title: Shifting moral values to enhance access to health care: harm reduction as a context for ethical nursing practice.
abstract: BACKGROUND
  People who are street involved including those experiencing homelessness and substance use are at increased risk of morbidity and mortality. Such inequities are exacerbated when those facing the greatest inequities in health have the least access to health care. These concerns have rarely been addressed in bioethics and there has been a lack of explicit attention to the dominant societal and organizational values that structure such injustices. The purpose of this paper is to describe the underlying value tensions that impact ethical nursing practice and affect equity in access to health care for those who are street involved.
  
  
  METHODS
  In this paper, findings from a larger qualitative ethnographic study of ethical practice in nursing in the context of homelessness and substance use are reported. The original research was undertaken in two 'inner city' health care centres and one emergency department (ED) to gain a better understanding of ethical nursing practice within health care interactions. Data were collected over a period of 10 months through face-to-face interviews and participant observation.
  
  
  RESULTS
  In order to facilitate access to health care for those who are street-involved nurses had to navigate a series of value tensions. These value tensions included shifting from an ideology of fixing to reducing harm; stigma to moral worth; and personal responsibility to enhancing decision-making capacity. A context of harm reduction provided a basis for the development of relationships and shifted the moral orientation to reducing harm as a primary moral principle in which the worth of individuals and the development of their capacity for decision-making was fostered.
  
  
  CONCLUSIONS
  Implementation of a harm reduction philosophy in acute care settings has the potential to enhance access to health care for people who are street involved. However, explicit attention to defining the harms and values associated with harm reduction is needed. While nurses adopted values consistent with harm reduction and recognized constraints on personal responsibility, there was little attention to action on the social determinants of health such as housing. The individual and collective role of professional nurses in addressing the harms associated with drug use and homelessness requires additional examination.
authors.affiliation: School of Nursing, University of Victoria, Box 1700, Victoria, BC V8W 2Y2, Canada. bpauly@uvic.ca
authors.forename: Bernadette Bernie
authors.initials: BB
authors.lastname: Pauly
mesh_terms: D000884:Anthropology, Cultural; D002170:Canada; D003625:Data Collection; D004993:Ethics, Nursing; D005260:Female; D040261:Harm Reduction / Q000941:ethics*; D006291:Health Policy; D006297:Health Services Accessibility / Q000941:ethics*; D006703:Ill-Housed Persons; D006801:Humans; D008297:Male; D024802:Nurse's Role / Q000523:psychology; D012935:Social Justice; D019966:Substance-Related Disorders / Q000451:nursing / Q000534:rehabilitation