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COMMUNITY HEALTH WORKER EXPERIENCES
WITH PEOPLE WHO USE DRUGS: A PHENOMENOLOGICAL STUDY
Kimberly Anne Wilbur
A Thesis Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master of Nursing
In the Graduate Academic Unit of Nursing
Supervisor: Tracey Rickards, PhD, Nursing
Examining Board: Khaldoun Aldiabat, PhD, Nursing
Sharon Hamilton, RN MN NP, Nursing
Adrian Guta, MSW, PhD, Social Work
This thesis is accepted by the
Dean of Graduate Studies
THE UNIVERSITY OF NEW BRUNSWICK
© Kimberly Anne Wilbur, 2020
ii
Abstract
People who use drugs (PWUD) are a marginalized population at risk of developing often
treatable and preventable health conditions; however, they avoid traditional health care
systems and providers. Community Health Workers (CHWs) make up an unrecognized
grass roots workforce that demonstrates a unique ability to engage the often homeless,
urban population of PWUD. Collaboration between CHW and Community Health Nurses
(CHNs) presents a valuable partnership opportunity. This study seeks to increase our
understanding of the lived experiences of CHWs working with PWUD. To this end, the
Giorgi (1970) Descriptive Phenomenological Psychological Method (DPPM) was applied
for both the collection and analysis of qualitative audio-recorded interview data from four
CHWs who work with PWUDs and are employed by non-profit organizations in Saint
John – New Brunswick. The descriptions are viewed through the disciplinary lens of
Vollman, Anderson & McFarlane’s (2004) Community-As-Partner Theoretical Model
(physical environments, education, safety and transportation, politics and government,
health and social services, communication, economics and recreation). The findings
include general structural descriptions (GSD) that are considered the essences or meaning
of the experiences and include “a safe space”, “do more with less” and “educate us to
educate them.” The findings have the potential to inform nurses and other health care
providers with greater understanding and insight in relation to CHWs and how best to
support and facilitate their work with PWUD as a highly complex and vulnerable
population in the community.
iii
Dedication
To my parents, Percy and Norma Wilbur and my son Drew Chenier I thank you
for your love, kindness and patience over the past years. This work has truly been a
family endeavor.
iv
Acknowledgements
To the Community Health Workers who agreed to share their lived experiences
and stories with me I am truly grateful. Without their insight and honesty my research
would not have been possible, thank-you.
I would like to thank Dr. Tracey Rickards and Dr. Khaldoun Aldiabat as members
of my thesis committee for their support and guidance throughout this process. Their
knowledge, understanding, and willingness to support my initial academic research
efforts will be forever appreciated.
A special thank you to my friends and fellow colleagues who have been so
supportive especially Dr. Anne Marie Creamer, Dr. Catherine Hamilton, Karen Crosby
Ralston, Dr. Enam Alsrayheen and Marilyn Morgan. Most importantly I would like to
extend my sincerest appreciation to the many, many individuals and families living with
mental health and substance use challenges whom I cared for in the community and have
been so gracious to include me in their lives.
v
Table of Contents
Abstract ............................................................................................................................... ii
Dedication .......................................................................................................................... iii
Acknowledgements ............................................................................................................. iv
Table of Contents ................................................................................................................. v
Abbreviations ..................................................................................................................... ix
List of Tables ...................................................................................................................... ix
List of Figures .................................................................................................................... xi
Chapter I: Background and Review of the Literature ........................................................ 1
Introduction ................................................................................................................... 1
Review of the Literature ............................................................................................... 4
Opioid use in Canada. ............................................................................................. 4
People who use drugs.............................................................................................. 5
Community Health Workers. .................................................................................. 6
Roles and responsibilities. ...................................................................................... 9
Community connectedness. .................................................................................. 10
Financial compensation. ....................................................................................... 12
CHW education, training and support. ................................................................. 13
Community Health Workers and the health care system. ..................................... 15
A Canadian perspective. ....................................................................................... 17
Nursing Practice and Community Health Workers .................................................... 19
Phenomenology and the Literature ............................................................................. 20
Search Strategy ........................................................................................................... 20
Conclusion .................................................................................................................. 21
Chapter II: The Research Method .................................................................................... 23
Introduction ................................................................................................................. 23
Philosophical Assumptions ......................................................................................... 23
Community-As-Partner Model ................................................................................... 26
Community assessment. ........................................................................................ 27
vi
Physical environments. ......................................................................................... 27
Education. ............................................................................................................. 27
Economics. ............................................................................................................ 27
Politics and government. ....................................................................................... 28
Safety and transportation. ..................................................................................... 28
Health and social services. .................................................................................... 28
Communication. .................................................................................................... 28
Recreation. ............................................................................................................ 29
Methods and Materials ................................................................................................ 29
Study Design ......................................................................................................... 29
Recruitment and sampling .................................................................................... 31
Data Collection ........................................................................................................... 33
The interview process. .......................................................................................... 33
Data Analysis .............................................................................................................. 35
Sense of the whole. ............................................................................................... 37
Determine meaning units. ..................................................................................... 37
Identify focal meaning. ......................................................................................... 37
Develop situated structural descriptions. .............................................................. 37
Create general structural descriptions. .................................................................. 38
Methodological Rigor ................................................................................................. 38
Ethical Considerations ................................................................................................ 40
Risk and harms. ..................................................................................................... 40
Informed consent. ................................................................................................. 41
Confidentiality. ..................................................................................................... 42
Chapter III: Study Results ................................................................................................. 43
Introduction ................................................................................................................. 43
Description of Participants .......................................................................................... 43
Main Qualitative Findings .......................................................................................... 44
Safe Space ................................................................................................................... 46
Do More with Less...................................................................................................... 48
vii
Educate Us to Educate Them ...................................................................................... 50
Chapter Summary ....................................................................................................... 53
Chapter IV: Discussion ..................................................................................................... 54
Introduction ................................................................................................................. 54
Discussion ................................................................................................................... 54
A Safe Space ............................................................................................................... 54
Housing. ................................................................................................................ 55
Creation of safe spaces.......................................................................................... 56
Self-care strategies. ............................................................................................... 57
Do More With Less ..................................................................................................... 58
Poverty. ................................................................................................................. 58
Decreased access to rehabilitation services. ......................................................... 58
Educate us to Educate Them ....................................................................................... 59
Educational programming. .................................................................................... 60
Education as a CHW. ............................................................................................ 61
Implications................................................................................................................. 62
Implications for Nursing Practice ............................................................................... 63
Implications for Nursing Education ............................................................................ 64
Implications for Policy Development ......................................................................... 65
Strengths and Limitations ........................................................................................... 66
Strengths ..................................................................................................................... 66
The Descriptive Phenomenological Psychological Method. ................................ 66
Community Health Workers in Canada. ............................................................... 66
Limitations .................................................................................................................. 67
Sample for the study. ............................................................................................ 67
Experiences of Community Health Workers. ....................................................... 67
Professional experiences as a Community Health Nurse. .................................... 68
Recommendations for Future Nursing Research ........................................................ 68
Chapter Summary ....................................................................................................... 69
Conclusion .................................................................................................................. 69
viii
References ......................................................................................................................... 71
Appendix A ........................................................................................................................ 93
Appendix B ........................................................................................................................ 94
Appendix C ........................................................................................................................ 95
Appendix D........................................................................................................................ 97
Appendix E ........................................................................................................................ 98
Appendix F ........................................................................................................................ 99
Appendix G...................................................................................................................... 100
Appendix H...................................................................................................................... 102
Curriculum Vitae
ix
Abbreviations
American Public Health Agency (APHA)
Canadian Institute for Health Information (CIHI)
Community Health Nurse (CHN)
Community Health Nurses (CHNs)
Community Health Worker (CHW)
Community Health Workers (CHWs)
Canadian Nurses Association (CNA)
DPPM (Descriptive Psychological Phenomenological Method)
Emergency Department (ED)
Focal Meaning (FM)
Focal Meanings (FMs)
General Structural Description (GSD)
General Structural Descriptions (GSDs)
Health Care Provider (HCP)
Meaning Unit (MU) and Meaning Units (MUs)
Non-profit Organizations (NGO)
People Who Inject Drugs (PWID)
People Who Use Drugs (PWUD)
Situated Structural Description (SSD)
Situated Structural Descriptions (SSDs)
World Health Organization (WHO)
List of Tables
x
Table 1. Participants’ Demographic Information ............................................................ 44
Table 2. Community-As-Partner Subsystems .................................................................... 45
xi
List of Figures
Figure 1. Community-as-Partner Model ........................................................................... 26
Figure 2. Flow Chart of Data Analysis Process. ............................................................... 36
1
Chapter I: Background and Review of the Literature
Introduction
Community Health Workers (CHWs) are defined by the World Health
Organization (WHO) as community members “selected by and answerable to the
communities for their activities, supported by the health system but not necessarily a part
of its organization, and have shorter training than professional workers.” (Lehmann &
Sanders, 2007, p. 5; WHO, 1987). This definition has been further expanded to include
their ability to bridge cultural and linguistic barriers, advocate for equitable health care
services, support health promotion initiatives and ensure appropriate utilization of health
care resources (APHA, 2017; Najafizada, Bourgeault, Labonte, Packer & Torres, 2015;
Rosenthal & Wiggins, 2015). The two most commonly cited definitions of CHWs in the
literature are derived from the World Health Organization (1987) and the American
Public Health Agency (APHA) (Malcarney, Pittman, Quigley, Horton & Seiler, 2017).
As an umbrella term, CHWs are broadly defined and not considered to be health care
professionals (Lehmann & Sanders, 2007; WHO, 1987).
The APHA, in collaboration with CHWs also created an American definition
that views CHWs as trusted, knowledgeable frontline health personnel who typically
come from the communities they serve, are culturally competent, speak the language of
the community and have the ability to improve access and health outcomes (APHA,
2017; Rosenthal & Wiggins, 2015). These definitions, although different, do highlight
the importance of CHWs being trusted by community members while addressing the
specific needs of their communities (APHA, 2017; Olaniran et al., 2017; WHO, 1986).
2
In Canada, CHWs are a relatively unrecognized workforce frequently employed by non-
profit organizations (NGO) to address basic health and social needs of marginalized
populations (Bhutta, Lassi, Pariyo, Huicho, 2010; Torres, Labonté, Spitzer, Andrew, &
Amaratunga, 2014).
The term peer support worker is often used interchangeably with CHW and for
the purposes of the study requires distinction. An individual with lived experience of
substance use has the capacity to provide emotional support through their lived
experiences and are considered to be peers. The CHW can provide one on one support,
familiar with the issues, however, they also act as a bridge to connect the needs of the
broader community with the resources and policy makers (Fisher et al., 2007; Javanparast
et al., 2018). They are often involved in advocating for changes in local housing, health
and social services and “are located at the front line of government initiatives to
implement policies to promote greater community involvement” (Murray and Zeigler,
2015, p. 339).
Individuals with substance use challenges are a highly complex and vulnerable
population. Escalating illicit and prescription drug use has had a devastating effect on
communities. All levels of government struggle to address the overwhelming impact on
health, justice and the social systems. In 2017, Statistics Canada reported 3977 deaths due
to opioid overdose, a 34% increase from the previous year and twice the number of
deaths associated with car accidents (Statistics Canada, 2018). Health care costs related to
substance use are rising exponentially as a result of the increasing incidence of
communicable diseases, injury, infection and malnutrition (Islam, Topp, Day, Dawson, &
3
Conigrave, 2012; McNeil, Kerr, Pauly, Wood, & Small, 2015; Pauly, McCall, Browne,
Parker & Mollison, 2015).
As a diverse, challenging and hard to reach population, people who use drugs
(PWUD) avoid traditional health care systems (Coles, Themessl-Hunter & Freeman,
2012; Day et al., 2011). Discrimination by health care providers combined with the
complexity of navigating health systems have created barriers to receiving equitable
health care services for PWUD (Morgan, Lee & Sebar, 2015; Neale, Tompkins, &
Sheard, 2008, Pauly et al., 2015).
To address these barriers, CHWs have been employed in various ways to interface
with professional service providers, navigate complex systems and advocate for the needs
of the community. CHWs have demonstrated a unique ability to connect with at-risk
populations and positively influence decision making of individuals through education
and advocacy (Ingram et al., 2008; Spencer, Gunter, & Palmisano, 2010). The role of the
CHWs includes identification of at-risk individuals, referrals to community-based
services, outreach, home visits and working on site at neighbourhood health clinics.
Evidence suggests that walk-in, primary health care delivered by health care providers
and supported by CHWs, within a harm reduction framework, are highly effective
services for PWUD (Day et al., 2011; Islam et al., 2012).
There is an expanding body of research exploring the role of CHWs who
effectively support highly challenging and disengaged populations. The current literature
provides evidence that CHWs have an ability to create positive differences for PWUD
through engagement, education and health promotion (Torres et al., 2014, 2017). An
identified gap in the literature is how CHWs explicitly engage with and experience their
4
work with PWUD (Fernandez, Johnson, Tran, & Miranda, 2012; Sabo, Allen, Sutkowi, &
Wennerstrom, 2017; Taylor, Mathers & Parry, 2018). This study was conducted to
contribute to our collective nursing and health care knowledge regarding CHWs and how
best to support and facilitate their work with PWUD from a Canadian lens. The purpose
of this phenomenological study is to understand and describe the everyday lived
experiences of CHWs working with a vulnerable population. In turn, this will lead to a
greater understanding of the perspectives and experiences of CHWs to ultimately inform
therapeutic relationships between health care providers, CHWs and PWUD.
Review of the Literature
Currently, the literature remains focused on the roles and responsibilities of
CHWs, how they are connected to the communities in which they work, the feasibility of
integrating CHWs into formal health and social systems and the ongoing need for
training, education and support. What is relatively unknown is how CHWs experience
their everyday work. This chapter explores the literature to provide a contextual
background on substance use and PWUD, workplace challenges facing CHWs, nursing
practice and CHWs and the value of a phenomenological approach. The chapter
concludes with the search strategy undertaken and the unique perspective of CHWs
working with vulnerable populations in Canada.
Opioid use in Canada. Opioid use has had a profound effect on Canadian society
(Love, 2015; Najafizada et al., 2015). In the context of addiction, it has caused
irreparable harm to individuals and families. The overall financial costs of increased
health and social care continues to escalate in communities (Blezak & Halverson, 2018).
In 2015, the United Nations reported opioid-related deaths of 190,900 worldwide
5
(UNAIDS, 2016). In Canada, during the first half of 2018, an estimated 3977 preventable
deaths occurred (Statistics Canada, 2018). The majority of these deaths (74%) were
young men between the ages of 30 and 39 years (Carrière, Garner, & Sanmartin, 2018;
Statistics Canada, 2016). Additionally, illicit drug use has resulted in higher emergency
room visits, increased hospitalizations and continued escalation of justice, social services
and health care costs (Kwan et al., 2018). Approximately 17 people are admitted to
hospital each day in Canada due to an opioid overdose and in the past five years the
province of Ontario has been leading the country with a 73% increase in opioid related
Emergency Department visits (Statistics Canada, 2018).
People who use drugs. PWUD are often socially and economically disadvantaged,
marginalized and experience lower levels of health than the general population (Jackson et
al., 2014). They are at increased risk of soft tissue infections, endocarditis, malnutrition,
communicable diseases and injuries due to violence and are reluctant to access formal
health care systems (Islam et al., 2012; McNeil et al., 2015; Pauly et al., 2015). Due to
previous negative experiences and membership knowledge within the PWUD community,
they often fear involvement with justice and social services and the negative judgmental
behaviours from health care providers (Coles et al., 2012; Love, 2015; Strike, Guta, de
Prinse, Switzer, S., & Chan Carusone, 2014; Van Boekel, Brouwers, van Weeghel, &
Garretsen, 2013). Increasing availability of highly potent, illicit street and prescription
drugs has created a perfect storm of justice, social, economic and health issues (Belzak &
Halverson, 2018; Carrière et al., 2018; Ozano, Simkhada, Thann & Khatri, 2018). In 2015,
Pauly et al., conducted an ethnographic study, clearly identifying that illicit drug use
“intersected with poverty and homelessness” and health care outcomes were significantly
6
lower than the general population (p. 121). In addition, lower levels of income and
education increased marginalization and health disparities of PWUD (Islam et al., 2012;
McNeill et al., 2015; Najafizada et al., 2015). These barriers guide and direct the work of
CHWs as health-brokers working in a bridging capacity on behalf of marginalized
individuals and the formal, publicly funded health and social care systems (MOHLTC,
2008).
To address the ever-increasing costs associated with these significant health
conditions and challenges of caring for hard-to reach populations, policy makers are
searching for new upstream models of care (McNeil et al., 2015). Consequently, the
unique ability of CHWs to engage marginalized individuals is of increasing interest
(Morgan et al., 2015).
Community Health Workers. There are currently over 100 hundred different
global terms used to describe CHWs (Fernandez et al., 2012; Lehmann & Sanders, 2007,
Olaniran, Smith, Unkels, Bar-Zeev, & van den Broek, 2017; Sabo et al., 2017; Strachan
Källander, & ten Asbroek, 2012; Torres et al., 2014). A variety of descriptors include:
Community Support Worker; Community Outreach Worker; ‘promotores de salud’
(Spanish term for Health Promoter); Community Advisor; Patient Navigator and
Community Health Advocate (Ingram et al., 2008; WestRasmus, Pineda-Reyes, Tamez,
& Westfall, 2012).
Although diverse, CHWs share a connection to their communities, have the
potential to improve access to basic health care and positively contribute to community
development (Lehmann & Sanders, 2007). CHWs often have a deeper understanding and
knowledge of cultural complexities such as language, behaviours and other barriers to
7
achieving optimal health in their communities (Rosenthal & Wiggins, 2015). Evidence
supports the capacity of CHWs to improve outcomes in child health, especially in
developing countries, such as Africa and Asia (Glenton et al., 2013). Currently, in
underdeveloped countries, CHWs are described as respected members of the community
who volunteer to conduct home visits, assist with immunization clinics, provide maternal
and infant education programs, and care for those affected by malaria and HIV/AIDS
(van Ginneken et al., 2013). Unfortunately, reliance on volunteers to provide ongoing,
unpaid social and health services is unsustainable (UNAIDS, 2016; WHO, 1986). In
1986, the World Health Organization (WHO) investigated the failure of primary health
care systems in third world countries and were able to make recommendations to
strengthen the performance of CHWs through a better understanding of their role,
functions, and requirements for formal support. In South America, countries such as
Brazil employ over 257, 265 ‘promotores de salud’, similar to CHWs, as paid employees
of their national health care system (Black et al., 2017). They support primary care teams
as health educators and navigators in family health programs (Fausto et al., 2011;
Johnson et al., 2013).
In the United States, there are over 141,000 CHWs employed in a variety of
settings which include both public and private health care agencies, academic research
institutions and the non-profit sector (Rosenthal et al., 2011). They are considered
paraprofessionals and are often trained and hired to support specific teams involved in
mental health and addiction services, maternal health, chronic conditions, and oncology
care through a network of public and privately insured service facilities (Herman, 2011;
Ingram et al., 2008). A recent participatory action study conducted in two predominately
8
African American communities in Chicago experiencing high perinatal and infant
morbidity and mortality rates highlighted the invaluable insight provided by CHWs. They
concluded that CHWs “opened a window onto the life experiences that constitute barriers
to care and service access for low income pregnant women” (Peacock, Issel, Townsell,
Chapple-McGruder & Handler, 2011, p. 2280). Despite the growing popularity of
community-based research, CHWs can provide a valuable and essential link due to a
“high level of suspicion and distrust of university-based researchers, particularly in low-
income ethnic minority communities” (Peacock et al., 2011, p.2279). These studies
highlight the importance of considering CHWs in health education, health promotion,
prevention and research particularly with underserved populations.
In Canada, CHWs are an unregulated and non-unionized workforce lacking
formalized training or certification. Consequently, CHWs are not employed by
provincially funded health care systems but instead are often hired by non-profit
organizations (NGOs) and faith-based agencies (Torres et al., 2014). Anecdotally, CHWs
are hired at minimum wage and do not have health care benefits in their employment
contracts. The apparent lack of benefits reinforces the low value placed upon CHWs as
they remain an “under-recognized, and underutilized public health workforce” despite
their evident capacity to reduce health inequities in marginalized populations (Najafizada
et al., 2015, p. 162). Evidence suggests that the inclusion of CHWs can “complement an
overstretched health workforce” and may be a solution to ensuring basic primary health
care navigation and education for at-risk populations in our community (Olaniran et al.,
2017, para. 2).
9
Roles and responsibilities. The umbrella term of CHW encompasses a variety of
roles and responsibilities and has been in existence for the past 50 years (Kaufmann &
Myers, 1997; Lewin et al., 2005, Rosenthal, 2009). The unique ability of CHWs to
interface on behalf of marginalized individuals improves the client’s relationships with
other service providers and ultimately increases their access to additional community
resources (Allen et al., 2018). The CHWs most often function as generalists conducting
outreach, home visits, providing chronic illness support, education on family planning
and basic first aid (Lehmann & Sanders, 2007). They may receive additional training to
function in more specialized roles to provide more in-depth patient education in maternal
health, chronic disease, TB, malaria control, HIV/AIDS, nutrition or promoting the
benefit of immunizations (Allen et al, 2018; Lehmann & Sanders, 2007). The role
includes advocacy and community development, which has been shown to have a
positive impact on health care utilization as individuals are being supported and directed
to appropriate services (Ingram et al., 2008).
In the areas of chronic disease management, screening, maternal and child health,
mental health and substance use the CHWs are viewed as being highly effective as they
are trusted members of the community and therefore more engaged and able to influence
health decision making (Johnson et al., 2013). CHWs can identify emerging needs in the
community and redirect or navigate complex health networks to support at-risk
individuals (Nemcek & Sabatier, 2003; Spencer et al., 2010). It is important to note that
the role of CHWs is not to provide clinical care nor to replace other health care providers,
but rather to complement services being delivered by formal health care systems.
10
In working with at-risk individuals, CHWs also improve overall long-term health
outcomes through their case management skills (Kangovi et al., 2017; Nemcek &
Sabatier, 2003). Morgan, Lee, and Sebar (2015), conducted a qualitative ethno-
methodological research approach using narratives and field notes of Australian CHWs
working with PWUD. The aim of this study was to understand the work of CHWs, the
unique skill set they possessed and “how it distinguished them from other health care
occupations” and how CHWs were distinct from other health care providers (Morgan,
Lee & Sebar, 2015, p. 382). The CHWs were cited as having “specific community
language, membership knowledge, values and behaviours” that fostered transparent,
genuine interest and support of PWUD to participate in health care consultations (Morgan
et al., 2015, p. 388).
Logan (2018) conducted a participatory action study involving six CHW.
Through photography the CHWs uncovered their work-related experiences and several
key themes emerged as participants displayed, interpreted and “co-constructed their lived
experiences” (Logan, 2018, p. 132). The study concluded that areas of concern were
legitimacy and an ability to navigate systems to provide resources for the populations
they served. The potential for CHWs to meaningfully contribute to research studies was
also not recognized by other health care professionals and further diminished the CHWs
feelings of inclusion.
Community connectedness. The value of community connectedness was
repeated throughout the literature. In 2007, Lehmann and Sanders stated that CHWs are
“carefully selected” by the community (p. 5). Through this process, people trust that
their needs are being genuinely represented by CHWs. When the community endorses
11
and supports CHWs, an unspoken permission is provided to the most vulnerable
members of that community to interface with CHWs to support their needs in a
meaningful way (Coles et al., 2012; Lehmann & Sanders, 2007). Community trust and
improvements occur over time through CHW relationship-building (McCollum, Gomez,
Theogald & Taegtmeyer, 2016).
Community Health Workers “typically share backgrounds, language, and a
cultural identity” with their clients, which allows them to be particularly effective in the
areas of advocacy, system navigation, education and addressing the social determinants
of health (Komaromy et al., 2017, p. 204). Unique and on-the-street knowledge of
community needs, available resources and shared life experiences provide CHWs with
the ability and knowledge to develop and create cultural affinity with community
members, particularly low-income and minority groups (Brownstein et al, 2007; Islam et
al., 2014). The ability to provide cultural mediation as it relates to appropriate health
education, service provision, informal counselling, advocacy and social support
demonstrates their capacity to more broadly support their community as well as
individual members. (Rosenthal, Wiggins, & Brownstein, 1998).
As members of the community they represent, CHWs share “a common language,
ethnicity, socioeconomic status, or life experience” which then allows them to act as
“language brokers between their own community and systems of care” (Love et al., 2004,
p. 418).
Cook and Wills (2006) explored the phenomenon of CHW experiences and
approaches with marginalized populations through a descriptive exploratory study of 10
CHWs employed in seven boroughs in London, England. The findings demonstrated that
12
if the CHWs were not from the community they served or were in some way formally
associated with the local health authority their ability to engage with vulnerable
populations was significantly reduced and they were subsequently viewed as being
outsiders. This was confirmed in a British participatory action study by, Murray and
Zeigler (2015), through narrative accounts of twelve CHWs who revealed that a lack of
belonging to the community led to “tensions in their everyday practice” as they
attempted to balance demands of management and expectations of community (p. 338).
Financial compensation. Legitimacy and financial compensation of the CHW
role continues to be challenging. In developing countries there is heavy reliance on
volunteerism and community donation studies have indicated that this is unsustainable
due to attrition rates of 3.2% to 77% and is an area for future research (Sen &
Bhattacharyya, 2001; Haines, et al., 2007; Winch, 2005). In the United States and United
Kingdom there are specific legislated job categories that authorize reimbursement for
CHW services (Balcazar, & George, 2018; Sprague, 2012). Formal job descriptions,
competencies and a system of accreditation creates legitimacy and improves financial
compensation for CHWs (Rosenthal et al., 2011). Appropriate funding mechanisms that
recognize and compensate CHWs are essential if they are to be more formally integrated
into the broader health system. In Canada, the number of CHWs remains relatively
unknown due to the lack of a standard employment category with the exception of health
liaison workers who work with First Nations populations (Najafizada et al., 2015). There
are currently, over 1,000 health liaison workers facilitating health care in First Nations
and Inuit communities, the majority of whom are women (Rosenthal et al., 2010).
Traditional financial benchmarks focus on hospital visits, length of stay,
13
prevalence and incidence rates while the social and community benefits are not as easily
quantifiable. When decision makers take responsibility for the health of their community
and value participation and flexible programming, as components of care rather than
alternatives to care, there are many positive benefits (Lehmann & Sanders, 2007;
Najafizada et al., 2015; Walker & Jan, 2005). Valuable contributions can be made by
CHWs within both acute and community settings, however, as a workforce they cannot
be viewed as “a cheap option to provide access to health care for underserved
populations” as unrealistic expectations and a lack of training and supports will lead to
program failure (Lehmann & Sanders, 2007, p. 5).
CHW education, training and support. To improve legitimacy there has been a
recent trend to move toward licensure and more formalized training of CHWs (Torres et
al., 2017). There are inconsistencies and wide variations in the length of more formalized
CHW training, ranging from a few hours to several months as well as on the job
requirements, which are often dependent on the complexity of the position and the needs
of the community (O’Brien, Squires & Larson, 2009; WHO, 1987). The training and
education available for CHWs varies broadly and may include community college
programming, on-the-job training, as well as specific certifications (Kash, May, & Tai-
Seale, 2007). In Canada, CHWs are not formally recognized resulting in a lack of career
paths and only episodic employment opportunities available to them (Torres et al., 2017).
Their “social location within the health care systems in Canada” has created challenges
14
for CHWs, who are often providing care and support in the periphery (Torres et al., 2017,
p. 533).
To facilitate confidence and support the uptake of CHWs there is a requirement
for increased competency-based education and training (Love et al., 2015; Duthie,
Phillippi, & Shultz, 2013; Lang et al., 2011; Barnett, Lau, & Miranda, 2018).
Unfortunately, this issue is compounded in Canada by the lack of recognized licensure or
accreditation structures for CHWs.
To develop educational programming for CHWs the training must be congruent
with the principles of adult learning. As experienced adult learners the literature
recommends course work that is flexible with options for distance and online educational
opportunities. In addition, the relevant practical skills should be case based and supported
by a strong mentorship model (Barnett, Lau, & Miranda, 2018). The literature highlights
the importance of including education on mental health, addiction, recovery and
treatment of substance use disorders, obesity prevention, cardiovascular and diabetes
management, palliative care and maternal-child health. Harm reduction strategies and
trauma-informed care are foundational to most training programs that target at-risk
populations who use substances (Love et al., 2015). Barriers to education highlighted by
CHWs most often relate to cost, travel, poorly defined roles or reservations that course
work will not be beneficial due to “formal lectures and dense written teaching materials”
(Kangovi, Grande, & Trinh-Shevrin, 2015, p. 205).
Understanding the motivation to become a CHW can guide the development of
educational programming. In 2014, Maes, Closser and Kalofonos, conducted three
ethnographic studies in —Ethiopia, Pakistan, and Mozambique that outlined why CHWs
15
were interested in working in their communities. The participants revealed that as a CHW
their work would allow them to address their own and others’ life circumstances and
hardships in addition to providing them with an opportunity to inform key decision
makers regarding inequities faced by marginalized populations.
It is important to recognize that many CHWs have lived experiences very similar
to their clients and are at risk for “emotional exhaustion, burnout, stress or secondary
trauma” (Barnett, 2018, p. 199). They are often women working in a lower wage capacity
further increasing their personal vulnerability (Torres, 2014). For these reasons, the
recommendations in the literature suggests that training or educational programming also
support emotional self-care and relaxation strategies, mindfulness and mental health
education (Barnett, 2018).
Community Health Workers and the health care system. The feasibility of the
CHW role has been reviewed extensively in the literature (Fawcett, Neff, Decker &
Faber, 2018; Felix, Mays, Stewart, Cottoms & Olson, 2011; Nemcek & Sabatier, 2003;
Peacock et al., 2011; Perez, Finley, Mejia & Martinez, 2006; Rosenthal et al., 2010;
Walker & Jan, 2005). Governments continue to struggle to reduce health care costs,
improve population and primary health prevention strategies, decrease acute care
admissions and narrow the rural-urban health gap (Javanparast, Baum, Labonte &
Sanders, 2011). Globally, the three main drivers of escalating health care costs are
“economic, societal and demographic” (Love et al., 2004, p. 419). The economic drivers
are related to the shortages of health care providers, increased salaries, cost of over-time
hours and the slow devolution of health care tasks from physicians and nurses to
paraprofessionals, lay providers as well as family members taking on these
16
responsibilities (Balcazar et al., 2011). Societal drivers emphasize the need to implement
upstream prevention and primary care initiatives and community rather than hospital-
based services. These factors are changing societal norms and our health care
environment while challenging traditional service delivery models. Finally, the
demographic driver, is the result of high-income countries experiencing a downward
trend in populations and in response changing their restrictive immigration policies.
There is a willingness to support the entry of diverse racial and ethnic groups resulting in
populations that require health systems to be more inclusive in providing linguistic and
culturally appropriate services (Balcazar et al., 2011).
From a purely fiscal standpoint a renewed interest has emerged in the feasibility
of utilizing CHWs in health and social systems. Oliver et al., (2015) conducted a study
that highlighted the skill set of CHWs through a structured, in-depth qualitative case
study of two communities in the U.K., one urban and one rural, that explored the roles
and day-to-day practices of CHWs “in their own words” (p. 4). Fourteen CHWs were
interviewed and the authors concluded that although the CHW’s described themselves as
health care generalists, they were involved in referrals, monitoring, reporting and
educational interactions despite having limited resources and training. There was a
consensus that programs co-designed with CHWs would be “easier to implement because
of their relevance to their practices and experiences” whereas those programs that sought
out CHWs to implement external priorities were much less likely to be successful (Oliver
et al., 2015, p. 1).
There is feasibility data coming from acute care facilities in relation to CHWs.
American researchers Lin et al., (2017) conducted a randomized controlled study at a
17
large urban medical centre that identified 72 clients frequently seen in the ED. The
patients were randomized to either a CHW or standard ED care. Over a 7-month time
frame there was a 35% decrease in the number of times they visited the ED and 31%
reduction in overall hospital admissions (Lin et al., 2017). Coordinating care with CHWs
in high cost acute care areas is a promising approach to reduce costs and hospitalizations
in addition to potential improvements in client satisfaction and health decision-making
(Lin et al., 2017; Martinez, Ro, Villa, Powell & Knickman, 2011).
A Canadian perspective. Over the past twenty years the Canadian health care
system has focused on disease prevention and programs that target health behaviours, the
social determinants of health and importance of community empowerment (Public Health
Agency of Canada, 2007). When CHWs are recognized as team members, there is a
reduction in health disparities experienced by highly marginalized populations such as
First Nations, homeless persons and those individuals living with substance use and
mental health challenges (Fawcett et al., 2018; Rosenthal et al., 2010; Torres et al., 2014).
Torres et al., (2017) points out that the “principle behind policy change is to advance an
agenda that connects social justice and transformation of health care systems, including
making CHWs a visible workforce” (p. 536). Policies that “facilitate improvement of
health equity by valuing CHW experience-based expertise” would highlight the
importance of the social determinants of health and overall health of our communities
(Torres et al., 2017, p. 538).
In Canada, CHWs remain a relatively unrecognized workforce, often employed in
non-profit agencies with underserved groups (Torres et al, 2014). The vulnerable
populations they support face many barriers in accessing equitable health care including
18
lower levels of education and literacy, language and cultural differences, social isolation,
poverty, discrimination, substance use and mental health challenges (MOHLTC, 2008).
The ability of CHWs to advocate, educate and support individuals and families positively
impacts the primary health care needs of this population (Trinh-Shevrin, Islan,
Nadkarnie, Park & Kwon, 2015).
As in many other countries, there is growing recognition of the value of CHWs,
however, the designation, training and linkages to our health care system are sporadic.
Canadian “evidence on CHWs is slowly emerging in the academic literature but often
remains located in grey literature” (Torres et al., 2014, p. 76). Community Health
Workers are often employed by independent NGOs and sporadically integrated into
publicly funded health care systems. In planning collaborative partnerships, it is
important that all stakeholders recognize the importance of having CHWs who are
“driven, owned by and firmly embedded in communities themselves” (Lehmann &
Sanders, 2007, p. 26). As an unregulated and informally organized workforce they
continue to struggle in their ability to be recognized. The CHWs in Canada, although
essential, remain somewhat hidden and invisible in our communities, which in turn limits
their potential (Rosenthal & Wiggins, 2015). Najafizada et al. (2015), conducted a
scoping review of 68 sources of interventions involving CHWs and concluded that they
were an under-recognized and underutilized public health workforce despite having the
capacity to reduce inequities in marginalized populations in Canada. The authors
recommended more thorough “mapping and investigation of the CHW landscape” and
clarity regarding their scope of practice (Najafizada et al., 2015 p. 162).
19
Nursing Practice and Community Health Workers
Although the current literature focuses on the CHWs roles, responsibilities,
efficacy, training and education from a fiscal or policy point of view. There is an
abundance of peer reviewed articles and studies to support the development of alternative
community-based models of primary health care especially in high risk groups such as
those who use illicit and prescribed substances (Coles et al., 2012; Cosgrove et al., 2014;
Lin et al., 2017; Olaniran et al., 2017; Treloar & Abelson, 2005). The ability of CHWs to
reach out and interface directly and effectively with high risk groups may provide a
solution. The lived experiences of CHWs will build upon nursing knowledge and provide
foundational information regarding the perspectives of this specific group of community-
based health providers.
Today, with escalating costs of providing health and social care to PWUD, there
is an emphasis on upstream health care prevention and promotion strategies. As key
decision makers and health care providers we are tasked with exploring new community-
based service models (Islam et al., 2012). There is also a renewed interest in the role of
CHWs (Rush, 2012). It has been demonstrated in the literature that CHWs, through their
ability to broker and interface between systems for clients, positively impacts health
outcomes and complement service delivery nursing practice (Lehmann & Sanders, 2007;
Matsumoto et al., 2017; Torres et al., 2014). With increasing awareness of the value and
unique ability of CHWs to engage PWUD, nurses are presented with an interesting
opportunity to add to their current knowledge and understanding of CHWs and how best
to support and facilitate their work within the context of community health nursing.
20
Phenomenology and the Literature
The primary research question was to describe the lived experiences of CHWs
working with PWUD. The accounts of everyday lived experiences of CHWs are rare and
fragmented with limited literature on their practices and perspectives. The Descriptive
Phenomenological Psychological Method (DPPM) is appropriate when little is known
about a phenomenon to uncover the meaning of lived experiences (Giorgi, 1997, 2009).
The “situations to be described are selected by the participants themselves and what is
sought is simply a description that is as faithful as possible to the actual lived-through
event” (Giorgi, 2009, p. 96). The use of the DPPM to investigate this phenomenon of
interest will enhance our understanding of CHWs experiences working with PWUD.
Search Strategy
To address this research, question a comprehensive review of the literature was
undertaken in four databases including CINAHL Full-text, PubMed, PsycInfo and
SocIndex. Relevant keywords and database subject headings were brainstormed from the
research question to include the concepts of “Community Health Workers,” “experience,”
and “vulnerable populations.” These terms were combined to create search strategies for
the databases (Table 1). The inclusion criteria required that the publications be available
as an abstract and in full text through the university library services or by contacting the
author, were peer reviewed and in the English language. The titles had to include the
keyword “Community Health Worker.” A date restriction was applied to only include
articles published from January 2000 to July 2019. Publications that were disease
specific, involved volunteerism or reviewed programs in developing countries were
21
excluded. A review of the grey literature was also conducted through Google Scholar,
related textbooks, known research projects and through hand referencing.
The search identified a gap in evidence-based research studies that addressed the
topic of interest. However, it did provide a very rich description and worldview of CHWs
working in different countries, in a variety of settings with distinct populations (Olaniran
et al., 2017).
Conclusion
A comprehensive literature review revealed limited research available on lived
experiences of CHWs working with PWUD. Exploring the lived experiences of CHWs
working with people who use drugs in Saint John – New Brunswick through a descriptive
phenomenological method was deemed appropriate to add to our current knowledge and
understanding of CHWs from a Canadian perspective and how best to support and
facilitate their work within the context of community health nursing.
The roles and contributions of CHWs are as varied as the terms used to describe
their work. They are found in isolated villages and in densely populated cities around the
world; yet there are similarities in that they are directly connected and committed to
creating a positive difference in the lives of their community members. The opioid crisis
has negatively impacted communities and resulted in PWUD living with significantly
increased risks of substance use related injuries, such as both communicable and blood-
borne viral infections (Islam et al., 2012). The lives of PWUD are often complicated by
homelessness and exacerbated by poor nutrition, mental health issues, violence,
exploitation and chaotic substance use (Islam et al., 2015; Pauly et al., 2015). Health care
and social systems are overwhelmed with the downstream costs both in acute care
22
facilities as well as justice and social services. The discrimination and stigmatization
experienced by PWUD creates distrust of formal systems and barriers to receiving
equitable care. CHWs share a common language, cultural affinity and understanding of
the life circumstances of PWUD and have the unique ability to develop trusting,
therapeutic relationships. Because of the limited literature available on the topic of
CHWs and their experiences with PWUD, there is relevance in exploring CHWs’
perspectives. The findings from this inquiry contribute in a meaningful way to our
collective community health nursing knowledge to enhance, support and facilitate CHWs
in their work with PWUD.
23
Chapter II: The Research Method
Introduction
The purpose of this study was to explore the lived experiences of CHWs working
with PWUD. A qualitative descriptive phenomenological method developed by Giorgi
(1970) was used to design the study and describe the meaning of these experiences. It is
an appropriate methodology when little is known about the phenomenon of interest to
enhance understanding of “the way in which the phenomenon is experienced within the
context in which the experience takes place” (Giorgi & Giorgi, 2003, p. 27).
In this chapter I provide an overview of the philosophical assumptions, research
study design, materials and methods, data collection, documentation and process of
analysis. In addition, I employed the Community-As-Partner model, which will be
reviewed, as it is a framework often utilized by Community Health Nurses (Vollman,
Anderson & McFarlane, 2004). As a novice researcher the intent of this study was to
acquire new knowledge and practical guidance to facilitate more collaborative,
interdisciplinary primary health care partnerships with CHWs through a deeper
understanding and appreciation of their lived experiences. The primary interview
question underlying the study was “Can you describe to me in as detailed a way as
possible your experiences as a Community Health Worker working with people who use
drugs?”
Philosophical Assumptions
The first step in the research process is formulating a research question.
According to Creswell (2013) this requires that the researcher initially reflect upon their
own personal philosophical assumptions or beliefs that are “deeply rooted in our training
24
and reinforced by the scholarly community in which we work” (p. 19). Thoughts and
values influence how we behave, articulate ideas, communicate and behave with one
another and therefore self-awareness is essential as a starting point in the research
process. Being reflexive and self-aware will enhance my ability to describe the lived
experiences of CHWs through a phenomenological lens (Giorgi, 2009).
In undertaking a qualitative study there are four philosophical assumptions
required by the researcher which include ontological, epistemological, axiological and
methodological beliefs (Creswell, 2013). Ontology refers to the nature of reality and in
conducting phenomenological research I will be reporting and describing the experiences
of CHWs from their reality and perspectives (Moustakas, 1994).
Epistemology is defined as the theory of knowledge and how this new knowledge
is acquired and justified (Guba & Lincoln, 1988). Phenomenology aligns with nursing
epistemology as I will be coming to know the lived experience of CHWs through
personal interactions, using quotes to support the findings rather than examining separate
parts of an individual to be measured, verified and validated (Giorgi, 2012).
Axiology refers to the role of values which is acknowledged within the research
and is openly discussed (Creswell, 2013). The participant’s values will be honored and
through the phenomenological reduction process and bracketing, I will recognize and
endeavor to set aside personal biases throughout the research process.
Methodology is the process of research to be used. In this study, I will be using an
inductive phenomenological approach with the interview as the primary method to
collecting data. The worldview is social constructivism whereby individuals grow and
25
develop through subjective experiences and their interactions and experiences (Giorgi,
2012).
Phenomenology is both a philosophy and a qualitative investigative approach to
explore lived experiences that both describe and interpret first person experiences which
include thoughts, imaginings, perceptions, memories and emotions (Dowling 2007;
Giorgi, 2009). Edmund Husserl (1859-1983) a philosopher and mathematician, believed
in the scientific validity of phenomenology and that all experiences or essences, whether
real or imagined, were intentionally directed (Giorgi, 2008b). An example is the emotion
of love; it is directed towards a person, an object, idea or something that no longer exists.
This emotion and experience of love does not exist in isolation it must be intentionally
directed (Giorgi, 2009). Martin Heidegger (1889-1976) influenced phenomenology
further by going beyond mere description to exploring the core concepts and hidden
meanings of the narratives of everyday life, known as hermeneutics (Lopez & Willis,
2004). At the same time, philosopher Maurice Merleau-Ponty (1908-1961) began to
highlight the importance of mind-body connections and that the processing of subjective
experiences required the use of multiple senses (Merleau-Ponty, 1962).
Phenomenology evolved and the core concepts, hidden meanings and subjective
experiences contributed to the foundation of a growing body of philosophical literature in
support of phenomenology however, method or meaningful clinical application was not
yet fully developed (Giorgi, 1970). Consequently, throughout the early 20th century,
phenomenology struggled for recognition as a natural science as researchers were
compelled to use more traditional, quantitative, empirical scientific approaches to study
human experiences. With the tragedies of World War II and the Holocaust, there was a
26
renewed interest by the academic community to support research in the area of human
psychology (Smith, 2010). In 1962, the Department of Psychology at Duquesne
University initiated their doctoral program in existential-phenomenology and a young
psychologist, Amedeo Giorgi, joined the faculty.
Community-As-Partner Model
Community-As-Partner is a theoretical model comprised of concepts and
statements that provide us with a view and approach to working in the community. The
Community-As-Partner Model, with an underlying philosophy of multidisciplinary
primary health care and public participation, anchors the CHWs narratives into the
language of nursing. This framework fits well with the many real-life aspects of health
while incorporating both “long-range goals and planning” often undertaken by CHWs
(Vollman, Anderson & McFarlane, 2004, p. 190).
Figure 1. Community-as-Partner Model
At the core of the community are members with their culture, beliefs, values, stories, histories and all of
their colorful and unique characteristics.
Communication
Recreation
Physical Environments
Economics
Education
Safety & Transportation
Health & Social Services Politics & Government
27
Community assessment. In this model, people who make up the community are
at the core surrounded by eight subsystems representing the broad determinants of health,
physical environment, education, safety and transportation, politics and government,
health and social services, communication, economics and recreation. (Figure 1). As a
framework, each system is connected to the other; they are not “discrete and separate but
influence one another” (Vollman et al., 2004, p. 193). With time, the community has a
normal level of health and a buffer zone, allowing for temporary responses to stressors as
a result of a disruption in the health of the community. In the descriptive interviews of
this research, the participants clearly articulated their concerns regarding the degree of
reaction or disruption caused by community stressors such as limited social services,
inequitable health care and lack of safe, affordable housing.
Physical environments. The physical environments include an assessment of a
community that is accomplished through careful observation and review of relevant
statistical data and includes incidence and prevalence of health conditions, population
age, gender, mortality and morbidity rates. An in-depth understanding of the geography,
air quality, housing stock, green spaces and community systems is also helpful.
Education. The general educational status of a community is dependent upon the
availability of schools, colleges, universities and local programming. Formal and
informal education and training in Saint John is supported by institutions, systems,
provincial and federal governments and by organizations and non-profit agencies.
Economics. Economic assessment includes aspects of the goods and services in
the community that may include household income levels, occupations, major employers,
28
and rates of employment. In addition, the number of lone parent households, seniors and
child poverty rates should be considered.
Politics and government. A cornerstone of a civilized society is the development
of acceptable behaviours, rules and regulations to provide necessary structure and
coordination of services for the community. This may include facets of economic
balance, policy and legislation, organized labor, social systems and availability of
resources.
Safety and transportation. The category of safety and transportation relates to
the ability of community members to safely move in and across boundaries. This includes
public and private transportation and the protective services of police, fire, ambulance
and first responders. Overall, safety is a constant concern for populations living in
priority neighbourhoods. High levels of crime, violence, trauma, abuse, overdose and
exposure to communicable diseases occur in areas with greater incidence of poverty,
especially those involved in drug and sex trades.
Health and social services. This is a broad category that encompasses all aspects
of social and health care services including accessible and equitable care and services.
Communication. Communication may be both formal and informal with the
more formal lines of communication including social media, newspapers, radio and
29
television. Informal communication is subtle and includes conversations and colloquial
language and hierarchies within the community, larger groups or organizations.
Recreation. Recreation assesses activities that assist members of the community
to maintain or increase their mental, social and physical health needs. It is essential that
there be safe, accessible recreational opportunities for all ages in the community.
Methods and Materials
The application of the methods and materials used for the study are discussed in
the sections below and include details on the study design, Community-As-Partner
Model, recruitment and sampling, ethical considerations, risks and harms,
methodological rigor and concludes with informed consent.
Study Design Giorgi recognized the importance of the study of subjective
psychological perspectives and that phenomenology as a human science requires a
systematic, methodical and critical approach (Giorgi, 1985, 1997). In 1970, Giorgi
developed the Descriptive Psychological Phenomenological Method (DPPM) which
involves assuming the phenomenological attitude, searching for and describing the
essence of the phenomenon (1970, 1985, 2009). The DPPM is a systematic and rigorous
five-step process that begins with participant interviews to elicit in-depth and insightful
descriptions of subjective experiences (Giorgi, 1985, 2009). As a psychologist and
qualitative researcher, he developed his method so that other disciplines could frame
phenomenon of interest through their disciplinary lens using various theoretical models.
As with every method there are strengths and challenges; Giorgi has published
30
extensively on this topic while vigorously defending the validity of DPPM (Giorgi, 1985,
1992, 2002, 2012).
The empirical scientific method has been considered the highest form of acquiring
knowledge; however, it is not perfect, especially when applied to the study of human
experiences, motivations, and behaviours. Quantitative research methods involve
measurements, numerical data and statistical analysis as in large double-blind
randomized controlled studies applied to the general population. In contrast, qualitative
research methods are focused on a deeper knowledge and understanding of human
experience through narrative descriptions and interpretation with smaller numbers of
participants. Each methodology has unique features that make it relevant to the research
question and topic of interest. The methodology developed by Giorgi provides the
researcher with the subjective perspective of the participant, which includes their
reactions, thoughts, memories and feelings (Giorgi, 2009; Giorgi, Giorgi & Morley,
2017).
The following are considered strengths of the DPPM:
(1) in-depth, one-on-one interviews with participants using an open-ended
question format allows for the descriptions to emerge without interference by the
researcher (B. Giorgi, 2011; Giorgi, 2009).
(2) Assuming an attitude of scientific phenomenological reduction ensures the
researcher is authentically present and open to receiving the data without bias
(Giorgi, 2012; 2014).
31
(3) Theoretical models from other disciplines allow researchers from other human
and social sciences an opportunity to use the methodology more broadly and view
lived experiences from their specific disciplinary lens (Giorgi, 2017; 2009).
(4) The model reflects the voice of the participant and lived experiences exactly as
they describe it (Giorgi & Giorgi, 2003).
Giorgi (2007) published “Difficulties Encountered in the Application of the
Phenomenological Method in the Social Sciences” in which he critiqued six
phenomenological dissertations, including three from the nursing discipline. He provided
practical suggestions for improvement despite the challenges in applying the
methodology and was supportive. He recommended that it takes time and experience to
develop proficiency and stated that “the solution is not to drive the researchers away,”
rather it would be more beneficial “to encourage them to apply the scientific
phenomenological method in a better way.” (Giorgi, 2007, p. 3).
Recruitment and sampling The study took place in the city of Saint John, New
Brunswick, the oldest incorporated city in Canada. Located on the shores of the Bay of
Fundy, the city has a metropolitan census of 126,202 residents (Statistics Canada, 2017).
It has a long history of mental health services, having been the site of the first psychiatric
facility in British North America (Goss, 1998). As a port city, it has a dense uptown core
which is considered a priority neighbourhood experiencing higher rates of crime,
homelessness and child poverty (Human Development Council, 2017). There are
currently 24 non-profit community agencies in the uptown area and eight key
organizations that provide support for PWUD. These agencies are comprised of shelters,
community food baskets, clothing depots, sexual health clinic and a mental health
32
recovery centre (Appendix A). Recruitment was facilitated by the Executive Directors of
key Saint John non-profit agencies who were contacted to gauge their interest in the
study. A Participant Recruitment Poster was offered to them to be posted on a bulletin
board on site or provided to staff electronically at their discretion (Appendix B). It
allowed participants to communicate with me directly to ask questions, request additional
information or indicate their desire to enroll in the study. On the day of the interview I
met with the participant to review and sign the consent form (Appendix C), answer
additional questions and complete the Demographic Information Sheet (Appendix D).
The demographic information provided descriptive information and demonstrated
transferability of the findings for others who live the same experiences as the study
participants.
In DPPM the sample size may vary from five to twenty-five participants (Aquino-
Russell, 2003; Creswell, 2013; Lovi & Barr, 2009). The focus of the methodology is to
gather rich and descriptive data, capture themes and patterns, while ensuring with
“certainty and confidence that the analysis is strong and the conclusions will be right”
(Richards & Morse, 2013, p. 223). It is recommended that there be a minimum of three
participants to ensure variation as it is the “number of instances of the phenomenon that
are contained in the descriptions” that are essential, rather than data saturation (Giorgi,
2009, p. 198).
A convenience sample of four CHWs were recruited through purposive sampling,
representing agencies working with PWUD. Purposive sampling is defined as the
inclusion of participants “who know the information required" and it is done with
purpose (Richards & Morse, 2013, p. 221). Four eligible participants voluntarily agreed
33
to participant in this study. All participants met the inclusion criteria: (a) were 19 years of
age or older and employed in the role of a CHW for at least one year by a Saint John non-
profit organization; (b) interfaced with formal services on behalf of PWUD; (c) English
literacy skills (ability to read and write English) and (d) willing to provide a written
consent to participate in the study.
Data Collection
Data collection included four in-depth semi-structured interviews that were
conducted between May 28 and May 30, 2019 at a time and location that was mutually
agreed upon and convenient for the participants. All four participants agreed to have their
interview recorded, although I offered to take notes or alternatively allow them to provide
me with their personal written responses to the primary research question. It is
understood that the collection of the interview data was essential to the research process.
The method is implicit that to ensure validity the researcher must respect and
analyze the lived experiences that are shared, described and believed by the participant to
be true and this was done accordingly (Giorgi, 2002). Giorgi’s phenomenological method
allows the researcher to have an in-depth interview with participants by asking them to
respond to an open-ended statement, without interference from the researcher (Giorgi,
2009). My role as the researcher was to be authentically present and actively listen
allowing participants to tell their story in their own way (Giorgi, 2009).
The interview process. Beaverbrook House was offered as a potential interview
venue option as it is centrally located with readily accessible parking. Two of the four
participants opted to be interviewed at Beaverbrook House while two preferred a private
office at their agency location. Once the venue had been agreed upon the interview was
34
set on a date and time that worked best for the participant’s schedule. Every effort was
made to ensure their comfort they were offered refreshments in the form of water and
unsweetened fruit juice. A pen and paper were placed within reach of participants to draw
or write down ideas, convey a message or provide any additional information during the
interview, which lasted approximately 60 to 90 minutes.
The interviews began with a question to elicit concrete descriptions of the CHWs
experiences and the “situation in which the phenomenon that the researcher is interested
in has taken place” (Giorgi, 2009, p. 96). The primary interview question as stated
previously was: “Can you please describe to me in as detailed a way as possible your
experiences as a Community Health Worker working with people who use drugs?” My
role as the interviewer was to “direct” the participant rather than lead their responses
(Giorgi, 2009, p. 123). Although Giorgi suggests that the “instrument for gathering
research data is a single sweeping question”, he also acknowledges that common sense is
important throughout the interview as participants may be hesitant to speak or may go
completely off topic (p. 123). According to Giorgi it is perfectly acceptable to gently
redirect the participant “back to describing himself or herself in the situation that is being
focused upon” (Giorgi, 2009, p. 122). Participants were gently redirected by asking, for
example, the following question, “Previously you described situation XYZ, I would like
to know more about that experience?” (Appendix G)
One of the challenges with face-to-face interviews is that they are a very personal
experience and there may be times that participants may not be comfortable in sharing
their personal experiences with the researcher (Elmir, Schmied, Jackson & Wilkes,
2011). A nonjudgmental attitude and demeanor is essential to provide the participants
35
with an open and supportive environment in which to share their experiences (Morecroft,
Cantrill & Tully, 2010). It is understandable that at times individuals may not feel
talkative and their interviews may vary in length, however, all participants communicated
well throughout the interviews and all were completed. At the conclusion of the
interviews participants were asked if they had anything further, they would like to
include. Whether the participant withdrew or completed the interview they were to be
provided with a signed copy of their informed consent and the $40 honorarium.
Giorgi recommends but does not insist that the researcher rewrites the text from
first to third person and personally transcribes all interview materials (Giorgi, 2011).
Each interview was transcribed verbatim from the electronic audio-recordings. Each
participant was assigned a unique identifier to label their interview notes in my research
journal, transcript, Demographic Information Sheet and audio-recordings (Appendix H).
Data Analysis
Validity of the method is supported by the accurate descriptions provided by the
participants and is simply whatever has been subjectively experienced, neither right nor
wrong (Giorgi, 2009). Giorgi (2009) asserted that “every single description is going to be
different from every other” (p. 132). The researcher reads and re-reads the transcripts,
reflects and may pause and return to the phenomenon of interest and viewing the data
from different perspectives, a process that respects the circular nature of the method. The
five steps of analysis and synthesis include: (1) Sense of the Whole (2) Determine
Meaning Units (3) Identify Focal Meanings (4) Develop Situated Structural Descriptions
and (5) Create General Structural Descriptions (Figure 2).
36
Figure 2. See Flow Chart of Data Analysis Process.
Reduction
the researcher
assumes the
attitude of
phenomenological
reduction
Interviews are conducted to
obtain a rich
description of their
lived experiences
working with
PWCD.
1. Sense of the
Whole this step requires
that the researcher
reads and each
transcript several
times to understand
the CHWs
experiences.
5. General
Structural
Descriptions requires the
collation of all the
SSDs to create
generalized
descriptions
3. Identify
Focal Meaning the words of
participants are
transformed into the
language or
expressions of the
researcher’s
discipline.
2. Determine
Meaning Units by re-reading each
transcript and
making slashes in the
text it will indicate
shifts and different
meanings in the lived
experiences.
4. Situated
Structural
Descriptions imaginative variation
is used to develop
focal meanings and
synthesize situated
structural
descriptions.
37
Sense of the whole. In the first step, I read and re-read the individual transcripts
while assuming an attitude of scientific phenomenological reduction. The attitude is a
distinct feature that requires that I be open to the data exactly as it was submitted by the
participants; a pure view without judgement. I was required to be fully present and
immerse myself into the world of description while suspending or “bracketing” any
preconceived ideas or assumptions and remain open and sensitive to the data (Giorgi,
2012). The task of bracketing required thoughtful reflection and the putting aside of my
theoretical knowledge and experiences with the phenomenon to ensure that I was not
introducing bias into the data through personal beliefs, assumptions or emotions.
Determine meaning units. To determine meaning units (DMU) I reviewed the
transcribed data while determining if there were any significant shifts in meaning within
the descriptions. This did not mean only reviewing the text contained in single sentences,
rather it required that I had an openness to viewing the transcripts as there were many
meanings embedded or threaded throughout several lines or sections of the text. I made
slashes in the transcription to indicate changes in meaning (Giorgi, 2009).
Identify focal meaning. The identification of Focal Meaning (FM) is the most
labor-intensive step in the process where the words of the participants were transformed
into expressions or language within the nursing discipline. Each meaning unit was
analyzed to draw out or elaborate upon the nursing implications of the descriptions as a
focal meaning. The framework of the Community-As-Partner model placed the
descriptions firmly into the discipline of nursing.
Develop situated structural descriptions. The fourth step required that I review
and synthesize each participants’ focal meanings to produce situated structural
38
descriptions (SSD). This process was enhanced through the process of imaginative
variation whereby focal meanings were freely pondered and “reflected upon from every
angle” (Giorgi, 2009, p. 89). Throughout the process I searched for the essence of the
experiences or unchangeable meaning of the phenomenon, to bring structure to the data
and grasp the intent of how the experience was understood from each participant’s
perspective (Giorgi, 2008a). The entire process was fluid and circular as the information
was reflected upon, read, re-read and moved as new meanings emerged and were created.
Create general structural descriptions. Synthesis was the final step in the
Descriptive Phenomenological Psychological Method (DPPM) and required a collation of
the SSD in the creation of the general structural descriptions (GSD). The details of
everyday perspectives were not highlighted; rather the intent was to provide an overall
generalization of the experiences. The GSD were produced from the analysis-synthesis of
the descriptions as viewed from the lens of the Community-As-Partner Model (Vollman
et al., 2004). These emerging themes are made apparent and explored in more depth.
Methodological Rigor
Within the context of methodological rigor, it is essential that I considered and
demonstrated the trustworthiness of my study which included credibility, dependability,
confirmability and transferability to support the integrity and quality of the research
(Creswell, 2013; Lincoln & Guba, 1985). In providing criteria regarding adequacy and
trustworthiness of qualitative research Lincoln and Guba (1985) were clear regarding the
importance of maintaining detailed documentation about decisions made during the
analysis process which I was able to accomplish by keeping progress notes in my journal.
39
Credibility or internal validity was demonstrated through my accurate and
meaningful collection and interpretation of the interview data. Credibility represents the
confidence in the truth of the data (Creswell, 2013). This was accomplished through clear
identification of the steps, adhering to the DPPM research method, and accurately
summarizing the data. I connected regularly with my supervisory committee members
who are experienced in qualitative research and was able to debrief and reflect upon this
process as necessary. I also presented the words of my participants in the findings of this
research study to demonstrate credibility.
Dependability was demonstrated through the reliable and consistent method of
data collection during the interview process, transcription, and data analysis. Maintaining
a journal was essential to this process, which took place over two years. Describing what
occurred during the interviews was also helpful in recollecting and ensuring
dependability so that the information was not lost or forgotten.
Confirmability was supported by my remaining neutral and objective, by
bracketing, and using scientific phenomenological reduction to review the data (Creswell,
2013; Polit & Beck, 2012, Richards & Morse 2013). I made all of the data, transcriptions,
journal entries, and documentation available to my supervisory committee to ensure
trustworthiness of the data that I collected.
Transferability is the extent to which findings may be transferred or used in other
similar environments (Lincoln & Guba, 1985). The demographic information collected
from the participants was useful in supporting the potential for transferability and
understanding the profile of the participants within the context of their role as CHWs.
40
Maintaining a high level of methodological rigor also supported the transferability of this
method of “the experiences of others” (Giorgi, 2009, p. 97).
Ethical Considerations
The study met the guidelines set out in the Tri Council Policy Statement (2014) on
the ethical conduct of research and was submitted and reviewed by the Faculty of Nursing
Ethics Committee and the University of New Brunswick Research Ethics Board. Applying
ethical principles ensured a balance between the potential benefits of scientific research
and protection of the participants from any research related harms.
Risk and harms. There was minimal risk expected in the study and participation
presented no greater risk than those experienced by CHWs “in those aspects of their
everyday life that relate to the research.” (CIHI Tri-Council Policy Statement, 2014, p.
22). I was aware that it was possible during the interview process that participants could
find it emotionally difficult to share their stories. As an experienced nurse, I had the
knowledge and skill to recognize, defuse and offer other strategies to deal with potential
distress.
Prior to the interviews I explained to the participants that they may become
uncomfortable or distressed. I was prepared to provide the participants with the following
option of stopping the interview entirely or waiting until they wished to resume and
assisting them upon request to contact a family member or friend. I provided each
participant with a copy of the Debriefing Document (Appendix E) and the CHIMO public
information pamphlet entitled “Helping Yourself and Others after Experiencing a
Traumatic Event; Building a Self-Care Plan” published by the Mental Health of
Commission of Canada (Appendix F). The interviews were uneventful, and the
41
participants did not appear to be distressed in any way. I reached out and connected with
each of the four participants following their interview, to inquire about their overall well-
being and about any additional thoughts, comments, concerns or questions.
Informed consent. The term consent means a “free, informed and ongoing
consent” and “that individuals who participate in research should do so voluntarily,
understanding the purpose of the research, and its risks and potential benefits, as fully as
reasonably possible (CIHR, 2014, p. 27). Prior to the initial interview I reviewed the
informed consent with each participant in accordance with the regulations set out by the
Tri-Council Policy Statement (CIHI, 2014) and UNB Research Ethics Board. I
communicated the research information to participants in plain language (Grade 8 or less)
so that the information was easily understood. The purpose of the study, procedures to
collect and record the data, confidentiality, and ability to withdraw at any time were
reviewed and discussed with each participant before they signed the consent. I reminded
participants that participation was completely voluntary, and they could withdraw from
the study at any time without penalty. I also informed them that although they would not
benefit directly from the study, the knowledge gained from the study would increase
nurses’ understanding of the CHW role within the broader health care system. Every
participant interviewed received an honorarium of $40 for their time and any related
expenses (i.e. parking).
Each participant signed the informed consent and were offered a hard copy
however, all four individuals refused, preferring an electronic copy, which was sent
following the interview. The participants were also offered a copy of the audio-recording
and copy of the interview transcript. Participants A01 and B02 asked for hard copies of
42
their transcripts which were hand delivered to them, none of the participants wanted the
audio-recordings. All four participants requested a copy of the Executive Summary of the
final thesis, which will be sent to them electronically at the email address they provided.
All the data will be held in a locked cabinet in my secure office for a period of seven
years following completion of the study as per the requirements of the UNB Research
Ethics Board.
Confidentiality. Confidentiality and anonymity cannot be absolutely guaranteed.
It was explained during the consent process that every effort would be made to ensure
their privacy during the interview (i.e. safe, quiet space), and that other than their
informed consent, all other documents and the recording would contain a unique
identifier which included the participants mailing and electronic addresses (i.e. A01,
B02).
In the following chapter, I will explore and explain the general structural
descriptions that emerged from the analysis of the data.
43
Chapter III: Study Results
Introduction
This chapter presents the findings from this descriptive phenomenological study
obtained through in-depth interviews with four community health workers (CHWs). The
primary focus of this qualitative study was to discover and explore the lived experiences
and roles of CHWs working with PWUD. Through the synthesis-analysis and utilization
of the Community-As-Partner Model, three general structural descriptions were revealed
(Vollman et al., 2004). These meanings or essences of CHW experiences and include; (1)
a safe space, (2) do more with less, and (3) educate us to educate them.
Description of Participants
I recruited CHWs employed by nonprofit agencies in Saint John – New
Brunswick who worked with PWUD. The four CHW who enrolled in the study identified
as being female. They ranged in age from 33 to 61 years of age, were employed in the
non-profit sector from 6.5 to 37 years and had been at their current agency from 6 to 20
twenty years. Two of CHWs held a certificate program from the local community college
and two CHWs had undergraduate degrees. In terms of the organizational benefits, two
participants received both medical and vacation benefits while two received vacation
only (Table 1).
All four participants were employed to support PWUD and their families in
securing safe and affordable housing, furniture, clothing and groceries. They interfaced
with social services and the justice system on behalf of their clients and often
accompanied them to medical appointments.
44
Table 1. Participants’ Demographic Information
Demographic Characteristics (n=4)
Age
Average 38
Range 33-61
Sex
Male 0
Female 4
Years Employed in Nonprofit Sector
Average 17.25
Range 6.5-37
Years at Current Agency
Average 8.8
Range 1.3-20
Highest Level of Education
High School Degree
Community College Certification 2
Bachelor’s Degree 2
Benefits
Paid Vacation Only 2
Medical / Health Benefits Only
Paid Vacation with Medical / Health Benefits 2
Core Qualitative Findings
The general structural descriptions (essences or meanings) of the lived
experiences of CHWS working with PWUD are presented in this section. The essences of
their lived experiences address the research question using Vollman, Anderson, and
McFarlane’s (2004) Community-As-Partner Theoretical Model as a lens to analyze-
synthesize the phenomenon being studied. This framework lends itself to the
45
interrelatedness of their work as it is similar for all four CHWs and results in the three
GSD of safety, resources and education (Table 2).
Table 2. Community-As-Partner Subsystems
Community-
As-Partner
Subsystem
Focus CHW Roles and Responsibilities
Physical
Environments
community boundaries
housing stock
identification and support for
individuals to access safe, affordable
housing options
Education community schools and places
for higher learning and
education
educating the public, decision
makers, HCP and pursuit of personal
education, training and certification
Safety and
Transportation
protective services and overall
safety for community members
safety in relation to violence, assault,
exposure to discriminatory language
and behaviours, importance of safe
spaces and harm reduction services.
Politics and
Government
governance, control, rules and
regulations within a civilized
community including funding
and leadership within
organizing structures.
access to community resources,
issues surrounding poverty, and
income assistance supports.
Health and
Social Services
all facets of health and social
services, professional services,
and individual self-care
practices
access to safe equitable and
nonjudgmental health care services
and employee health benefits
Communication community collaboration,
partnerships, support,
advocacy, issues around
discrimination, stigma and
judgment
poverty, chaos, substance use,
dismissal, bias, verbal and nonverbal
discrimination, importance of
trusting relationships, safe and
culturally appropriate language
Economics community goods and services,
employment and occupations
issues of poverty, diminished
resources, increased risk of injury,
illness and vulnerability in lower
socioeconomic class, substance use
and risk of overdose.
Recreation provision of opportunities for
community members to be
active to address their physical,
social and mental health needs
physical and emotional wellness and
personal safety including self-care
practices
Vollman, Anderson & McFarlane’s (2004) Community-As-Partner Theoretical Model
46
Safe Space
Interactions that create a safe space for open dialogue are fundamental in
developing trusting, supportive and therapeutic relationships (McEldowny & Connor,
2011). The meaning of safe spaces from the perspective of CHWs was consistently
defined as either a physical or emotional space where individuals could freely express
their thoughts and emotions without fear of violence, discrimination or judgement.
Woven into the narratives of the CHWs in this study was how unsafe spaces increased
their stress in the following ways: (1) searching for safe and affordable housing options
for PWUD, (2) ensuring safe and respectful language by health care providers (3)
creating safe physical spaces (4) witnessing the negative health consequences on PWUD
as a result of discriminating behaviours of health care providers and, (5) the importance
of ensuring their own emotional safety and well-being as front line workers. The
following are participants’ words (meaning units) which depict this essence.
A01 So, my role is to provide housing supports and advocate for those in need.
So, primarily women and their families, some men if they’re the primary
caregiver of children. This includes housing prevention, we advocate with
landlords, if there has been an eviction issue and we try to resolve it and if
we can’t do that, we start looking at options to find rapid rehousing. This
includes looking up available places, calling landlords that we’ve
established a relationship with and contributing to damage deposits or
cutting deals to do a payment plan for the remainder we can’t cover. (1)
C03 Yeah, if we had access to more housing that would just take such a stress
off of us and our agency. We are not into housing folks, yet, all you face
every day is clients coming in that have been kicked out of their place. (1)
B02 Something as simple as the nurse saying, “Oh wow your 9th pregnancy,”
has a whole history of judgement behind it. So, in that moment, you’ve lost
them. (2)
A01 Our space is a safe space, it is a safe zone. The clients know this too. If
there’s a woman who maybe collects money on the street, and if they are in
our office and another woman comes in that owes money, and they’re on
47
opposite sides of this, they know that our space is the place to have any of
that conversation. They know they both have an equal right to be there.
There are no arguments, it is only about support and they respect it. (3)
D04 How much physical pain did she have to be in, it is so unbelievable, the
unimaginable amount of pain that she was willing to endure, to avoid the
treatment and discrimination she was going to get at the hospital. . . that’s
a very sad commentary on the state of our health care and the people who
are working in it! (2,4)
D04 In another situation a young girl had her jaw broken on the street and was
afraid to go to the hospital without our support ... people have been told
that they break bones on purpose so they could go the Emergency
Department to get opiates and it’s not safe, x-rays were never done! (4)
B02 This is definitely hard work, so I make a real effort today on self-care. That
comes up often when we’re talking about working with highly complex
populations, vulnerable individuals, marginalized individuals, because it is
very stressful. And it’s hard, the resources are limited, so it increases the
amount of stress that people feel. So as non-profit frontline workers, we
work sick, we stay sick. We talk about self-care. We don’t have the time or
the luxury to do it. There is no back up and if we have a sick day that means
we need to make it up when we come back. I made a concentrated effort to
reduce my workload which was not successful. So, we work, we work, we
work, trying to find a balance and trying to push back. So, I mean, I would
say, yeah, I’m going to take time for myself or I am going to become a
client! (5)
C03 For the non-profit sector, this work is hard and not an easy business to be
in, right? We’re dealing with everyday crises in people’s lives. And I think
self-care is usually set at the bottom of the list. However, we are going to
bring in a counsellor every few years to do a talk, because we cannot afford
individual counselling services. We do, you know an afternoon debriefing
almost every day, we try to debrief with each other. And once a year, we try
to plan a nice staff outing ... We offer free yoga and we offer flexible time
to the staff too. We are very good to each other and I think that is what keeps
us all going here, we’ve known each other for a long time, so yeah, I think
this is special, yeah, I do, we care for each other very, very much. (5)
A01 When you’re doing this type of work, so, me specifically, because I don’t
have coverage and do counselling myself, right? Because I know that
vicarious trauma is a very real thing, I see little signs of it in myself and
recognize it. And I know that as I continue with this career, those are, you
know, going to get heavier. So, yeah, where I don’t have benefits and can’t
access counselling, and then also, it would be with community partners. So,
I’d pretty much have to go out of the city for it. What I do is I go to the gym,
and I just work off the negative energy. Go to the gym, sometimes I have a
48
glass of wine. I do major self-care and I always make sure I keep clear
boundaries with my work. So, I don’t take work calls after hours, I don’t
take them on weekends because, that’s, yeah, I have to maintain them. (5)
A01 So, there has been a lot of focus lately on self-care front line workers
because there is so much burnout happening, right? And they need us so we
need to take care of ourselves to be there for them. (5)
D04 When I go out the door, I leave work at work. It’s a lovely environment
here. Like you have so much support, I find, yes, we do support each other.
We do debrief each other and check in on one another but I think the biggest
things and I tell young people this all the time, you need to be able to go out
the door and leave work here. So, when you’re at home and you’re sitting
there thinking about this person you saw today, you have to say, “Wait a
minute, that’s work, I’ll deal with that tomorrow,” and move on and do
something else ... there will always be people in crisis. I come to work and
work as hard as I can and now, I am going to go home and rest. I’m going
to come back tomorrow, and I am going to work hard again. (5)
Safe spaces were defined by CHWs in the context of their work with
PWUD. They expressed their frustration in attempting to secure safe and
affordable housing. They felt angry when they witnessed discriminatory language
and judgemental behaviors towards PWUD by health care providers. The CHWs
also expressed fear regarding their lack of health benefits and the need to ensure
their own emotional well-being through self-care practices. The following section
elaborates upon many of the same emotions CHWs describe their experiences of
having to do more with less community resources.
Do More with Less
The continued lack of comprehensive and easily accessible basic services presents
daily challenges, frustration, and anger for CHWs. With limited resources, CHWs
expressed feelings of fear for their clients, having previously witnessed devastating
consequences. The complexity and multi-faceted role of a CHW to address the needs of
49
PWUD created an increased level of stress for the CHWs. This is clearly articulated by
B02 when she states:
“The demand is high, so we’re social workers, mothers, we’re a nurse,
sometimes we’re called upon to be a pharmacist, a community police
officer, engineer, cook, teacher, childcare provider, everything, right?
Grief counsellor, dog sitter. We are pieces of all of those professions.”
The reduction in government funding to support individuals living in poverty and
diminishing health and social services limited the CHWs ability to provide basic needs
for PWUD and access to rehabilitation services. The following are participants’ words
(meaning units) that depict the essence.
A01 There’s certainly no end in site either, with homelessness you know …
vacancy rates are low, but rents are way beyond what people can afford
and it’s a challenge … I think we could use more supportive housing. I
mean we are working with the hardest to house, which complicates
matters even more. (1)
C03 Poverty is at the root of a lot of work that we do. You know, we don’t see
people who are managing their addictions if they are financially able to,
right? So, we’re only seeing people who aren’t … governments are making
decisions in an effort to save a little bit of money. . . not saving a lot of
money. . . in some cases people have been so frustrated, that they’ve
actually gone back on drugs, because they can’t, you know, achieve it. (1)
B02 My favorite is when you have someone who’s living off $537 a month and
they are five months pregnant and the doctor is saying, “The baby is too
small, and they need to start eating healthier.” And I say, “Well, their rent
is actually $525 a month and we’re having them live off of food bank
donations or they can go back to doing sex work.” (1)
C03 Like, making any reduction to social development is just the worse thing
governments can do, it is asinine, yet … wanting to do more with less.
When they started out cutting social assistance and support programs, that
hits people very hard because they have already been hit by policies that I
mean are crazy! (1)
B02 There are expectations on us from health care providers, government
officials, businesses, municipalities. Like, everyone relies on our work, but
no one wants to pay for it, right? So, we are 3.5 full time staff operating on
$98,000 operating budget and in 2018 we prevented homelessness for 1457
people that included 377 children that we kept off the streets. I mean, we
50
stretch. We get the work done because we want to help people and change
the world, but there is a cost, there is a cost. (1)
D04 I think one of the most disappointing things in the community is that we
can’t access services and it is the one thing over all these years we have not
been able to fix - easy access to detox and things like that…..because when
people are at rock bottom, usually it’s today, and if you don’t get them in
today they can go way lower, and that is when people just end it all. Just
suicide you know and I can’t even talk about it or even tell you the number
of suicides we’ve had over the years. (2)
C03 She needed to get into rehab … she needed a physical break. Right? She
was so sick that her body just needed to have some rest and some food for
a couple of days, whereas the staff only thought about her getting off the
drugs. They didn’t have any beds and I was afraid I would find her dead the
next day! (2)
Understanding the scope and broad responsibilities of CHWs and limited
resources to address the needs of PWUD would be a positive step in supporting their
many roles in the community.
Educate Us to Educate Them
The third general structural description that was generated from the data analysis-
synthesis was the importance of education. In the narratives, the CHWs expressed a
belief that educating students would enhance their awareness of the challenges facing
vulnerable populations and importance of advocacy. This in turn, would decrease the
stress they experienced in supporting PWUD. They also expressed an interest in their
own professional development through enhanced educational opportunities that would
create less conflict and ambiguity in their roles and more legitimacy within the health
care sector. The CHWs also felt that through the education of students, there is hope for a
kinder and more inclusive environment for PWUD in the future. Education was cited to
be beneficial in a number of ways including: educating health care providers about the
realities of living with substance use challenges would decrease the discrimination
51
directed towards PWUD, increased awareness by governments and decision-makers
regarding the realities of substance use, harm reduction and the depth of poverty
experienced by PWUD would support additional available resources, value in having
more formalized CHW education, less ambiguity and more legitimacy as front line non-
profit workers and, belief that education of youth and students from local area high
schools, colleges and universities was the first step towards creating more inclusive
environments for all members of the community.
The following are participants’ words (meaning units) that depict the essence.
B02 For some women, especially our gals in the sex trade, it is just too much to
go to the hospital, it’s too much judgment and they just chose not to do so.
They continue with the pregnancy, they continue with the drug use and not
eating properly. We see where that gets them! (1)
A01 There are specific case managers now at Social Development for assistance
or even with like child protection, that we work with. They are taking steps
to understand a lot better the individual challenges and working with us
really well in cases just to better people’s lives and not just take things and
more stuff away from them. I think it is because we've made a lot of noise.
Right? And we will keep making noise! (1)
B02 I started helping to facilitate conversations and going to almost every
doctor’s appointment with clients because they were not listened to or they
presented poorly. Their concerns were not taken seriously .... they were
immediately judged, barriers put up, health care providers are hesitant to
believe them, they are always labelled as drug seeking! It is so frustrating.
Don’t the doctors and nurses understand! Sometimes our clients cannot
even describe what they are feeling … they just assume that because they
are using drugs, they are a certain way! But when a provider takes the time
to get to really know a patient it can be such a positive experience. (1)
B02 There is so much bias and discrimination out there! We would be appalled
if we had people of color being treated differently. If someone said, “I have
no desire to work with him, he’s black, he’s making me uncomfortable,”
because that is not acceptable. It’s okay to say, “I don’t really want to touch
that person because I can tell she does drugs, she’s dirty, she does sex
work,” so that is still acceptable. That is a moral judgement. We’re okay
with moral judgements, you’re bad because you do drugs! (2)
52
C03 When you actually run the figures, it is financially detrimental for women
with children under the school age to try to get off income assistance and
go to work! Like, it’s just the numbers, you make more money on welfare
… and with being on welfare there comes a whole lot of judgement! (2)
D04 Why do governments do what they do? They just don’t understand what is
going on. In an effort to save a little bit of money, they make crazy decisions
and, in the end, they are not really saving any money. It is so frustrating for
us and in some cases, people have actually gone back on drugs, they just
can’t you know, achieve it! (2)
B02 The demand is high, so we’re social workers, mothers, we’re a nurse,
sometimes we’re called upon to be a pharmacist, a community police
officer, engineer, cook, teacher, childcare provider, everything, right? Grief
counsellor, dog sitter. We are pieces of all of those professions, and we’re
called upon to do it full time for every single one. Its exhausting being
everything for everyone! (3)
B02 I started doing course work, certificate level, just around being better able
to support them. Again, with limited budgets it is increasingly difficult to
obtain and maintain certifications and attend educational programming. (3)
C03 I always try to learn and make a point of telling staff to bring out the best in
yourself and think beyond … the future. Yeah, I think that is important to
keep learning and keep going. (3)
D04 So, we’re able to bring students here and have a conversation around harm
reduction. And we’ve been doing that for a long time, and we’ve been
increasing the numbers, because I’m getting up there and the number of
years left to talk about what’s in my head and what’s in my heart, is running
out. So, it’s almost like I need to, I need to do that ... so young people
understand why we do what we do and that it is right. And so, if I can have
those students just for a couple of hours a morning or an afternoon, I can at
least plant a seed to think a little bit differently ... change the way people
think ... be an example, a champion who is willing to say the way it is …
seeing the person first as a human being who deserves basic health care,
who deserves a roof over their head and food to eat. (4)
In summary, the CHWs highlighted the need for education and public awareness
regarding the complexity of substance use and the unique role of CHWs in supporting
this at-risk population. Educating policy decision-makers and health care providers would
enhance funding of community-based services while reducing the barriers for PWUD to
53
access equitable health care services. Educating students and youth would create a more
accepting and less judgmental environment for individuals living with substance use
challenges in the future. There was consensus that ongoing education for CHWs in the
form of courses and certification would legitimize their role within health care and social
service systems. In conclusion, all of these educational initiatives would support the work
of CHWs, of contributing to easier navigation and additional resources to support
PWUD.
Chapter Summary
In this chapter I have presented the findings of the qualitative study. I have
included a description of the participants. The meanings of the CHWs in their work with
PWUD was viewed through the lens of the Community-As-Partner model and from my
perspective as a Community Health Nurse. The data analysis-synthesis identified the
following three general structural descriptions (essences): “a safe space”, “do more with
less” and “educate us to educate them.” Quotes from the interviews support the essence
of lived experiences of CHWS working with PWUD. The next chapter provides a
discussion of the findings as they related to the literature, implications, recommendations,
limitations and strengths.
54
Chapter IV: Discussion
Introduction
The purpose of this phenomenological study was to develop an understanding of
the lived experiences of CHWs working with PWUD. In this chapter I discuss findings
that emerged in the descriptive interviews of four CHWs from the theoretical lens of
Community-As-Partner Model (Vollman et al., 2004). There are relatively few studies
that describe the experiences of CHWs working with PWUD. I discuss the research
findings in terms of relevant literature in the context of community care providers
experiences with vulnerable populations. The implications for nursing practice, education
and policy are outlined followed by a review of the strengths and limitations. The chapter
highlights recommendations for future nursing research and concludes with a summary
based upon the knowledge gained from the study.
Discussion
An in-depth review of the literature provided very few comparable studies;
however, it reaffirmed the need for this qualitative descriptive study to explore the
meaning of the CHWs experiences in relation to their work with PWUD. The essences of
the general structural descriptions (meanings) of these experiences include, “a safe
space”, “do more with less” and “educate us to educate them” which are discussed in
more detail in this section.
A Safe Space
The CHWs described their everyday work experiences in terms of the complexity
of caring for PWUD. They described their frustration and anger due to their inability to
secure safe and affordable housing for PWUD. The need for safe spaces for PWUD
55
allows for individuals to seek care and support (Pauly, et al., 2015; Strike et al., 2014).
For individuals who use substances, safety is enhanced when language, behaviours and
acceptance are provided by community members and health care providers (Sabo et al.,
3013). In this study the CHWs described feelings of distress in witnessing discriminatory
behaviours towards PWUD. Threaded throughout the interviews the CHWs also voiced
their fears and concerns for their own personal safety in terms of their emotional and
physical well-being as front-line workers.
Housing. Identifying safe affordable housing options for individuals who live
precariously with substance use is extremely challenging (Hauff & Secor-Turner, 2014;
Coles, Themessl-Hunter, & Freeman, 2012). Findings in similar studies on homelessness
identified the emotional burden experienced by community workers who witness abject
homelessness described as “feelings of powerlessness, anger, and sadness” (Fisk et al.,
1999, p. 242). Various approaches to improving access to housing in local communities
has been attempted, however, more collaboration is required in the midst of the current
housing crisis (Green et al., 2013). In the city of Saint John, NB, identifying safe and
affordable housing is compounded by high rent and low vacancy rates (Human
Development Council, 2018). Basic provincial income assistance has not increased since
2010, therefore, the rate of $537 per month makes securing housing extremely difficult
(Human Development Council, 2018). Despite this frustration, the CHWs remained
focused and committed to their clients as highlighted by B02 as she states, “You
56
negotiate, you check in on people, you do whatever you have to do to make it happen, we
all need a place to call home, housing first, that is where it all starts.”
Creation of safe spaces. Language and behaviours that do not discriminate and
are nonjudgmental allow for the creation of safe physical and emotional spaces which
includes location. Language, terminology, colloquial expressions and use of nonverbal
body language, are also essential in developing safe spaces (Cameron et al., 2014; Pauly
et al., 2015). The CHWs described many examples of unsafe actions and words targeting
PWUD. A01 states, “a word can be a trigger, words can make our clients feel unsafe”.
The use, tone and language used by the public, decision-makers and health care
professionals were also deemed to be absolutely essential by all of the study participants
(Strike et al., 2014). They expressed their anger when PWUD were labelled by health
care providers and D04 questions this when she states, “Why do doctors and nurses
always think that they are just drug seeking, when they really are sick?”
Words such as “drug addict”, “drug abuse” and “misuse” have been replaced by
neutral terminology such as “People Who Use Drugs” and “substance use” (PHAC,
2018). A number of studies have given considerable attention to unprofessional,
discriminatory practices and the negative impact on marginalized populations (Farrell et
al., 2005; Love, 2015; Martin, 2008; Pauly et al., 2015). Often patients in lower
socioeconomic and minority groups will delay seeking health care or leave hospital
against medical advice, resulting in negative health consequences (Pauly et al., 2015;
Strike et al., 2014; Van Boekel et al., 2013). This was clearly perceived by all of the
CHWs as extremely stressful.
57
Self-care strategies. The recurring theme of safety was raised by the CHWs and
the impact of their experiences as front-line workers. They reiterated the importance of
self-care strategies for their long-term health and wellness. The participants often
describe feelings of distress as A01 states,
“If I’m at work and I need to go cry for an hour I do that.” “So, there has
been a lot of focus lately on self- care for frontline workers, because there
is a third of us who burn out, right . . . and they need us, so we need to
take care of ourselves to be there for them.”
These findings align with previous studies that highlight when caregivers are
continually exposed to patients’ stories and heightened emotions, they are at increased
risk of burnout and stress (Austin, Goble, Leier, & Byrne, 2009).
The participants did not describe safety in terms of their personal physical safety
despite often working in chaotic and potentially violent neighbourhoods with PWUD
(Islam et al., 2012; McNeil et al., 2015). CO3 briefly refers to an awareness personal
physical safety in her statement, “There are things happening on the street that we always
need to aware of” otherwise it was simply not described by the participants as a concern
or experience. Findings in other studies indicate that often outreach workers in the
community will cross boundaries that put them at risk of harm as they often develop a
false sense of security and ignore basic safety precautions (Farrell, et al., 2005; Fisk et al.,
1999).
Overall, the concerns expressed by the participants were in relation to the distress
they experienced in attempting to secure housing, witnessing discriminatory language
and behaviours and the need for physical and emotional self-care to support their
continued work with PWUD.
58
Do More With Less
The participants in the study described feelings of anger in relation to a never-
ending cycle of poverty, the difficulty in obtaining necessary basic resources and
accessing rehabilitation services for PWUD.
Poverty. Poverty is complex and is seen as the inability to acquire and maintain
economic self-sufficiency or to meaningfully participate in society (Vollman et al., 2004).
A discussion paper published in 2016 entitled “Towards A Poverty Reduction Strategy in
Canada” defined poverty as going beyond income to include food insecurity, social
exclusion, inadequate housing and other hardships.
The participants in this study described poverty as a never-ending cycle that
contributed to intergenerational poverty and lower levels of health. B02 describes this in
her statement, “so you’re a young kid, from a bad neighbourhood, your family is poor,
your parents have issues, so you’re kind of easily overlooked.” This finding is similar to
many studies addressing poverty, diminishing resources and the significant negative
impact on social determinants of health (Harris & Haines, 2012; Ingram et al., 2008;
Islam et al., 2012; Jackson et al., 2014).
There was also a sense of hopefulness as expressed by A01 who described that
health and social services were beginning to acknowledge her role as both an advocate
and a CHW, and is reflected in her statement,
“They are trying to work with us, just to better people’s lives and not just
take things more stuff away from them. I think it’s because we’ve made a
lot of noise, right, and we’ll keep making noise. I think we are making baby
steps and I think there is still a long way to go, but at least we are on the
radar and they are hearing us!”
Decreased access to rehabilitation services. The study participants expressed
concern in accessing rehabilitation services for PWUD. The long wait times, abstinence
59
only programs and health care provider discrimination were felt to be significant barriers
to receiving health care. In 2014, a study conducted by Cameron et al., found similar
issues in addressing health disparities for First Nations peoples in Canada. The results
called for nurses to turn their attention to the structural injustices that act as “barriers to
access such as addressing the stigma, stereotyping and discrimination” experienced by
marginalized populations (p. 1). The author went further in explaining that “Access to
health care services entails not only the ability of individuals or groups to obtain required
services but also how the services are delivered” and that “access is widely regarded as
an important social determinant of health”. (Cameron et al., 2014, p. 3). Access to care
was described by the CHWs as b a source of frustration and resignation in attempting to
support their clients. C03 expresses her feelings, “we elect a new government, hoping for
change, and what happens, they cut funding, reduce social and health services, wanting
us to you know, do more with less”. The reduction in health care programs, lengthy wait
times and disparities in the delivery of available services was described by the CHWs as
causing them a high degree of stress and frustration.
Educate us to Educate Them
Participants in this study described the importance of public and health care professional
education as having the potential to positively impact their everyday work, reduce
frustration and lower the discrimination experienced by PWUD. Education was also
raised by CHWs in the context of their overall career development, knowledge and
legitimacy as community-based care providers. (Mobula et al., 2014; Barnet, Lau &
Miranda, 2018; Torres et al., 2017; Van Boekel et al., 2013).
60
Educational programming. The CHWs described educational programming in
terms of public substance use awareness campaigns, rapid access addiction services,
changes to acute health care policies and the adoption of harm reduction strategies as
having value in their work. There was a high level of frustration voiced by the CHWs in
terms of public understanding of the underlying issues of substance use. As B02 states,
“Do people not understand the trauma these people have had to deal with, trauma, trauma
and more trauma, childhood trauma, sexual assault and everyday more trauma . . . they
just don’t get it!”
The participants spoke passionately about how they incorporated a harm reduction
approach to care and how difficult this was in terms of creating awareness at the health
professional level, B02 states “So in the last two years it has been a large piece of our
work, harm reduction and advocacy, sometimes successful, sometimes not, depends on
the doctor”. Although PWUD have increased health care issues, health care professionals
have not yet aligned services with the specific needs of this population (Couto E Cruz et
al., 2018; Morgan et al., 2015; Torres et al., 2014).
There are many studies which recommend the need for changes in public
perception of substance use, terminology, bias of health care professionals toward PWUD
and in-hospital policies that stigmatize this population. It is well established in the
literature that health professionals and organizations that demonstrate cultural
competency can successfully develop strategies that improve the quality of care delivered
to patients from diverse groups, reduce health care disparities and improve health
outcomes (Mobula et al., 2014;Barnet, Lau & Mranda, 2018). Organizational cultural
61
competency also allows providers to understand the unique needs of the populations
being serviced, engage communities and maximize community resources.
Education as a CHW. B02 describes how she became aware of the impact of
poverty and how that became the impetus for her to continue with her education as a
CHW stating, “I started doing course work, certificate level, just so I could be better able
to support people, but I want to do more”.
Studies indicate that CHWs identify as advocates, being present, educating and
supporting clients and being viewed as trusted members of the community (Logan, 2018;
Murray & Zeigler, 2015). The participants in this study experienced and described similar
thoughts about their work and the value they placed on continuing their education. B02
states,
“My original certificate education-wise is administrative assistant with a
concentration on medical, then I moved into revenue development,
financial, which really gave me a solid foundation for moving forward in
non-profits. The more education you have, the more people have respect for
what you do”.
In 2018, Komaromy et al, developed a new model of educational training and
support for CHWs that generated considerable interest in the US. The Extension for
Community Healthcare Outcomes (ECHO), was developed as a distance education tool
for CHWs, recognizing that as adult learners, remaining in their communities and
providing flexibility to complete modules was essential. The modules provide education
on motivational interviewing, boundary setting, basic primary health care and both
mental health and addiction services (Komaromy et al., 2018). In the literature, there are
many different views and interpretations of the expected competencies of CHWs for
certification and various training tools and curricula (Komaromy et al., 2018; Kok et al,
62
2017; Maes et al., 2017). In Canada, CHWs are not integrated, recognized nor regulated
into the universal health care system and remain relatively disconnected (Torres et al.,
2014). In becoming an organized Canadian workforce of care providers a website was
developed. The site defines their roles, responsibilities with suggestions for basic training
and events. Standardized education and certification respects the unique contributions of
CHWs in the community, the certification process will “maximize, rather than
compromise the value of CHW” (Malcarney et al., 2017).
Education was a common recurring issue described by the study participants.
There was a recognized and identified need to expand upon public and health care
professional awareness and education regarding substance use. The participants felt this
was one mechanism that could alleviate the stress they experience in their work with
PWUD. Educating decision makers could support changes in public funding and policies
regarding affordability of housing and basic needs. With awareness, there could be more
opportunities to create safe spaces. Finally, the importance of education in terms of
legitimizing their role as community care providers was also acknowledged. Further
discussion in the next section will focus on implications for community nursing practice,
education and health care policy.
Implications
The study findings have several implications for nursing practice, education, and
health care policy. These findings assist nurses to understand the lived experiences of
CHWs working with PWUD. It is essential to be aware of how CHWs experience their
everyday work so that nurses and other health care providers can acknowledge their
63
strengths and support them in the care they provide to vulnerable populations in our
community.
Implications for Nursing Practice
The findings in this study assist nurses to understand the lived experiences of
CHWs while highlighting their unique skills and abilities to develop positive and trusting
relationships with PWUD. This study provides insights into the struggles and needs of
CHWs who work with PWUD. The subjective data contributes to and broadens our
knowledge and understanding of their situation. The strong advocacy role of CHWs
clearly defines an important aspect of their work, and one which aligns with nursing
practice which states that “nurses endeavour, individually and collectively, to advocate
for and work toward eliminating social inequities” (CNA, 2017, p. 5). The CHWs voiced
feelings of frustration and anger in terms of their work and the many barriers they faced
in identifying and securing housing and addressing the basic needs of their clients.
The Code of Ethics for Registered Nurses (CNA, 2017) clearly states that nurses
must recognize the “significance of the social determinants of health and advocate for
policies and programs that address them (e.g., safe housing, supervised consumptions
sites)” (p. 18). Nurses are perfectly positioned to collaborate with others such as CHWs,
to advocate for changes in laws, policies or practices, which can be “a powerful political
instrument” to bring about change (CNA, 2017, p. 4). In this way, nurses can address
disparities and barriers, be reflexive in their practice and reorient themselves to the
importance of social justice to create positive changes.
Building community capacity requires nurses to have strong communication
skills. Nurses are encouraged to share information and actively listen to the challenges of
64
CHWs in their experiences and build upon their working relationships.
Acknowledgement of CHWs experiences and their expertise legitimizes the value of their
role within the community when working as CHWs and care providers for PWUD.
Nurses must be aware of their language, bias and nonverbal behaviours when
working with PWUD. The CHWs repeatedly expressed their anger and fear regarding the
discrimination by health care providers while attending to their clients. One of the tenets
of nursing practice is the delivery of safe, compassionate, competent and ethical care.
Ethical practice demands that nurses “refrain from judging, labelling, stigmatizing and
humiliating behaviours” (CNA, p. 15). Nurses have a responsibility to ensure safe spaces
through awareness of their own preconceived ideas, demonstrate reflexivity, importance
of role modelling and creating educational opportunities to enhance safe environments
(Cameron et al., 2018).
Implications for Nursing Education
Education plays an important role in nursing as a professional health care
discipline. Nurses are accountable for the care they provide to all of their patients. When
working with PWUD, the evolving nature of substance use creates an ongoing need for
further education. The findings from the study align with nursing education to remain
knowledgeable, competent and responsive to health concerns. There are implications for
nursing education which include; (1) education regarding the role and value of CHWs in
community practice, (2) educational strategies to reduce stigma directed at PWUD and
increase public awareness on substance use, (3) education of student nurses and other
health care providers regarding prevalence, assessment, risks, diagnosis and treatment of
substance use, (4) education on the implementation of harm reduction strategies based
65
upon the best available evidence and, (5) facilitation and support of CHWs to legitimize
their own role through education, training and certification.
Understanding the role and value of CHWs in community practice requires that
nurses seek out and engage the non-profit agencies and CHWs that support PWUD. This
may include local food banks, clothing and food depots, needle exchange agencies and
shelters. Meaningful conversations with CHWs shed light on what barriers to health care
in the community.
Education of the public including awareness campaigns will reduce the stigma
associated with substance use and enhance harm reduction efforts (CNA, 2017).
Education of nursing students sets the path towards improved practice. Previous literature
has consistently demonstrated that there is little educational content on substance use in
undergraduate nursing programs (Finnell et al., 2018). With increasing prevalence of
substance use in the community nursing students are not well prepared to support this
population either in acute or community settings.
Implications for Policy Development
To reduce disparities in community and enhance the delivery of health care
services, nurses have an opportunity to be involved in policy development. The findings
from this study strongly indicated the need for policy change in terms of the availability
of safe and affordable housing and basic community resources, recognition of the role of
CHWs and the need for health benefits as front line workers, and support of CHWs to
obtain training, licensure and certification as care providers.
The tenets of harm reduction align with nursing practice as they support safe,
compassionate, competent and ethical care. Supporting the development of harm
66
reduction policies in both acute care and community settings are equally important as
together, they could positively impact the everyday work of CHWs. A culture of harm
reduction supports personal choices and does not demand abstinence, it is about being
culturally competent, providing low barrier treatment options and using appropriate and
sensitive language and ensuring safe spaces (Mc Neil et al., 2015; Pauly et al., 2015).
Strengths and Limitations
The strengths and limitations of this study and the methodology used to explore
the meaning of the lived experiences of CHWs working with PWUD is discussed in this
section.
Strengths
A significant strength of the study is that it focuses on the everyday, lived
experiences of CHWs from the lens of the Community-As-Partner Model. The interviews
capture the vivid descriptions and rich experiences of the CHWs from the context of their
work with PWUD.
The Descriptive Phenomenological Psychological Method. The DPPM
developed by Giorgi (1970) was an appropriate method to provide a deeper
understanding and knowledge of the CHWs experiences as they describe them and the
essences (meanings) that emerge.
Community Health Workers in Canada. There is very little information
available on CHWs in Canada, as they often work in traditionally underserved areas and
non-profit organizations and are not integrated within “government-funded universal
healthcare systems resulting in little data on the actual size of the workforce” (Torres et
67
al., 2014, p. 78). This is the first study that explores the descriptive lived experiences of
CHWs working with PWUD from a Canadian perspective.
Limitations
There are limitations in this study as the findings are not necessarily transferable
and results can only apply to the individuals who participated in the study. The results do
not represent a diverse group of participants and there is a risk of gender bias as all four
CHWs identified as women from Saint John. The descriptions of their work with PWUD
does however build upon what is currently known and available about CHWs.
Sample for the study. The sample size for this study was small (n=4) but
permissible for a qualitative phenomenological study. If there had been opportunities for
further enrollment, additional data could have been created. The study also focused on
CHWs from a large urban city, however, the inclusion of CHWs from different Canadian
geographical areas and within the context of both urban and rural communities may have
enhanced our understanding.
Experiences of Community Health Workers. The CHWs spoke about their
feelings and experiences in terms of anger and frustration in relation to their work on
behalf of PWUD, but not explicitly about how they experienced their everyday work as a
CHW. This may be viewed by some readers as a limitation; however, this can be seen as
participants describing their experiences and contextualizing their work through the
complexity of caring for PWUD. In DPPM Giorgi has stated that “what one seeks from a
research interview in phenomenological research is as complete a description as possible
of the experience that a participant has lived through” (Giorgi, 2009, p.123). To ensure
validity of the data, it is essential that the researcher respect the participant’s experiences
68
as they are shared, described and believed by the participant to be true (Giorgi, 2002).
Giorgi’s phenomenological method allowed in-depth interview with each participant by
asking them to respond to an open-ended statement (Giorgi, 2009). My role as the
researcher was to be authentically present, an active listener and allow participants to tell
their story in their own way (Giorgi, 2009). Being true to the method, neither interrupted
their rich descriptions nor redirected their narratives.
Professional experiences as a Community Health Nurse. As a Community
Health Nurse was not a limitation however, it does require consideration as I had known
these individuals for many years in my work in the community. It was important that I
remain unbiased so as not to limit the CHWs responses with my professional nursing
experiences. I used mindfulness techniques prior to the interviews and during the writing
process to remain calm and unhurried. The use of a reflexive journal allowed me to write
out my thoughts and reflect on how I viewed the research process, the work of CHWs,
my nursing practice and perceptions of PWUD and their life circumstances. These were
appropriate and helpful practices for me as a means of remaining focused, true to the
method and reflexive.
Recommendations for Future Nursing Research
An important strategy moving forward is the development and support of the
CHW workforce. Supporting this under-acknowledged workforce could serve to address
disparities for underserved populations and could be achieved through ongoing studies.
Future research should address and include the lived experiences of CHWs from other
genders and different geographic areas such as rural and urban. It could be helpful to
understand the experiences of CHWs caring for other community members such as lone
69
parent families or isolated frail elderly community members. Further qualitative and
quantitative analyses could add to our understanding of the role, scope and impact of the
work conducted by CHWs. Additional research studies would provide new knowledge
regarding the experiences and legitimacy of CHWs and ultimately explore system level
changes to improve the health of our communities.
Chapter Summary
The findings that emerged in this study describe CHW experiences working with
PWUD. Although there are relatively few comparable studies there is available literature
on studies with other minority populations such as First Nations people, individuals
living with HIV and the LGBTQ2+ community. There were similar results that highlight
the need for safe housing, safe spaces, resources and ongoing public and health care
professional education. The experiences described by the study participants supports the
recommendations for future nursing research and potential for improvements in the
health care system that support CHWs and ensure safe, ethical and competent care of
PWUD in our community.
Conclusion
The rising prevalence and devastating consequences of substance use in our
communities has significant implications in all areas of health care. As a unique and
trusted member of the community, CHWs have the ability to engage PWUD. The aim of
this study was to describe and bring meaning to the experiences of CHWs working with
this at-risk population. The findings from the study add a rich and valuable understanding
of the CHWs perceptions and experiences of their work with a marginalized population. I
applied the Giorgi (1970) Descriptive Phenomenological Psychological Method (DPPM)
70
was applied to both the collection and analysis of the interviews from four CHWs
employed by nonprofit organizations in Saint John – New Brunswick. The descriptions
were viewed through the disciplinary lens of Vollman, Anderson & McFarlane’s (2004)
Community-As-Partner Theoretical Model. The three essences (meanings) emerged
which included “a safe space”, “do more with less” and “educate us to educate them.”
The findings from this study enhance nurses and other health care providers
understanding of the everyday work experiences described by CHWs. This new
knowledge then allows nurses to support and facilitate the work of CHWs with PWUD as
a highly complex and vulnerable population in the community.
71
References
Allen, C. G., Brownstein, J. N., Cole, M., Hirsch, G., Williamson, S., & Rosenthal, E. L.
(2018). Building a framework for community health worker skills proficiency
assessment to support ongoing professional development. Journal of Ambulatory
Care Management, 4(4), 298–307. doi:10.1097/JAC.0000000000000251
American Public Health Association (APHA) (2017). Community health workers.
Retrieved from http://www.apha.org/apha-communities/member-
sections/community-health-workers
Aquino-Russell, C. (2003). Understanding the lived experience of persons who have a
different sense of hearing (Doctoral dissertation). Curtin University of
Technology, Perth: Australia. Retrieved from
http://hdl.handle.net/20.500.11937/2524
Austin, W., Goble, E., Leier, B., & Byrne, P. (2009). Compassion Fatigue: The
Experience of Nurses. Ethics and Social Welfare, 3(2), 195-
214, doi: 10.1080/17496530902951988
Balcazar, H. & George, S. (2018). Community health workers: Bringing a new era of
systems change to stimulate investments in health care for vulnerable US
populations. American Journal of Public Health, 108(6), 720–721.
doi:10.2105/AJPH.2018.304427
Balcazar, H., Rosenthal, L., Brownstein, J. N., Rush, C. H., Matos, S., & Hernandez, L.
(2011). Community health workers can be a public health force for change in the
United States: Three actions for a new paradigm. American Journal of Public
Health, 101(12), 2199–2203. doi: 10.2105/AJPH.2011.300386
72
Barnett, M.L., Lau, A., Miranda, J. (2018). Lay health worker involvement in evidence-
based treatement delivery: A conceptual model to address disparities in care.
Annual Reivew of Clinical Psychology 14, 185-208. doi: 10/1146/annurev-
clinpsy-050817-084825
Belzak, L. & Halverson, J. (2018). The opioid crisis in Canada : A national perspective -
La crise des opioïdes au Canada : Une perspective nationale. Health Promotion
and Chronic Disease Prevention in Canada: Research, Policy and
Practice, 38(6), 224-233.
Bhutta, Z. A., Lassi, Z. S., Pariyo, G., & Huicho, L. (2010). Global evidence of
community health workers for delivery of health-related millennium development
goals: A systematic review, country case studies, and recommendations for
integration into national health systems. Geneva: World Health Organization.
Retrieved from:
https://www.who.int/workforcealliance/knowledge/resources/chwreport/en/
Black, R. E., Taylor, C. E., Arole, S., Bang, A., Bhutta, Z. A., Chowdhury, A. M. R... &
Zhu, Z. (2017). Comprehensive review of the evidence regarding the
effectiveness of community-based primary health care in improving maternal,
neonatal and child health: Summary and recommendations of the expert
panel. Journal of Global Health, 7(1), 433–444. Doi: 10.7189/jogh.07.010908
Brownstein, J. N. (2007). Effectiveness of community health workers in the care of
people with hypertension. American Journal of Preventive Medicine 32(5). p. 435
- 447
73
Cameron, B. L., del Pilar Carmargo Plazas, M., Santos Salas, A., Bourque Bearskin,
R.L., & Hungler, K. (2014). Understanding inequalities in access to health care
services for First Nations people: a call for nursing action. Advances in Nursing
Science, 37(3), pp. E1–E16
Canadian Institutes of Health Research, Natural Sciences and Engineering Research
Council of Canada, and Social Sciences and Humanities Research Council of
Canada. (2014). Tri-Council policy statement: Ethical conduct for research
involving humans. Retrieved from http://www.preethics.gc.ca
Canadian Nurses Association (CNA). (2017). Code of ethics for registered nurses.
Ottawa, ON: Author. Retrieved from http://www.cna-aiic.ca
Canadian Nurses Association (2017). Harm reduction & illicit substance use:
Implications for nursing. Ottawa, ON: Author. Retrieved from http://www.cna-
aiic.ca
Canadian Nurses Association. (2017). Code of ethics for registered nurses. Ottawa, ON:
Author. Retrieved from https://cna-aiic.ca/html/en/Code-of-Ethics-2017-
Edition/index.html#
Canada, Public Health Agency of Canada (2018). National report: Apparent opioid-
related deaths in Canada (January 2016 to March 2017). Retrieved from
Statistics Canada website: https://www.canada.ca/en/public-
health/services/publications/healthy-living/apparent-opioid-related-deaths-report-
2016.html
74
Carrière, G., Garner, R., & Sanmartin, C. (2018). Social and economic characteristics of
those experiencing hospitalizations due to opioid poisonings. Health Reports,
29(82), 8.
Coles, E., Themessl-Hunter, M., & Freeman, R. (2012) Investigating community-based
health and health promotion for homeless people: A mixed methods review.
Health Education Research, 27(4), 624-644.
Cook, T., & Wills, J. (2012). Engaging with marginalized communities: The experiences
of London health trainers. Perspectives in Public Health, 132(5), 221–227. doi:
10.1177/1757913910393864
Cosgrove, S., Moore-Monroy, M., Jenkins, C., Castillo, S., Williams, C., Parris, E., Tran,
J.H., & Rivera, M.D. (2014). Community health workers as an integral strategy in
the REACH U.S. program to eliminate health inequities. Health Promotion
Practices 15(6), 795-802. doi: 10.1177/1524839914541442
Creswell, J. W. (2013). Qualitative inquiry and research design: Choosing among five
approaches (4th ed.). Thousand Oaks, California: Sage Publications.
Day C. A., Islam M., White, A., Reid, S. E., Hayes, S., & Haber, P.S. (2011)
Development of a nurse-led primary healthcare service for injecting drug users in
inner-city Sydney. Australian Journal of Primary Health 17(1). doi:
10.1071/PY10064
Dowling M. (2007). From Husserl to van Manen. A review of different
phenomenological approaches. International Journal of Nursing Studies, 44(1),
131–142. doi: 10.1016/j.ijnurstu.2005.11.026
75
Duthie, P., Philippi, E., & Schultz, J. (2005). Collaboration for training: A partnership to
improve quality, consistency and cost-effectiveness of essential training for
community health workers. Journal of Health Education, 36(2), 113-116. doi:
10.1080/19325037.2005.10608168
Elmir, R., Schmied, V., Jackson, D., Wilkes, L. (2011). Interviewing people about
potentially sensitive topics. Nurse Researcher, 19(1), 12-16.
Fausto, M.C., Giovanella, L., de Mendonça, M.H., de Almeida, P.F., Escorel, S.,
de Andrade, C.L., Martins, M.I. (2011). The work of community health workers
in major cities in Brazil: mediation, community action, and health care. Journal of
Ambulatory Care Management, 34(4). 339-353.
doi:10.1097/JAC.0b013e31822cbe60
Farrell, S.J., Huff, J., MacDonald, S., Middlebro, A., & Walsh, S. (2005). Taking it to the
street: A psychiatric outreach service in Canada. Community Mental Health
Journal 41(6), 737-746.
Fawcett, K. J., Neff, J., Freese Decker, C., & Faber, J. (2018). Achieving IHI’s triple aim
by utilizing core health program with community health workers in rural
communities. Family & Community Health, 41(4), 255–264.
doi:10.1097/FCH.0000000000000196
Felix, H.C., Mays, G.P., Stewart, M.K., Cottoms, H., & Olson, M. (2011). The care span:
Medicaid savings resulted when community health workers matched those with
needs to home and community care. Health Affairs, 30(7), 1366—1374.
doi:10.1377/hlthaff.2011.0150
76
Fernandez, R., Johnson, M., Tran, D. T., & Miranda, C. (2012), Models of care in
nursing: A systematic review. International Journal of Evidence‐Based
Healthcare, 10, 324-337. doi:10.1111/j.1744-1609.2012. 00287.x
Fisk, D., Rakfeldt, J., Heffenan, K., & Rowe, M. (1999). Outreach workers’ experiences
in a homeless outreach project: Issues of boundaries, ethics and staff safety.
Psychiatric Quarterly, 70(3), p. 231-246.
Fisher, E. B., Ayala, G. X., Ibarra, L., Cherrington, A. L., Elder, J. P., Tang, T. S., …
Peers for Progress Investigator Group (2015). Contributions of Peer Support to
Health, Health Care, and Prevention: Papers from Peers for Progress. Annals of
Family Medicine, 13(1), p. S2-S8. doi: 10.1370/afm.1852
Giorgi, A. (1970). Psychology as a human science: A phenomenologically based
approach. Oxford, England: Harper & Row.
Giorgi, A. (1985). Phenomenology and psychological research. Pittsburgh, PA:
Duquesne University Press.
Giorgi, A. (1992). Description versus interpretation: Competing alternative strategies for
qualitative research. Journal of Phenomenological Psychology, 23(2), 119–113.
Giorgi, A. (1997). The theory, practice, and evaluation of the phenomenological method
as a qualitative research procedure. Journal of Phenomenological Psychology,
28(2), 235-260. doi: 10.1163/156916297x00103
Giorgi, A. (2002). The question of validity in qualitative research. Journal of
Phenomenological Psychology, 33(1), 1–18.
77
Giorgi, A. (2007). Concerning the phenomenological methods of Husserl and Heidegger
and their application in psychology. Collection du Cirp, 1, 63-78. Retrieved from
http://www.cirp.uqam.ca/documents%20pdf/Collection%20vol.%201/5.Giorgipdf
Giorgi, A. (2008a). Concerning a serious misunderstanding of the essence of the
phenomenological method in psychology. Journal of Phenomenological
Psychology, 39(1), 33-58. doi: 10.1163/156916208X311610
Giorgi, A. (2008b). Difficulties encountered in the application of the phenomenological
method in the social sciences. Indo-Pacific Journal of Phenomenology, 8(1), 1-9.
doi: 10.1080/20797222.2008.11433956
Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified
Husserlian approach. Pittsburgh, PA: Duquesne University Press.
Giorgi, A. (2012). An affirmation of the phenomenological psychological descriptive
method: A response to Rennie (2012). Psychological Methods, 19(4), 542–551.
Giorgi, A. (2014). Phenomenological philosophy as the basis for a human scientific
psychology. The Humanistic Psychologist, 42(3), 233–248.
Giorgi, A. (2017). A response to the attempted critique of the scientific
phenomenological method. Journal of Phenomenological Psychology, 48(1), 83–
144. doi:10.1163/15691624-12341319
Giorgi, A., Giorgi, B., & Morley, J. (2017). The SAGE handbook of qualitative research.
In C. Willig & W. Rogers (Eds.), The descriptive phenomenological
psychological method. (pp. 176-192). Thousand Oaks, CA: Sage Publications Inc.
Giorgi A, Giorgi B. (2003). The descriptive phenomenological psychological method. In
Camic, P., Rhodes, J., & Yardley, L. Qualitative research in psychology.
78
Expanding perspectives in methodology and design, (pp. 243-273). Washington:
American Psychological Association. doi: org/10.1037/10595-013
Giorgi, B. (2011). A phenomenological analysis of the experience of pivotal moments in
therapy as defined by clients. Journal of Phenomenological Psychology, 42(1),
61–106. doi: 10.1163/156916211X567497
Glenton, C, Colvin, C.J, Carlsen, B, Swartz, A, Lewin, S, Noyes, J., & Rashidian, A.
(2013). Barriers and facilitators to the implementation of lay health worker
programmes to improve access to maternal and child health: Qualitative evidence
synthesis. Cochrane Database of Systematic Reviews, (10), N.PAG.
doi:10.1002/14651858.CD010414/full
Goss, D. (1998). 150 years of caring: The continuing history of Canada's oldest mental
health facility. Saint John, NB: MindCare NB.
Green, M.E., E., Weir, W., Hogg, V., Etches, K., Moore, D., & Hunter Birtwhistle, R.
(2013). Improving collaboration between public health and family health teams in
Ontario. Healthcare Policy 8(3): e93–104
Harris M. J., Haines A. (2012). The potential contribution of community health workers
to improving health outcomes in UK primary care. J R Soc Med, 105(8), 330–35.
doi: 10.1258/jrsm.2012.120047
Hardill, K. (2006). From the Grey Nuns to the streets; A critical history of outreach
nursing in Canada. Public Health Nursing, 24(1), 91-97. doi: 10.1111/j.1525-
1446.2006.00612.x
79
Hauff, A., & Secor-Turner, M. (2014). Homeless health needs: Shelter and health service
provider perspective. Journal of Community Health Nursing, 31(2), 103-117.
doi: 10.1080/07370016.2014.901072
Herman, A. (2011). Community health works and integrated primary health care teams in
the 21st Century. Journal of Ambulatory Care Management 34(4), 354–361.
Ingram, M., Sabo, S., Rothers, J., Wennerstrom, A., & de Zapien, J.G. (2008).
Community health workers and community advocacy: Addressing health
disparities. Journal of Community Health, 33(6), 417–424. doi:10.1007/s10900-
008-9111-y
Islam, M.M., Topp, L., Day, C.A., Dawson, A., & Conigrave, K.M. (2012). Accessibility,
acceptability, health impact and cost implications of primary health care outlets
that target injecting drug users: A narrative synthesis of literature. International
Journal on Drug Policy 23(2), 94-102. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/21996165
Jackson, L.A., McWilliam, S., Martin, F., Dingwell, J., Dykeman, M., Gahagan, J., &
Karabanow, J. (2014). Key challenges in providing services to people who use
drugs: The perspectives of people working in emergency departments and shelters
in Atlantic Canada. Drugs: Education, Prevention and Policy, 21(3), 144-153.
doi: 10.3109/09687.2013.870534
Javanparast, S., Baum, F., Labonte, R., & Sanders, D. (2011). Community health
workers’ perspectives on their contribution to rural health and well-being in Iran.
80
American Journal of Public Health, 101(12). 2287-2292. doi:
10.2105/AJPH.2011.300355
Javanparast, S., Windle, A., Freeman, t., & Baum, F. (2018). Community Health Worker
programs to improve healthcare access and equity: Are they only relevant to low-
and middle-income countries? International Journal Health Policy Management
10(10), P. 943-954. doi: 10.15171/ijhpm.2018.53
Johnson, C.D., Noyes, J., Haines, A., Thomas, K., Stockport, C., Neves, Ribas, A., &
Harris, M. (2013). Learning from the Brazilian community health worker model
in North Wales. Globalization and Health 9(25). doi: 10.1186/1744-8603-9-25
Kangovi, S., Mitra, N., Grande, D., Huo, H., Smith, A.S., & Long, J.A. (2017).
Community health worker support for disadvantaged patients with multiple
chronic diseases: A randomized clinical trial. American Journal of Public Health
107(10), 1660-16667.
Kash B. A., May M. L., & Tai-Seale, M. (2007). Community health worker training and
certification programs in the United States: Findings from a national
survey. Health Policy, 80(1), 32–42. doi: 10.1016/j.healthpol.2006.02.010
Kauffman K.S. & Hickes- Myers, D. (1997). The changing role of village health
volunteers in Northeast Thailand: An ethnographic field study. International
Journal of Nursing Studies 34(4), 249-255. doi: https://doi.org/10.1016/S0020-
7489(97)00012-6
Kok, M.C., Broerse, J.E.W., Theobald, S. et al. Performance of community
health workers: situating their intermediary position within complex
81
adaptive health systems. Hum Resour Health 15, 59 (2017)
doi:10.1186/s12960-017-0234-z
Komaromy, M., Ceballos, V., Zurawski, A., Bodenheimer, T., Thom, D.H., & Arora, S.
(2018). Extension for community healthcare outcomes (ECHO): A new model for
community health worker training and support. Journal of Public Health Policy
39(2), 203–216. doi: 10.1057/s41271-017-0114-8
Kwan, B. M., Rockwood, A., Bandle, B., Fernald, D., Hamer, M. K., & Capp, R. (2018).
Community health workers: Addressing client objectives among frequent
emergency department users. Journal of Public Health Management & Practice,
24(2), 146-154. doi: 10.1097/PHH.0000000000000540
Lang, L., Orton, S., Sallah, D., Hewitt-Moran, T., Zhang, D., Cullen, S., ... Chen, R.
(2011). A survey of engagement and competence levels in interventions and
activities in a community mental health workforce in England. BMC Health
Services Research, 11(1). doi:10.1186/1472-6963-11-352
Lehmann, U. & Sanders, D. (2007). Community health workers: What do we know about
them? The state of the evidence on programmes, activities, costs and impact on
health outcomes of using community health workers. Geneva, Switzerland: WHO.
Lewin, S, Dick, J, Pond, P, Zwarenstein, M, Aja, G, N, van Wyk, B, E, Bosch‐
Capblanch, X., & Patrick,M. (2005). Lay health workers in primary and
community health care. Cochrane Database of Systematic Reviews No.:
CD004015. doi: 10.1002/14651858.CD004015.pub2.
82
Lin, M. P., Blanchfield, B. B., Kakoza, R. M., Vaidya, V., Price, C., Goldner K., &
Schuur, J.D. (2017). ED-Based care coordination reduces costs for frequent ED
users. American Journal of Managed Care, 23(12), 762-7665.
Logan, R. (2018). Not a duty but an opportunity: Exploring the lived experiences of
community health workers in Indiana through photovoice. Qualitative Research
in Medicine and Healthcare 2(3). doi: 10.4081/qrmh.2018.7816.
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage.
Lopez, K. A., & Willis, D. G. (2004). Descriptive versus interpretive phenomenology:
Their contributions to nursing knowledge. Qualitative Health Research, 14(5),
726–735. doi: 10.1177/1049732304263638
Love, M. B., Legion, V., Shim, J. K., Tsai, C., Quijano, V., & Davis, C. (2004). CHWs
get credit: A 10-year history of the first college-credit certificate for community
health workers in the United States. Health Promotion Practice, 5(4), 418–428.
doi: 10.1177/1524839903260142
Love, R. (2015). Street level prostitution: A systematic literature review. Issues in Mental
Health Nursing, 36, 568-576. doi:10.3109/01612840.2015.1020462
Lovi, R., & Barr, J. (2009). Stigma reported by nurses related to those experiencing drug
and alcohol dependency: A phenomenological Giorgi study. Contemporary
Nurse, 33(2), 166-78.
Maes, K., Closser, S., & Kalofonos, I. (2014). Listening to community health workers:
How ethnographic research can inform positive relationships among community
83
health workers, health institutions and communities. American Journal of Public
Health 104(5), e5-9. doi: 10.2105/AJPH.2014.301907
Malcarney, M., B., Pittman, P., Quigley, L., Horton, K., & Seiler, N. (2017). The
changing roles of community health workers. Health Services Research, 52, 360–
382. doi: org/10.1111/1475-6773.12657
Martins, D.C. (2008). Experiences of homeless people in the health care delivery system:
A descriptive phenomenological study. Public Health Nursing, 25(5), 420-430.
doi: 10.1111/j.1525-1446.2008.00726.x
Mathers, B.M., Degenhardt, L., Phillips, B., Wiessing, L., Hickman, M., Strathdee, S.A.,
Wodak, A., Panda, S., Tyndall, M., Toufik, A., & Mattick, R.P. (2008). Global
epidemiology of injecting drug use and HIV among people who inject drugs: a
systematic review, Lancet 372(9651), 1733-1745. doi: 10.1016/S0140-
6736(08)61311-2
Martinez, J., Ro, M., Villa, N. W., Powell, W., & Knickman, J. R. (2011). Transforming
the delivery of care in the post-health reform era: What role will community
health workers play? American Journal of Public Health, 101(12), e1-5.
doi:10.2105/AJPH.2011.300335
Matsumoto, C., O’Driscoll, T., Lawrence, J., Jakubow, A., Madden, S., & Kelly, L.
(2017). A 5- year retrospective study of emergency department use in Northwest
84
Ontario: A measure of mental health and addictions needs. CJEM, 19(05), 381–
385. doi:10.1017/cem.2016.387
McCollum, R., Gomez, W., Theobald, S., & Taegtmeyer, M. (2016). How equitable are
community health worker programmes and which programme features influence
equity of community health worker services? A systematic review. BMC Public
Health 5, e1-16.
McEldowney, R., & Connor, M. J. (2011). Cultural safety as an ethic of care: A
praxiological process. Journal of Transcultural Nursing, 22(4), 342–349.
McNeil, R., Kerr, T., Pauly, B., Wood, E., & Small, W. (2015). Advancing patient-
centered care for structurally vulnerable drug-using populations: A qualitative
study of the perspectives of people who use drugs regarding the potential
integration of harm reduction interventions into hospitals. Society for the Study of
Addiction, 111(4), 685–694. doi:10.1111/add.13214
Merleau-Ponty, M. (1962). Phenomenology of perception. New Jersey: The Humanities
Press.
Ministry of Health and Long-Term Care (MOHLTC) (2008). Ontario Public Health
Standards 2008. Toronto: Government of Ontario. Retrieved from
http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/op
hs2008
85
Morecroft, C., Cantrill, J., & P, Tully, M. (2010). Can in‐depth research interviews have a
‘therapeutic’ effect for participants? International Journal of Pharmacy Practice,
12, 247-254. doi: 10.1211/0022357045002
Morgan, K., Lee, J., & Sebar, B. (2015). Community health workers: A bridge to
healthcare for people who inject drugs. International Journal of Drug Policy,
26(4), 380–387. doi: 10.1016/j.drugpo.2014.11.001
Murray, M., & Ziegler, F. (2015). The narrative psychology of community health
workers. Journal of Health Psychology, 20(3), 338–349.
doi:10.1177:10.1177/1359105314566615
Najafizada, S. A. M., Bourgeault, I. L., Labonte, R., Packer, C., & Torres, S. (2015).
Community health workers in Canada and other high-income countries: A
scoping review and research gaps. Canadian Journal of Public Health, 106(3),
e157–e164. doi:10.17269/cjph.106.4747
Neale, J, Tompkins, C., & Sheard L. (2008). Barriers to accessing generic health and
social care services: A qualitative study of injecting drug users. Health & Social
Care in the Community, 16(2), 147–154. doi: 10.1111/j.1365-2524. 2007.00739.x
Nemcek, M. A., & Sabatier, R. (2003). State of evaluation: Community health
workers. Public Health Nursing, 20(4), 260–270. doi: 10.1046/j.1525-1446
2003.20403.x
Nurses Association of New Brunswick. (2017). Continuing competence program.
Fredericton, NB: Author. Retrieved from http://www.nanb.nb.ca/practice/ccp
86
O’Brien, M. J., Squires, A. P., & Larson, S. C. (2009). Role development of
community health workers: An examination of selection and training processes in
the intervention literature. American Journal of Preventive Medicine, 37(6), S262-
9. doi: org/10.1016/j.amepre.2009.08.011
Olaniran, A., Smith, H., Unkels, R., Bar-Zeev, S., & van den Broek, N. (2017). Who is a
community health worker? A systematic review of definitions. Global Health
Action, 10(1). Retrieved from doi: org/10.1080/16549716.2017.1272223
Oliver, M., Geniets, A., Winters, N., Rega, I., & Mbae, S. M. (2015). What do
community health workers have to say about their work, and how can this inform
improved programme design? A case study with CHWs within Kenya. Global
Health Action, 8. doi: 10.3402/gha. v8.27168
Ozano, K., Simkhada, P., Thann, K., & Khatri, R. (2018). Improving local health through
community health workers in Cambodia: Challenges and solutions. Human
Resources for Health, 16. doi: 10.1186/s12960-017-0262-8
Pauly, B., McCall, J., Browne, A. J., Parker, J., & Mollison, A. (2015). Toward cultural
safety. Advances in Nursing Science, 38(2), 121–135.
doi: 10.1097/ANS.0000000000000070
Peacock, N., Issel, L. M., Townsell, S. J., Chapple-McGruder, T., & Handler, A. (2011).
An innovative method to involve community health workers as partners in
evaluation research. American Journal of Public Health, 101(12), 2275–2280.
doi: 10.2105/AJPH.2011.300263
87
Perez, M., Findley, S., Mejia, M., & Martinez, J. (2006). The impact of community health
worker training and programs in New York City. Journal of Health Care for the
Poor and Underserved. 17(1), 26–43. doi: 10.1353/hpu.2006.0011
Phillips, M., DeBeck, K., Desjarlais, T., Morrison, T., Feng, C., Kerr, T., & Wood, E.
(2014). Inability to access addiction treatment among street-involved youth in a
Canadian setting. Substance Use Misue 49(10). 1233-1240. doi:
10.3109/10826084.2014.891618
Polit, D., & Beck, C. (2012). Nursing research: Generating and assessing evidence for
nursing practice (9th ed.). Philadelphia: PA: Lippincott Williams & Wilkins.
Public Health Agency of Canada. (2007). The 2007 report on the integrated Pan
Canadian Healthy Living Strategy. Retrieved from http://www.publichealth.gc.ca
Public Health Agency of Canada (2018). Stigma and substance use. Retrieved from
https://www.canada.ca/en/health-canada/services/substance-use/problematic-
prescription-drug-use/opioids/stigma.html
Richards, L. and Morse, J.M. (2013) Readme first for a user’s guide to qualitative
methods (3rd ed). Thousand Oaks, CA: Sage.
Rosenthal E., L., Wiggins, N., & Brownstein, J.N. (1998). The Final Report of the
National Community Health Advisor Study: Weaving the future. Tucson, AZ:
University of Arizona. Retrieved from
https://crh.arizona.edu/publications/studies-reports/cha
Rosenthal, E.L., Brownstein, J.N., Rush, C.H., Hirsch, G.R., Willaert, A.M., Scott, J.R.
... Fox DJ. (2010). Community health workers: Part of the solution. Health
Affairs, 29(7), 1338–1342. doi: org/110.1377/hlthaff.2010.0081
88
Rosenthal, E., Wiggins, N., Ingram, M., Mayfield-Johnson, S., & De Zapien, G. (2011).
Community health workers then and now. Journal of Ambulatory Care
Management, 34(3), 247–259. doi: 10.1097/JAC.0b013e31821c64d7
Rosenthal, E. L., & Wiggins, N. (2015). Community health workers: Advocating for a
just community and workplace. Journal of Ambulatory Care Management, 38(3),
204-205. doi: 10.1097/JAC.0000000000000101
Rush, C. H. (2012). Return on investment from employment of community health
workers. Journal of Ambulatory Care Management, 35, 133-137. doi:
10.1097/JAC.0b013e31822c8c26
Sabo, S., Allen, C. G., Sutkowi, K., & Wennerstrom, A. (2017). Community health
workers in the United States: Challenges in identifying, surveying, and supporting
the workforce. American Journal of Public Health, 107(12), 1964–1969. doi:
10.2105/AJPH.2017.304096
Saint John Human Development Council (2018). Reboot for poverty reduction. Retrieved
from http://sjhdc.ca/a-reboot-for-poverty-reduction.html
Sen, S., & Bhattacharya, C. B. (2001). Does doing good always lead to doing better?
Consumer reactions to corporate social responsibility. Journal of Marketing
Research, 38(2), 225–243.
Smith, D. (2010) A history of Amedeo P. Giorgi’s contributions to the Psychology
Department and Phenomenology Center of Duquesne University in his twenty-
four years there. Pittsburgh, PA: Duquesne University Press.
89
Spencer, M.S., Gunter, K.E., & Palmisano, G. (2010). Community health workers and
their value to social work. Social Work, 55(2), 169–180. doi: org/sw/55.2.169
Sprague, L. (2012). Community health workers: A front line for primary care? National
Health Policy Forum. Retrieved from
https://hsrc.himmelfarb.gwu.edu/sphhs_centers_nhpf/26
Statistics Canada (2018). Canadian motor vehicle traffic collision statistics: 2016.
Retrieved from https://www.tc.gc.ca/eng/motorvehiclesafety/canadian-motor-
vehicle-traffic-collision-statistics-2016.html
Statistics Canada. (2017). Census profile, 2016 - Saint John, City, New Brunswick
Canada. Retrieved from https://www12.statcan.gc.ca/census
Statistics Canada. (2016). Overview of national data on opioid-related harms and deaths.
Retrieved from https://www.canada.ca/en/health-canada/services/substance-
use/problematic-prescription-drug-use/opioids/data-surveillance-research/harms-
deaths.html
Strachan, D., Källander, K., & ten Asbroek, A. (2012). Interventions to improve
motivation and retention of community health workers delivering integrated
community case management: Stakeholder perceptions and priorities. American
Journal of Tropical Medicine, 87(5), 111-119.
Strike, C., Guta, A., de Prinse, K., Switzer, S., & Chan Carusone, S. (2014). Living with
addiction: The perspectives of drug using and non-using individuals about sharing
space in a hospital setting. International Journal of Drug Policy, 25(3), 640-649.
doi: 10.1016/j.drugpo.2014.02.012
90
Taylor, B., Mathers, J., & Parry, J. (2018). Who are community health workers and what
do they do? Development of an empirically derived reporting taxonomy. Journal
of Public Health, 40(1), 199–209. doi: org/10.1093/pubmed/fdx033
Torres, S., Balcázar, H., Rosenthal, L. E., Labonté, R., Fox, D., & Chiu, Y. (2017).
Community health workers in Canada and the US: Working from the margins to
address health equity. Critical Public Health, 27(5), 533–540. doi:
10.1080/09581596.2016.1275523
Torres, S., Labonté, R., Spitzer, D. L., Andrew, C., & Amaratunga, C. (2014). Improving
health equity: The promising role of community health workers in Canada.
Healthcare Policy = Politiques De Sante, 10(1), 73-85.
Treloar, C., & Abelson, J. (2005). Information exchange among injecting drug users: A
role for an expanded peer education workforce. International Journal of Drug
Policy, 16(1), 46–53.
Trinh-Shevrin, C., Islam, N. S., Nadkarni, S., Park, R., & Kwon, S. C. (2015). Defining
an integrative approach for health promotion and disease prevention: A
population health equity framework. Journal of Health Ccare for the Poor and
Underserved, 26(2), 146–163. doi:10.1353/hpu.2015.0067
UNAIDS. (2016). Do no harm: Health, human rights and people who inject drugs.
Geneva: Switzerland. Retrieved from
http://www.unaids.org/sites/default/files/media_asset/JC2559_local-
epidemics_en.pdf
Van Boekel, L.C., Brouwers, E.P.M., van Weeghel, J., & Garretsen, J.F.L. (2013).
Stigma among health professionals towards patients with substance use disorders
91
and its consequences for healthcare delivery: Systematic review. Drug and
Alcohol Dependence, 131(1-2), 23-35. doi: 10.1016/j.drugalcdep.2013.02.018
Van Ginneken, N., Tharyan, P., Lewin S., Rao, G. N., Meera, S.M., Pian, J., Patel, V.
(2013). Non-specialist health worker interventions for the care of mental,
neurological and substance-abuse disorders in low- and middle-income
countries. Cochrane Database of Systematic Reviews, (11). doi:
10.1002/14651858.CD009149.pub2
Vollman, R.V., Anderson, E.T., & McFarlane, J. (2004). Community as partner.
Philadelphia, PA: Lippincott, Williams & Wilkins.
Walker, D. G., & Jan, S. (2005). How do we determine whether community health
workers are cost-effective? Some core methodological issues. Journal of
Community Health, 30(3), 221–229. Retrieved from
https://login.proxy.hil.unb.ca/login?url=http://search.ebscohost.com/login.aspx?di
rect=true&db=c8h&AN=106340956&site=ehost-live&scope=site
WestRasmus, E. K., Pineda-Reyes, F., Tamez, M., & Westfall, J. M. (2012). Promotores
de salud and community health workers. Family & Community Health, 35(2),
172–182. doi: 10.1097/FCH.0b013e31824991d2.
Winch, P.J., Gilroy, K.E., Wolfheim, C., Starbuck, E.S., Young, M.W., Walker, L.D., &
Black, R.E. (2005). Intervention models for the management of children with
signs of pneumonia or malaria by community health workers. Health Policy &
Planning, 20(4), 199–212. doi: heapol/czi027
World Health Organization. (1986). Ottawa Charter for Health Promotion: First
International Conference on Health Promotion Ottawa, 21 November
92
1986. Retrieved
from https://www.healthpromotion.org.au/images/ottawa_charter_hp.pdf
World Health Organization. (1987). The community health worker: Working guide,
guidelines for training, guidelines for adaptation. Geneva, Switzerland: World
Health Organization. Retrieved from http://www.who.int/iris/handle/10665/38101
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Appendix A
List of Key Saint John Non-profit Agencies
1. First Steps Housing Initiative
2. Outflow Saint John
3. Coverdale Saint John
4. Sophia Recovery Centre
5. Fresh Start Services
6. Elizabeth Frye Society
7. Avenue B Harm Reduction Inc.
8. The Saint John Learning Exchange
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Appendix B
Participant Recruitment Poster
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Appendix C Informed Consent
COMMUNITY HEALTH WORKER EXPERIENCES
WORKING WITH PEOPLE WHO USE DRUGS
Kimberly Wilbur, RNBN
University of New Brunswick, Faculty of Nursing
[email protected] (506) 648-5664
Graduate Supervisor Director of Graduate Studies
Dr. Tracey Rickards Dr. Kathryn Weaver
[email protected] [email protected]
(506) 447-3412 (506) 458-7648
This research has been reviewed by the UNB REB and is on file as 2019-064.
I am invited to be a part of the research study conducted by Kim Wilbur under the
supervision of Dr. Tracey Rickards. I understand that the study is a graduate project for
Kim Wilbur’s Master of Nursing research project. The reason for the study is to increase
the understanding of the lived experiences of Community Health Workers (CHWs)
working people who use drugs, in Saint John, New Brunswick.
• I volunteer to take part in one interview that could last from 60 to 90 minutes.
• I understand I will be asked general information about my age, education and
work.
• I understand that the interviews about my work in the community will be recorded
and once it is typed and reviewed the original electronic files will be deleted from
all devices.
• I understand I can refuse to have the session recorded and the researcher can make
notes during our conversation about my work.
• I can stop or withdraw from the study at any time, it is my choice.
• If I am anxious, upset, or not comfortable, Kim Wilbur will stop the interview so
that I can pull myself together. If I am still anxious, upset or not comfortable she
will help me to find support. She will give me information on where I can get help
such as the Chimo 24 Hour Help Line.
• Taking part in this study will allow me to talk about my being a Community
Health Worker. As a stressful job, talking about it can make me feel better about
my work.
• I can stop to call a friend or family member if I feel I need to do so.
96
• All of my information will remain confidential. My name will never appear in a
presentation, publication or report.
• The study information will be kept in a locked cabinet in the secure office of Kim
Wilbur for three years. Once the study is finished the information will be
destroyed as per the requirements of the UNB Research Ethics Board.
• I have the right to decide to withdraw from the study at any time. All of my
information and recordings may be withdrawn at that time.
• I understand I will receive $40 in appreciation for my time and to cover any travel
costs. This cash gift will be given to me after my interview even if I decide to stop
or withdraw from the study.
I understand that the study has been reviewed and given approval by the Faculty of
Nursing Ethics Committee and the University of New Brunswick Research Ethics Board.
I agree to take part in the study being done by Kim Wilbur and may get in touch with her
if I have any questions.
I may get in touch with her Supervisor, Dr. Tracey Rickards or the Faculty of Nursing,
Director of Graduate Studies, Dr. Kathryn Weaver if I have any other questions. I can
also get in touch with Chair of the Research Ethics Board, Dr. Steven Turner at (506)
453-5189, in the Office of the Vice- President Research UNB.
A copy of this consent form will be given to me at the time of my interview. I would like
to have a copy of the interview and recordings when the study is finished. Yes __No __
and a copy of the Executive Summary of the final thesis document. Yes __No __
I am giving my consent and understand the following:
• I am being asked to talk about my everyday work experiences today. I allow this
conversation to be recorded for study use only.
• My name will never appear in any reports or presentations about the study. The
results may be published and presented at meetings.
• I will receive $40 as a thank you for taking the time to talk about my work today
• I have been given the chance to ask questions and they have all been answered.
_____________________________________________ ________________________
Participant’s Printed Name Date [day/month/year]
_____________________________________________
Participant’s Signature
_____________________________________________ ________________________
Researcher’s Signature Date [day/month/year]
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Appendix D
Demographic Information
This research has been reviewed by the UNB REB and is on file as 2019-064.
Participant ID Code: _________________ Date: ___________________
[day/month/year]
A. Personal Information
1. Age _______________ 2. Gender ____________
B. Education
1. Diploma ____________ 2. Certificate __________ 3. Degree ______________
C. Employment
1. How many years have you been working with non-profit agencies?
2. What is your current job title?
3. What are your current job responsibilities?
4. What is the focus for your agency where you are currently working?
5. How long have you been working with this agency?
6. What is your current case load?
7. What type of position do you have? Full Time ___ Part-time ____ Casual
____
8. Do you have a permanent position?
9. Are you provided with benefits such paid sick leave ____, vacation ____, medical
insurance____ or other benefits _____?
10. Prior to this position did you work in the field of health or social services?
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Appendix E
De-Briefing Document
Community Health Worker Experiences Working With People Who Use Drugs
Principle Investigator: Kimberly Wilbur, Faculty of Nursing, [email protected]
It is important to know that thinking and talking about your everyday lived experiences as
a Community Health Worker working with people who use drugs can sometimes make
you feel anxious, uncomfortable or emotionally distressed. For some individuals these
feelings of distress may occur during the interview or even days afterwards.
Common signs of a stress may include:
Nausea Dizziness Anger Guilt Sadness Restlessness Chest
Tightness
Vomiting Heart
Palpitations
Sweating Fear Panic Sleep
Changes
Shortness
of Breath
Emergency Care
If you are feeling unwell you can access the Urgent Care Department at St. Joseph’s
Hospital or the Emergency Department at the Saint John Regional Hospital or dial 911.
Tele-Care
Is a free and confidential telephone service that provides bilingual access to a Registered
Nurse who can offer health advice and information to all residents of New Brunswick, 24
hours a day, 7 days a week by dialing 811.
Chimo Helpline
Is a free telephone crisis telephone service that provides support to all residents of New
Brunswick, 24 hours a day, 7 days a week. Provincial Helpline: 1-800-667-5005 (toll-
free, province-wide)
Helpful Tips to Manage Stress
It is important to be kind to yourself and do those activities that make you feel good such
as: ▪ Regular exercise and spending time outdoors
▪ Relaxation exercises
▪ Listening to music, writing, keeping a journal
▪ Eating healthy and keeping a daily routine
▪ Getting enough sleep
▪ Talking, laughing and spending time with people or pets who care about you. Be with
people who energize you
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Appendix F
MENTAL HEALTH COMMISSION OF CANADA DOCUMENT
https://www.mentalhealthcommission.ca/sites/default/files/MHCC_ExperiencingTraumaticEvents_Nov2014_ENG_0.pdf
100
Appendix G
Study Interview Guide
Exploring Community Health Workers Lived Experiences
The interviews will align with this semi-structured guide, with potential probes
being generated during the interview in the context of the participant’s responses.
Introduction: Thank-you for agreeing to participate in my research study to explore your
experiences as a Community Health Worker in Saint John working with people who use
drugs. This interview will take approximately 60-90 minutes, however, if it is necessary
to take a break or if for whatever reason you need to discontinue the interview, please let
me know.
Your participation is completely voluntary, and you may withdraw from this research study
at any time. All of the information you provide will be kept strictly confidential and neither
your identity nor your employer will not be revealed. Outside of the informed consent for
the study all of the information related to your interview such as the notes or audio-
recordings will be identified using a unique code.
If you have any questions or require clarification on any issues during the interview feel
free to stop me at any time. You indicated in the consent that you would allow me to record
the interview, is this still okay with you? Are you comfortable and is there anything you
need before we begin?
Let’s begin with you telling me a little bit about the agency where you’re working.
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Can you please describe to me in as detailed a way as possible your experiences as a
Community Health Worker working with people who use drugs?
Prompts:
What have been your experiences as a Community Health Worker?
Can you describe the needs of individuals you work with and how you are able to meet
their needs?
What is it like working as a Community Health Worker?
What are the really positive aspects of your work?
What are the challenges of working as a Community Health Worker?
What is the most significant barrier to your being effective as a Community Health
Worker?
What is the impact of your work on your overall health and well-being?
So can you talk about that a bit more?
So if I am understanding you correctly…..was I right?
Can you describe this for me?
Previously you described situation XYZ, I would like to know more about that experience?
How did this make you feel at the time? Later on….
What does ………….mean?
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Appendix H Master Participant List
Initials (First, Last) Identification Code
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
A01
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
B02
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
C03
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
D04
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
E05
Audio Recording & Transcript Yes __No __
Mailing Address
Thesis Document Yes __No __
Email Address
F06
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Table 1
Example of Search Strategy
# Query Results
1
“Community Aid” OR “Community Health Aid” OR “Community
Health Representative” OR “Community Support Worker” OR
“Community Health Advocate” OR “Community Health Agent” OR
“Community Health Worker” OR “Lay Community Health Outreach
Worker” OR “Lay Health Worker” OR “Lay Health Promoter” OR
“Lay Health Navigator” OR “Front Line Public Health Work” OR
“Multicultural Health Broker” OR “First Nations Health Workers”
OR “Paraprofessional Health Worker” OR “Community Navigator”
OR “Community Support Worker”
721
2
(DE "LGBT people") OR (DE "SUBSTANCE abuse") OR (DE
"HOMELESS persons") OR (DE "PROSTITUTION") OR (DE
"PSYCHOTHERAPY patients") OR (DE "MENTALLY ill") OR (DE
"INDIGENOUS peoples") AND (DE "HEALTH of indigenous
peoples" OR DE "HEALTH of LGBT people") OR PWCD OR PWID
OR “people who use drugs” OR “people who inject drugs” OR
Addicts OR HIV OR AIDS OR homeless OR runaways OR LGBTQ
OR Prostitutes OR marginalized OR vulnerable OR “street people”
OR “street youth” OR “sex trade workers” OR “Mental Illness” OR
“serious and persistent mental illness” OR “medically underserved
populations”
150,219
3
(DE "ETHNOLOGY") OR (DE "STRESS (Psychology)") OR (DE
"POST-traumatic stress disorder") OR (DE "QUALITY of life") OR
(DE "QUALITY of work life") OR (DE "WELL-being --
Psychological aspects") OR (DE "BURNOUT (Psychology)") OR
Psychology OR Narratives OR Ethnography OR “Lived Experiences”
OR Burnout OR “Life Experiences” OR Stress OR “Quality of Life”
OR “Well-Being” OR Resiliency OR “Work Experiences”
369,448
4 1 AND 2 AND 3 11
SocINDEX (EBSCOhost)
Search conducted on 7/9/2018
Limits: Published Date: 20000101-20181231; Peer Reviewed
CURRICULUM VITAE
Kimberly Anne Wilbur
Education
1982 L'Ecole des Infirmieres de Bathurst School of Nursing - Valedictorian
2004 University of New Brunswick Nursing Baccalaureate UNB SJ - Honours
Publications
Weaver, K., Chenier, K., LeBlanc, H., & Reid, A. (2017). Metaphors of
interdisciplinary collaboration to overcome the theory-practice gap when
transitioning from RN to Advanced Practice Nurses. International Journal of
Advanced Nursing Education and Research, 2, (2), 63-74, PDF.
Nagel, D. A., Keeping-Burke, L., Pyrke, R. J. L., Boudreau, C. L., Goudreau, A.,
Luke, A., Wilbur, K., Waycott, L., & Hamilton, C. (In press). Frameworks for
evaluation of services and outcomes for community health centers: A scoping review
protocol. JBI Database of Systematic Reviews and Implementation Reports.
Conference Presentations
June 8 – 10, 2017 Weaver, K., Chenier, K., Leblanc, H., & Reid, A. “Metaphors
of interdisciplinary collaboration to overcome the theory-practice gap when
transitioning from RN to Advanced Practice Nurses.” Atlantic Region Canadian
Association of Schools of Nursing AGM & Research Conference
(ARCASN2017). Université de Moncton, Moncton, NB.
October 25-28, 2018 Brunt, C., Chenier, K., Giles, S., & Brennan, E. “Harm
Reduction Policies from the Street to the Bedside.” (Abstract Poster Accepted)
Canadian Society of Addiction Medicine Scientific Conference. Vancouver,
British Columbia.
November 20, 2018 K. Wilbur “Exploring the Lived Experiences of Community
Health Workers” Poster and Presentation at the Canadian Research Initiative in
Substance Misuse Atlantic Symposium. (CRISM 2018). Moncton, New
Brunswick.
