This page was originally published in 1996. Many aspects of the environment
have changed since then. This page is republished as a historical document.
Nursing Close to the Street:
Home Care Nursing in Vancouver's
By Evanna Brennan, R.N. & Susan Giles, R.N. July 1996
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.
Population is over 8000
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
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
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.
very low self-esteem
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
Their immune system has already been adversely affected by:
IV drug use
transient housing & suboptimal personal hygiene
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.
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.
This is a home for the difficult to house multi-diagnosed person.
70 room hotel
funded by Downtown Eastside Residents Association and Greater Vancouver
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
Elements of the program include:
Building that trust is the most important aspect of the relationship between
the nurse and the client.
work collaboratively with clients to establish a plan of care which recognizes
provide regular and consistent service by primary nurses
follow a harm reduction philosophy that includes sterile
mixers and information on vein maintenance and safer injection techniques
provide a client's daily cigarettes, pocket money and nutritional supplement
as a reward for successful nursing transactions
provide care that is non-judgmental and recognize that for most clients
abstinence from drug use is not a viable option
support the client, not the habit
establish an environment of trust by being consistent and reliable through
regular visits-at the same time with the same nurse when possible
Major problems for our clients are abscesses caused by injecting a variety
of drugs (cocaine, heroin, pyribenzamine, etc.).
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.
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:
by any means acceptable
as quickly as possible
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.
hands before injecting
use alcohol swab
use clean equipment (new or bleach-cleaned syringe)
use clean water
use good tying off technique
avoid sharing needles
know where to shoot and where not to shoot
encourage clients to "save" one vein
encourage clients to reduce the number of injections by one per day
link the client to available resources
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."
1995) In this model, limit setting is based on behaviour not on the
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
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.
they resist hospitalization until their situation becomes acute
their acute needs increase the cost of already-expensive hospital care
they do not function well in a hospital setting
their substance needs are often not addressed in a manner that is adequate
There has been an increased visibility and acceptance of home care nursing
services by the hotel's residents.
The program is well accepted by clients in the hotel.
Word-of-mouth referrals have risen: clients not previously on the caseload
drop in for care.
There seems to be decrease in emergency department admissions for problems
such as cellulitis and abscesses.
There is increased client involvement with nursing care, resulting in better
outcomes, e.g., healing of wounds, resolution of infection.
Personalized attention encourages them to develop interest in improving
their health status.
Development of a proven mix of client-centred methods used in negotiating
health care with multi-diagnosed individuals can improve the overall effectiveness
Keeping the approach client-centred and not strictly hewing to traditional
guidelines can result in significantly better outcomes for the client.
The nursing practice is enriched.
Client-driven experiences guide further interventions.
1. Duncan, D. et al. "Harm Reduction: An emerging
New Paradigm for Drug Education," J. Drug Education, Vol. 24(4) 281-290,
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.