A case study exploration of harm reduction implementation and related barriers and facilitators in an emergency department in British Columbia, Canada

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.

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