described having to ‘think dierently’ about drug use
and people who use drugs, recognizing stereotypes and societal
conditions that contribute to the harms of drug use.
Patients highlighted that nurses’ attitudes and mannerisms are
as important as what they say and do. Patients repeatedly told
us that when nurses took time with them and provided honest
explanations, it helped them feel more comfortable.
You ask for things; if they’re there, they’ll give it to you, if
not, they’ll explain why. They don’t just say ‘no, there isn’t’,
Explaining actions and decisions was important for many
reasons: to show respect, to avoid surprising patients, and to
give patients control over their own health care. To promote
cultural safety, nurses can:
Recognize that angry or frustrated behaviours often stem
from life situations and health problems, and are not a
personal attack on the care provider.
Encourage and help other sta members to see each
patient’s behaviour in the context of their life and possible
Recognize that people may be ‘on guard’ if they have
experienced abuse, homelessness or victimization.
Be prepared to go the extra mile in providing people with
options – be explicit about supporting their choices, and
avoid unnecessary power struggles.
Explain what you want to do before you do it to prevent
Explain decisions rather than just saying yes or no – so
that patients do not feel as if they are being criminalized,
dismissed or punished.
Avoid a rushed or hurried manner. People may be very
sensitive to body language that can be interpreted as
Be exible in helping to create a safer environment in
hospital. For example, people who have experienced
trauma may not feel safe in a mixed-gender room; some
may want to sleep with the lights on, etc.
Ensure opportunities for sta to develop competencies in
caring for people who have experienced trauma related to
4. Culturally safe care emphasizes relationships and
trust as priority outcomes.
Developing trust is critical to facilitating access to health care
services 8, 9 and consistent with principles of cultural safety.
Building positive relationships with people who use(d) illicit
drugs should be a high priority for nurses.
The whole thing that motivates me is to maybe plant a seed
of safety, trust… Because a large proportion of our patients
have a really hard time trusting people; it’s really hard for
them to access any kind of treatment or services. I don’t
really think our patients need any more people judging them.
In this study, we found that patients felt safer, more welcome
and comfortable when they felt that nurses trusted them.
You can roam around, do what you want. As long as you let
them know what you’re doing…They don’t mind, as long as
you don’t… cause trouble or get out of hand or get ornery,
you’re ne. They’ll let you be, right? They check on you, right,
see how you’re doing and they ask you if you need anything.
Patients also felt more comfortable knowing that nurses could
be trusted to recognize and respect their physical as well as
[The nurses are] caring; they care. They make sure that you’re
really comfortable…it’s like, they know me, they’re able to
say ‘OK, well, she doesn’t feel comfortable talking about that’,
and switch to another subject.
5BULLETIN: cULTUraLLy safE carE
Repeatedly, patients recounted times when nurses did ‘little
things’ that made them feel safer and more comfortable.
They’ll take that extra couple of minutes. And, you know, see
that you’re okay… ‘let me grab a blanket’ or, you know, ‘are
you sure you don’t need something for pain?’ You know, you
can tell by just even their voice that there’s genuine concern.
When patients expect to face stigma and discrimination, little
things matter and help patients to feel seen and respected
rather than written o or discarded. To promote cultural safety,
Resist assuming that people trust you because you are a
health care provider.
Prioritize building a trusting relationship as a key pathway
and outcome of good care.
Be aware that showing trust is a good way to build patients’
trust in you.
Show genuine concern and empathy, call patients by name,
oer small things, and get to know something about the
patient – these can become profound acts.
Seek and promote educational opportunities that focus on
developing relational skills.
5. Culturally safe care requires a culture of respect
and safety within the unit or workplace, where all
patients are valued and seen as deserving of care.
Culturally safe care is easier to provide in a supportive
environment where the health care team shares similar values
and consistent approaches to care. In our study, we found that
sta turnover and resource constraints posed challenges to
creating culturally safe environments, and heightened tensions
around who is most deserving of care. Shared approaches and
understandings of substance use are important to creating a
health care culture that fosters cultural safety. Conversely, many
nurses indicated that they had few opportunities within their
basic or continuing education to develop skills related to care
for people dealing with substance use and social disadvantages.
We recommend that nurses, managers and educators:
Build strength within interdisciplinary teams: provide
education on drug policy and substance use to all sta,
including physicians, nurses, pharmacists and other
Encourage peer-to-peer support, and work as a team to
manage and debrief dicult situations or behaviours.
Use respectful and non-stigmatizing language at all times,
and avoid stereotyping. Overhearing sta conversations
can reinforce patient fears and mistrust; health care
providers also benet from consistent messaging and role-
modelling of respectful treatment by health care leaders.
Address stang shortages and policies that can limit
nurses’ ability to engage with patients and build their trust.
Promote mentorship opportunities for new nurses, support
them to develop expertise and skills, and to understand
unit norms and expectations related to substance use and
Cultural safety is especially relevant in the provision of nursing
care for people who use(d) illicit drugs and live with social
disadvantages such as poverty and homelessness. Specic
attention to these ve elements of culturally safe care holds
promise for improving nursing practice in ways that can foster
equity and social justice in health care.
© Centre for Addictions Research of BC 2013 | www.carbc.ca
We gratefully acknowledge research funding from Michael
Smith Foundation for Health Research (MSFHR), under the
British Columbia Nursing Research initiative.
We acknowledge with deep gratitude and respect the
advisory committees for this project. Special thanks to the
Society of Living illicit Drug Users (SOLID), and the nurse
advisors who gave their time to review interview questions
and interpret the ndings.
Thank you to all the nurses, managers, peers, and advocates
who participated in the study and the policy forums in
Vancouver and Victoria.
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