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Published on January 4, 2008

Author: Churchill

Source: authorstream.com

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Structural Stigma:  Structural Stigma Barbara L. Paterson, RN, PhD Professor & Tier 1 Canada Research Chair I will talk about ---:  I will talk about --- What structural/institutional stigma is Why we need to address it Some examples from a pilot study Some questions/issues Structural forces that result in stigma :  Structural forces that result in stigma economic, political, legal, and social structures embedded in the functioning and processes of the institution, such as the way resources are allocated, or policies about bed allocation Why Do We Need to Address Structural Stigma?:  Why Do We Need to Address Structural Stigma? individualistic and psychological conceptualizations dominating the body of health services research about stigma have had little impact and have had little sustainable practical utility Pilot Study Findings:  Pilot Study Findings 30 service providers 15 service providers in hospitals 15 service in CBOs; 10 Hep C positive Structural/Institutional Forces:  Structural/Institutional Forces Resources Bed allocation policies/procedures Security Confidentiality Triage and admission policies/procedures Communication and reporting structures Environment Institutional culture Complaint procedures/responses Referral procedures/practices Resources:  Resources “We made a conscious decision to hire people who really had a passion for this population. If they don’t know much about Hep C or addiction or poverty, they are at least willing to learn. They believe in harm reduction. They love their work. That has made all the difference.” Bed Allocation:  Bed Allocation “I think the more conservative nurses are …I wouldn’t say punitive but sometimes punitive… they would say ‘the next patient is an old lady who is short of breath, I am not going to keep her out of a bed for some intravenous drug abuser’, and you would see that kind of thing. Intravenous drug users would be …we run out beds in emergency all the time and put people in corridors. They would be pushed to the corridors before the equivalent patient who wasn’t an intravenous drug abuser would be.” Security:  Security “Speaking from a security side - when a person walks in to the emergency department or any part of the hospital, they’re not carrying a sign that says, “I am an IV user”. From my experience it has only been after behavioral problems that we pay attention to people and I am not just…it is like I said it is not because they are an IV user it is their past performance. Now I can only speak for myself and when I was in the emergency department, I was the supervisor up there and that was policy, you treat people as people until. …they prove they don’t deserve to be treated the same way, based on past behavior. If the person has been in there 2-3 times and they have caused a problem every time, of course when he walks in you are going to pay attention and you are going to make sure nothing else happens and that basically has nothing to do with his life style other than his life style while he’s in the emergency department.” Confidentiality:  Confidentiality “Something in great big letters that makes it really clear when you walk in the door what the procedure is, what it is you need to do, someone there…a lot of people can’t read, or read well, or read well enough and if you are high, your level of reading ability may go down, and someone there, so someone can say what do I need to do? I need to see a doctor, what do I need to do? And someone very succinctly and clearly say, “step one is, step two is, step three is”, that would be helpful. “ Triage/Admission Procedures:  Triage/Admission Procedures “The paramedics call that we have an IV drug user coming in so we call out the forces to come and meet the person at the door, and does that exasperate the acting out? Or does it help? Or does it actually calm the acting out? Well it exasperates the acting out all together, so once again how quickly do we provide service? How quickly do we get them assessed and triaged? Through that moral framework, you did this to yourself so you can wait; this person fell and broke their arm and that wasn’t their fault. Force meets with force, so if you display force you are going to get force back, it is predetermined. Is there an opportunity to have people garbed differently? Is there an opportunity to offer triage more quickly? Is there an opportunity to have someone with some expertise in addictions and non-violent intervention available to them in those situations?” Communication Structures:  Communication Structures “There is so much that somebody was saying “laws bylaws” and it is our job to know what the bylaws are…we have an information book that nobody reads. No body reads policies and procedure; no one reads letters and it has gotten to the stage where it is very difficult …communication has become so efficient that people are just overloaded with communications that they are actually communicating less than they used to.” Environment:  Environment “Location…if you go to the cardiac rehab, pretty nice place, fresh air, open windows, brand new equipment, nice juice stand - and you came to my building this morning where it is dilapidated, run down, broken ---- you would just look around and say, “health care goes on here?” We always…addictions services or services having to do with…even the chronically mentally ill or addiction seem to always be the second class environment, not the second class individual but the second class environment, or an add-on to other things. I think even coming to a building can be stigmatizing. If you’re arriving at this building on the grounds of the Nova Scotia Hospital people know why you are coming, where if you arrive at the QEII, you could be there for any reason. If you take the 60 into Eastern Passage and get off at our front doors, chances are you are coming for one of two reasons, and people don’t come here because that is stigmatizing. Where if we were in a more of a holistic area or space that is still accessible to the general public, people could be coming for any reason. They wouldn’t know if you are there for an x-ray, CT scan or to visit someone. So, environment and location stigmatize and marginalize as well.” Institutional Culture:  Institutional Culture Protocols for detecting drug-seeking Harm reduction vs paternalism Expectations Perspectives about appropriate use of ER Slide15:  “So what we do when we suspect --- when there are indicators of drug-seeking like needle track marks --- we look for contradictions in their history. Or if they are really smooth operators and give a coherent history, we give a placebo and then wait to see if it works.” Harm Reduction vs Paternalism:  Harm Reduction vs Paternalism “I also hear the issue of harm reduction… I hear people coming back from the Infectious Disease Clinic saying, “the doctor doesn’t believe in harm reduction, they need to just stop.” There isn’t …people let me know that there…they tell the doctor “well I am not shooting, I am just snorting now, or I am just smoking it now” and the doctor response is “well you need to stop all together” vs “wow, ok good step”, so I think there is a disconnect around harm reduction, which I think harm reduction is essential and a recognition of harm reduction is essential within health care, and I am not sure exists.” Expectations:  Expectations “We have come to see that Hep C and IDU mean certain things in terms of how problematic this person is going to be. They will tend to need more personalized attention, to have little tolerance for waiting, to have complicated care needs. They may be abusive and hostile. Frankly, I dread looking after people when I read on the chart that they are an IDU with Hep C.” Perspectives about what is appropriate:  Perspectives about what is appropriate “Because thinking about some of the chronic pain patients who come frequently and repeatedly to the emergency department seeking injections of narcotics, elicit a…periodically they elicit a hostility in part of the caregivers, in part I think because we feel it is an inappropriate use of the emergency department. There is a fellow that has chronic has chronic back pain and if he doesn’t have back pain he has a migraine and he is an inadequate individual, again he is known by his first name and it is interesting how people acquire this…he has had so many injections that you can’t get a needle into him anymore it is all scarred. At one point people tried to teach him how to do his own injections and he said he can’t do it because get a needle in - there is to much scare tissue, and he elicits a sense of frustration on the part of the people caring for him because he such a ….hopeless exercise. You know that nothing is ever going to change, he is going to be with us for the next 10-15 years until he dies or something else, and so there is a sense of frustration because of our inability to actually change anything and recognition that this is just going to continue forever, but that applies to any of the addicted populations… the alcoholics.” Complaint Procedures/Responses:  Complaint Procedures/Responses “We’ve heard about the same doctor for years but nothing seems to be done about him. The hospital says that people should complain but when you look at what you need to do to file a complaint --- well, it’s very unlikely that our people are going to do that.” Referral Systems:  Referral Systems “And speaking of dietitians, I have a lot of people who are on community services and they need extra money for more nutrition, and so to get that, and this is a whole systemic issue, but to get that they need to see the dietitian, so the dietitian writes a note that then gets taken to their community service worker, so they can get a supplement. Well they have to make an appointment to see the dietitian, sometimes that appointment is two months down road, and they are not going to make that appointment, they will make but they aren’t going to get there, they’ll have the appointment but they aren’t going to get there, there is no reminder call, there is no…plus it is two months down the road. They are just not going to get there; it is just not going to happen.” What we have learned:  What we have learned People need help thinking in structural ways Many of the structural factors were not identified by service providers within the hospital There is frustration and a sense of powerlessness about the ability to change structural factors Slide22:  “Most of what we see in the Emergency Department is self-destructive, the chronic IV drug abuser who comes in repeatedly with abscesses. This …I am thinking about one of them who refuses to allow me to see him because I objected when he forged my name on a prescription; I took exception to it, so he …when he comes in with his abscess, incidentally denying that he is using IV drugs, and he specifically says he will not see me - that I am not ….so we have to go find someone else to look after him. But I don’t think he gets treated any differently than any of the others.” Slide23:  “I guess what I am saying is what is NOT done rather than what IS done, so perhaps we don’t offer the array of other services. We may not get as many referrals from the emergency room or as many referrals from more front line health care. Is there an offer of self-help material, is there an offer of phone numbers, is there an offer to see the social worker department or is the front line care provider just providing the acute care that is needed? For example, in the emergency room, a practitioner may see the same IV drug user 30 times a year, do they ever make the connection to other services that Capital Health offers or do they just continue to see the acute symptomology? So I would say THAT is stigmatization. If we know we have an appropriated treatment for addiction, yet we never offer the addicted that appropriate treatment, that stigmatizes them in that no one is purposely doing that, so it is not what they are doing it is what they are not doing. “ So what’s next?:  So what’s next? More intensive study The voice of those who are stigmatized and those who observe stigmatization Advocating for a new approach Questions/issues:  Questions/issues How do we overturn structures that are well-established in the system? How do we sell this to policy developers and practitioners who are happy with how it is? How do we address the structural issues without negating individual and societal level interventions? Thank you!:  Thank you! “Courage my friends. ’Tis not too late to make a better world.” Tommy Douglas

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