Sammy Iammarino
Doctor of Philosophy in Nursing (PhD)
Research Topic
Complex health systems and power: responding to the toxic drug poisoning crisis through harm reduction and overdose prevention and response in nursing practice.
Vicky Bungay
Professor
Relevant Thesis-Based Degree Programs
Graduate Student Supervision
Doctoral Student Supervision
Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
Testing the theoretical framework of the Runaway Intervention Program (2023)
Background: Runaway, sexually victimized adolescents require evidence-based interventions focused on reducing trauma symptoms, fostering healing, and promoting healthy development. The Runaway Intervention Program (RIP), a nurse designed and led intervention, aims to support runaway adolescents (≤ 17 years) who have experienced sexual violence, including sexual exploitation. The program is theoretically informed by developmental traumatology, resilience theory, and positive youth development. Although previous studies have demonstrated evidence of the RIP’s effectiveness, its theoretical framework has not been tested. Aim: This dissertation aimed to test the RIP theoretical framework. Methods: Ten years of administrative and questionnaire data from RIP participants (N = 666) were analyzed using growth curve and parallel process models. These models examined: 1) changes in participants’ protective factors (maternal support, school connectedness, other caring adults) and health outcomes (emotional distress, substance use) from program entry up to 24 months; 2) relationships between intervention elements (nurse visits, nurse case management, parent visits, empowerment group sessions) and participants’ protective factors; 3) whether increases in protective factors contributed to improvements in health outcomes; and 4) whether the theoretical framework functioned similarly for sexually exploited and non-sexually exploited adolescents. Results: The emotional distress parallel process models showed that increases in the growth rate of each protective factor contributed to decreases in the growth rate of emotional distress, and three intervention elements (nurse visits, empowerment group sessions, parent visits) contributed to increases in protective factors. The substance use parallel process models showed similar patterns. The growth rates of school connectedness and other caring adults contributed to decreases in the growth rate of substance use, and the same three intervention elements contributed to increases in protective factors. Despite sexually exploited participants having statistically significantly higher emotional distress and substance use and lower protective factors at program entry, the theoretical framework functioned similarly for sexually exploited and non-sexually exploited adolescents. Conclusion: The analyses consistently reproduced the RIP’s theorized mechanisms of effect; providing provisional support for the RIP theoretical framework. Sexually exploited adolescents may need longer interventions to meet their unique needs. Parallel process modelling served as a rigorous approach for testing this complex theoretical framework.
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Nurses' enactment of equity-promoting practices in the emergency department: a discourse analysis (2022)
In Canadian emergency departments (EDs), there are significant and persistent inequities in the provision of health care, which both reflect and perpetuate structural inequities. Nurses are the largest group of health care providers in the ED and with the nursing profession recognizing equity as a core value, nurses are ideally positioned to remediate structural inequities and promote equity within this setting. However, this potential is hindered by limited empirical research examining how nurses enact equity-promoting practices within everyday work in direct care settings. This Foucauldian discourse analysis explores how discourse shapes nurses’ enactment of equity-promoting practices in the institutional context of the ED. Data were collected through individual interviews (N=33) with nurses, nurse leaders, and other key ED health care providers intersecting with nursing work, as well as nursing professional and institutional texts (N=31) that illuminate how discourse shaped ED nurses’ practices. Findings illustrate that discursive power operated within the ED to facilitate nurses’ practices that upheld dominant discourses and to constrain nurses’ enactment of equity-promoting practices. As such, equity-promoting practices constituted subversive action, with nurses drawing on key contradictory discourses of equity and relational engagement to subvert discursive power. However, persistent tensions between power and equity in the ED institutional context ultimately limited nurses’ potential for promoting equity, which was positioned as optional, a matter of knowledge and awareness as opposed to practice, and outside of core ED nursing work. These findings highlight how intersecting dominant discourses constrained nurses’ enactment of equity-promoting practices within the ED. Further, despite claims of equity as a central guiding principle within the nursing profession, equity was not institutionally or professional positioned as a nursing practice. To remediate inequities in health and health care, equity must be reframed as a dominant discourse, enacted practice, and core competency within the nursing profession and across the health care system. Institutional and educational supports may additionally facilitate and guide nurses’ enactment of equity-promoting practices in complex contexts in which equity is devalued. Further empirical research is needed that examines nurses’ enactment of equity-promoting practices across diverse health care settings and explores institutional strategies for promoting equity.
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Work experiences and conditions among people who use drugs engaged in peer work: a critical examination of peer work in British Columbia, Canada (2019)
Engaging with ‘peers’, or people with lived experience of illicit substance use (past or present) who use their experiential knowledge to inform their professional work in decision-making and service provision, has been increasingly recognized as best practice within mainstream health and ham reduction institutions across British Columbia, Canada, and elsewhere. Yet, the operationalization and structure of work in peer engagement contexts have not been studied in great depth. In this research, I generate a critical and in-depth understanding of peer work conditions, the organization of peer work, and the structural factors that shape equity, inequities, and constraints in the context of the everyday work experiences of peer workers. Grounded in critical theoretical perspectives and a qualitative research design informed by interpretive descriptive methods, I conducted fifteen interviews with people engaged in peer work in British Columbia. Data coding and analysis occurred concurrent to data collection and themes were generated inductively and recursively using constant comparison techniques. Study findings indicate that peer work was demanding, oppressive, and inequitable. The emotional demands of peer workers’ day-to-day working lives were illustrated by reports of trauma and structural harms. Expressions of oppression, including powerlessness, marginalization, and exploitation, were linked to a range of interlocking, interrelated systems that structurally shaped peer work conditions and perpetuated inequity. These findings illustrated how, despite peer workers’ efforts to engage in their work, systems of oppression and inequity that were structured into the organization of peer work may enable or constrain peer workers’ agency in these settings. Inequitable access to supports appeared to make it challenging for peer workers’ roles to be effectively utilized or recognized within institutions. Collectively, study findings suggest how equity, inequity, and oppression can be shaped through the organization and operationalization of peer work. While there may be good intentions to promote the inclusion of people who use drugs in health promotion and harm reduction organizations, I provide evidence that there are potential consequences to work that is misunderstood, poorly organized, and unsupported.
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An exploration of middle-aged and older gay men's health and illness practices (2018)
Background: Despite a wealth of knowledge that demonstrates middle-aged and older gay men experience substantial health inequities when compared to heterosexual men, little information is available pertaining to the health and illness practices of gay men. Methods: This dissertation includes three qualitative manuscripts with the overarching aim of exploring middle-aged and older gay men’s health and illness practices. Data were collected via conversational interviews with 25 men who self-identified as gay. The first qualitative descriptive manuscript examined how middle-aged and older gay men developed resilience over time to promote health and wellness. Next, a grounded theory was conducted to describe the processes by which middle-aged and older gay men managed their health. The third manuscript involved a qualitative description of how men experienced their mental health and the strategies they used to mitigate the deleterious effects of mental health challenges.Results: The findings from the first manuscript demonstrated that resilience was developed over time by: (1) building and sustaining networks, (2) addressing mental health, and (3) advocating for self. The grounded theory indicated that the core process of health management is overcoming adversity, which is achieved by three overarching and interrelated processes: (1) advocating for health needs, (2) knowing about health issues and treatments, and 3) engaging in health promoting practices. The third manuscript findings yielded three categories as to how mental health was experienced, and how the deleterious effects of mental health challenges were mitigated: (1) gaining new perspectives of mental health over time, (2) reaching out to formal health services for support with mental health challenges, and (3) engaging in practices to maintain and improve psychological well-being. Conclusion: These findings highlight the influence of age and experience, historical and ongoing discrimination, as well as capacity, to middle-aged and older gay men’s health and illness practices. Consequently, meaningful and effective health services must be developed with recognition of men’s strengths and capacities amidst discrimination. Potential approaches to health service development and delivery to improve health outcomes include equity-oriented primary health care, trauma-informed care, social public health approaches and peer-based services and resources.
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Contributing to the development of community-based knowledge translation through the creation, implementation and evaluation of a youth mental health promotion initiative (2015)
Background: Mental health challenges have been identified as the most significant health issue facing young people. Leaders in the field have advocated for public health approaches to better address this issue. Some scholars have called for interventions informed by young people to enhance relevance and effectiveness of interventions. Knowledge translation (KT) has emerged in the health context as a strategy to promote the uptake of evidence to improve health outcomes; however, the majority of KT research to date has focused on clinical settings. The needs of researchers and practitioners working in community settings to address population-level health outcomes have not been adequately attended to, leading to calls for further development of community-based knowledge translation (CBKT), an approach underpinned by the tenets of participatory research and KT. Given these gaps, the purpose of this research was to contribute to the field of CBKT through the development, implementation and evaluation of a youth-driven mental health promotion initiative. Methods: This study utilized a case study design and was conducted in a rural community located in North-Central British Columbia, Canada. A mixed methods approach incorporating quantitative surveys, qualitative interviews and ethnographic field notes was used to examine the contextual factors associated with adolescent mental health, develop a CBKT framework to inform future work in this field, and assess the influence of a CBKT initiative on youth mental health. Findings: Findings demonstrate ways in which adolescent mental health may be influenced by contextual factors, evidence that can be used to inform change efforts to improve youth mental health. Further, a theoretically-driven and evidence-informed CBKT framework is introduced and used to illustrate how it can inform context-relevant, youth-driven initiatives. The CBKT approach utilized was shown to make a contribution to enhancing positive aspects of mental health such as resilience and connectedness among young people. Further, this approach was linked by study participants to changes at a community-level that foster mental health outcomes such as civic engagement, shifting norms and empowerment. Conclusions: CBKT shows promise as an approach to addressing one of the leading public health issues facing young people today, mental health challenges.
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Master's Student Supervision
Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
Ethical issues in research engagement with community service organizations: a secondary analysis (2023)
No abstract available.
Perspectives on global health in nursing education (2020)
No abstract available.
Consent as contested relationships: research ethics in practice with people engaged in sex work (2018)
No abstract available.
Exploring the healthcare experiences of peritoneal dialysis patients with their nurses (2018)
Chronic kidney disease (CKD) is a multidimensional global health issue that can affect various individuals worldwide. Although renal transplantation is the preferred form of renal replacement therapy for most individuals with CKD, the lack of kidneys from suitable donors means that most of these individuals will not receive one. Many of these individuals living with CKD manage their kidney failure through peritoneal dialysis (PD) at home and under the guidance and support of nurses working with them in an outpatient clinic. Literature has suggested that healthcare providers perceive primary nursing as the ideal care delivery model for many patients and that the elements of primary nursing are correlated to improved patient outcomes. Although literature supports the use of primary nursing, there is very little known about this model from the perspectives of patients and the experiences of PD patients. The purpose of this study was to explore the nursing care experiences of PD patients managed by a primary nursing care delivery model and further understand the unique healthcare experiences of this population. Using interpretive description as a research methodology, 15 participants were purposefully sampled from an outpatient PD clinic and participated in one-on-one face-to-face interviews. Interviews were digitally audio-recorded and conducted using a semi-structured interview guide. Findings from the study illustrated that PD patients were not experiencing all of the elements associated with primary nursing. A modified form of primary nursing was being experienced by the patients in which they received individualized and comprehensive nursing care. The nursing care of the patients was underpinned by a philosophy of patient-centred care that emphasized relational engagement between patients and nurses. In addition, organizational influences of nursing care such as PD nurse availability and operational hours of the PD clinic contributed to the experiences of patients having to navigate through unforeseen challenges in their care. This study can inform future research involving the analysis of health outcomes for PD patients, understanding family perspectives, and exploring nursing leaders’ perceptions to further improve the nursing care experiences of PD patients.
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Nursing students' experiences in mental health practicums: a narrative inquiry (2017)
Mental health challenges are one of the leading global health concerns, yet health care for people experiencing these health issues is severely lacking, in both accessibility and quality. Nurses are uniquely positioned to provide direct care to this population, however nurses’ attitudes towards individuals with mental health challenges are frequently characterized by stigma and misconceptions. Mental health practicums within nursing school are a key venue for student learning, development, and experience in working with this population, yet research demonstrates that students frequently hold negative attitudes toward mental health nursing as a career path and do not feel adequately prepared to work with individuals with mental health challenges in any health care setting. To address gaps in understandings of these issues, this qualitative study explored students’ experiences within mental health practicums through a narrative inquiry approach. Individual interviews were conducted with 15 nursing students following their practicum experiences. Findings describe the narrative of resistance within the students’ practicums that emerged from participant stories of their experiences. The students identified this practicum as fundamentally different from others, and as such, their pre-engagement included particular preparation strategies to maintain their emotional well-being through the practicum, and critical engagement with societal stereotypes around mental health. Within the practicum, the students’ recognized the ways in which nursing care of patients was characterized by power relations, enacted through disengagement and unsafe and unethical practices. Participants enacted resistance through connecting with patients, enacting ways of knowing that contrasted with dominant nursing practices, and drawing on their student role to justify their resistance. Informing participants’ enactment of resistance, narratives spoke to the complex interplay of empowerment and disempowerment in the setting, shaping their experiences in the practicum and expectations of future nursing practice. Study implications include theoretical contributions to the concept of resistance within nursing education. Additionally, this study supports the need for increased educator support for students in advance of, and during, their mental health practicums; findings further speak to the need for systemic changes in the practice environment to support safe and effective patient care.
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Communications in Sex Work: A Content Analysis of Online Sex Work Advertisements Among Men, Women and Transgender People in Vancouver (2015)
The increased use of technology to purchase goods and services has changed the landscape of how we advertise, buy and sell commodities. This has contributed to an increase in off-street sex work advertised on the Internet. It is estimated that 80% of sex work in British Columbia occurs off street and the use of web advertising for services has grown exponentially (O’Doherty, 2011). While street-based sex work has been well studied, and there is a significant and growing body of knowledge concerning off-street sex work, communications in advertising sex work online is an emerging field of inquiry. There have been few studies that have examined these communications, and most have been population specific. In this study, 75 online advertisements for sex work in Vancouver, British Columbia were compared to determine what information was regularly communicated and how this information differed between men, women and transgender people using this medium to conduct business. Content analysis was employed as a method to extract the data from the websites in a systemized, categorical way and the results were analyzed to compare differences between groups, focusing on communications, health, safety, and business information. The findings suggest that while there are similarities between men, women and transgender people advertising sex work online, there are important differences that require further study to determine if they have impacted the health and safety of sex workers. This study summarizes what is being communicated in online advertisements of sex workers and contributes to understandings about how sex workers are communicating about health, safety and business to their clients. These insights can assist health care providers and policy makers in creating interventions to improve health and safety for sex workers and their clients.
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A Qualitative Study: Community Nurses' Experience of Organized Trust (2014)
This qualitative inquiry explored nurses’ experience of organizational trust and factors that influence it within a community health context. The study aims were to provide awareness to health organizations as to how they may avoid negative impacts of decreased trust of community nurses' and increase the likelihood of positive acceptance of changing health services and a restructured organization. The British Columbia healthcare system is becoming more reliant on the community nursing sector to address increasing demands in healthcare due to several factors such as an aging population, rise in chronic diseases, and limited financial and human resources. If community nurses do not have trust in the health organization, there may be resistance to changes that have been designed to improve health services. This may result in poorer health outcomes for the population and increased burden on the acute care system. Health organizations that are not aware of factors that may influence community nurses’ organizational trust may encounter higher rates of job turnover, decreased productivity, and challenges in maintaining a viable healthcare system. A qualitative design with an interpretative description approach was used along with theoretical concepts pertaining to organizational trust. Community nurses within the interior region of British Columbia, Canada received invitations to participate via email. Data collection involved semi-structured interviews with 10 participants which were digitally recorded and transcribed professionally. Three main themes identified were 1) leadership support 2) organizational restructure 3) evolving health services and practices. These main themes yielded the following conclusions: that nurses’ perception of leadership support, particularly nurse-leader relationships can significantly influence their trust in the health organization; and that nurses’ lack of participation in decision-making during change can negatively impact their trust in the health organization. The major implications that arose from this study include: 1) implications for leadership to implement strategies to improve interpersonal relationships with nurses, collaborative change processes and a shared vision, opportunities for nurses to engage with organizational structures; 2) implications for practice to include nurses in decision-making and utilize change models; 3) implications for policy to have a nurse representative at the senior level of leadership.
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Perceptions of Experienced Nurses to What Influenced Their Decision to Leave Clinical Practice y (2014)
Nursing turnover (the loss of experienced nurses from a clinical setting) remains a pressing problem for healthcare delivery in acute care inpatient settings. Turnover contributes to increased recruitment and orientation cost, reduced quality patient care, and the loss of mentorship for new nurses. The purpose of this research was to critically examine the factors that contribute to turnover of experienced nurses’ including their decision to leave clinical practice settings and seek new employment in another nursing position. The study objectives were to explore experienced nurses’ decision-making processes in leaving current clinical practice settings and to examine the personal and environmental factors experienced nurses’ perceive that influenced their decision to leave. An interpretive descriptive approach was used to guide the study. Interviews were conducted with 12 nurses, averaging 16 years in clinical practice. Participants were equally represented from clinical units, which included critical care and medical-surgical areas. The sample drew on perspectives from point-of-care nurses and nurses in leadership roles, primarily charge nurses and clinical nurse educators.The findings indicated that nurses’ decisions to leave clinical practice were influenced by several interrelated environmental and personal factors such as higher patient acuity, increased workload demands, ineffective working relationships among nurses and with physicians, gaps in leadership support, and significant impact to nurses’ health and personal well-being. When participants experienced ineffective working relationships with other nurses and a lack of leadership support, they described being ill equipped to perform their job and reported a loss of job satisfaction. The impact of high stress was evident on the health and emotional well-being for those who stayed, and family relationships and lifestyles were adversely affected. It is vital that healthcare organizations learn to minimize turnover and retain the wealth of experienced nurses in acute care settings to maintain quality patient care and contain costs. The study highlights the need of healthcare leaders to reexamine how they promote collaborative practice, enhance supportive leadership behaviours, and reduce nurses’ workplace stressors in order to retain the wealth of skills and knowledge offered by experienced clinical practice nurses.
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Nurse managers and certified practice in British Columbia (2012)
The new Health Professions Act (HPA) is umbrella legislation that represents achange in health policy. Some activities that nurses historically performed under medicaldelegation like diagnosis and treatment of sexually transmitted infections (STI) are nolonger allowed unless additional training and certification occurs. As a result of their rolein the system, nurse managers were given the responsibility for implementing certifiedpractice. The purpose of this study was to explore the experience of nurse managers inleading the implementation of certified practice in order to gain some understanding ofthe process of change management in our health care system.I chose complexity theory as a lens to understand change in the healthcare systembecause it emphasizes connection and inter-relationship. I undertook an interpretativedescriptive study to analyze the events and contextual factors that have impacted thenurse manager’s experience of implementing certified practice. I conducted nine semistructuredinterviews in one-on-on and group formats with a total of sixteen nursemanagers.Thematic analysis of the data revealed two overarching and inter-related themes,namely (a) consistency with nursing values; and (b) structural constraints. The first themecomprised three sub-categories: autonomy, recognition and role clarity. The secondtheme, structural constraints, had three sub-categories: multiple models of practice;training and education barriers; and competing system changes. Certified nursing practiceis consistent with the goals of the nursing profession of being a regulated and recognizedprofession; however multiple and competing challenges constrained attainment of thesebenefits.This study aligned with the existing research on change management in thehealthcare system in that it identified what is required for successful implementation of anew health policy. The barriers that were identified also aligned with the literature. Thetheme of multiple models of practice has not previously been reported. This researchhighlights the difficulties of a complex system that is comprised of different parts thatmay operate independently when in truth they are highly inter-related. When this is nottaken into consideration, miscommunication and competing system demands caninterfere in the implementation of new health policy such as STI certified practice.
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The process of safer crack use amongst women in Vancouver's downtown eastside (2011)
Crack cocaine is prevalent in Vancouver’s Downtown Eastside, with evidence suggesting women use more than men. Crack cocaine poses many harms to the body, and women face unique harms due to the gendered use of crack. However, there has been little investigation into how women go about minimizing some of the harms associated with crack. Informed by harm reduction and women’s-centred philosophies, a grounded theory approach was employed to explore the process that women engage in to limit the physical, psychological and interpersonal harms associated with crack use, as well as identify the social, economic and political factors that influence the process of safer use. Data were collected via seven group interviews (n=27) that took place over a three month period with women who were actively using crack cocaine. Data illustrated women’s crack use patterns shifted over time from heavier to more intermittent use, and four central processes that enabled women to practice safer crack use were identified. At the root of these processes was a dedication to care for the self and others. The processes were identified as: establishing a safe physical space, building trusting relationships, learning about safer crack use, and accessing safer use equipment. These strategies were in turn influenced by larger contextual factors including the spatial environment (violence and police activity), economics (living with extreme financial limitations) and politics (the instability of supportive housing and lack of safe places for women). Women demonstrated proficiency to care for themselves and others in the context of crack use, but many changes within the political and health care systems are necessary to facilitate safer practices to improve health outcomes. Firstly, a political agenda that is dedicated to the development of supportive housing is essential for safer use, as is greater access to income assistance. Furthermore, harm reduction programming that focuses on women’s contributions and expertise in the realm of safer use is essential to ongoing development of a supportive community of women. Moreover, the availability of safer use equipment is quintessential for women to apply knowledge regarding safer crack use to minimize some of the harms associated with crack.
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Current Students & Alumni
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