Staffing needle exchanges
Needle exchanges in the UK, with some notable exceptions, tend to be underfunded, understaffed and undervalued. Staff often derive little status from needle exchange work, which can be stressful and ethically challenging.
The training, information and support needs of staff are too often overlooked or ignored. The supervision needs of staff also often appear to be poorly addressed.
In order to maximise and maintain staff effectiveness and avoid loss of staff or 'burn out', consideration should be given by managers to:
Development of an adequate policy and practice framework to support the work.
Who should provide needle exchange?
There are roles to be played by many different organisations and services in the provision of needle exchange. As already mentioned there are roles for:
Pharmacy syringe exchange
GPs/primary health care services.
The roles played by all will be different. However the majority of exchanges will probably always be conducted by specialist agencies and pharmacy syringe exchange.
Minimum standards for pharmacy syringe exchange should include:
Adequate staffing and space
Adequate staff training
Hepatitis B vaccination for relevant staff
Accurate record keeping
Safe storage and disposal of returns
Awareness of boundaries i.e. age, level of advice
Good communication with specialist schemes and other specialist agencies.
Specialist needle exchanges have a crucial role to play in the delivery of a comprehensive service. In order to preserve and extend this role it is important that services:
Offer levels of advice and intervention in excess of those available from pharmacy exchange schemes
Take note of research developments
Provide outcome data as identified by the 'Task Force' review
Recognise, define and build upon good practice
Maximise their efficiency and effectiveness by regularly reviewing and altering practice where necessary
Establish agency policies for difficult situations which may occur
Where necessary extend the range and type of service provision offered.
The limitations of the needle exchange model
As Stimson and Donoghoe have observed, formal needle exchange tends to be rooted in a 'client-worker' relationship a manifestation of an individualistic public health model. Stimson and Donoghoe talk of:
"a certain irony that when professionals talk of 'enabling' or 'empowering' their clients, they are encouraging them to be more sophisticated consumers of services provided by professionals." 115
Regular training for needle exchange workers is vital if they are to be expected to:
Keep up to date with developments
Remain focused on the aims and objectives of the project
Develop their roles
Provide the best available service for injectors.
Key training areas
The priority training areas for needle exchange staff are:
Safer injecting techniques
Prevention of transmission of blood-borne viruses
Advice giving and limit setting
Primary health care issues, including recognition and referral of common injecting injuries
The promotion of safer sex practices.
Primary health care provision
In general, injecting drug users, despite often having greater need, do not utilise primary health care as much as the general population.
Many problem opiate users do not have GPs until or unless they are required to obtain one as a condition of methadone treatment by a specialist treatment service.
There is a good case for arguing that primary health care services such as basic health checks and treatment of injecting injuries should be provided, where possible, within needle exchanges.
This approach gets around the barriers to referral to general medical services, such as difficulties in attending appointments and judgemental attitudes of some staff in these services. One disadvantage of service-based primary health care, is that it takes drug users out of the mainstream of treatment, so that the unhelpful attitudes of some mainstream practitioners may be left unchallenged and poor practice may prevail.
Some of the factors that may influence the interaction between drug users and primary health care providers are:
A belief on the part of many drug users that all their physical health care needs are drug related; for example, an asthmatic who has not been diagnosed may not attend a doctor for treatment because she believes that her breathlessness and wheezing are a direct result of her heroin smoking
A belief on the part of many primary health care providers that all drug users' physical health care needs are drug related or part of an attempt to obtain drugs
Users' bad experiences of primary health care treatment services
Primary health care services' bad experiences of treating users.
The role of the nurse
Nurses offer an important contribution to needle exchange in the level of background knowledge that they can provide, especially in health-related areas. It is important that nurses working in needle exchanges realise their potential in terms of providing a vital service to clients.
Nurses have a formalised code of conduct, which makes them personally accountable for their actions to their professional body, The United Kingdom Central Council for Nurses and Midwives (UKCC). The UKCC code of conduct sets out their responsibilities to represent and protect the interests of patients and clients. This is in addition to those legal constraints which will apply to all workers.
The first four clauses of the UKCC code of professional conduct are fundamental for nurses working in needle exchanges, but can be generalised as good practice for all workers:
"As a registered nurse, midwife or health visitor, you are personally accountable for your practice and in the exercise of your professional accountability, must...
1 act always in such a manner as to promote and safeguard the well-being of patients and clients
2 ensure that no action or omission on your part, or within your sphere of responsibility, is detrimental to the interests, condition or safety of patients or clients
3 maintain and improve your professional knowledge and competence
4 acknowledge any limitations in your knowledge and competence and decline any duties or responsibilities unless able to perform them in a safe and skilled manner..."116
The duty of a nurse to follow the code of conduct is higher than the duty to follow instructions given by a manager, where to follow instruction would be a breach of the code.
Outreach and peer intervention
Outreach into communities of injecting drug users is closely associated with specialist needle exchange. There are various different models of outreach provision, including:
Peer intervention outreach.
Professional outreach workers (who in the main are not current or past injectors) are employed to provide advice, information or referral to other agencies for drug injectors not in contact with agencies. This is the form of outreach which predominates in the UK and some have suggested that this has limited its effectiveness117. This approach is restricted both by the numbers of contacts that can be made and by the fact that those contacts tend to be 'one to one' and unsustained.
Outreach workers can affect behaviour by:
Being able to offer on the spot advice to groups of injectors
Carrying a range of sterile injecting equipment and being familiar with its safe use
Encouraging injectors to use other routes of administration
Encouraging safe disposal of used equipment.
Peer interventions in their purest form are products of drug users' own efforts to limit drug-related harm. They can be assisted, encouraged and advised in maximising the potential benefits to be gained from such interventions.
As Rhodes says:
"...drug users' risk behaviour is not simply the product of individual's beliefs and intentions, but also depends on the types of social relationships and situations in which such behaviours occur, and the social norms and values of particular peer groups, social networks and subcultures."118
Examples of encouraging peer-based projects include:
Indigenous leader models which seek to identify important members of communities or networks119
Approaches which aim to reward peer educators for the number of contacts they make and the amount and quality of information passed on120.
A particularly practical guide to community-based peer intervention has been produced by the North Thames Peer Intervention Forum121.