This edition of the Standards in Focus highlights the Standards of Practice and Conduct that speak to harm reduction and care of the client with substance use. This article will allow you to reflect on how you apply the standards in your practice. 1
Several standards speak to expectations related to harm reduction. Category one (I) of the Standards is focused on professional accountability and states that licensed practical nurses conduct themselves as professionals and make decisions that are in the interest of their clients and the public. Licensed practical nurses accept accountability for their practice and their conduct. The Standard related to harm reduction states the following:
As an LPN you must:
- Treat people fairly, with dignity, and without discrimination, bullying or harassment (Standard 10)
Category two (II) of the Standards is focused on competent practice and states that licensed practical nurses are responsible for safe, compassionate, and ethical nursing practice that is informed by evidence and demonstrates competence. The Standard related to harm reduction states the following:
As an LPN you must:
- Demonstrate an understanding of trends in nursing, health, health care, and society, which impact practice. (Standard 27)
Category three (III) of the Standards is focused on therapeutic relationships and states that licensed practical nurses establish therapeutic relationships and maintain professional boundaries at all times. The Standard related to harm reduction states the following:
As an LPN you must:
- Demonstrate trust and respect for the client, by displaying caring actions and caring attitudes. (Standard 33)
Category five (V) of the Standards is focused on collaborative care and states that licensed practical nurses practice in partnership with clients and a team of health care providers using a participatory, collaborative, and coordinated approach. The Standard related to harm reduction states the following:
As an LPN you must:
- Demonstrate respect for diversity, and practice in a manner that promotes a culturally safe environment for clients and members of the health care team. (Standard 46)
Category seven (VII) of the Standards is focused on leadership and states that licensed practical nurses apply leadership competencies in their practice, whether or not they practice in formal leadership positions. The Standard related to harm reduction states the following:
As an LPN you must:
- Demonstrate an understanding of issues facing marginalized and vulnerable clients and act as an advocate, by challenging poor practice and discriminatory attitudes and behaviours relating to their care. (Standard 65)
Harm reduction expectations are also outlined in the CLPNM document Entry-Level Competencies for the Licensed Practical Nurse in Manitoba. The entry-level competencies of the profession include the ability to 2:
- Identify clients who are at risk of harming themselves or others and implement appropriate measures to ensure safety of the client, self, and health care team.
- Assess needs and implement strategies related to risk management and harm reduction.
- Incorporate principles of harm reduction to reduce negative effects of client behaviours on health.
Harm Reduction in Nursing Practice
LPNs in Manitoba care for a diverse population of clients, and have a responsibility to provide safe, compassionate, competent, and ethical care. 2 Manitoba’s LPNs provide care to clients across the lifespan and in a variety of settings. 1 As such, nurses may encounter situations in which the health of a client is impacted by legal and/or illegal substance use and the circumstances that surround this.
In some cases, a nurse may be the first point of contact for populations that are vulnerable to the harms of substance use and addiction. If an LPN was to approach a client living with a substance use disorder with disdain and rejection, regardless of how subtle, the client may reject care from that LPN. Adverse encounters may result in a missed opportunity for the client to receive care, and a missed opportunity for the client to receive education about important treatments. 3
Clients with substance use disorders need non-judgemental care to help them to reduce their risk of harm associated with their addiction. A lack of knowledge by the LPN about substance use and addiction may lead to a nonacceptance attitude which may further lead to poor care provided to the client. 3 Using evidence-based interventions is key to helping clients with substance use achieve the highest level of health and wellness.
Harm reduction is part of a comprehensive healthcare response plan. The harm reduction response plan is focused on marginalized populations who experience health and social harms related to substance use. 3 Harm reduction refers to policies, programs, and practices that intend to reduce the adverse health, social, and economic consequences that may result from substance use. 3 The negative consequences of health and social harms on the client is the target of harm reduction. 4 The focus then, is to reduce harm while the substance use continues. 4
Health and Social Harms
Many health and social harms are associated with legal and/or illegal substance use. Some of the risks or harms include 3:
- blood-borne infections – needle sharing (substance use via injection) and unprotected sex are associated with the transmission of HIV, and HCV blood-borne infections
- overdoses – one study reported that close to one in five people who used injected substances had an overdose experience within a six-month timeframe
- soft-tissue infections and wounds – abscesses and cellulitis are associated with the injection route
- stigma – social devaluing, and discrimination can restrict the person using substances’ access to healthcare and result in a negative impact on their health
- dependence – tolerance and dependence happen through chronic activation of opioid receptors in the brain
- addiction – can be physical and/or emotional
Addiction is recognized and treated as a chronic brain disease/illness that is often associated with relapses.4 Many factors influence addiction such as 4:
- behavioural attributes, and
Once initial exposure has occurred, addiction is steered by the neurochemical changes in the brain that occur because of substance exposure. With substance use the available level of dopamine in the brain increases, and with continued substance use, tolerance builds. This leads to an increased amount of substance required to achieve the same feeling, or even to achieve normal functioning. 3 Once a client is addicted, the brain and natural functions are affected markedly by the substance and the desire to obtain the substance. 3
Principles and Approaches
The most commonly cited principles and approaches to harm reduction include 5:
|Humanism||care without moral judgement|
|Pragmatism||supportive care, abstinence is not the goal|
|Autonomy||provider-client relationships, client-driven care|
|Incrementalism||any positive change is a step forward|
|Accountability without termination||help clients understand the impact of choices|
For resources on harm reduction please see the following links 6, 7:
- The Harm Reduction Nurses Association https://www.hrna-aiirm.ca/
- The Canadian Federation of Mental Health Nurses https://www.cfmhn.ca/
Nursing Practice Scenario
Peyton, a 32-year-old female, is brought to the emergency department by emergency medical services. Peyton is an IV drug user and has had multiple hospital visits due to substance usage. Tim, LPN will be Peyton’s nurse today. During Tim’s assessment, Peyton has rigours and a temperature of 40.1. Tim sees a large abscess on Peyton’s left antecubital fossa, and multiple small open wounds and scabs on her arms, face, and legs. While doing his assessment, Tim hears a colleague expressing their frustration about “fixing these people up only to have them return again and again with the same issue.”
Suddenly, Peyton becomes angry and wants to leave. Tim sits down and calmly talks with Peyton about her reasons for wanting to leave. After some time, the conversation turns towards Peyton talking about her life, and how people treat her. Francine, LPN approaches and offers Peyton a sandwich, juice, and a warm blanket, which Peyton accepts. Tim informs Peyton that he will go to check the orders for her treatment. Tim then gathers the supplies to start an IV, and the IV antibiotic that has been ordered. When Tim returns to Peyton’s bedside, she displays implied consent for Tim to start the IV and the IV antibiotics.
Tim has heard on the local news about safe injection sites and needle exchanges, and Tim is aware that injection-related complications can be reduced through education on safe injection practices. He recognizes that nurses have a responsibility to provide client education to help reduce the risk of harm associated with substance use. Tim understands the importance of being perceived as non-judgemental and compassionate as he initiates client teaching on safe injection practices. Peyton slowly warms up to receiving the information.
Later in the shift, Tim seeks out the colleague who made the disparaging remark about his client and other people who have substance use disorders. Tim is aware that as a regulated nurse, he has a responsibility to address issues that perpetuate stigmas and contribute to inequality in client care. Tim asks to speak to his colleague in private, where he reminds his colleague of their professional responsibility to provide safe, compassionate, competent, and ethical care to every client always.
In this scenario, Standard 10 (Treat people fairly, with dignity, and without discrimination, bullying, or harassment) and Standard 33 (Demonstrate trust and respect for the client, by displaying caring actions and caring attitudes) are both displayed as Tim sits with Peyton to discuss her wanting to leave and as he listens to her personal experiences. Standard 27 (Demonstrate an understanding of trends in nursing, health, health care, and society, which impact practice) was upheld when Tim recalled what he had heard on the news about safe injection sites and needle exchanges, and combined that with his knowledge of injection-related complications. Tim also upheld Standard 65 (Demonstrate an understanding of issues facing marginalized and vulnerable clients and act as an advocate, by challenging poor practice and discriminatory attitudes and behaviours relating to their care) and Standard 46 (Demonstrate respect for diversity, and practice in a manner that promotes a culturally safe environment for clients and members of the health care team). These standards were upheld when Tim approached his colleague and reminded the colleague of their professional responsibility to provide safe, compassionate, competent, and ethical care to all clients always.
Consider engaging in self-reflection about your nursing practice and ask yourself the following questions:
- Am I compassionate when providing nursing care to all clients?
- Am I treating this client differently from other clients?
- Are my actions in the client’s best interest?
- Is my behaviour in the client’s best interest?
- Can I identify any discrimination in my nursing practice?
- Do I need further education on harm reduction to provide quality client care?
To reduce the risk of harm associated with substance use, clients need safe, compassionate, competent, ethical non-judgemental care. Often, the entry point into the healthcare system is through contact with LPNs, placing LPNs in a unique position to affect the health and well-being of clients who use substances. LPNs must have knowledge about substance use, and harm reduction to provide quality, best-evidence care to clients.
- College of Licensed Practical Nurses of Manitoba (CLPNM). (2021). Standards of Practice and Conduct for Manitoba’s Practical Nurses. Retrieved from https://www.clpnm.ca/wp-content/uploads/2022/07/CLPNM-Standards-of-Practice-and-Conduct-2021.pdf
- College of Licensed Practical Nurses of Manitoba (CLPNM). (2022.) Entry-Level Competencies for the Licensed Practical Nurse in Manitoba. Retrieved from https://www.clpnm.ca/wp-content/uploads/2022/07/Entry-Level-Competencies-2022.pdf
- Canadian Nurses Association (CNA). (2017). Harm Reduction and Illicit Substance Use: Implications for Nursing. Retrieved from https://hl-prod-ca-oc-download.s3-ca-central-1.amazonaws.com/CNA/UploadedImages/05255e6e-9517-43bc-8bc1-f1768316d4e5/Documents/Harm_Reduction_and_Illicit_Substance_Use_Implications_for_Nursing.pdf
- Bartlett, R., Brown, L., Shattell, M., Wright, T., Lewallen, L. (2013). Harm Reduction: Compassionate Care of Persons with Addictions. National Library of Medicine. Medsurg Nurs. 22(6); 349-358. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070513/
- Hawk, M., Coulter, R., Egan, J., Fisk, S., Friedman, M., Tula, M., Kinsky, S. (2017). Harm Reduction Principles for Healthcare Settings. Harm Reduction Journal. 14, 70. doi.org/10.1186/s12954-017-0196-4. Retrieved from https://link.springer.com/article/10.1186/s12954-017-0196-4
- Harm Reduction Nurses Association. (2022). Retrieved from https://www.hrna-aiirm.ca/
- Canadian Federation of Mental Health Nurses. (nd). Retrieved from https://www.cfmhn.ca/