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Please note, this post originally appeared on the ARNBC Blog in June 2016. It is shared with permission.

The role of street nurses in increasing access to health care for marginalized populations

By Meaghan Thumath, RN, BScN, MSc PH

The downtown eastside is a fascinating place to practice nursing with a rich history, diverse population and artistic flair. It is also a place where many people struggle daily without adequate housing, employment or support to manage substance use and mental health issues exacerbated by trauma and pain.

But there are numerous individuals who have made it their life’s work to support and encourage the community to thrive. Street nurses are some of the most forthright, committed and determined healthcare professionals in the country. They have made an enormous difference in the lives of those who are marginalized in places like the Downtown East Side, and they will continue, with minimal applause or accolades, to work with individuals who many others have simply written off.

While the history of street nursing in Canada has been largely undocumented, Vancouver appears to be an early pioneer of street nursing in Canada. Following the sexual revolution in 1960s-1970s, four nurses also known as “street nurses in blue jeans” began providing oral contraceptive pills and sexually transmitted infection (STI) treatment to youth. In 1988, the HIV/AIDS epidemic in Vancouver led to the creation of BC Centre for Disease Control’s (BCCDC) AIDS Prevention Street Nurse Program.

Much of the success of street nursing in Vancouver can be attributed to Liz James, the first nurse to be hired by BCCDC to provide outreach services. Sadly, Liz passed away earlier this year, but she has left a legacy of caring for those who are marginalized and struggling in Vancouver.

Liz began working in Venereal Disease control in the 1970s and later found herself working in Vancouver city jail, where she found her passion for working with marginalized populations. Liz epitomized what it meant to build a trusting, non-judgemental therapeutic relationship with clients - many of the women she worked with saw her as a mother figure. With the rise in HIV/AIDS in the 1980s among men who have sex with men (MSM) and injection drug users in the 1990s, Liz worked with community members and purchased needles from a sympathetic pharmacist to begin a needle exchange. For every used needle she collected from clients, she would exchange one clean needle in return. Starting out as a program which targeting those that were at high risk of HIV and STIs such as injection drug users, and MSM, Liz's needle exchange expanded to provide services to other marginalized populations such as sex workers, the broader LGBT community, and those involved with the correctional system. While the program’s primary mandate was to control and prevent the spread of HIV/AIDS and STIs, nurses like Liz also addressed the broader social determinants of health by providing resources to increase her client’s access to health and social services. Throughout the 1990s, street nurses such as Liz were determined activists, and were among the first to advocate for supervised injection services, bringing harm reduction services to correctional facilities, and education related to alcohol detoxification, to those who wouldn’t seek treatment otherwise.

According to "From the grey nuns to the streets: a critical history of outreach nursing in Canada" the grey nuns started public health visits for the sick poor in what is now known as Quebec. During the first half of the 19th century, the grey nuns spread all over the northern and western parts of Canada, where they founded many of the first hospitals within those regions. Moving into the mid-19th century, several prominent nursing leaders such as Florence Nightingale, Lillian Wald, and the Victorian Order of Nurses (VON) began to understand the relationship between the broader social determinants of health, such as housing conditions and income, and the need to reform policies that would improve the health of individuals.

The social reform movement during the turn of the 19th century led to the belief that introducing nurses into areas where people were at high risk of disease would reduce those risks, which subsequently led to the introduction of public health nurses across the country. However, with the dominance of the medical model in the early 20th century, many nurses were removed from health promotion activities. During the late 20th century, despite the presence of a universal health coverage model, the growing inequities in access to health care and determinants of health led to what we now call street nursing in large urban areas. Street nurses began working predominantly with individuals who were marginalized such as the homeless.

Street nursing today not only focuses on controlling the spread of infectious diseases such as HIV/AIDS and STIs, but also on the broader social determinants by connecting individuals to health and social services. Street nurses work in a variety of settings ranging from clinics to alleys and parks, to detox centres and correctional facilities, to name a few. The ability of nurses like Liz to build trusting, non-judgemental and non-threatening relationships with their clients is a significant contributor to the positive outcomes of these clients. She demonstrated the importance of the humanistic side of nursing, and that being empathetic and listening to the needs of patients is at the core of good nursing practice.

If this history teaches us anything, it’s that nurses have the ability to improve the lives of individuals and communities, not only through knowledge, but by building trusting relationships, empowering patients to take control of their health and well-being, and speaking out for the needs of patients. Liz James’ passing serves as an opportunity to reflect back on the incredible individuals who have not only transformed the role of street nurses, but shifted the discussion around harm reduction and improved the health of marginalized populations by challenging inequities and refusing to succumb to the status quo. While our roles as nurses become increasingly complex, nurses like Liz will always serve to remind us that we should never underestimate our ability to be leaders and influence policy.

In the words of Liz’s colleague and former street nurse Janine Stevenson in the film Bevel Up "Nursing is a very political act. It is also, potentially, a revolutionary force that asks what kind of society do you really want to live in?"

The author would like to acknowledge the generous contributions of street nurses Caroline Brunt, Fiona Gold and James Tigcehlaar who provided valuable insight into the history of street nursing and their colleague Liz James.

About Meaghan Thumath

Meaghan Thumath is a registered nurse and public health leader in HIV and drug policy. A former coordinator at Insite and leader of BC's provincial HIV strategy she has over 10 years of clinical and health policy experience. Her research interests include drug addiction, health equity and gender.

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