Abstract

Prince Albert, Saskatchewan, is experiencing a substance use and addiction crisis with devastating consequences. To engage local stakeholders on substance use and addiction issues, nurse researchers at the University of Saskatchewan, Prince Albert Campus, planned and organized a one-day community engagement and knowledge exchange forum. The forum provided the opportunity for interested community groups, members and individuals to share their experiences and to explore novel ways to prevent and respond to the substance abuse and addiction challenges in the region. Participants included community leaders, people and families living with addiction, service providers, local stakeholders, health professionals, researchers and Indigenous Elders. This paper describes the process and outcomes of this event and describes the role of nurse scholars in leading these efforts.  

Background 

Prince Albert is the third largest city in Saskatchewan with a population of approximately 35,000 (Statistics Canada 2016). The city and the surrounding area are facing a substance abuse and addiction challenge. The Prince Albert and Area Community Alcohol Strategy (2016) report on substance use indicates that alcohol and illicit drug use are associated with severe social issues for people of all ages including youth (Fenno 2016). The report further indicates that 73.8% of Prince Albert’s grade 10–12 students consume alcohol in comparison to the national average of 62.2% for this age group. Specifically binge drinking among this population in Prince Albert is estimated to be 67.9%, which is approximately 20% higher than the national average (Prince Albert and Area Community Alcohol Strategy 2016). 

Indigenous people, who make up approximately 39% of the population in the Prince Albert region, are disproportionately impacted by substance abuse and addiction challenges compared to non-Indigenous people (Kelly-Scott 2016). A 2015 report on Saskatchewan HIV incidence showed that 81% of those diagnosed with HIV self-identified as Indigenous (Population Health Branch 2016). Injection drug use was the most reported risk behavior for HIV infection among Indigenous people in Saskatchewan, accounting for 61% of all HIV cases (Population Health Branch 2016). 

In Prince Albert, approximately 9.2% of all emergency room visits and 18.2% of hospital admissions are attributed to substance abuse and addiction-related ailments (Rossouw 2017). Between January 2015 and June 2016, 23 patients suffering from complications of substance abuse and addictions spent a combined total of 668 days in acute care; however, only a small percentage of these patients completed their treatment regimens (Rossouw 2017). 

The adverse impact of substance use and addiction in Prince Albert has also led to the straining of community policing resources. The Community Mobilization Prince Albert (CMPA 2015) reports that between 2010 and 2012, the Prince Albert Police Service (PAPS) arrested close to 6,000 people for public intoxication, which cost the PAPS approximately $2.5 million dollars. The CMPA further reports that in 2012, over 1,300 hours were spent by PAPS on public intoxication arrests (CMPA 2015). Between September 1, 2013 and August 1, 2014, alcohol and drugs comprised 65% and 42%, respectively, of the cases presented for discussion at CMPA (CMPA 2015) hub meetings. CMPA hubs comprise designate staff from community agencies and government ministries in Prince Albert that meet twice a week to address specific situations regarding clients who exhibit acute elevated risks of self-harm or harm to the community. Other risk factors for these individuals include physical and emotional violence, involvement in criminal activities, challenges with parenting, antisocial behaviors, mental illness and victimization (CMPA 2015). 

Literature Review 

An ecological view of the determinants of health indicate that health inequalities, such as those described in Prince Albert, are rooted in the larger socioeconomic conditions that prevail in a population (McCloskey et al. 2011; McLaren and Hawe 2005). Therefore, community engagement may be an ideal vehicle through which communities affected by health inequalities can have a say in policy development, service programming and the allocation of resources to address such inequalities. The Centre for Disease Control (1997) defines community engagement as “the process of working collaboratively with and through groups of people affiliated by geographic proximity, special interest, or similar situations to address issues affecting the well-being of those people” (p. 9). A community engagement event creates a forum for listening to community needs and responding to them (Tamarack Institute 2017). Through community engagement, partners and stakeholders come together on behalf of their communities to learn from one another and to forge new ways of realizing the vision of their shared futures (Tamarack Institute 2017). Community engagement can take the form of community outreach, consultation, involvement, collaboration or shared leadership (Community Places 2014). It begins with the identification of stakeholders based on community interests so that those who are affected are given a platform to have a say in shaping better health outcomes, health services and systems (Centre for Addiction and Mental Health 2017; Community Places 2014). 

Every effort should be made to be as inclusive in the involvement of partners so that diverse interests and voices are captured. Holding public community engagement meetings provides an opportunity to consult many people, and to receive immediate feedback. Such meetings can be used to increase awareness of an issue, as a starting point for, or an ongoing means of further public involvement, or to build a feeling of “community” (Environmental Protection Agency 2017). The capacity of stakeholders to engage in community engagement should be considered to determine the mode of community engagement (Community Places 2014). 

Relative to research, community engagement allows academic partners to gain a deeper understanding of the issues at hand and the role and value of involving communities in the identification of needs (Ahmed and Palermo 2010). In so doing, researchers gain an understanding of the importance and legitimacy of the issues to be studied and can enhance receptivity of the public to be involved in the research (King et al. 2014; Moloughney 2012).

Nurse researchers taking the lead 

The involvement of nurse researchers at the University of Saskatchewan’s College of Nursing, Prince Albert Campus, in addressing substance abuse and addiction issues was partly informed by their experiences as healthcare providers and researchers working in the region. Engaging stakeholders in dialogue on substance use and addiction issues was chosen because it can bring significant benefit to knowledge production (Phillipson et al. 2012). Furthermore, the engagement and knowledge transfer between researchers and relevant community members can provide an opportunity for stakeholders to increase their awareness and use of evidence in their work, as well as provide a platform for ongoing interactions and reciprocal learning (Keown et al. 2008). 

In this work, the research team adopted Bourne and Walker’s (2006) definition of a stakeholder as an individual or group(s) who has expert knowledge, is essential to the implementation of the study findings and who has a vested interest in the outcome of the research findings or a project. Based on this definition, the nurse researchers in the present work envisioned substantive engagement at the event (and afterwards) of these stakeholders that would entail dialogue that encompasses interested parties coming together to identify issues of mutual interest (Elsabbagh et al. 2014; Stirling 2008). 

Engagement opportunities identified in the literature include topic consultation, feedback meetings and the dissemination of research findings (Keown et al. 2008). Through these interactions, researchers can identify topics, methods and knowledge dissemination strategies that are meaningful to the local context. In addition, participating in community engagement may lead to the improvement in health outcomes and reduction of health inequalities (O’Mara-Eves 2015). 

The research team drew upon participatory action research approaches and community engagement literature to inform the facilitation of the community engagement and knowledge exchange forum (Baum et al. 2006). Participatory action research in the context of health research involves empowering a group of people to act and have more control over their health. In this forum, a diverse group of community members were engaged in the process of identifying priority focuses for addressing the substance abuse and addiction challenges in Prince Albert. The process for selecting areas of priority was done using a modified group priority sort method (Jacobson et al. 2011). The process for organizing, hosting and identifying outcomes of the community forum event is described below. 

The Event 

Following the award of the Canadian Research on Substance Misuse (CRISM) seed funding, the project was granted ethics exception by the Research Ethics Board of the University of Saskatchewan. The researchers engaged stakeholders such as health professionals, community service workers, people living with addiction, family members, police, school division representatives and Indigenous Elders. More than 10 face-to-face meetings were held between members of the research team and key stakeholders (as individuals and in groups) to seek their input on the event. The event date was collaboratively identified with key stakeholders. Email invitations were then sent to potential participants four weeks in advance of the event. Logistical preparations for the event such as venue booking and catering were taken care of by the researchers. 

The event was referred to as “The change we want: A community engagement and knowledge exchange for substance use and addiction in Prince Albert,” and was held on June 14, 2017. The goals of the forum were to: (1) have community members share their experiences with substance abuse and addiction challenges; and (2) collaboratively identity priority focuses for addressing substance abuse and addiction challenges in Prince Albert. Participants were drawn from diverse backgrounds and represented different organizations and/ or services, and held varying relationships to the substance abuse and addiction challenges in the community of Prince Albert. Participants at the event comprised health professionals, community representatives, Elders, social service providers, law enforcement officers, correction officers, school administrators, patient and family representatives as well as university researchers. Participants were drawn from the Prince Albert Parkland Health Region, (PAPHR), Prince Albert Community Health Centre (PACHC), social services such as the YWCA and Catholic Social services, Indigenous organizations, i.e., Northern Inter-Tribal Health Authority (NITHA) and Prince Albert Grand Council (PAGC), local school divisions, Prince Albert Police, Ministries of Justice and Social Services, corrections and the University of Saskatchewan. Family and patient representatives attended as expert advisors and presented during the panel discussion. Table 1 provides a breakdown of the organizations represented in the community engagement event. 

The day began with a welcome and a prayer from an Indigenous Elder, followed by two presentations by prominent Prince Albert addiction physicians on the state of the substance use and addiction in the Emergency Department and in the Community. Afterwards, a panel comprising three individuals, a person with lived experience of substance use and addiction, a family member and an outreach care navigator, shared their experiences with the audience. The panel set the stage for the modified group priority sort activity that took place afterwards. 

*Denotes an Indigenous organization.

The group priority sort is a participatory method for informing decision-making (Jacobson et al. 2011). The method is a structured approach that can be adopted by healthcare leaders to make decisions on a variety of different issues, and involves drawing from the experiences and perspectives of different stakeholders. Critical success factors of this method include developing a pool of items, selecting the right participants, grouping the participants appropriately, having experienced facilitators present and using an open mind when conducting the analysis (Jacobson et al. 2011). The approach was modified by having the group of attendees first identify the items to be used in the priority sort, and to complete the priority sort by the larger group rather than each of the sub-groups. 

For the forum being described, the pool of items was self-generated by the stakeholders themselves. This was done through an activity where the larger group broke out into five groups, each with a facilitator present. The makeup of the groups was purposefully diverse to ensure that a variety of different opinions and perspectives were present. Individual participants received a colored piece of paper within their forum materials package which informed them as to which group they would be working with over the course of the day. In these groups, participants brainstormed through a “strengths and weaknesses” exercise, considering both “what we are doing right in relation to substance abuse and addiction in Prince Albert” (strengths) and “what do you think are the greatest substance abuse and addiction needs” (weaknesses). Moreover, through an envisioning exercise, participants brainstormed “if you were to change the substance use and addiction landscape in Prince Albert, what would you alter?” The items generated from these discussions were then used to develop a list of priorities for the broader group. The broader group was then facilitated to determine priority focuses, and categories for these focuses. This was done through discussion, and then participants had the opportunity to self-select which priority areas resonated most with them. 

Later in the afternoon, presentations by CRISM Prairie Node, and the Saskatchewan Centre for Patient Oriented Research (SCPOR) focused on building capacity for community-based and patient-oriented research. 

Groups provided input at each stage of the group priority sort exercise, and this input was recorded by the lead of each group on a flip chart paper. Specifically, during the strength and weakness analysis, visioning exercise and prioritization of desired future exercise, comments and themes generated by each group were written onto flip chart paper so that they could be viewed by the broader group. Issues raised at the strength and weakness sessions informed the visioning exercise where group members identified a desired future. Thereafter, participants were asked to prioritize issues that needed urgent attention and did so by indicating their recommended area of priority via a coloured sticker, which they stuck beside the theme on the flip charts. 

Results 

The forum was attended by 52 (n = 52) participants from 12 different stakeholder groups representing over 15 different organizations. Table 2 shows a selection of the “strengths” and “weaknesses/opportunities” generated during this activity. During the visioning exercise participants brainstormed how they might alter the substance abuse and addictions landscape in Prince Albert to improve the current situation. During this activity, the following four themes were identified by the forum participants: (1) prevention, (2) treatment, (3) community supports/resources and (4) harm reduction. These themes were identified through a discussion with the broader group to ensure that consensus had been reached. Numerous ideas for future research were then generated by the broader group for the specific themes. A selection of these ideas for each of the themes is shown in Table 3. 

Once participants had the opportunity to discuss the ideas and themes amongst themselves, they then discussed how they might prioritize each idea. This was first done as a group, and then individually each participant was given a sticker to place next to the intervention they chose to be their highest priority. As a result, the following four main priorities were identified: (1) transitional housing, 

(2) longer term/duration treatment options in Prince Albert, (3) a “one stop shop” for connecting people with services and healthcare providers and (4) many areas of prevention including addressing social determinants of health- and school-based programs. Several other priorities were identified by individual participants including developing a culturally appropriate advisory team or committee for research activities, creating safe spaces in healthcare organizations for spiritual care and engaging in data collection and research at community agencies. 

Participants were provided with an evaluation form that was collected by the researchers at the end of the event. In addition, two debriefing meetings were held by the research team. The first debriefing meeting took place on the evening of the community event and the second meeting took place approximately one week later. Follow-up activities required of individual or community stakeholders and feedback obtained from participants was discussed at these meetings.  

The researchers found topics identified that aligned with their emerging program of research and expertise. Given the diversity of priorities identified during the forum, each team member was able to identify a research focus that they would lead in the future. These nurse researchers planned to work with interested members of the community to identify the most appropriate research approaches and engage in research collaboratively. Also, the research team plans to continue to work collaboratively to apply for funding to engage in these initiatives. 

Discussion 

The research team drew upon participatory action research methods (Baum et al. 2006), and used a modified group priority sort in this work (Jacobson et al. 2011). Efforts were made to ensure the success of the event by using these previously developed approaches. The event generated new ideas for the nurse researchers to consider, and allowed the team to have a better understanding of the priorities of the community. In doing so, the researchers became aware of “where the community was” with regard to substance abuse and addiction service needs, opportunities and challenges. 

Holding a public community forum on substance use and addiction in Prince Albert allowed for the engagement of people who might otherwise not have had a platform to do so (Community Places 2014). For instance, experiences of a person with a history of addiction, and a family member impacted by addiction, were given prominence through their participation as panelists in the forum. These experiences shaped the development of a grant proposal focusing on families affected by addiction given the forum attendees recommendations to do so. Because all participants at the engagement event were provided with a forum to share their experiences, the event created possibilities for community ownership of the ideas generated for the research team to act upon. 

This event provided the researchers with the benefit of community input in the identification of issues that are of priority to the community. Community partners contributed their expertise, which enhanced the understanding of addiction issues in Prince Albert. This understanding and networking fostered collaborative partnership that can support future grant development (Israel et al. 1998). 

Despite the many challenges that stakeholders described, some issues were deemed to be more pressing than others. For example, all groups described a lack of family support programs and services for families with clients living with substance abuse and addiction issues as a pressing necessity. Moreover, challenges with the capacity of detox services in the city meant that clients sometimes had lengthy waits before being able to be admitted to the unit. Furthermore, because of a lack of long-term addiction treatment services in the region, it was reported that clients who suffered from chronic addiction may have used a significant number of health services that were originally developed for short-term use, and which prevented other clients from gaining access to short-term services. In addition, a lack of integrated mental health and addiction services “under one roof” was described by some stakeholders as a barrier to the provision of client-centred care. Participants also underscored the need to invest in upstream interventions and prevention services which were deemed to be lacking. These include services such as community support and transitional housing for clients living with substance abuse and addiction issues. 

The issues raised at the event reflected the two dominant voices that emerged. The care providers’ voices raised concerns of how to improve the care given to people living with addiction. The Indigenous voice was reflected in the suggestions around developing upstream interventions. 

The traditional format of holding a community engagement event which entails large and small group discussions may have inadvertently hindered the participation of some attendees. For instance, a sharing circle format (a traditional approach used by Indigenous people to facilitate meeting, and one that promotes egalitarianism and an equal opportunity among the participants to talk) might have addressed this challenge. Coming to the event, participants had a varying degree of expectations, which were reflected through the contributions they made throughout the forum. There was a level of uncertainty as to what the outcome of the event might be, especially for participants who were new to the model that was adopted to engage the community. 

Lessons learned 

The nurse research team learned a number of lessons through the planning and hosting of the community knowledge exchange event. First, the importance of nurse researchers meeting with a number of the stakeholders face-to-face to discuss the event and invite them to participate cannot be overestimated. Although the face-to-face meetings were time consuming, they enabled the researchers to receive and incorporate input from the stakeholders and to expand the network of potential stakeholders to include in the invitation. Once the key stakeholders bought into the planned event, the majority of stakeholders became ambassadors for the event themselves. 

Second, despite concerted efforts by the research team to be inclusive in the invitation of the stakeholders, after the event, there were feelings that particular voices were not as heard during the forum. For instance, one of the researchers was approached by an Elder who was present at the forum to register her concern that her call to reinstate Indigenous spiritual interventions in addiction recovery was not taken up by other participants. Therefore, holding follow-up debriefing and consultation meetings with this stakeholder was a necessity to ensure that their input was captured by the research team. 

Third, the success of this event attested to the fact that nurse researchers can provide a credible leadership to social issues of shared importance such as substance use and addiction. The team of researchers found that organizing and facilitating the event was a natural fit to the goals of nursing and their roles as nursing researchers/educators. Also, community members felt comfortable sharing with the nurse researchers both their experiences with substance abuse and addiction challenges and their feedback (both positive and constructive) about the event. 

Fourth, the use of community-based participatory research methods in engaging stakeholders on issues such as substance use and addiction, is an ideal approach to mobilize stakeholders and to harness their collective inputs. This success therefore places an onus on the nurse researchers to identify innovative ways to continue with community engagement towards a lasting legacy on substance use and addiction in the region. 

Fifth, although some of the issues identified by the community were beyond the capacity of the researchers to address through research alone, they can provide a basis for engagement with the health region as stakeholder feedback on substance use and addiction services. 

Last, ensuring that panel members are briefed as to expectations of the panel, and debriefed after the event, would be of value. 

Recommendations 

The community engagement event was successful in bringing together diverse stakeholders to deliberate on substance use and addiction issues affecting Prince Albert, to build a vibrant community of practice for addressing substance use and addiction. It is imperative to have continuous engagement with stakeholders to map the progress of the deliberations that accrued from the event. For anyone proposing to hold such an event, we recommend the following: 

1. Involve stakeholders in identifying who should be invited to the event, and how the event should be structured. 
2. Communicate with event attendees after the event about the outcomes and future directions of the researchers. 
3. Include opportunities for students to learn about the topic, and to learn about the process of conducting a community engagement event.
4. Use a structured approach to gather data and select themes that is facilitated during the engagement session, e.g., through a Delphi method, nominal group consensus, group priority sort, etc. 

Conclusion 

The community engagement and knowledge exchange event provided the research team with immense opportunity and privilege to explore priorities of substance abuse and addiction issues in Prince Albert, Saskatchewan, that are meaningful to the community. Using a community knowledge exchange event approach is an ideal avenue to co-create research questions for further exploration. It also created and expanded networking opportunities between the researchers, professionals, community representatives and diverse agencies in Prince Albert, Saskatchewan. The networking and sharing between the stakeholders and the researchers created opportunities for collaboration that led to sharing of community resources. For instance, a researcher was invited to assist in the data extraction and analysis of the community hub dataset. A patient-oriented grant proposal focusing on exploring the need for and developing resources for families affected by addiction was developed based on inputs from the community engagement event. Co-applicants on this grant were involved in the community engagement event and willingly accepted the invitation to join the grant application. 

Funding 

The project described in this manuscript was funded by the Canadian Research Initiative in Substance Misuse (CRISM) Prairie Node through the Canadian Institutes of Health Research (CIHR Grant no: CIHR CRISM 139151; Subgrant RES S0025123), and the University of Saskatchewan, College of Nursing. 

About the Author

Geoffrey Maina, RN, PhD, Assistant Professor, College of Nursing, University of Saskatchewan, Prince Albert, SK

Brenda Mishak, RN (NP), PhD, Assistant Professor, College of Nursing, University of Saskatchewan, Prince Albert, SK

Anthony de Padua, RN, PhD, Assistant Professor, College of Nursing, University of Saskatchewan, Prince Albert, SK

Gillian Strudwick, RN, PhD, Project Scientist, Centre for Addiction and Mental Health, Toronto, ON

Angelica Docabo, Nursing Student, College of Nursing, University of Saskatchewan, Prince Albert Campus, Prince Albert, SK

Hira Tahir, Nursing Student, College of Nursing, University of Saskatchewan, Prince Albert Campus, Prince Albert, SK

Correspondence may be directed to: Geoffrey Maina, RN, PhD, College of Nursing, University of Saskatchewan (Prince Albert Campus), 214-1301 Central Avenue, Prince Albert, SK S6V 4W1; tel.: (306)765-3887; e-mail: geoffrey.maina@usask.ca. 

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