Working in Harm Reduction – Using Chaos Narratives to Support and Sustain Frontline Staff: A Qualitative Study

Context: Increased access to integrated harm reduction (HR) health and social services is needed for growing numbers of older people marginalized by substance dependence. Working in harm reduction settings is associated with high rates of staff turnover and burnout. Retaining and supporting frontline staff are crucial for quality service delivery.

Objective: To understand staff experiences providing harm reduction services in this setting, with a view to developing supports.

Study Design and Analysis: Qualitative interview study, thematic analysis informed by Art Frank’s typology of the chaos narrative. Chaos narratives are difficult to articulate and lack narrative order; they tend to be disjointed in time, location or character. They typically do not have resolution.

Setting: a 68-bed supportive housing setting for older people with experiences of homelessness; includes on-site HR services (managed alcohol and tobacco programs) delivered by an integrated primary health and social care team.

Population studied: All staff working in the setting were eligible to participate. 19/32 staff participated (family physicians 3; nurses 2; social work 1; personal support workers 6; recreation therapy/mental health support team 2; kitchen and housekeeping 2; management 3). 4 participants were interviewed twice.

Final dataset: 23 interviews (length 30-60 minutes), transcribed verbatim.

Findings: Providing HR was stressful and a privilege. HR was conceptualized broadly. Staff prioritized ‘housing first’ as fundamental; keeping residents stably housed was ‘a HR win’. Relational care was foundational, allowing flexibility in HR delivery. Staff respected residents’ decisions, even if they went against staffs’ personal views. Deep listening and investing in relationships enabled staff to ‘voice’ residents’ unexpressed needs, including advocating with external agencies. Staff were subject to resident anger and experienced distress witnessing behaviours which resulted in poor health or social outcomes for residents. Despite this, working with the residents was a source of inspiration, as staff honoured longstanding adversity, resulting in a strong sense of accountability towards residents. Member checking supported our interpretation.

Conclusion: Frank’s chaos narrative helps understand apparently unpredictable behaviours of people with histories of marginalization. This not only benefits patient care but can also inform training and wellness supports for staff.