Analysis of hospital-based healthcare provision for people living with HIV who use drugs in Ontario, Canada: “Beyond my Scope!”

Abstract

People living with HIV (PLWH) who use drugs are hospitalized at higher rates than the general population and report receiving poor care during hospitalization. The patient experience of PLWH during hospitalization is influenced by the clinical practice of healthcare providers (HPs). However, there is a gap in the literature that articulates the perspectives of HPs who deliver care to this population. Semi-structured interviews were conducted with HPs on in-patient hospital units in Toronto and Ottawa, Canada. Structuration-theory-informed thematic analysis was used to explore the beliefs and rules identified and utilized by HPs that affect healthcare delivery during the hospital stay of PLWH who use drugs. Interviews were audio-recorded and transcribed verbatim. The participants included 26 hospital-based HPs (i.e. Physicians, Registered Nurses, Social Workers, Pharmacists, Dietician, and Nurse Practitioner) who deliver healthcare services to people who are living with HIV and who use drugs during the hospital admission. Most HPs stated that no explicit hospital rules exist to guide their clinical practice when engaging with people who use drugs and many indicate that providing care to this population is beyond their scope of practice. The lack of explicit rules results in implicit rules and actions that may negatively impact the delivery of equitable healthcare for PLWH who use drugs.

Keywords:

• Drug use
• health equity
• HIV
• qualitative research

REVIEWING EDITOR:

• Komalsingh Rambaree, Social Work and Criminology, University of Gävle, Gävle, Sweden

SUBJECTS:

• Social Work; Sociology; Allied Health; Health Conditions; Nursing; Public Health Policy and Practice; Social Work and Social Policy; Medicine; Nursing; Allied Health

Background

People living with HIV (PLWH) who use drugs are hospitalized more frequently than the general population, and hospitals have taken on the role of primary care providers (O’Leary et al., 2022; Strike et al., 2020). Drug use in the context of HIV is a compounding factor that increases the likelihood of hospitalization. Drug use, as described in this paper, refers to the consumption of illicit drugs (e.g. cocaine, heroin).

The negative health impacts of drug use, as well as the method of use (e.g. injection), are prominent topics of focus in the literature linked to hospital admissions of drug users. People who use drugs, inclusive of the different types of drugs and various methods of ingestion, are at high risk for a range of medical issues including infections, injuries, overdoses, suicide, and concurrent mental health problems (Calvert et al., 2022; Larney et al., 2017). The negative impact of drug use on a person’s physical health can result in a need for interaction with healthcare services.

Initiating lifesaving and extending medical treatment commonly occurs during hospital admission. The overall patient experience of hospital admission is directly influenced by the clinical practice and decision-making of healthcare providers (HPs), such as physicians, nurses, social workers, and other allied health professionals (O’Leary et al., 2018; Penta et al., 2022). Although we know that PLWH who use drugs are reported to be admitted to hospitals more frequently than the general population, there is little literature that articulates the perspective of HPs who deliver care to this population or proposes strategies to improve the HP’s scope of practice as it relates to hospitalized PLWH who use drugs.

Theoretical framework

Structuration theory, posited by Anthony Giddens, allows for a focused exploration of the interconnectedness of agency and structure (Giddens, 1984); Giddens refers to this interconnected relationship as the ‘duality of structure’ (Giddens, 1990). As a person’s actions are guided by the structure (e.g. the hospital), it is those very actions that construct and perpetuate the structure. Fundamental to the construction of a structure are the rules used by a person when taking action (Misir, 2015). The rules that guide actions are directly linked to a person’s core beliefs (O’Leary et al., 2022).

Knowledge

There are two interconnected types of knowledge that directly influence the actions taken and not taken by a person: ‘practical knowledge and discursive knowledge’ (Giddens, 1987). Practical knowledge comprises unconscious and internalized beliefs and rules that guide the actions we take (Kondrat, 1999). With discursive knowledge, it is possible for a person to describe the action taken, their rationale for taking the action, and how, if necessary, the action could be altered going forward. By surfacing practical knowledge at the discursive level for examination, beliefs that inform the rule(s) that guide the person’s actions can be altered. (Giddens, 1984).

Reflexivity

Engaging in reflexivity is intended to intentionally raise beliefs and rules situated within our practical knowledge to the discursive level for examination, deconstruction, and reconstruction (Calvert et al., 2022; O’Leary et al., 2022). Most people are capable of reflection, yet it is not a routine practice for HPs to utilize a critical self-awareness approach to better inform their professional practice decisions and actions.

This study uses structuration theory to analyze, and discuss, HPs’ internalized beliefs and rules (i.e. practical knowledge) that guide their clinical practice when providing healthcare for PLWH who use drugs (Giddens, 1984). The following two research questions guided this study:1) How does HPs’ practical knowledge influence the construction of PLWH who use the drug’s patient identity? 2) What rules do HPs identify as influencing healthcare delivery during hospital admission of PLWH who use drugs? Practical knowledge of an individual HP, brought to the discursive level via this research study, enables the deconstruction of actions taken or not taken by HPs.

Methods

Research Design

This paper reports on data from a qualitative study that explored the challenges of providing healthcare in a hospital setting for drug using patients living with HIV and/or HCV (Strike et al., 2020). The study utilized a purposive sampling strategy to recruit and interview 26 HPs (i.e., Physicians, Registered Nurses, Social Workers, Pharmacists, Dietician, and Nurse Practitioner) in Toronto and Ottawa, who provided direct care to patients who used drugs in inpatient wards at three large urban Canadian hospitals.

The 26 participants provided informed consent and were compensated for their time ($50 gift cards). The HPs completed a short demographic questionnaire prior to participating in a semi-structured interview. Interviews were conducted by phone or in person. The semi-structured interview guide was designed to elicit data about participants experience of providing care to people who use drugs and included questions about the participants’ attitudes and experiences in providing care to this population, medication prescribing practices (e.g. opioids), the management of illicit drug use in the hospital setting, and suggestions to improve care.

Data management and analysis

Interviews were audio-recorded, transcribed verbatim by a professional transcriber, and uploaded into NVivo version 12 qualitative software to facilitate organization and analysis (QSR International Ltd, 2019). The research coordinator verified the completeness and accuracy of the transcription. The analysis of the questionnaire data was completed using SPSS version 22 (IBM Corporation, 2013). Structuration theory, used to inform thematic analysis, was employed to address the research questions by focusing on the practical knowledge of HPs manifested at the discursive level through research interviews. The ‘sensitizing concepts’ (Blumer, 1954) of agency, rules and beliefs, knowledge (i.e. practical and discursive), identity, institution, and stigma, were utilized during data analysis. Structuration theory based sensitizing concepts served as a point of reference to guide the phases of thematic analysis (Bowen, 2006). As themes emerged from the data some sensitizing concepts were deemed irrelevant and removed (Padgett, 2004).

Thematic analysis has enabled the detection, identification, and analysis of patterns of meaning in the study dataset using manifest content (i.e. explicit and/or directly observable) as a route to identify latent content (i.e. implicit and unspoken themes) (Clarke & Braun, 2013). A thematic analysis was undertaken using Braun and Clarke’s (2006) six-phase approach. After becoming familiarized with the data via multiple readings of the transcripts (i.e. phase 1), initial codes were generated (i.e. phase 2), leading to the identification and review of themes (i.e. phases 3 and 4); themes were defined and named (i.e, phase 5) before this paper was produced to convey the story of the data (i.e. phase 6).

Results

When asked to consult or become actively engaged in providing care, the phrase “beyond my scope” is sometimes offered by HPs taking part in this study. The phrase, “beyond my scope” is most often linked to the HPs assessment that they are not appropriately educated, trained, and/or resourced to act (Coutinho et al., 2015). This phrase is conveyed to objectively identify what goes beyond the clinical practice skills and/or responsibilities of the HP. Many HPs participating in this study (see Table 1 for a description of participant characteristics) identified that deficits in their education and training impacted their clinical practice, when discussing care delivery for people who use drugs. In addition, most HPs in this study indicated that the hospital failed to provide them with the necessary resources (e.g. access to an addiction team) to best manage substance-using patients and behaviors associated with drug use. Most HPs stated that they were not aware of any explicit hospital rules that can support and guide their clinical practice when providing care to, or managing behaviors of, people who use drugs, yet they regularly encounter drug-use related behaviors that were unacceptable to them and that they felt warranted discharge. For example, HPs often identified that there is no rule to prevent a patient from exiting the hospital to use drugs and that this activity is disruptive to treatment being provided.

Table 1. Characteristics of participant healthcare providers.

Providers (n = 26)	% (n)
Gender^a
Female	53.8 (14)
Age (median, range)	45, 29-60
Race
White only	75 (18)
Other (non-white)	26.9 (7)
Type of provider
Physician	42 (11)
Registered Nurse	19 (5)
Pharmacist	15 (4)
Social Worker	15 (4)
Dietician	3.8 (1)
Nurse Practitioner	3.8 (1)
Experience (years)	Mean, range
Working at their hospital	13.4, 1.6-26
Working with people living with HIV	15.3, 1.6-30
Working with people who use drugs (average, range)	15.7, 1.6-30
Continuing education in any of the following areas^b	% (n)
Drug addiction	69 (18)
Hazardous drinking	42 (11)
Treatment of substance use disorders	62 (16)
Harm reduction	62 (16)

Column percents shown. Values in parentheses are numbers of participants. When values were missing from some participants, proportions were calculated among the remainder with non-missing information.

^a Gender options included male, female, and transgender. None identified as transgender.

^b Participants were asked, ‘Since your training, have you attended any continuing education courses, seminars or conferences about…?’ Options included: yes, no.

(Asked if there are rules specific to illicit drug use in the hospital) If there are, I don’t know them, and I’ve been here for a long time… (Physician - Toronto)

…you know, the reasons that drive them to do what they do, or initially got them addicted, are way beyond my scope to address. (Physician - Ottawa)

If there was a fall, we have a falls team. There’s a protocol for managing falls, that sort of thing, but if someone just went out, smoked crack, came back in, and somehow, we knew that they did that, I’m not sure there is a protocol (referring to a protocol for working with PLWH who use drugs). (Social Worker - Toronto)

HP’s construction of the difficult patient identity

Over time, the professional lived experience of interacting with patients who use drugs was acknowledged by HPs as directing their clinical practice and decision-making when delivering care to PLWH who use drugs. Professional lived experience informed what the HP believed was an objective understanding of the medical needs and life experiences of PLWH who use drugs. At times, this professional, lived-experience-informed understanding superseded and was not well supported by research findings or evidence in the relevant literature:

So, some of the physicians I work with here at (hospital) are very judgemental around patients who use substances and others are a little more, in my opinion, easy going and more aware of harm reduction research and outcomes … it feels that we are still in an era where each clinician bases a lot of their treatment attitudes on their own moral or ethical stance of people who use substances and if that sits well with them or not, as opposed to looking over research and hard data on outcomes around treatment with people who are HIV positive and/or Hep C who use substances. (Social Worker – Toronto)

Many HPs lack sufficient knowledge to treat PLWH who use drugs and are in situations in which there are no explicit rules. The phenomenon of PLWH who use drugs needing to leave the hospital to use drugs is a central issue illustrating how the practical knowledge of the HP is relied upon when providing care.

Based on their professional lived-experience, HPs identified patterns and/or generated patient profiles associated with the phenomenon of needing to exit the hospital to use drugs. These patterns, premised on behaviors/activities, were viewed through an existing lens (i.e., practical knowledge) used by the HP to guide their clinical practice. For example, the frequency of time a person who used drugs exited the hospital and the duration of time they spent away were linked to drug use. Reasons for leaving, such as boredom, a need for exercise, fresh air, and so on, were not within the HP’s internalized narrative; therefore, HPs typically assumed a more nefarious rationale (e.g., smoking a cigarette should only take × amount of time, so they must be using crack):

… We had three episodes in the psychiatric inpatient unit, where the patients died. Died because they used OxyContin. The patients were in hospital for a few weeks. Psychiatric units are different because they cannot leave. So, they had withdrawal. And then, when they are close to being discharged, they are on the ward. They can go out. These three patients who died, they went out; they used drugs, and they used the same amount they were using before. (Physician – Toronto)

Relying on the use of professional lived experience to guide clinical practice demonstrated that HPs failed to acknowledge or account for their actions, which were guided by personal beliefs.

The dominant discourse

When describing the patient population (i.e. PLWH who use drugs), several HPs provided reasons for why the practice of using assumptions was reasonable and necessary to provide a good health assessment and care provision. The assumptions that HPs used were informed by the behaviors believed by the HP to be intrinsic to drug use. The HPs, when asked, offered a description of the population and behaviors exhibited during admission that was laden with implicit assumptions (e.g. agitated, personality disorder, challenging) that reinforced the dominant discourse and influenced construction of the “difficult patient” identity:

So, it’s not your average, and forgive me for being kind of blunt about it, high-functioning professional, you know, doctor, dentist, lawyer, researcher, what have you, who is addicted to drugs. So, when they come in, there are usually mental health issues, personality disorders, psychosis, what have you, which can also make it challenging to provide care or to try and get them to understand why we are doing certain things. (Physician – Ottawa)

… We tend to judge people based on what they look like. You know, are they living on the street? While I suspect that quite a few of our patients who are middle-class, high-income earners are using crack or maybe heroin, crystal meth. However, because their lives have not become chaotic, they’ve not been identified as a problem. And probably, people would not view it that way. (Nurse – Toronto)

Implicit assumptions and the labels applied to PLWH who use drugs, derived from beliefs centered in the HPs’ practical knowledge, inform the difficult patient identity, and can negatively impact therapeutic relationship building, in turn, influencing the HPs clinical practice.

The carceral environment

The difficult patient identity construction applied to PLWH who use drugs enables HPs to impose restrictions on the patients’ behaviors. The belief that PLWH who use drugs hold the identity of a difficult patient is supported by the HP’s practical knowledge; many HPs, when bringing their belief to the discursive level to allow for inquiry, indicated that a more carceral environment would lead to positive benefits to the health of PLWH who use drugs (e.g. treatment compliance and decreased drug use).

Relying on practical knowledge leads to the creation of implicit rules. The HP’s belief that a carceral environment is needed allows for a clinical practice approach better suited to meet care delivery for patients with an atypical patient identity. Often, the action taken by the HP was framed as being in the best interest of a difficult patient. For example, in a carceral environment, people are allotted liberties by way of rules that are within the purview of the overseers of their environment.

When you’re in the hospital, you cannot use, you can’t have anything, you’re in between four walls, and you cannot smoke even. You have to always be escorted; this patient we have now, she’s going out often for a smoke, but she’s being escorted. Maybe feel like it’s. I don’t know what the feeling of being escorted all the time, like if you’re in jail or what. (Pharmacist - Ottawa)

… something that should be brought up sort of in a contract kind of situation, on a patient’s admission, saying ‘You know, you’re coming in to be treated for -’ whatever. But if you’re going to continue going outside to the park and doing what you’re doing, we’re not going to admit you.’ (Nurse – Toronto)

The benefits of this carceral ideology are linked to HPs’ practical knowledge via the belief that treatment outcomes would improve using clinical approaches that promote or enable the removal of liberties. For example, some HPs discussed their support for requesting a urine drug screen when patients exited the hospital for an extended period and when the patient was believed to have used drugs. Although clearly in need of care, the patient is admitted to the hospital for a medical issue, the inability to control the actions (e.g. exiting the hospital to use drugs) of the patient highlights the HP belief that, in these instances, the liberty of access to healthcare should be denied:

…they would leave the unit for a couple of hours and then come back and then the nurse would report the next morning, ‘Patient came back; looked groggy; looked confused; agitated’ and so we brought it to rounds and then told the patient… “This is not acceptable in the hospital setting. Now you’re aware. Next time this happens, we’re going to have to test you for drugs. And if it’s positive, then you’re going to be discharged on the spot.” (Nurse – Ottawa

The denial of healthcare services is used in a punitive manner to reinforce the expected action of the HP; drugs are not to be used during the hospital stay of PLWH who use drugs.

Clinical practice within the institutional context

There is a discrepancy between what is or can be accomplished during the admission of patients who use drugs during hospitalization. Planning and collaboration can be problematic because of the HP belief that PLWH who use drugs lack the aptitude to meaningfully contribute to the development of a treatment/care strategy; the objectives and goals of admission are often those of the HP (i.e. acute medical issues). Further complicating care delivery and treatment decision making are that it is often an individual HP, or a small team, guiding care, yet HPs report being under resource for the task expected of them.

Providing care

Many HPs’ acknowledged frustration with not being able to effect “real” or “big” changes during the admission of PLWH who use drugs. A key barrier identified by HPs to making changes to the health of the patient is the patient themselves. As a result, some HPs believed that a prerequisite to providing lifesaving/extending healthcare was the cessation of drug use or provide a person with suboptimal treatment:

…it often becomes a discussion around ‘Well, this would be the ideal option, but because of their substance use, I think it’s extremely unlikely they will be offered any therapy at all, but a sub-specialist. (Physician - Toronto)

Substance use withdrawal and the need to be “realistic” about prescribing analgesics were concerns identified by several HPs that influenced their clinical practice during hospital admission. Notably, analgesics, specifically the misuse, abuse, and dependency factors within this patient population, were discussed by several HPs. When brought to the discursive level, the HP’s belief that the hospital is a place to treat acute medical issues is problematized by their concern about prescribing analgesics, a common tool used in care delivery. In addition, management of a common health issue related to substance use and withdrawal complicates HPs’ decision-making when prescribing analgesics, as it is unclear what “pain” they are treating. The question as to whether the hospital is the appropriate place to address “addiction” issues was often raised:

And I say, ‘Well, yeah, if the patient is taking 80 mg on the street (referring to the dose of drug the individual uses in the community), do you think that your 10 mg in hospital will do anything? (referring to what is deemed appropriate by a hospital-based HP) … I’m more concerned about underdosing these drugs in people who have chronic abuse, than overprescribing. I’ve never heard of anybody who has drug addictions to be overdosed in the hospital. (Pharmacist - Ottawa)

The participant further stated that:

… If someone was smoking, in the hospital you give him a patch. Okay? Somebody is using morphine in the street and, or heroin and he goes in the hospital, you give him nothing… If we believe that a hospital is a place for detox, fine. I mean, you can try to be arrogant or say, ‘You should refrain from illicit drug use.’ However, we know that this is not the case. We are a terrible place for that.

Although not explicitly asked about it during the interview, several HPs discussed how the primary focus of their clinical practice when providing care to PLWH who use drugs was no longer HIV; this disease, although often at the root of the acute medical issue to warrant hospital admission, was believed to be secondary to the chronic health impact of drug use and the social determinants of health.

…I think it’s important to realize that a lot of what I’ve been saying is not specific to the fact that the person that we’re talking about has HIV. It has to do foremost with the fact that they have an addictions problem. And in fact, HIV is more likely than not, secondary to that. (Social Worker – Toronto)

The perceived shift in requisite healthcare services for PLWH who use drugs moving from HIV to addiction treatment left many HPs at a loss regarding how best to provide care to this population.

Improving care

Among the more revealing pieces of evidence of how HPs are drawing on practical knowledge is their use of “they.” The hospital, and non-clinical persons who were viewed as acting on its behalf (e.g. administrators, security staff), were implicitly referenced via the descriptor “they.” HPs acknowledged that care could be improved but held a belief it was not within their ability or power to make, or advocate for, the requisite changes; it is the “they” that were positioned to do so:

The patient was crushing them in the washroom (referring to oral morphine). He had a syringe hidden in the ceiling and then he was injecting himself. They (security staff) found him. They (administrators) make the rules even more difficult. And the guy left. Had endocarditis and he left. I don’t know what happened with him. He didn’t come back. I wouldn’t be surprised if he’s dead by now. (Pharmacist – Ottawa)

HPs commonly stated their belief that any substantial changes to the delivery of care for a difficult patient population were only possible if initiated by the hospital itself.

An identified obstacle to providing care to a difficult patient population is the perceived lack of available resources that are necessary to offer treatment and support. Clinical practice for many HPs was guided by the belief that cessation of drug use was required to offer “good care”; it then becomes clear why an “addictions team” was the resource most cited as lacking in the hospital yet was seen as most necessary if care is to improve. HPs placed sole responsibility on the hospital to make available resources to support their clinical practice when providing care to a difficult patient:

We are exhausting ourselves. We have limited number of social workers, physiotherapists, and occupational therapists. And so, they have to do their work, taking care of other patients as well, but not that they’re taking care of these addicts, um, patients with addictions less, just about the same. But maybe they will need more care than the general population, and we don’t do that. (Physician – Ottawa)

Although taking steps to bring effective change was often deferred by the HP, as this was believed to be the responsibility of the “they,” there were ideas endorsed by some HPs to bring about clinical practice modifications to improve care delivery and treatment outcomes. An idea that may be deemed too radical by the “they” who develop policy and manage risk and liability to the hospital, but have prohibited harm reduction exposure, can be viewed by HPs as being a best practice approach:

… If you teach someone to inject safely, you can teach them to inject safely through a PICC (peripherally inserted central catheter). The nurses do it all the time. If they’re a user, they’re going to, and they’re not going to stop, well, you just gave them a PICC. Like, they’re not dumb. (Physician - Ottawa)

Institutional rules

HPs identified a void in hospital rules when delivering care to a drug using patient population; this perceived void in explicit rules was met by the HPs’ use of implicit rules. Implicit rules, and the professional lived-experience HPs identified as informing their clinical practice, were guided by the HPs’ practical knowledge. When HPs discussed the void of explicit rules, situations and issues believed to be beyond their ability to control or to be of any help, were identified.

Beyond my control

A void in explicit rules brings more HP-identified complications; for example, when an HP is aware of what is the best practice (e.g., IV antibiotics delivered via PICC) but does not provide it based on the belief that the patient may engage in inappropriate action (e.g., IDU). This perceived complication was situated in the HPs’ certainty that there was a lack of explicit rules to mitigate the patient’s actions:

…If they’re an injection drug user, and they need long term antibiotic treatment, it does influence your decisions regarding what antibiotics you chose and what form they’re administered. You’re often not very keen to put a PICC line into somebody, if you’re concerned that they’re going to use that line for drug use. (Physician - Ottawa)

A lack of explicit rules to prevent injection drug use, for this HP, demonstrates how treatment for PLWH who use injection drugs is guided by an implicit rule that sub-optimal treatment is deemed appropriate for this population.

Addressing the explicit rules void

As stated, HPs were not aware of any explicit hospital rules applicable to guiding their clinical practice when delivering care to PLWH who use drugs. Instead, HPs identified applying implicit rules that guided their clinical practice that were penalizing in nature, known only to them and possibly a few team members. Without explicit guidelines, PLWH who use drugs have nothing explicit to call on when navigating their hospital admission.

I could go on forever about what happens to people’s care when they piss off staff. It doesn’t get better. When people piss off staff, when people are known as quote unquote ‘a difficult client’…, I mean, it’s all rather logical, they get visited less by everyone. They get more of the skeleton service, like the ‘as needed’. They won’t get, the allied health, whether it’s social work or physiotherapy or dietitian or pharmacy or whatever, they won’t get people just like wander in, ‘Oh, so how are you doing?’ that sort of thing. (Social Worker - Toronto)

It’s just escalation, right? ‘I’m going to make rules a bit harder for you to cheat. And if you cheat, I’m going to make it harder.’ And at some point, the patient will leave. I find, if you piss him off, well, he’s going to leave. (Pharmacist - Ottawa)

Discussion

The construction of identity: The difficult patient

Within the hospital environment a single category identity for PLWH who use drugs, the difficult patient, was constructed. This single category identity was applied in such a way that it limited the actions (i.e., agency) and meaningful inclusion of PLWH who use drugs and branded most PLWH who use drugs as having a uniform lived-experience, perspectives, and needs.

A single category identity such as the difficult patient can bring about a single category approach to clinical practice; narrow in scope and constructed based on one aspect of a person’s life (e.g., should the addictions team meet with all PLWH who use drugs?). The standard clinical practice of requiring the patient to meet with a specialized addictions team for the purpose of stopping drug use before initiating treatment is not equitable. As stated by Strathdee et al. (2012), “…most of all, we need to overcome addictophobia, which manifests as the desire to refer drug users somewhere else, anywhere else, or to deny them access to life-saving interventions ‘for their own good’” (pg. 323).

A single category identity, in conjunction with the participant-acknowledged benefits of using assumptions for the purposes of providing appropriate care, demonstrated a glaring contradictory position. The HPs’ practical knowledge (i.e., internalized rules and beliefs that guide clinical practice) influenced their scope of practice, which in turn guided their day-to-day actions; however, their discursive knowledge, examined during a research interview, identified what “should” be done. For example, many HPs effectively stated, “we need to use a non-judgemental approach” or “we need to reduce the stigma these people encounter”. However, reflexive monitoring of practical knowledge, aided by probing questions, indicated that most discussions, as evidenced by the data presented, were situated within judgemental and stigmatizing statements that reinforced the constructed single-category identity of difficult patient.

Many HPs indicated that a more carceral hospital environment would enable clinical practice that would lead to positive outcomes in care delivery for PLWH who use drugs. When considered within the carceral environment ideology and the use of labelling, reported in this paper and substantiated in the literature, the difficult patient identity construction applied to PLWH who use drugs is that of people who are bad, deviant, lacking in personal control and, as a result, during hospital admission become aggressive, manipulative, and unable to make reasonable decisions or meaningfully contribute to care planning (Calvert et al., 2022; O’Leary et al., 2018). The constructed difficult patient identity enabled HPs to provide the care they believed was required by way of stricter, more controlling implicit rules being used. As indicated, implicit rules applied in the hospital environment in relation to the use of illicit drugs often resulted in the patient exiting the building to use the drugs and returning when detection was less likely. The patients guided their actions based on an implicit rule that drug use is not tolerated during the hospital admission. The implicit rule is learned, experienced by the patient, through stigmatizing interactions with HPs. Of note, in a study that surveyed 64 healthcare workers based in health facilities that had in place a harm reduction policy specific to onsite drug use, participants reported that broadening their scope of practice via education and training in harm reduction approaches enhanced the quality of care provided to PLWH who use drugs (O’Leary et al., 2018).

The hospital

Hospitals are not oppressive entities that must be overcome; instead, they are constructions shaped by the actions or in-action of people. HP-identified barriers to taking action to provide optimal treatment for PLWH who use drugs were not solely the result of the behaviors of an individual patient or a lack of a responsive “they” on the part of the hospital.

This study clarified the HP perspective that the hospital was a place for the treatment of acute medical issues. However, the issue that had the greatest influence on admission and received the highest focus on clinical practice and care delivery was the chronic health issue of drug use. Drug use and drug use behaviors, deemed by HPs to be the responsibility or within the purview of the hospital (i.e. “they”), were often presented as barriers to providing optimal care. Drug use behaviors were a barrier because they were presented as issues that fell beyond the scope of practice of the HP. The HP’s rationale for focusing their clinical practice on acute medical issues and not attending to the chronic health issue of drug use was supported by a central belief: the hospital only permitted a brief admission to treat acute issues and did not provide requisite resources to attend to chronic health issues, making treatment of the chronic health issue of drug use fall outside of what the HP believed they could accomplish during a brief admission. As indicated in this study and supported by Martin et al. (2022), many HPs believe that the treatment of drug use should result in abstinence and this guiding belief, which is fundamental to the practical knowledge of many HPs, is a driver of clinical practice during hospital admission.

The institutional rules

As previously indicated, most HPs stated that they did not know of any explicit hospital rules that supported or guided their clinical practice when providing care to PLWH who use drugs. The HPs’ frustration when encountering events and/or situations they experienced as being beyond their control and/or ability to be helpful was evident in the findings. The “beyond my scope” belief conveyed by HPs taking part in this study indicates where deficits in education and training impacted their clinical practice regarding care delivery for a drug-using patient population.

Based on their professional lived-experience, HPs identified patterns and/or generated patient profiles associated with the phenomenon of needing to exit the hospital to use drugs. Patterns, largely premised on behaviors/activities, were viewed through an existing lens (i.e., practical knowledge) used by the HP to guide their clinical practice. For example, the frequency of time a person who used drugs exited the hospital and the duration of time they spent away were linked to drug use. Relying upon the use of professional lived experience to guide clinical practice demonstrated that HPs failed to acknowledge, or account for, their actions being guided by personal beliefs, demonstrating how HPs’ practical knowledge is not brought to a discursive level for the purpose of examining their belief system and the actions they take.

A tenet of structuration theory is to change our actions is to shift our knowledge; the exercise of reflexive monitoring (i.e., reflexivity) makes this shift possible. Reflexive monitoring supports the development of healthcare equity by probing the clinical practices of HPs (Clark, 2012). For example, during the interview process, HPs reflected on their practical knowledge, bringing it to a discursive level, and created an opportunity to examine the difficulties experienced in a hospital environment when wanting to deliver “good care” for PLWH who use drugs (i.e., no explicit rules to direct their clinical practice, the use of stigmatizing assumptions, and a lack of training and specialized HPs). The HP, their knowledge at the discursive level for analysis, had created an opportunity to use reflexive monitoring to shift their awareness of the near impossibility of hospitalized PLWH who use drugs, making the presumed necessary changes (e.g., abstaining from drug use); thus, less than optimal treatment was then offered. The necessary changes expected to occur during hospital admission were situated within the HPs’ practical knowledge and were unknown to the patient unless experienced by way of implicit rules that guide clinical practice and care provision. Reflexive monitoring is a significant tool provided by structuration theory to bring about change. Engaging in reflexive monitoring of practical and discursive knowledge can highlight the role of HPs in maintaining power relations that discourage the delivery of equitable healthcare for PLWH who use drugs and other marginalized communities.

Limitations

There are limitations to consider regarding the interpretation and application of the results of this study. HPs participating in this study worked in large urban hospitals and, on a regular basis, were engaged in care delivery for PLWH who use drugs; ongoing interaction influenced the professional lived experience of the HP, and this would differ from an HP working in an area with lower HIV prevalence rates and/or a smaller population of people who use drugs. In addition, although the study HPs indicated there was a lack of resources to provide good hospital care for PLWH who use drugs, there was greater direct access to specialized HPs in the hospitals that this study was based in, than in that of a hospital in a rural or remote setting. Notwithstanding these limitations, this study demonstrated that practical knowledge of HPs is a significant factor in the status quo delivery of hospital care, and exploring knowledge at a discursive level provides an opportunity to bring change to this status quo.

Conclusion

HPs participating in this study were not aware of any explicit hospital rules that supported their clinical practice when engaged in care delivery for PLWH who use drugs during their hospitalization, and most HPs reported that their professional lived experience, not education or training, guided their clinical practice when delivering care.

Providing and managing healthcare for a complex population such as PLWH who use drugs, without the support of explicit hospital rules, created a vacuum in which HPs filled with implicit rules that were in line with their beliefs and professional lived-experience (i.e., practical knowledge). The practical knowledge of HPs played a significant role in informing the construction of both the dominant discourse and the identity of PLWH who use drugs who are hospitalized, the difficult patient. Implicit rules informed and perpetuated the HPs scope of practice when delivering clinical care to this patient population. When advocacy for equitable care was discussed, it was identified as being outside the scope of practice of the HP, yet HPs acknowledged advocating on a case-by-case basis. Case-by-case advocacy/action, although somewhat inclusive of PLWH who use drugs, does not directly influence the development and application of explicit rules.

The translation of HPs’ practical knowledge into action is the foundation for implicit rules applied to healthcare delivery for PLWH who use drugs. A lack of explicit rules to guide clinical practice that acknowledge the unique care needs of PLWH who use drugs results in implicit rules and actions that may negatively impact the delivery of equitable healthcare for PLWH who use drugs. Explicit rules alone (e.g., a policy) are not the only solution to HPs utilization of implicit rules for healthcare delivery for PLWH who use drugs; however, explicit rules can be useful in directing training requirements, providing clarity on a best-practice approach, and ensure accountability of all people in the hospital setting (e.g. patients, visitors, staff, managers, and HPs). Of note, a patient centred policy linked to drug use during a hospital admission requires the voice of key stakeholders (i.e. patients who use drugs) be included in its development; ergo, PLWH who use drug would have a voice in the development of the explicit policy.

By engaging in a process, an action, that stimulates reflexive monitoring, reconstruction of beliefs may take place, and this can offer real-time transformation to the HPs’ clinical practice when providing care to a complex patient population such as PLWH who use drugs.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

William O’Leary

William O’Leary, PhD, RSW is an Assistant Professor at Wilfrid Laurier University, Lyle S. Hallman Faculty of Social Work. His research and advocacy aims to ensure equity within healthcare practice/services for people who use drugs.

David J. Brennan

David J. Brennan, MSW, PhD, is a Professor of Social Work and Associate Dean Research at the Factor-Inwentash Faculty of Social Work at the University of Toronto. He is the founding director of the CRUISElab, an interdisciplinary community-based social work research lab centered on issues of health and well-being among gay, bisexual, two-spirit and other men who have sex with men (GB2M), with a focus on HIV/STBBIs, and community use of online spaces for socio-sexual connections, health education and service access.

Rachelle Ashcroft

Rachelle Ashcroft is an Associate Professor with the Factor-Inwentash Faculty of Social Work, and cross-appointed to the Department of Family and Community Medicine at the University of Toronto. Dr. Ashcroft holds a BSW and MSW from the University of Manitoba, a PhD from Wilfrid Laurier University, and completed postdoctoral training at the Centre for Addictions and Mental Health (CAMH) in Toronto, Ontario. She has over 14 years of experience as a social worker in community health and tertiary care settings. Dr. Ashcroft is a health systems researcher focused on the integration of social and mental health care in interprofessional primary care teams, interprofessional collaboration, organizational and policy contexts of healthcare, and patients’ experiences of virtual care. In addition, Dr. Ashcroft advocates for social workers in Ontario as a member of the Board of Directors of the Ontario Association of Social Workers.

Soo Chan Carusone

Soo Chan Carusone is the Managing Director of the McMaster Collaborative for Health and Aging and an adjunct assistant professor in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is committed to working in partnership and using her mixed methods training to improve equity and fairness in health and research.

Adrian Guta

Adrian Guta, PhD, MSW, RSW is an associate professor in the School of Social Work at the University of Windsor. His research examines the health and wellness needs of people living with HIV and people who use drugs.

Carol Strike

Carol Strike, PhD, is an Associate Dean, Public Health Science and Professor, Social and Behavioural Health Sciences at the Dalla Lana School of Public Health, University of Toronto. Her research program aims to improve health services for people who use drugs and other marginalized populations.