Note: This page was originally published in 1996. Many aspects of the environment have changed since then. This page is republished as a historical document.

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Nursing Close to the Street:
Home Care Nursing in Vancouver's Urban Core

By Evanna Brennan, R.N. & Susan Giles, R.N. July 1996


Issue:
Traditional home care nursing to clients living in Vancouver's Downtown Eastside who have a combination of HIV/AIDS, substance abuse and mental health problems (i.e., multi-diagnosed) has proven inadequate. The challenge is how best to change our approach to serve this population.
Evanna Brennan on the mean streetsDemographics
  • Population is over 8000 
  • 74% Male 
  • Poorest area of Vancouver 
  • Double the mortality rate 
  • Large First Nations population: 10% of the men and 25% of the the women diagnosed as HIV+ in 1995 were aboriginal. All tested self-identified transsexuals are HIV+. 
  • Over 5000 registered with needle exchange 
  • Over 600 known HIV positives (probably double). It is estimated that people infected with HIV and TB are 400 times more likely to develop active TB. 
  • New sero-conversions in 1995 averaged 1 per day-50% of all BC sero-conversions. If we continue at this rate it is estimated that by the year 2000 all beds in St. Paul's Hospital will be occupied by people with HlV and AIDS. 
Typical ClientResident of Downtown Eastside
  • very low self-esteem 
  • unemployable 
  • lived in multiple foster homes 
  • usually comes from an abusive background, physical and/or psychological 
  • first experience with an illegal substance by the age of 12 

The diagnosis of HIV+ doesn't rate high on a client's list of relevant situations.

Their immune system has already been adversely affected by:

View from typical roomTypical Living Situation
  • Single room occupancy hotel 
  • No fridge - no stove 
  • Shared toilet and bath 
  • Mice and cockroach infested 
  • $325 to $425 per month rent 

Because of their unpredictable lifestyle, this population is not suitable for anti-retroviral therapy, yet without this intervention they will become sick more quickly.

Supplying appropriate nursing service to our clients often requires methodologies outside the boundaries of traditional practice.

We have developed some strategies that work for us. They are described below in terms of a particular project and a set of procedures.

Project:
A group of frontline home care nurses has defined the effectiveness of a particular mix of modalities. The Portland Hotel was selected and a program designed for its residents.
 
The Portland HotelThe Portland Hotel

This is a home for the difficult to house multi-diagnosed person.

  • 70 room hotel 
  • funded by Downtown Eastside Residents Association and Greater Vancouver Mental Health 
  • staffed by workers experienced with mental health and drug use problems 
  • residents can remain active drug users without fear of eviction 
  • in-house needle exchange and methadone programs available 

Procedure:
Elements of the program include:

Building that trust is the most important aspect of the relationship between the nurse and the client.

Major problems for our clients are abscesses caused by injecting a variety of drugs (cocaine, heroin, pyribenzamine, etc.).
 
 
Pyro user's table
Keloids on a pyro user's arm
Pyribenzamine 

In Vancouver's multi-diagnosed community pyribenzamine, which is an over-the-counter antihistamine, is a particular problem. Cheap, at $.25/tablet, it gives a quick buzz. Easily obtained at any drug store, pyribenzamine causes deep wounds with purulent drainage that often undermine to form craters. This is probably due to the buffers used in the tablets. A long term effect is keloid formation which limits mobility.

Our approach to care of these wounds is guided by our client's tolerance to pain, attention span and preference for wound care products. We have discovered a combination of products that work well: application of silver sulfadiazine cream (antifungal, antibiotic, possibly antiviral) covered with a hydrocolloid dressing. In doing this, we do not adhere to traditional protocols. The advantage of this dressing is that it occlusively covers the wound but leaves access for the client to inject around it; it is less likely to be taken off by the client 2 minutes after we finish the dressing.
Treating leg wound 1Treating leg wound 2Ulcer on legInjecting around dressing

This being said, one keeps in mind that care is client-driven. Some clients do not like the hydro-colloid dressing but insist upon traditional gauze. Our goal is always to clean and cover a wound:

We reduce the harm that our clients do to themselves and others by teaching vein maintenance. Some of the strategies we teach include: Information is provided about community health resources such as the needle exchange, the street nurse program, methadone options, treatment centres, local AIDS service organizations, meal programs and food supplement coverage.
 
Harm reduction

A model and set of strategies which recognizes that "people always have, and always will use drugs and, therefore, attempts to minimize the potential hazards associated with drug use, rather than the use itself." Duncan, 1995) In this model, limit setting is based on behaviour not on the substance.

Goals:

  • to improve client health status 
  • to minimize risk of HIV, TB, endocarditis, hepatitis, drug overdose 
  • to exchange information and create trust 
  • to empower the substance user and health care provider 

RewardsTo ensure the client's cooperation with nursing care we and the hotel's staff have created a policy that daily cigarettes and money are distributed after a successful nursing transaction. Nutritional supplements are handed out following care. These actions have significant impact on obtaining success with the care plan.

Our goal is to maintain these individuals in their own environment:

For substance users who are generally controlled by their habit, using the above harm reduction strategies affords them a sense of control - empowerment - which may be the starting point for entering treatment.

Results:

Lessons learned: Footnotes:

1. Duncan, D. et al. "Harm Reduction: An emerging New Paradigm for Drug Education," J. Drug Education, Vol. 24(4) 281-290, 1994.


Nursing Close to the Street:
Home Care Nursing in Vancouver's Urban Core

Evanna Brennan, R.N.
Susan Giles, R.N.
Photography by Brooke Richardson

© Susan Giles & Evanna Brennan, 1996


Revised April 2003.