Episode 018: Bernie Pauly
Prof. Bernie Pauly studies nursing and the healthcare issues around homelessness. She talks about personal cost to nurses of the ethical dilemmas they encounter, which can stay with them for years. She discusses the dos and don'ts of conducting research on vulnerable people, and the power of a good survey instrument.
Transcript
Cameron: My guest today is Professor Bernadette Pauly of the School of Nursing at the University of Victoria. Bernie is a scientist at the Canadian Institute for Substance Use Research, and a Registered Nurse. Her areas of research include social justice and health equity for vulnerable groups in our healthcare system. She's done a lot of work around harm reduction in substance use and housing, and is the lead investigator on at least two major projects funded by the Canadian Institute for Health Research. Bernie, welcome to the podcast.
Bernie: Thanks, Cameron. Great to be with you.
Cameron: I'm quite interested in people who have real formal training outside of academia who end up coming into academia and of course, in my field of accounting, there's lots of people who were accountants and decided to become academic researchers. Your practical training, your skill set, is in nursing. What leads a nurse to decide to abandon all those wonderful patients and come into academic research?
Bernie: I'd like to share with you why I went into nursing and then why I moved from nursing practice to nursing academia. I graduated with a two-year diploma in nursing, which at the time was the very minimum requirement because I really loved the opportunity to be with people, to work with people, to see them go from struggling with health challenges to really recovering and moving on. I worked in a lot of different areas of practice, but I quickly came to realize that so much of our practice was either facilitated or constrained by policies, regulations, and in many ways, health system beliefs. If you think of the health system as a culture, it has its own set of kind of beliefs and values that people hold. It was really those that I kept rubbing up against all the time. I was the nurse working in an emergency department. I was getting some further education and I came to this realization that I could keep bumping up against those in practice, or I could move into academia with the hope of actually either influencing those policies and regulations, or producing research that would inform some changes that were based on evidence. The most profound experience I had that propelled me to do that was as I was working in the emergency department on a particular shift, and someone who had overdosed came into the department and a much more senior person than I whispered to me and said, "You know, you should make this as difficult to experience as possible for them so that they don't do it again."
Cameron: Really?
Bernie: It still is difficult for me to kind of share that because my profession has values that say we treat everyone with respect and dignity, and that we respect client choices, and that we try to understand people's experience and we use the best evidence possible. Those are written right into our codes of ethics and our practice standards. And that experience wasn't really an isolated experience. There were often situations that I would run into that I would go, well, we're not really treating this person in a respectful way, for whatever reason. So I felt like I needed ... I thought at that moment, I had a choice. My choice would be to stay and maybe take up some of those cultural values and beliefs about certain things -- and it was often related to substance use and beliefs that were held about people who use substances that we understand and would name as stigma -- or to continue my education and look at either moving into a policy-related position like a management position, or moving into academia. I chose academia at the end of my doctorate because I saw the potential in research, particularly in research that works in collaboration with communities and what we call community-engaged research as an approach, as a way of working to bring new knowledge that would challenge some of those cultural values, some of those beliefs around substance use that are very deeply embedded in our systems. So although the story I told you happened many years ago, I still feel that I made the right choice to move into research to try to influence policy and practice in an area that is so deeply embedded with stigma. So that's my story of moving from practice into academia.
Cameron: There's different motivations for academics. Some people are just motivated by intellectual curiosity, which is wonderful. Others are motivated by issues that are bothering them, and I tend to be attracted to people in the latter category because there's an emotional content in what they're trying to pursue. Your attention to these kinds of emotional issues come through in some of the research that you've published and I'm thinking of the 2009 article in Nursing Ethics that you've published on registered nurses perceptions of moral distress, this notion of moral distress for a nurse, and the ethical climate that the hospital creates around them. I don't know, it's just I'm not used to seeing academic articles that have the word "distress" in them. So it calls to me in some way. The way that you went about this research was using surveys. So you could have had the choice of interviewing people, or you could have done what you've done here, which is send out a survey. So can you tell me about the choice of how you went about approaching such a sensitive topic, and why you chose a survey instrument to do that.
Bernie: The article you're referring to on moral distress and ethical climate emerged out of a program of research and the first part of the program of research did use focus groups to speak with nurses about what they saw as ethical challenges in their practice. Times when they felt that they could not act in the way that they felt was aligned with their professional ethics. I was actually a doctoral student and part of that program of research, and I had come across the moral distress scales and the ethical climate scales. I was really taken with the idea that we could quantify, in a survey, some of the things which were in nurses stories and experiences that we had been gathering through the focus groups for many years. I was a doctoral student, and I actually brought it to the attention of the team, and I said, this woman in the States has developed this moral distress scale and this other nurse had -- both nurses, by the way! -- the other one had developed an ethical climate scale and I said, "This could be a way that we could really quantify and show decision makers in the health system the extent to which this exists, to which this phenomena of moral distress exists among nurses." Because I think we have been hearing about it qualitatively, but we didn't have any way of saying what's the extent to which this is being experienced across the health system, at least in our local area, because we were looking at the province of British Columbia. So the team, we had some money that we were able to obtain and the team was extremely supportive and thought, yeah, let's do it. Let's see if we can quantify it. So that was really how the decision was made, was to complement a program of what was largely qualitative research into these concepts.
Cameron: Do you feel that you already had a practical understanding of the experience of moral distress?
Bernie: I definitely think we had a good understanding of what nurses found as ethical challenges that caused them distress. I'm making that distinction because we had never asked them really about, do you experience moral distress and what's an example of moral distress, or that kind of thing, which we actually did somewhat later. We had always asked them about their practice and what they found ethically challenging. So I think we had a good understanding of what was distressing to them in their practice, which could be mapped on to this idea of moral distress going into the survey.
Cameron: So what does this survey allow you to do, then in terms of the breadth of research, the coverage of the people you're looking at? Obviously, with interviews, you've got to be there in person, but surveys allow you to get at a different question.
Bernie: Yeah, we were able to reach a very broad number of nurses in very diverse areas of practice, because we did the recruitment through the professional nursing organization. They sent out the survey to all of their members, and we were specifically focusing on acute care nurses, so it was sent to all of the acute care nurses. So we got a very, very broad range of nurses in different areas of practice, but also in different regions of the province, which would have been very difficult to do using some of the other methods. Because, obviously traveling and doing the interviews and the focus groups is very costly, whereas the survey went out electronically, people could return it electronically. And I just want to add, Cameron, that at the end of the survey, people had the opportunity to fill in some open-ended questions. Oh my gosh, they wrote on both sides of the page, and in the margins and in the header and in the footer. We ended up with this huge amount of qualitative data that we also subjected to content analysis, following, as well.
Cameron: That's interesting. So you touched a nerve.
Bernie: We touched a nerve test.
Cameron: Help me understand the way that you use surveys because it's quite important to the managed alcohol program that I want to talk to you about. It's also quite different from the kind of research that I do. I'm not used to using surveys. I have two questions. One is about the response rate and the other is about what makes for a high quality survey instrument. So first of all, the response rate, you talked about being able to send this out to all the nurses in the province because of the cooperation that you got from the professional bodies. Yet, in your article, you said that the response rate was 22% and I think you considered that a little bit low. What do you need for a good response rate and what do you do if it's lower than you wanted, and why was this low?
Bernie: Yeah, and I think we touched on some of this in the article around the moral distress survey, that nurses are busy. They often, in addition to their work, are responsible for family responsibilities. They're often the people who volunteer in the community, they help out the neighbors, they are taking on a lot of additional things. So when this survey came into their mailbox -- because at that time, it was a mail-out survey, not an electronic online platform, which we have now -- I would guess that's why the response rate was low. We did send out reminders, which are very important to helping to boost your response rate, but on the other hand, we were also sending it out to a very, very large group, as well. So of course, even though we got a decent sample back, it was still a low percentage.
Cameron: So approximately how many nurses would there have been in BC at that time? 10,000?
Bernie: At least 10,000. I could probably check. It may even be in the article just
Cameron: So even at 22% you've got a couple of thousand or more surveys to deal with once they come back and they're on paper. So it's a lot of work.
Bernie: Yeah, we didn't get that many back because we wouldn't have sent it out to all the 10,000 nurses because remember, some of them are educators, some of them are working in public health.
Cameron: So you were targeting people who were actually working in this particular setting?
Bernie: Yeah, we were targeting people in acute care for that because we wanted to get the acute care nurse. It would have been nurses that were practicing in the hospital would have been our primary group. So it would have been smaller than that. If you want, Cameron, I can look it up because we did do the metrics on what it was at the time, but my mind is just blanking right now and I don't know what it was.
Cameron: That's okay. I can always post it on the website. So you got 22%. Is that enough to work with?
Bernie: I think it was enough to work with and some people would say, some survey experts would say, if you're getting more than 20%, you're doing okay, because people just don't have the time and energy to respond to you. We have the strength that people were randomly selected. We weren't picking people, but then those who responded, the question always becomes what's the characteristic of those individuals that are responding. Are they people who answer every survey? Are they people who have more moral distress? Are they people who have less moral distress? Is there something about your participants who are responding?
Cameron: So judging from the quantity of qualitative responses that you got, the people writing in the margins and so forth, if those are the people who are responding then it sounds like they may be the ones who are particularly touched by this issue. So there's a possibility that, as you say, that it could be not necessarily representative of all the nurses, but there's certainly going to be representative of the nurses who have experienced it. So I guess you can interpret the results that way.
Bernie: Absolutely. I think that's an accurate way to say it is that we definitely got people who felt that the issue was important and that they had an experience that they maybe wanted to share or needed to share. So they definitely were very much that kind of group who were responding. So, you can say something important, I think about the fact that 22% of the nurses that responded to that, that's like a quarter, not quite a quarter, a fifth, let's say of your workforce, and that's significant. There's one thing, Cameron, that I regret still to this day about that survey. You asked the question, what makes for a good survey? We used standardized instruments that had established reliability and validity, which is important, but the instrument had been developed in the US. So we had to revise it because the healthcare system is quite different. We had to revise it for the Canadian context. So we lost some of our reliability and validity, but we couldn't have used it directly as it was. There's been much more work done on it since we used it to make it more applicable internationally, but the thing that I regret is, I wish we had asked one additional question, which is, have you thought about leaving your job because of moral distress or have you left your job, a job because of moral distress? Just a simple yes/no question that would have been outside of the actual instrument. And if we had had that one question, we would have been able to really link to a very important nursing agenda that was very prominent at the time, which was recruitment and retention of nurses. If we had been able to link moral distress to people leaving or thinking about leaving their employment, I think it would have made that applicability of the work quite a bit more impactful than it was because people ... you said people have different motivations for doing research. I'm never doing research because I want to get published in a good journal. That's a secondary thing. I'm always trying to do research that's going to have some kind of impact, and that's why I raised that example about, had we asked that question we could have linked to this really important nursing agenda at the time.
Cameron: That's quite interesting to me because here, what you're talking about is that in order to create research that's going to matter to somebody else, you have to think that in right from the beginning in the design of the questions that you're asking, and if you miss that opportunity, then you can't go back. There's no do-over.
Bernie: There's no do-over. There's a next research study, but again, you can appreciate, Cameron, the amount of time it takes to secure the funding and get the ethics and mount another follow-up study, which is really the only option. But it's always really challenging, I think to think about what the agendas are of the time and the timing of your research. Those are two things that are running in parallel, and how you bring them together -- I could give lots of examples where I think we were maybe ahead of our time and others were behind and out of sync, and then the occasional one where maybe you're in sync.
Cameron: You found that -- and this is me trying to read and understand a nursing paper, so let me try and put it in my words, and you can tell me if I've got it right -- one of the things you found was that it's not so much that there's a lot of moral distress incidents, but that when they happen, they are particularly memorable to the nurses and a lot of their sense of who they are in nursing hinges on these particular incidents. So it's not just like a continuous, you know,"I had a two out of five day today in terms of moral distress." It's particular incidents that become significant.
Bernie: Yeah, that's a very accurate interpretation. Because what's happening is people are carrying that moral distress with them for years, which we knew from our qualitative research because we would be asking people to give an example of an ethical challenge in practice that was distressing, and they would tell us this example as if it had happened yesterday. I remember very vividly in one focus group tuning in and saying, "When did that happen?" It had happened like a decade ago. So you're right, it's the fact that it's the intensity of it and how it's affecting people over time, which was then coined as moral residue, in that you're carrying this around with you into your practice, and I think sometimes nurses would use that in a positive way. I recognize this situation, this is what happened before, and I'm going to try to act in a different way to see if I can get a different outcome. Although sometimes that works and then other times, that's just frustrating and you're ending up with the same outcome. Because moral distress isn't about just the fact that you have emotional distress or burnout because you have a big workload or whatever. It's because you know the right thing to do and you can't do it. You know what you should be doing, you know the care that you should give, but because of a policy, because of workload, and so on, you're not actually able to do it. I think we were able, through the survey, to be able to say something about moral distress and the impact it has on nurses. As I said, I think we would have had even more impact if we had been able then to link back to recruitment and retention, to something that matters to employers. Or even sick leave might be another example. We needed to link it to some kind of outcome, and that's where a survey is really a perfect methodology. Because if we had the moral distress scale, and then we had a question about intention to leave work, or we had questions about workplace satisfaction, you could imagine that, right? A scale of people's workplace satisfaction, and you could start to ... with surveys, you can correlate those kinds of concepts. There's one other thing I want to mention about surveys because it's one that I find particularly important because I am a very qualitative researcher. So I think about things like concepts like moral distress or workplace satisfaction. I think about those things in terms of what do nurses say those are. In survey work, it's how is that concept defined in the instrument that you're using? And that's a very important consideration because you do not want to pick up an instrument with a definition of a concept that doesn't fit with the way that maybe other literature -- or maybe a more critical analysis of the concept -- if it doesn't fit with that, then it's actually not that useful to measure something that isn't well defined.
Cameron: So do you have to wait until you've got a good handle on these things before you can develop a survey?
Bernie: Absolutely. I think there are few instances, I can't think of a lot of instances, where I've developed a survey. I've done a fair number of surveys but you really need to have conceptual and operational definitions for what you're measuring. I think you're looking for an instrument that reflects conceptual and operational definitions that make sense of the concept in a way that's meaningful to the work that you're doing. Then, let's just take moral distress. If the moral distress scale had been about individuals and individuals being the problem, they just don't know how to handle emotion, or they don't know how to do navigate systems.
Cameron: Or are unfamiliar with the ethical rules.
Bernie: Exactly. To me, that would have been a very individualized kind of approach to moral distress, whereas from our previous work, we knew that the environment, the workplace, has a huge role and impact on moral distress. So it's the systems that nurses are working in, and where they're unable to act for reasons of constraints in those systems. So when we looked at moral distress, that's what drew us to what's called the MDS, the moral distress scale that had previously been developed, because it took a broader view of moral distress. I look frequently at how is the concept defined and then how is it measured -- and that's what I mean by conceptual and operational definitions -- to ensure that it does reflect something that is consistent with theoretical understandings or a strong conceptualization because, I don't particularly want to contribute to an understanding that we have flawed individuals. "That's the problem. Nurses, they just don't have strong enough constitutions or characters!" Are you kidding me? We deal with trauma, we deal with death, we deal with palliative care. Please, we don't want to blame people for those things. So when I'm critiquing -- as a researcher, you often get sent articles to review, and I wouldn't say that I am the strongest at analyzing the statistical aspects of the paper, but I am really good at analyzing the conceptual aspects of what concepts the survey is measuring, how those concepts are being operationalized and I think that kind of front end work is really critical in designing surveys.
Cameron: I'd like to shift gears and talk about the next project that we agreed to talk about, which is the managed alcohol program. So for full disclosure, I was a co-applicant on the funding application for this and I've really enjoyed working with you and taking part in the meetings that took place here in Toronto. The question that we need to start with is what does "managed alcohol" mean?
Bernie: So managed alcohol programs are alcohol harm reduction programs for people with severe and long term problems with alcohol and generally combined with homelessness, or unstable housing. There's about 22 or so programs across the country that have been designed to meet the needs of this group of people who are often overlooked in our healthcare system and are often drinking, not just large volumes of alcohol, but often consuming non-beverage alcohol. Things like rubbing alcohol and hand sanitizer because it's a cheaper, sometimes more accessible source of alcohol. So the programs have been designed to respond to assisting with managing alcohol without expecting sobriety as a goal, providing housing and other supports.
Cameron: So the program itself then delivers a steady dosage, if you will, of alcohol to the participants. This seems to me like a very problematic kind of a program: given the political climate around things like the opioid crisis and safe injection sites, the idea that we would actually have a research team that is dispensing alcohol to alcoholics seems like it might attract some criticism from that sector of moral outrage.
Bernie: [laughs] So the research program does not provide the alcohol. We partner with programs that provide a managed dose of alcohol to people who meet the criteria throughout a day.
Cameron: So those programs themselves have funding at the nursing level?
Bernie: Yeah, they have funding to run their programs, some have nurses, some have, they would have like counselors or harm reduction workers possibly. So your comment's interesting about the controversial nature of the programs. I think there often is kind of a response like, "What? Give alcohol to people who have problems with alcohol?" That's one response, but if you place it into a harm reduction frame where we are concerned about preventing harm, such as seizures, withdrawal, assaults, violence, stigma, all of the things that harm people who are living in this situation, and we provide a safer place to drink, a safer source of alcohol, we are actually providing a harm reduction space where people can get stabilized, they're not struggling to survive, and they can make a choice about their drinking. Obviously, we do not want to accelerate harm. We want to reduce harm. So, the volume of alcohol has to be a consideration, which is different than other types of harm reduction programs. When you put it in that kind of context, it's really a supervised setting. If you kind of understand supervised injection sites and you understand heroin prescription programs, it actually aligns quite nicely with other types of harm reduction strategies in the approach.
Cameron: So do you find yourself waging any battles against that kind of stigmatization, though, from the political side?
Bernie: I'm just going to give you -- this is anecdotal, Cameron -- because I've done a lot of media around managed alcohol programs, newspaper, radio, that kind of thing, I noticed something really interesting a couple of years ago around the time that the number of overdoses was increasing in British Columbia and across the country. What I noticed is people's attitudes towards the MAP were shifting. Because prior to that people who were interviewing, radio commentators, for example, would often start with, "Oh, you're giving alcohol to alcoholics." That might be kind of the opening line, or, "Oh, that sounds like people are just having a party." Then of course, I would give the same explanation that I just gave you and they'd go, "Oh, that makes a lot of sense. I see where you're coming from." When the overdose crisis emerged publicly, what I saw was a huge shift -- and again, this is just my experience -- is people no longer were saying those things. In fact, I have a number of interviews where the commentator started off and said, "We know about the importance of supervised consumption sights to prevent overdoses, and we know about heroin prescription programs. Today, my guest is Bernie Pauly, and she's going to talk about manage alcohol programs." I have to admit, the first time I heard an announcer do that, it happened several times, it kind of blew me away. What struck me is that it was really probably a symbol of the Canadian public (because I think about media as being representative of public ideas) really shifting around harm reduction and the lifesaving nature of harm reduction interventions, and being able to look at something like an alcohol harm reduction intervention, which we don't talk about very much, and putting it in kind of that same health and safety perspective. I found that really interesting that that was happening. What we're also finding now is that people, there's so much more openness to talk about substance use. Again, I'm reflecting my British Columbia context where the conversations around how much are people drinking and conversation about problems with alcohol are actually opening up a little bit. I wouldn't say it's fantastic, don't get me wrong, but substance use is now a conversation. So there's more opportunities, I think, to talk about harm reduction and understandings of a broad range of harm reduction.
Cameron: Right. Well, even the language that you use around this when you say substance use, as opposed to substance abuse is instructive. When did that shift take place?
Bernie: It's hard for me to say because I've been using that language for a long time, and specifically, spending a lot of time correcting journalists and saying "substance use" and here's what I mean by substance use, and talking about the broad ranges of use of different types of substance, from for reasons of pleasure to problematic. And in the public, I definitely think the last three to five years, we're seeing shifts. Again, I'm using media as my kind of go-to, and some media more than others I think have taken up that language of substance use. Certainly we see it in governments, moving away from "substance abuse" to "substance use."
Cameron: The study that we started talking about around moral distress for nurses, you're dealing with a population that you're studying there who are under significant pressure, but they are trained professionals. In this situation, you're dealing with people who are under a lot of distress as well, but I think it's fair to say that they are a much more vulnerable segment of the population. So what changes in the way that you do your research when you realize that you're dealing with people who are in this kind of a situation?
Bernie: Anytime we're doing research, we're concerned about informed consent, ensuring that people understand what we're asking, what we're going to do with the information. I think, it's one thing to write that down and explain it to professionals. It's quite another thing to explain it and discuss it with someone who may have university education or may be illiterate -- there could be quite a range in there -- and may be under the influence of alcohol. So we had quite a lot of strategies to really ensure that people were clear about what they were doing, everything from assessing people prior to interviewing to make sure that it was a good time, that they were at a point in the day where they weren't intoxicated. So we ended up doing a lot of surveys in the mornings because that was the best time. We worked really closely with service providers and people with lived experience to figure out some of these things. We also identified that you're taking away time from people, you're taking away time that they need for survival, maybe finding a shelter bed or finding food. So the payment is really important, but-
Cameron: You paid people to participate in your surveys?
Bernie: Yes, and that is standard practice for when you are engaging people in research who are not doing it as part of their job. So, if we interview policymakers, let's say, and they're doing it in their paid day, same with staff, then we wouldn't pay them of course, but for individuals, especially vulnerable individuals, where you're asking very precious time away from survival mechanisms, the standard is to pay them for the interviews. But you have to ensure that the pay is not coercive, so that people are not feeling like they have to participate to get the money.
Cameron: What would coercive pay look like? Too high a payment?
Bernie: It could be the amount that people receive. It could be ... for example, in our consents, we do not require that someone completes the interview. They would still be paid if they don't complete the interview. Some programs, we worked with them around what compensation should look like. So I should say compensation rather than pay, really, because in some cases, programs recommended gift cards, as opposed to cash. Although, guidelines in the substance use field are shifting more so towards cash. At that point in time, we worked very closely with our partners to determine what would be the best means of pay. So when you're designing the survey, I think the ethical components are really important to take into account the vulnerability of the population you're working with. When it comes to recruitment and retention, we used a couple of strategies. One was the research assistants who did the surveys at baseline had information about various ways to contact people and follow up with them. Then rather than waiting and doing a six-month follow up, we actually did a shortened monthly follow up. So the research assistants had monthly contact with the participants. So that did a couple things. It gave us multiple data points on some things, but even more than that, it really boosted our retention rates and our retention rates were phenomenal. In the managed alcohol program, we had two groups, MAP participants and controls. And the participants -- because they were in the program, we knew where they were -- it was about 90%. And in the controls, it was 70%.
Cameron: Which is still high.
Bernie: Which is very high, especially when you factor in that this is the group of people that most people in the health system would describe as hard to find or hard to reach, because they're moving about.
Cameron: Tell me about the multidisciplinary nature of this, the kinds of people that are involved in your program. How big is this research project?
Bernie: The team is significant in size, as you know, Cameron, from being part of it. We have more than -- for sure, at this point -- more than 30 actual team members, which are composed of people with lived experience, policymakers from different levels (health authority levels as well as provincial level), and we also have service providers. They're a key part of the research team. Those are people who actually run managed alcohol programs. And then of course, ourselves, the researchers. What's really exciting is we have that core research team, but we have a community of practice, which anyone who is either involved in running or setting up or has any interest in manage alcohol programs can join. As of yesterday, our community of practice coordinator told me we have about 250 people who are part of that broader community of practice. So they're participating in webinars and roundtables where they're connecting with other people who have an interest in this area, but they're also informing the research and we're providing the research at early stages back to the programs.
Cameron: That was my next question, is how far are you through the project and what have you learned so far?
Bernie: So from the project, we actually are now in what we're calling phase three. Phase One started in about 2013. Maybe even a little sooner. That was kind of our first official funding was 2013. We had done one pilot study before that, and what we did was the baseline surveys, we did qualitative data collection, we did some document analysis, and what we generated out of that first phase is an understanding that people feel much safer in the managed alcohol program, and it reduces the dangers of being on the street. It really addresses issues related to stigma that people experience in hospital when they enter hospital or other healthcare settings. I think importantly, what it's shown us is that people in the managed alcohol program, they tend to drink on more days, but overall, they tend to drink less and they experience fewer harms, and those harms are physical, social, financial. They keep their housing, which is significant, because in a couple of our pilot studies, people had been homeless for many years prior, and were able to retain their housing. Then we did one small cost benefit analysis, which highlighted that it was cheaper and an alternative. We're looking forward to doing more of that, as we get the data. We're just, just getting it now. The data that I know you'll be very interested in, Cameron, about trying to do a look at an impact of the costs and benefits of the program.
Cameron: This is the stuff that you're learning as you go along. How does that then translate into results or an impact? Who needs to learn about this and how do you make sure that they learn it?
Bernie: Yeah, that's a great question. I think there's different learnings that are going on for all of those different groups in the research team. I think for the service providers, we've generated a lot of insights that have helped them to maybe address issues and refinements in their programs, which is a very practical kind of impact, right? We've also, I think, really helped provide for many of the programs an evaluation that's allowed them to secure ongoing funding, which is significant because evaluations are requirements of the funders. So they've been able to use the research to support ongoing. In some cases, the research has helped at the program level. People who want to start a program, they're not starting from ground zero. They're able to start from what we've learned, and I'll just give you an international example of that. I collaborate with a group at the University of Sterling, who are just conducting a feasibility study of MAP and they took our six dimensions of a MAP program, which we had published an article about. They basically structured the feasibility questions for service providers in Edinburgh and elsewhere, Edinburgh and Glasgow, I guess, to ask them about, here's kind of important components of MAP, what would you envision would work in this setting? So we're helping to inform design, new approaches to programs in other countries. We regularly consult with people around designing programs, frequently consult. I actually can't quite keep up on it. It's often through email and other kinds of requests.
Cameron: So these people come to you?
Bernie: Yeah.
Cameron: How do they find out about it?
Bernie: I would say most of the time, they've either come across an article we've written or they somehow find their way to our website, the managed alcohol program website. The other learnings, how are the other learnings being applied? I think we ourselves as researchers are identifying new areas for research. So I mentioned we're in phase three now, which is looking at the feasibility of cannabis substitution for alcohol. So now that we're in a legalized environment for cannabis, looking at that as an option to substitute for alcohol. So that directly came out of the research. I think that the programs are informing us on particular questions for analysis, things to look at. Then I think in terms of policymakers, I think they're looking to the evidence to say, this clearly is an area we should be looking at in terms of our suite of programs. I think that is something where, I don't think we get quite as many questions, but we do definitely get questions from policymakers about what's the state of the evidence and how should we be thinking about this in terms of overall funding and policy initiatives and directives. So those are just some examples.
Cameron: Do you ever get a chance to address policymakers directly yourself?
Bernie: Yes. The most direct is usually at the what I would call the regional level. So at the health authority level, and that's often a request to share what the current evidence and research is, which I do a fair amount. At the provincial level and the federal level, not so much. I don't know that ... I mean, we've had provincial-level requests for sure, but I don't know that I could think of an example of a federal-level kind of request. So, thinking about policymakers at each of those levels, it does make sense when you're talking about a program like this, that it's coming from people who are in a more regional-level position, because they're identifying a gap in their services usually. They're saying, we have this group of people, we know we're not serving them very well.
Cameron: It's also a function of the way health care is delivered. Constitutionally, in Canada, it's a provincial responsibility. Maybe it takes some of the burden off of you that you don't have to talk to every policymaker in Canada, you can convince a few and let them spread the knowledge.
Bernie: Cameron, the other thing too, is we have to remember as researchers ,when we're talking to the media, we're talking to policymakers often.
Cameron: Okay. I'll keep that in mind.
Bernie: Yeah. We're talking to everyone from the grandparents, the parents, the siblings, and the policymakers and the health care providers when we are talking to the media, and I'm always thinking about how do we get our evidence out there in a way that is accessible and understandable through the media.
Cameron: It's an important part of your work. I think I've kind of come to the end of my questions. It's a fascinating approach to research. It's highly engaged, quite structured. I think you're really thinking through every step of the way, and yet you're doing it in a way where you are learning constantly from the collaborators and partners that you've got. So it's a fantastic model, for me to learn from anyway. I'm always looking at new ways of conducting my research, and maybe that's the hidden agenda of this podcast is actually. I'm just trying to grab all the good ideas and figure out how to use them myself.
Bernie: I think we all do that. Thanks for including me, Cameron ,and I appreciate that you're doing this because I think it's important to have conversations that people can listen in on that are usually just held between researchers in their offices sometimes.
Cameron: That's part of the hope for the podcast is that it gives people a sense of listening to people talk about what's really going on in the research and hopefully, learning from it. Thank you so much for your time, Bernie. It's, as always a great joy to talk with you and I appreciate you being here today.
Bernie: Thanks, Cameron.
Links
Bernie Pauly on Twitter
Full text of one of her papers on moral distress in nursing
Canadian Institute for Substance Use Research
A presentation about MAPs
Credits
Host: Cameron Graham
Producer: Bertland Imai
Photos: University of Victoria
Music: Musicbed
Recorded: November 13, 2019
Location: York University, University of Victoria
