Harm by Omission

Nursing schools have a responsibility to improve access to harm reduction education

I’m in a classroom at 3pm on a Friday. The room is full of nursing students, all of whom do not look like they want to be here. I’ve been allotted one hour to provide a guest lecture on harm reduction at the tail-end of a “community nursing” course.

“By a show of hands, who here plans to work in mental health and substance use?”

Two students raise their hands after an awkward silence. One of them probably means it, but the other is definitely trying to make me feel better.

“By a show of hands, who here could define harm reduction, without using the words ‘harm’ or ‘reduction’?”

Nobody. Crickets.

“By a show of hands, who here feels comfortable working with people who use drugs?”

The same two students raise their hands. Others are notably trying to avoid eye contact with me.

“By a show of hands, who here knows someone who’s died from a drug poisoning, or overdose?”

Everyone. Every single person in the room raises their hand.

Every year, I get a few requests to guest lecture nursing students about harm reduction. These were fourth year nursing students this time, nearly ready to embark on their careers as regulated health care professionals. None of them were familiar with the concept of harm reduction, or how it related to their nursing practice. None of them had received any substantial teachings on cultural safety and humility, or trauma- and violence-informed care. These are common gaps in nursing education.

I start with a similar series of questions almost every time I get a chance to teach future nurses. This is not to condescend or point out gaps in the curriculum. I am not expecting a different outcome or tracking the responses. And by the way, this is a pretty normal interaction between students and guest lecturers. As a former nursing student, I can say I’ve been on both sides of the experience. It’s tough to engage with a guest speaker when all you want to know is “will any of this be on the final?”

This line of questioning serves as a launch point to talk about bias, unconscious and conscious. It’s an opportunity to check assumptions before getting into the content of the day. Many of the students think they will only encounter drug use if they work in mental health and substance use nursing roles. Many of the students will develop, or already have, stigmatizing beliefs and attitudes toward people who use drugs. Some of them may provide or contribute to substandard care based on those beliefs and attitudes in their future practice.

According to Health Canada (2020), “Substance use stigma is prevalent throughout the health system and contributes to poorer quality of care and negative health outcomes”. Well, no shit. In harm reduction, we see the discrimination and stigma play out every day. When I worked as a street nurse, I often had to accompany clients to the hospital because of the past trauma they experienced at the hands of the healthcare system. Some people would risk getting sick, losing a limb, or even dying to avoid being subjected to further discrimination and trauma. It is well-documented that drug-related stigma in healthcare fosters mistrust, increases barriers to access, and widens inequities for marginalized groups (Health Canada, 2020). These all drive up risk for preventable harms and death.

How and what we teach nursing students is in dire need of change.

In 2019, the Harm Reduction Nurses Association (HRNA) published a position statement titled “Harm Reduction Education in Baccalaureate Nursing Programs”. In this statement, it was noted that “Currently, there is no requirement for nursing programs to include harm reduction education specific to substance use. As a result, they tend to present major knowledge-to-practice deficits and overemphasize abstinence-based approaches”. Unfortunately, that is still true today.

In 2021, HRNA launched a member survey to determine strategic priorities for the new board of directors. The results of the survey further highlighted gaps in nursing education, with nurse mentorship, improved education in nursing school, continuing competency education, and anti-stigma training being among the most recurrent needs identified.

To improve healthcare outcomes for people who use drugs, repair mistrust, and tackle stigmatizing attitudes and beliefs shared by many nurses, we must address the gaps in current curricula. Harm reduction cannot be an afterthought, facilitated by a guest lecturer, at the end of the term. In 2019, we suggested the following topics be covered, at minimum:

But I would suggest we need to take this one step further. Harm reduction is not merely a specialized practice area. It is an underpinning philosophy of practice rooted in principles that uplift and honour the rights of people who use drugs. Nursing students need to be able to apply a harm reduction approach in every facet of their practice. Whether it’s on the labour and delivery unit, acute care, or public health, nurses interact with people who use drugs everyday. Harm reduction education should be woven throughout nursing education, revisited and reflected on in clinical placements, and the education should be co-created and facilitated alongside people who use drugs.

This call to improve access to harm reduction education is not only to address bias, stigma and discrimination. We need to do this because we need to do a better job at building capacity and confidence among nurses entering the profession. We are in a healthcare crisis, and new graduates are being hurled into complex environments without the tools to do the job well and sustainably. Addressing gaps in nursing education will better prepare nurses, improve health care outcomes and reduce experiences of burnout.

The nursing students in the opening example are at a critical juncture. Often, after a guest lecture, or a one-off workshop, I hear back from a handful of students who reflected on the lesson and want to learn more. That’s a positive outcome for such a small intervention. We have the potential to influence a shift in practice if we can optimize the educational experience of nursing students. But we need to see strong buy-in from post-secondary institutions to make harm reduction education a priority.

Nursing schools have a responsibility to improve access to harm reduction education.