Exclude

Training Guide

Guide to Developing and Managing Syringe Access Programs

This module covers:

• “Know Thyself”
• Staffing Considerations
• Supervision in a Harm Reduction Workplace
• Safety Issues

SAPs face unique organizational issues given the unconventional work environment, varied personal experience of staff and volunteers, and the commitment to creating a workplace that is consistent with the social justice values of harm reduction. For an SAP to be truly successful in upholding its principles, operations and relations with staff must be consistent with the nonjudgmental, holistic and empathetic services it provides to participants.

 

“KNOW THYSELF”

An SAP is more than a social service or public health intervention. It is a creative social justice project that has the potential to challenge your world-view and take you to new and exciting places – personally as well as professionally. understanding what brings you and others to the work of starting an Sap is an important step in the process.

• Consider the following questions for yourself and encourage potential staff to do the same:
• What personal experience drives you to do this work?
• Why are SAPs important to you?
• What do you hope to gain from starting the SAP?
• What are your fears or anxieties as you enter into the process of starting an SAP?
• What strengths, and weaknesses, do you bring to the work?
• What biases do you bring to the work?
• Do you feel supported by your agency?
• What resources do you have for nourishing your spirit and keeping yourself grounded throughout the process?

Some of these questions may seem relevant to you; others may not. perhaps there are other questions that will help you to locate yourself within the work. either way, careful consideration of all that you and/or your agency hope to achieve in pursuing this project will likely prove helpful throughout the process.

 

 STAFFING CONSIDERATIONS

A strong team of staff and volunteers brings varied experience, skills and energy to the SAP. Building a competent, knowledgeable and approachable staff will ensure good relationships with engaged participants. A unified staff that works well together and feels supported will be able to function as a better team, resulting in a safer and more enjoyable work environment. All staff must be on board with the mission and vision of the SAP and should understand the need for syringe access as well as the various components that make up the SAP.

SAPs face unique staffing challenges. For an SAP, hiring staff with current and past experience with drug use is an asset and a responsibility. It can be difficult to manage dynamics between staff with histories of drug use and those who may have limited or no experience with drug use. Also, staff are likely to have different educational backgrounds and varied employment histories. A well-run SAP ensures that the skills of all staff and volunteers are maximized and utilized in an appropriate way.

Before beginning the hiring process, evaluate the total number of individuals that will be needed to run the program. Consider a good mix of full- and part-time staff, peer workers, stipend workers and any volunteer opportunities. Budget and resources will dictate how many paid staff the SAP will be able to employ. SAPs with insufficient resources to pay for enough staff coverage or rely largely on volunteer support may face significant challenges to sustainability. However, volunteers and paid peer workers can be a tremendous asset to the SAP. Find an appropriate staffing balance based on the breadth of services the SAP provides.

Volunteers and Peer Workers

Volunteers can be a great asset. While using volunteers can help keep program costs down, volunteer workers still require supervision, training and support. Consider instituting a trial period for volunteers to assess whether they are a good fit for the program and vice versa. Where appropriate, provide some form of compensation to volunteers if resources allow, such as travel reimbursement and/or stipends.

Some professions and academic programs require people to gain clinical or experiential training hours. In cases where the program and the individual make a good fit, this can be a mutually beneficial relationship and great way to access the expertise of medical students, social workers, etc. Professionals in these types of relationships gain the insight and expertise unique to working in an SAP, which can lead them to become champions for harm reduction, syringe access and the rights of drug users in their future careers.

Peer workers bring personal experience of drug use to an SAP and insight into their communities. While employment of people with varied experiences with drug use will be discussed in greater detail below, peer workers are somewhat unique because of the emphasis on their shared experience with other participants. Utilizing peer workers can amplify the voices of users and participants as well as extend the reach of the SAP. In addition, peer programs can help transition people who may have limited employment experience or who have been out of the workforce for extended periods back into a professional environment. As with anyone working in an SAP, proper training is important for peers. Given the close relationships peers may have with other participants, peer training should emphasize how to define and set individual limits and boundaries in the workplace. Of course, it is important to provide peer workers with equal recognition for their work, acknowledgement of their expertise, and compensation for their time and efforts.

Hiring and Working with People Who Use Drugs

People are drawn to the work of providing syringe access for any number of reasons. The truth is one would be hard-pressed to find anyone who has not, in some way, been impacted by substance use, be it first-hand, through the experience of friends or loved ones or more peripherally. While some people may be comfortable disclosing their own drug use when seeking employment at an SAP, others may not be able or willing to share this information. Peoples’ experience along the continuum of drug use should be acknowledged and valued along with any number of other characteristics they would bring to the job. Once hired, staff should be measured on the merits of their work and their ability to perform the tasks required of them, regardless of their former or current drug use.

However, from the perspective of an SAP as a social justice project committed to advancing the rights of IDUs, it is only appropriate to deliberately seek the employment of active IDUs. Active IDUs will have insight into current cultural norms among drug users, may be able to gain trust from participants more easily, and give credibility to the program. In addition, IDUs come with a set of skills and experiences that need to be honored and acknowledged. Conversely, IDUs who are too close to the participant base may find it difficult to set appropriate boundaries or discuss sensitive health information and risk behaviors. Current IDUs may also face challenges with reliability and the demands of work while juggling the needs of drug use. Proper supervision, training, and support can be especially vital to workers who are actively injecting drugs.

Former IDUs and those in recovery may also be good candidates to staff an SAP. As with active IDUs, former injectors will bring first-hand knowledge of cultural norms and sensitivities of drug users as well as the experience of making changes to their drug use. Former users may find that working at an SAP is especially rewarding given their own struggles and a desire to help others. However, it is not uncommon that former drug users sometimes exhibit heightened judgment toward current users and will have a difficult time supporting the struggles and experiences of active IDUs. While often well intentioned, some former IDUs can further marginalize participants by over-identifying with them or proselytizing about their own path to abstinence. In addition, an SAP may be a difficult environment for some former IDUs if abstinence from drugs is their goal. Again, supervision and training will be important to avoid potential problems and provide a supportive work environment for former IDUs.

People with limited, recreational, and/or no drug experience can also be valuable assets to an SAP. However, unlike the traditional protocol where drug-users have an initial bias to overcome, in this case the burden of building trust may be on the non-user. Of course, non-IDUs can bring valuable skills and a fresh perspective as well. Non-IDUs may need additional training on the process of injection, common slang, and cultural norms to best understand how to counsel participants about risk and engage in a comfortable and non-threatening way.

In addition to considerations regarding experience with drug use, staff should reflect the full diversity of the populations that the SAP will be serving. A culturally competent staff will be attentive to a broad range of factors including, but not limited to:

• Race/ethnicity
• Culture (including first languages)
• Gender
• Age
• Sexual orientation
• Life experience (for example sex workers, history of incarceration, etc.)

The best staff team will be one that brings a variety of experiences to an SAP. Of course drug use is not something that can be defined in the moment a person is hired at an SAP; drug use can fluctuate for anyone at any time, regardless of previous history. It can be dangerous to make assumptions about who is using drugs, how, and when. An SAP should be a place where drug users – staff and participants alike – can feel safe and supported as individuals. Lines of communication should remain open and people should be afforded the opportunity to disclose concerns about their drug use without fear of reprimand. Unfortunately, stigma around drug use, especially in the workplace, is so pervasive that even despite the best efforts to create an open and supportive environment, some staff may be unable or unwilling to discuss their use – especially in cases where it becomes problematic and/or interferes with their job. Supervisors and management should be trained on how to best manage these situations, and staff should be offered extra support.

Skills/Qualifications

There are a number of general characteristics and values that are important for SAP workers to have. In addition  to an interest in the health and well-being of drug users, the following are additional characteristics to look for:

Non-judgmental: Having an open mind and the capacity to accept people, regardless of one’s own opinion on their personal choices, are of primary importance when working in an SAP. Participants at SAPs may make choices that are hard to understand, that threaten their own health and safety (as well as that of those close to them), and that pose great challenges to making changes. It is critical that SAP staff understand how to educate and help people understand their behaviors while offering unconditional support that allow people to be autonomous, make mistakes and ultimately to decide what is best for them.

Flexibility: An SAP is a dynamic environment and requires workers to think on their feet, be creative and be flexible with conditions they may not be able to control. While it is important for SAP workers to be trained and skilled in setting appropriate boundaries, the ability to roll with the unexpected will be very helpful – be it a result of staff/ participant behavior, shifts in funding, staff turnaround or many other reasons.

Authenticity and honesty: Given the illegal nature of drug use and the subsequent stigma and negative consequences often associated with it, many drug users have developed an ability to read people and their intentions very well as a protective measure. SAP workers who genuine, honest, and are up front with their intentions will be more effective in building trust with participants.

Good communication: Effective and clear communication skills are crucial for SAP staff. It is important to be able     to articulate expectations, concerns and observations. Furthermore, good communication can minimize conflict  and misunderstanding with staff, participants, community members and external entities (such as law enforcement).

Listening skills and empathy: Inherent to good communication is the ability to listen. Sometimes the most valuable service an SAP can provide is as a place for people who have too often been ignored and discounted to tell their stories, voice their concerns, and be heard and validated. 

Emotional stability: Given the stressful and sometimes overwhelming nature of working in an SAP, staff who are well-grounded emotionally will best be able to handle the work environment. Of course, everyone has periods of ups and downs; however, people who are very easily upset, fragile, or emotionally volatile may not be best suited  to work in an SAP. Assess the coping skills and support systems of potential staff members in the hiring process.

Professional and reflective use of self and thoughtful boundaries: Staff should  be  provided  with  additional  training  to understand and set thoughtful boundaries. However, it is helpful to look for staff who may already have a good grasp of these concepts. While each individual will bring their own unique set of experiences and needs to work in an SAP, it is a valuable skill to be able to decipher when and how to insert these experiences and needs into professional work.

The following specialized knowledge can also be valuable for potential SAP workers:

• Harm reduction
• HIV and/or HCV
• Counseling and/or crisis intervention
• Office and administrative skills
• Professional skills such as social work, psychiatry, sociology, or medical training

SUPERVISION IN A HARM REDUCTION WORKPLACE

Thoughtful and attentive supervision is especially important at an SAP given the complex dynamics between the intensity of the work, potential for drug use and recovery issues among staff, high turnover common in social service jobs and burnout associated with direct service and social justice work. Beyond ensuring that all staff receives proper training and support, supervision in a harm reduction workplace requires special attention to the holistic care of staff. Working in an SAP can entail experiencing a type of vicarious trauma, through the witnessing of suffering, poverty, violence, addiction and desperation among an already marginalized group; simultaneously, there is opportunity for camaraderie, celebration and personal development. Supervision and workplace structure in general must be attentive to the complexities that exist when working at an SAP.

For people working in an SAP, the line between the personal and the professional may sometimes be unclear. This requires a special finesse and the capacity of supervisors to understand when it may be necessary and appropriate to discuss factors affecting staff outside of the workplace.

Supervisors in an SAP should communicate clear expectations to staff. They should meet regularly with staff to acknowledge accomplishments, recognize challenges, and discuss overall job performance. In addition, supervision meetings should provide an outlet for staff to discuss any struggles or issues related to drug use or support they may need in relation to their use. It is recommended that supervisors have an open door policy where staff can feel free to come to them with suggestions, concerns, or questions.

Staff Burnout

An SAP working environment can be emotionally challenging. While the work also provides many rewarding experiences, the more difficult aspects of syringe access work can take a toll on workers.

SAPs are traditionally marked by unconventional hours and a day-to-day work environment that is constantly shifting based on the flow of participants. In addition, unlike some jobs wherein tasks are assigned and completed and new tasks are begun, the work of providing syringe access and helping drug users is never “finished” work. This can sometimes leave workers struggling to feel a sense of accomplishment or success. Similarly, it can be difficult for staff to witness participants struggling with their use and/or other factors in their lives – such as relapse, homelessness, and mental health problems. Working with drug users means dealing with life and death situations on a daily basis. Overdose, trauma, and violence are unfortunate and often frequent realities for many drug users, and staff will inevitably absorb some of that pain.

In addition, as participants struggle to survive in a difficult and hostile world, workers may witness behaviors that are hard to reconcile, such as lying or manipulation, even among people they have developed strong and friendly bonds with. This can be very difficult on workers and can feel very personal. When these circumstances do present themselves they, can have a serious impact on the well-being of staff, leading to burnout.

Burnout in the workplace is often marked by patterns such as:

• Frequent absenteeism or tardiness
• High staff turnover
• Conflicts among staff
• Low level of job satisfaction
• Ineffective service delivery
• Anger towards participants
• Impact on physical health

While each person experiences burnout differently, it can often best be prevented and addressed at an organizational level. Thorough training and supervision is necessary to properly nourish staff and promote success on the job, allowing workers to feel confident and prepared. Attentiveness to team-building and communication will foster a supportive work environment where staff does not feel isolated. A commitment to fairness, transparency, and authentic involvement in the direction of the program will also help to prevent workers from growing resentful or feeling removed and disconnected.

Other ways to prevent burnout include:

• Supporting staff in setting appropriate boundaries with participants and work.
• Ensuring complete staff coverage so that people are not putting in too many hours.
• Prioritizing ongoing training and staff development.
• Regular team building exercises.
• Sharing data and program evaluations on a regular basis so that staff knows the value of their work.
• Individual or group clinical supervision for staff with an outside social worker, psychologist, or psychiatrist.
• Recognizing staff accomplishments and promoting people where possible and appropriate.
• Sending staff and peers to local and national conferences to provide them with networking opportunities and the sense of being part of a larger “movement” or community.

Above all, an SAP that is committed to a spirit of care, community and health for its participants must translate these same ideals to volunteers and staff. Preventing staff burn-out must come from a broader awareness of who your staff are, what they need to feel supported and appreciated, and how they learn and process information. Patience, forgiveness, and attention to the emotional health of workers will go a long way. In addition, it is vital to understand that burnout can be contagious and must be addressed at every level of the organization. Staff turnover will impact the day-to-day functioning of an SAP. It increases the amount of work on remaining staff, while also raising general stress levels due to transition and the need to rebuild trust with new hires.

Staff Training

Staff training is a vital component to a successful and responsible SAP. Training informs the way that services are delivered and ensures a consistent knowledge base among staff. Solid training about the values driving the program ensures that all participants entering an SAP will feel welcome, comfortable and respected.

All staff and volunteers should complete a core training curriculum. Ideally, there will be several qualified “in- house” trainers (either staff or volunteers) who can deliver training according to a regular schedule or on an as- needed basis. Records should be kept of when trainings occurred, who conducted the training, where the training occurred, and who attended the training. In some cases, it may be appropriate for people to attend refresher courses as needed.

The following training basics are recommended for all program staff and volunteers:

• Agency policies and procedures and relevant regulations, including emergency/safety procedures, general operating procedures, reporting requirements, etc.
• Harm reduction 101
• Legal and law enforcement issues and policies
• Syringe disposal and safety, including needlestick procedures
• HIV and Hepatitis basics and prevention
• Safer injection and overdose prevention
• Referral networks and procedures, including drug treatment, and medical care
• Cultural competency, including sensitivity to the needs of youth, lesbian/gay/bisexual/transgendered individuals, people of color, women, sex workers and other participant populations.

In addition to the core training program, advanced training and ongoing staff development should also be prioritized. There are a number of institutions that provide technical assistance and ongoing training in cases where in-house training is not possible and/or appropriate. Inviting guest speakers and trainers to staff meetings can be a good vehicle to provide ongoing education. In addition, conferences and off-site training institutions offer a good opportunity for staff and volunteers to network with other providers and gain important experience and insight. Some topics for ongoing/advanced training include:

• Drugs and alcohol 101
• Wound and abscess care
• Outreach methods and practices
• Motivational interviewing and the stages of change
• Interpersonal skills including boundary issues and engagement
• Case management
• Mental health and harm reduction
• Domestic violence and harm reduction
• Harm reduction for sex workers

SAFETY ISSUES

The safety and security of staff, volunteers and participants must be of utmost concern. SAPs face unique safety issues for several reasons including:

• The illegal and potentially violent culture associated with buying and selling drugs and obtaining money to buy drugs.
• Unpredictable behaviors sometimes exacerbated or caused by the use of drugs (including paranoia and potential delusions).
• The vulnerability of drug users to exploitation and abuse.
• The presence of sharp and potentially contaminated materials, including needles, syringes and other equipment.

Proper planning and protocols can help to minimize certain risks and potential threats.

Staff and volunteers should be encouraged, if not required, to work in pairs or groups. This will minimize vulnerability and allow workers to look out for each other, respond to any issues more effectively, and consult each other for guidance and support.

Staff and volunteers should be discouraged from wearing especially valuable jewelry or adornments to work. Staff and volunteers should also be provided with a designated area to lock up any personal belongings or valuables when they report to work. In addition, the SAP should secure any valuable items such as laptops/computers, money and electronics.

Should safety or security be compromised in any way, be sure to debrief with any staff and learn from the incident. Consider necessary program measures to prevent a similar incident from happening again. Additional training and review of policies may be necessary if problems are ongoing or serious.

Dealing with Conflict

If conflict occurs at an SAP, the safety and security of staff and participants must be the priority. However, the  health and safety needs of those individuals involved in the conflict must also be taken into consideration. Setting clear expectations with participants will be essential, as well as outlining any consequences for disruptive or violent actions.

As a team, SAP staff should develop a strategy for dealing with conflict at the program. Establish a set of general policies that can be tailored to the individual circumstances of any single incident. When making decisions about appropriate responses, it is necessary for all staff involved to have their concerns heard and validated. Staff should understand and respect any policies and decisions that are implemented, back each other up, and respond consistently to conflict as a team.

Often, conflict will arise as a result of individuals experiencing increased levels of stress, desperation, anxiety or fear. Consider ways of setting appropriate boundaries and imposing consequences with participants involved in conflict that will not exclude them from services such as syringe access. Again it is likely that conflict will arise when participants are most in need of support and assistance. Finding ways to engage these participants about their actions, demonstrate unconditional care for their health and well-being, and encourage them to learn from their actions will likely be more helpful for everyone than simply denying all services to difficult participants.

SAP staff should discuss and take the decision seriously when considering calling law enforcement for assistance. With little exception IDUs have not had positive interactions with law enforcement. While some situations may indeed warrant police involvement, bringing police to an SAP can have serious implications on trust and relationships with participants. Be sure to communicate clearly if and when police have been called. Give participants who are not involved in the incident the chance to leave before police arrive and to the extent possible, explain why it was necessary to involve law enforcement.

Needlestick

SAPs should properly educate staff and volunteers about the risk of accidental needlestick. Training must be provided on the proper handling and disposal of needles and syringes, as well as the proper protocol for responding to needlestick injuries should an accident occur. It may be necessary to report any needlestick injuries to regulators and/or the Health Department especially if the program receives oversight from a governing body. See Appendix H online for a sample needlestick injury response protocol.

The risk of transmission of blood-borne infections from needlestick injuries varies based on numerous factors including:

• The type of needle – Hollow-bore needles (such as those used for drug injection) increase likelihood of viral transmission from needlestick.
• Whether the needle passes through gloves, clothing or other protective layers prior to breaking skin.
• The length of time that any blood in the syringe has been outside of the body.
• The conditions the syringe has been in prior to the stick – i.e. temperature, location.
• The depth of the puncture.
• The amount of time the needle is in the skin.

According to a 1993 study by L.J Short and D.M. Bell, the risk of infection from a single needlestick incidence was calculated as follows:

HIV: 0.3%

HCV: 2%

HBV: 20%

Tips for Preventing Needlestick Injuries

The following precautions should be taken to avoid accidental needlestick injuries:

• Staff should NEVER handle participant syringes.
• Encourage participants to recap their own syringes.
• In cases where loose syringes need to be picked up by staff, tongs and heavy-weight gloves should be provided and used.
• Advise participants not to break the tips off of needles, explaining that the practice increases risk of accidental needlestick.
• Syringe transactions should be handled one person at a time.
• Empty biohazard containers when they are 3/4 full; do not let them get overfilled.
• Never insert hands into biohazard bins for any reason.
• Distribute and encourage participants to use sharps containers.
• Advise staff and volunteers against wearing open-toe shoes to an SAP.

Vaccinations

Staff and volunteers should be educated about the protective benefits of getting vaccinated for hepatitis A and hepatitis B.

Education should also be provided about HIV post-exposure prophylaxis (PEP), the use of antiretroviral drugs to reduce the likelihood of transmission after potential exposure to HIV.