"Food engages people, as we know": health care and service providers' experiences of using food as an incentive in HIV care and support in British Columbia, Canada.

Food insecurity is widely documented among people living with HIV (PLWH) worldwide, and it presents significant challenges across the spectrum of HIV care and support. In North America, the prevalence of food insecurity among PLWH exceeds 50%. In the province of British Columbia (BC), it exceeds 65%. It comes as no surprise that food has become an essential tool in supporting and engaging with PLWH. Over the past decade, however, a shift has taken place, and food has become an incentive to boost uptake and outcomes of prevention, testing, treatment, and support. To explore this practice, we drew on a qualitative case study of incentives in the care and support of PLWH. This paper presents the findings of a targeted analysis of interviews (N = 25) that discuss food incentives and explores two main themes that shed light on this practice: (1) Using food to engage versus to incentivize and (2) Food is more beneficial and more ethical. Providers perceived food more positively than other incentives, despite the goal remaining somewhat the same. Incentives, such as cash or gift cards, were considered ethically problematic and less helpful (and potentially harmful), whereas food addressed a basic need and felt more ethical.

How an emergency department is organized to provide opioid-specific harm reduction and facilitators and barriers to harm reduction implementation: a systems perspective.

BACKGROUND: The intersection of dual public health emergencies-the COVID-19 pandemic and the drug toxicity crisis-has led to an urgent need for acute care based harm reduction for unregulated opioid use. Emergency Departments (EDs) as Complex Adaptive Systems (CASs) with multiple, interdependent, and interacting elements are suited to deliver such interventions. This paper examines how the ED is organized to provide harm reduction and identifies facilitators and barriers to implementation in light of interactions between system elements. METHODS: Using a case study design, we conducted interviews with Emergency Physicians (n = 5), Emergency Nurses (n = 10), and clinical leaders (n = 5). Nine organizational policy documents were also collected. Interview data were analysed using a Reflexive Thematic Analysis approach. Policy documents were analysed using a predetermined coding structure pertaining to staffing roles and responsibilities and the interrelationships therein for the delivery of opioid-specific harm reduction in the ED. The theory of CAS informed data analysis. RESULTS: An array of system agents, including substance use specialist providers and non-specialist providers, interacted in ways that enable the provision of harm reduction interventions in the ED, including opioid agonist treatment, supervised consumption, and withdrawal management. However, limited access to specialist providers, when coupled with specialist control, non-specialist reliance, and concerns related to safety, created tensions in the system that hinder harm reduction provision with resulting implications for the delivery of care. CONCLUSIONS: To advance harm reduction implementation, there is a need for substance use specialist services that are congruent with the 24 h a day service delivery model of the ED, and for organizational policies that are attentive to discourses of specialized practice, hierarchical relations of power, and the dynamic regulatory landscape. Implementation efforts that take into consideration these perspectives have the potential to reduce harms experienced by people who use unregulated opioids, not only through overdose prevention and improving access to safer opioid alternatives, but also through supporting people to complete their unique care journeys.

Impact of safer supply programs on injection practices: client and provider experiences in Ontario, Canada.

OBJECTIVES: Fentanyl has contributed to a sharp rise in the toxicity of the unregulated drug supply and fatal overdoses in Canada. It has also changed injection practices. Injection frequency has increased as a result and so has equipment sharing and health-related risks. The aim of this analysis was to explore the impact of safer supply programs on injection practices from the perspective of clients and providers in Ontario, Canada. METHODS: The data set included qualitative interviews with 52 clients and 21 providers that were conducted between February and October 2021 across four safer supply programs. Interview excerpts discussing injection practices were extracted, screened, coded and then grouped into themes. RESULTS: We identified three themes, each theme corresponding to a change in injection practices. The first change was a decrease in the amount of fentanyl used and a decrease in injection frequency. The second change involved switching to injecting hydromorphone tablets instead of fentanyl. Finally, the third change was stopping injecting altogether and taking safer supply medications orally. CONCLUSION: Safer supply programs can contribute to reducing injection-related health risks in addition to overdose risks. More specifically, they have the potential to address disease prevention and health promotion gaps that stand-alone downstream harm reduction interventions cannot address, by working upstream and providing a safer alternative to fentanyl.

Implementation of a nurse-led overdose prevention site in a hospital setting: lessons learned from St. Paul's Hospital, Vancouver, Canada.

OBJECTIVES: In May 2018, St. Paul's Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned. METHODS: Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff. RESULTS: The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response. CONCLUSIONS: Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

Blowing the whistle during the first wave of COVID-19: A case study of Quebec nurses.

The experiences of nurses who blew the whistle during the COVID-19 pandemic have exposed gaps and revealed an urgent need to revisit our understanding of whistleblowing. AIM: The aim was to develop a better understanding of whistleblowing during a pandemic by using the experiences and lessons learned of Quebec nurses who blew the whistle during the first wave of COVID-19 as a case study. More specifically, to explore why and how nurses blew the whistle, what types of wrongdoing triggered their decision to do so and how context shaped the whistleblowing process as well as its consequences (including perceived consequences). DESIGN: The study followed a single-case study design with three embedded units of analysis. METHODS: We used content analysis to analyse 83 news stories and 597 forms posted on a whistleblowing online platform. We also conducted 15 semi-structured interviews with nurses and analysed this data using a thematic analysis approach. Finally, we triangulated the findings. RESULTS: We identified five themes across the case study. (1) During the first wave of COVID-19, Quebec nurses experienced a shifting sense of loyalty and relationship to workplace culture. (2) They witnessed exceedingly high numbers of intersecting wrongdoings amplified by mismanagement and long-standing issues. (3) They reported a lack of trust and transparency; thus, a need for external whistleblowing. (4) They used whistleblowing to reclaim their rights (notably, the right to speak) and build collective solidarity. (5) Finally, they saw whistleblowing as an act of moral courage in the face of a system in crisis. Together, these themes elucidate why and how nurse whistleblowing is different in pandemic times. CONCLUSION: Our findings offer a more nuanced understanding of nurse whistleblowing and address important gaps in knowledge. They also highlight the need to rethink external whistleblowing, develop whistleblowing tools and advocate for whistleblowing protection. IMPACT: In many ways, the COVID-19 pandemic has challenged our foundational understanding of whistleblowing and, as a result, it has limited the usefulness of existing literature on the topic for reasons that will be brought to light in this paper. We believe that studying the uniqueness of whistleblowing during a pandemic can address this gap by describing why and how health care workers blow the whistle during a pandemic and situating this experience within a broader social, political, organizational context.

What are the ethical implications of using prize-based contingency management in substance use? A scoping review.

BACKGROUND: The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications. PURPOSE: The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration. METHODS: The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications. RESULTS: We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics. CONCLUSIONS: This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

A qualitative study on overdose response in the era of COVID-19 and beyond: how to spot someone so they never have to use alone.

BACKGROUND: Spotting is an informal practice among people who use drugs (PWUD) where they witness other people using drugs and respond if an overdose occurs. During COVID-19 restrictions, remote spotting (e.g., using a telephone, video call, and/or a social media app) emerged to address physical distancing requirements and reduced access to harm reduction and/or sexually transmitted blood borne infection (STBBI's) prevention services. We explored spotting implementation issues from the perspectives of spotters and spottees. METHODS: Research assistants with lived/living expertise of drug use used personal networks and word of mouth to recruit PWUD from Ontario and Nova Scotia who provided or used informal spotting. All participants completed a semi-structured, audio-recorded telephone interview about spotting service design, benefits, challenges, and recommendations. Recordings were transcribed and thematic analysis was used. RESULTS: We interviewed 20 individuals between 08/2020-11/2020 who were involved in informal spotting. Spotting was provided on various platforms (e.g., telephone, video calls, and through texts) and locations (e.g. home, car), offered connection and community support, and addressed barriers to the use of supervised consumption sites (e.g., location, stigma, confidentiality, safety, availability, COVID-19 related closures). Spotting calls often began with setting an overdose response plan (i.e., when and who to call). Many participants noted that, due to the criminalization of drug use and fear of arrest, they preferred that roommates/friends/family members be called instead of emergency services in case of an overdose. Both spotters and spottees raised concerns about the timeliness of overdose response, particularly in remote and rural settings. CONCLUSION: Spotting is a novel addition to, but not replacement for, existing harm reduction services. To optimize overdose/COVID-19/STBBI's prevention services, additional supports (e.g., changes to Good Samaritan Laws) are needed. The criminalization of drug use may limit uptake of formal spotting services.

"It gets people through the door": a qualitative case study of the use of incentives in the care of people at risk or living with HIV in British Columbia, Canada.

BACKGROUND: There has been growing interest in the use of incentives to increase the uptake of health-related behaviours and achieve desired health outcomes at the individual and population level. However, the use of incentives remains controversial for ethical reasons. An area in which incentives have been not only proposed but used is HIV prevention, testing, treatment and care-each one representing an interconnecting step in the "HIV Cascade." METHODS: The main objective of this qualitative case study was to document the experiences of health care and service providers tasked with administrating incentivized HIV testing, treatment, and care in British Columbia, Canada. A second objective was to explore the ethical and professional tensions that arise from the use of incentives as well as strategies used by providers to mitigate them. We conducted interviews with 25 providers and 6 key informants, which were analyzed using applied thematic analysis. We also collected documents and took field notes. RESULTS: Our findings suggest that incentives target populations believed to pose the most risk to public health. As such, incentives are primarily used to close the gaps in the HIV Cascade by getting the "right populations" to test, start treatment, stay on treatment, and, most importantly, achieve (and sustain) viral suppression. Participants considered that incentives work because they "bring people through the door." However, they believed the effectiveness of incentives to be superficial, short-lived and one-dimensional-thus, failing to address underlying structural barriers to care and structural determinants of health. They also raised concerns about the unintended consequences of incentives and the strains they may put on the therapeutic relationship. They had developed strategies to mitigate the ensuing ethical and professional tensions and to make their work feel relational rather than transactional. CONCLUSIONS: We identify an urgent need to problematize the use of incentives as a part of the "HIV Cascade" agenda and interrogate the ethics of engaging in this practice from the perspective of health care and service providers. More broadly, we question the introduction of market logic into the realm of health care-an area of life previously not subject to monetary exchanges.

What Can we Learn from the English-Language Media Coverage of Cannabis Legalization in Canada?

Background: In October 2018, Canada became the second country in the world to legalize cannabis. However, at this stage in the implementation process, it can be challenging to get a sense of the outcomes of this policy shift - hence why we turned to media. Purpose/objectives: We present the results of a qualitative content analysis conducted on the media coverage between October 2018 and April 2019. Methods: We used Google News and ProQuest database to complete our search. We included online media articles published between October 2018 and April 2019 in English. This left us with 81 eligible articles. These articles were analyzed by blending deductive and inductive approaches. Results: The articles were grouped into 5 categories: 1) housing, 2) access, 3) workplace, 4) driving, and 5) public consumption. Each category was then analyzed to identify emerging themes across news stories. Overall, we found that non-governmental actors such as landlords and employers were given a great deal of flexibility to introduce overly broad and restrictive regulations that disproportionately impact various communities. We also found that emphasis was placed on banning cannabis in various spheres of life as opposed to adapting to the new reality that cannabis is now legal. Conclusion: Real-time observations are critically needed to better understand the impact of policy implementation across the three levels of government: federal, provincial and territorial, and municipal. Our findings suggest that media coverage analysis can help us understand and track issues as they arise.

Whistleblowing: A concept analysis.

The concept of whistleblowing, which began to emerge in the 1970s, has gained significant traction over time and across disciplines, including law, management, public administration, sociology, psychology, and health sciences. Interestingly, nurses and nursing students account for the majority of the participants in studies pertaining to whistleblowing. Nursing research conducted in the past two decades provide a good foundation on which to build a better understanding of the context in which whistleblowing takes place, the process of whistleblowing itself, and the repercussions experienced by whistleblowers, but major conceptual gaps remain. In fact, limited attention has been given to the conceptual underpinnings and the use of the concept of whistleblowing in nursing. The goal of the present conceptual analysis was to start addressing this gap and raise some critical questions about the future application of this concept in nursing, including potential opportunities and limitations. Our analysis allowed us to identify a number of antecedents, attributes, and consequences of whistleblowing in nursing. It also revealed three areas needing more attention: the concept itself, organizational culture, and research into the complexities of whistleblowing.

"There is a chain of connections": using syndemics theory to understand HIV treatment side effects.

Side effects are central to the experience of living longer with HIV but rarely have they been studied alone. Unlike other aspects of that experience, like quality of life, treatment adherence, chronicity, episodic disability, aging, health, and viral load suppression, side effects have not benefited from the same level of empirical and theoretical engagement from qualitative researchers. In this paper, we draw on syndemics theory and 50 qualitative interviews to better understand the experience of HIV treatment side effects. Two main categories were identified in the data: side effects as a product and side effects as a risk factor. The first category suggests that side effects are not just the product of taking antiretroviral drugs. They are also the product of particular conditions and tend to cluster with other health problems. The second category puts forward the idea that side effects can act as a syndemic risk factor by exposing PLWH to a greater risk of developing health problems and creating conditions in which psychosocial issues are more likely to emerge. The paper concludes by calling for more research on the complex nature of side effects and for the development of comprehensive approaches for the assessment and management of side effects.

Teaching HIV-specific content for pre-licensure nursing and health professions students: a review and synthesis.

Persistent Human Immunodeficiency Virus (HIV) prevalence rates remain a challenge, particularly because health care providers (HCP) are not fully prepared to engage in HIV care. This hesitancy to engage creates access to care barriers for people living with HIV (PLWH). We conducted a systematic review to identify educational interventions focused on developing HIV competencies in higher education across health science disciplines. We searched databases for primary studies focused on interventions. Using PRISMA guidelines, we identified 20 articles from 19 distinct studies. While there was an overwhelming body of literature that assessed knowledge, skills, and attitudes in health sciences students on HIV and AIDS, the low number of intervention studies was notable. With the exception of two studies, PLWH were not included in the interventions. This finding stands in sharp contrast to the well-established Greater Involvement of People Living with HIV and/or AIDS (GIPA) and Meaningful Engagement of People Living with HIV and/or AIDS (MEPA) principles. The primary means of the educational intervention was focused on delivering lectures to address HIV and AIDS knowledge for HCP. There was a significant lack of focus on historical, cultural, policy and legal contexts of HIV and AIDS care; theoretical justifications for the interventions were absent. No study focused on the impact of an intervention on the care provided to PLWH by HCP after graduation. There is an urgent need to develop long-term sustainable and scalable interventions that address the consistently identified lack of knowledge and skills, and stigmatizing attitudes of HCP and students.

The HIV self-testing debate: where do we stand?

BACKGROUND: Emphasis on HIV testing as a gateway to prevention, treatment and care has grown tremendously over the past decade. In turn, this emphasis on testing has created a demand for new policies, programs, and technologies that can potentially increase access to and uptake of HIV testing. HIV self-testing (HST) technologies have gained important momentum following the approval of the over-the-counter self-tests in the United States, the UK, and France. While the renewed interest in HST has given rise to a number of high quality reviews of empirical studies conducted on this topic, we have yet to find an article that captures the extent of the debate on HST. MAPPING THE DEBATE: A critical review of the literature on HST was conducted and organized into three categories based on the focus of the article: 1) Empirical research, 2) Arguments, and 3) Context. We focused exclusively on the second category which included ethical analyses, policy analyses, editorials, opinion pieces, commentaries, letters to the editor and so forth. 10 lines of argument on HST were identified in the literature: 1) Individual - Public Health, 2) Strengths - Limits, 3) Benefits - Harms, 4) Screening - Testing, 5) Target - Market, 6) Health Care - Industry, 7) Regulation - Restriction, 8) Resource-Rich Settings - Resource-Limited Settings, 9) Ethical - Unethical, and 10) Exceptionalism - Normalization. Each line of argument is presented and discussed in the paper. CONCLUSION: We conclude by providing examples of critical questions that should be raised in order to take the debate to another level and generate new ways of thinking about HST.

Power, discourse, and resistance: Poststructuralist influences in nursing.

Based on our respective research programs (psychiatry, forensic psychiatry, public health, HIV/AIDS, harm reduction) this article aims to use purposely non-conventional means to present the substantial contribution of poststructuralist perspectives to knowledge development in nursing science in general and in our current research in particular. More specifically, we call on the work of Michel Foucault and Deleuze & Guattari to politicize nursing science using examples from our empirical research programs with marginal and often highly marginalized populations. We discuss the concepts of power, discourse, and resistance to illustrate the essential contribution of poststructuralism to marginal, even "nomadic", nursing research.

[Patient-physician relation: a grounded theory of the experience of HIV treatment side effects.] / La relation patient-médecin : une théorisation ancrée de l'expérience des effets secondaires des antirétroviraux.

Antivirals induce many significant side effects and reduce the quality of life for People Living with HIV (PLWHIV). The management of side effects is crucial to maintain the patient's quality of life and adherence to treatments. The patient-physician relation is essential when managing side effects as it influences the experience for the PLWHIV. This grounded theory analyzes the patient-physician relationship in context with side effects. In the greater Ottawa/Gatineau area, 50 PLWHIV have participated in a semi-structured interview to share their experience with side effects. Four categories were highlighted with this analysis : healthcare model, medical power (central category), strategies and impacts. Results show that physicians are in a monopoly position when taking charge of PLWHIV, who then develop mechanisms of selfpreservation against medical authority. Patients must also develop their own strategies to overcome side effects. Nevertheless, a conflictual relation between patient and physicians may cause multiple devastating effects for the PLWHIV (isolation, withdrawal and distress).

[Mechanical ventilation with explicit recall: a concept analysis.] / Rappel explicite d'une ventilation mécanique : une analyse conceptuelle.

Mechanical ventilation in the intensive care unit requires the use of medication to reduce pain, discomfort, anxiety, and agitation. An explicit recall refers to the phenomenon where the person remembers the perceptions that occurred under sedation during mechanical ventilation. Severe psychological consequences may occur as a result of an explicit recall. This phenomenon is not well-defined and there is no common language in the literature. A conceptual analysis was carried out using Rodgers' evolutionary method in order to clarify the concept of explicit recall. A total of sixty-eight articles were analyzed interdisciplinarily. The results indicate that an explicit recall occurs following treatment, requiring anesthesia or sedation, and the response to medication varies according to individual characteristics. The explicit recall is defined as perceptive, interpretative, subjective, dynamic, and temporal. Following an explicit recall, the psychological trajectory has various psychological consequences that can lead to post-traumatic stress disorder.

The complex patient: A concept clarification.

Over the last decade, the concept of the "complex patient" has not only been more widely used in multidisciplinary healthcare teams and across various healthcare disciplines, but it has also become more vacuous in meaning. The uptake of the concept of the "complex patient" spans across disciplines, such as medicine, nursing, and social work, with no consistent definition. We review the chronological evolution of this concept and its surrogate terms, namely "comorbidity," "multimorbidity," "polypathology," "dual diagnosis," and "multiple chronic conditions." Drawing on key principles of concept clarification, we highlight disciplinary usage in the literature published between 2005 and 2015 in health sciences, attending to overlaps and revealing nuances of the complex patient concept. Finally, we discuss the implications of this concept for practice, research, and theory.

Working in a 'third space': a closer look at the hybridity, identity and agency of nurse practitioners.

Nurse practitioners (NPs), as advanced practice nurses, have evolved over the years to become recognized as an important and growing trend in Canada and worldwide. In spite of sound evidence as to the effectiveness of NPs in primary care and other care settings, role implementation and integration continue to pose significant challenges. This article utilizes postcolonial theory, as articulated by Homi Bhabha, to examine and challenge traditional ideologies and structures that have shaped the development, implementation and integration of the NP role to this day. Specifically, we utilize Bhabha's concepts of third space, hybridity, identity and agency in order to further conceptualize the nurse practitioner role, to examine how the role challenges some of the inherent assumptions within the healthcare system and to explore how development of each to these concepts may prove useful in integration of nurse practitioners within the healthcare system. Our analysis casts light on the importance of a broader, power structure analysis and illustrates how colonial assumptions operating within our current healthcare system entrench, expand and re-invent, as well as mask the structures and practices that serve to impede nurse practitioner full integration and contributions. Suggestions are made for future analysis and research.