General

Guideline Title

Implementing supervised injection services.

Bibliographic Source(s)

Registered Nurses Association of Ontario (RNAO). Implementing supervised injection services. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2018 Feb. 104 p. [134 references]

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

NEATS Assessment

Disclosure of Guideline Funding Source

Disclosure and Management of Financial Conflict of Interests

Guideline Development Group Composition: Multidisciplinary Group

Guideline Development Group Composition: Methodologist Involvement

Unknown

Guideline Development Group Composition: Patient and Public Perspectives

Use of a Systematic Review of Evidence: Search Strategy

Use of a Systematic Review of Evidence: Study Selection

Use of a Systematic Review of Evidence: Synthesis of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Grading the Quality or Strength of Evidence

Evidence Foundations for and Rating Strength of Recommendations: Benefits and Harms of Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Evidence Summary Supporting Recommendations

Evidence Foundations for and Rating Strength of Recommendations: Rating the Strength of Recommendations

Specific and Unambiguous Articulation of Recommendations

External Review

Updating

Recommendations

Major Recommendations

Definitions for the levels of evidence (Ia, Ib, IIa, IIb, III, IV, V) are provided at the end of the “Major Recommendations” field.

Practice Recommendations

Recommendation 1.1

Develop trusting relationships based on respect and a non-judgmental approach at every encounter with people who inject drugs to support continued engagement.

(Level of Evidence = IV)

Recommendation 1.2

Use reflective practice to recognize and acknowledge health inequities that result from past and ongoing experiences of trauma, marginalization, and stigma experienced by people who inject drugs.

(Level of Evidence = IV)

Recommendation 1.3

Promote and engage in shared decision-making with people who inject drugs at every encounter and intervention to minimize discrimination and stigma.

(Level of Evidence = IV)

Education Recommendations

Recommendation 2.1

Design educational programs that incorporate multiple teaching methods and strategies (in-person or technology-enabled) for health workers and students to increase knowledge, skill, confidence, and improve attitudes required to provide high quality care to people who use drugs.

(Levels of Evidence = Ib, IIb, and IV)

Recommendation 2.2

Incorporate people with lived experience and practice experts in the delivery of educational programs for health workers and students to increase knowledge and confidence, and improve attitudes required to provide high-quality care to people who use drugs.

(Levels of Evidence = IIb and IV)

Recommendation 2.3

Modify the format and structure of educational programs for health workers to support effective learning by focusing on:

Location of training
Resources required for training
Frequency and longevity of training
Method of delivery

(Levels of Evidence = Ib, IIb, and IV)

Organization and System Policy Recommendations

Recommendation 3.1

Integrate peer workers into the programming of supervised injection services by:

Increasing access to peer workers as a vital resource for people who inject drugs
Including peer workers in organizational decision-making processes

(Level of Evidence = IV)

Recommendation 3.2

Integrate comprehensive services into the programming of supervised injection services to ensure that people who inject drugs have access to:

Testing and counselling for blood-borne infections
Primary care providers
Mental health clinicians
Housing and social services

(Levels of Evidence = Ib and IV)

Recommendation 3.3

Embed harm reduction programs that include supervised injection services into existing health and social settings to improve retention in care and reduce adverse health outcomes among people who inject drugs.

(Level of Evidence = IV)

Recommendation 3.4

Align the location, physical space, and operating hours of facilities to the needs of the local population, and make operational improvements and structural redesign (as needed) to decrease barriers for access to supervised injections services for people who inject drugs.

(Level of Evidence = IV)

Recommendation 3.5

Advocate for legislation and regulations to support ethical policies and procedures that increase access to and utilization of supervised injection services for:

People who require assisted injection support
Youth who inject drugs

(Level of Evidence = IV)

Definitions

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.

III Synthesis of multiple studies, primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies, descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion, committee reports, or clinical experiences of respected authorities.

Adapted by the RNAO Best Practice Guideline Development Team from: Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer’s handbook. Edinburgh: Scottish Intercollegiate Guidelines Network; 2011; and Pati D. A framework for evaluating evidence in evidence-based design. Health Environments Research and Design Journal. 2011;21(3):105-12.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Substance abuse

Guideline Category

Counseling
Evaluation
Management
Treatment

Clinical Specialty

Family Practice
Internal Medicine
Nursing

Intended Users

Advanced Practice Nurses
Nurses
Patients
Physician Assistants
Physicians
Substance Use Disorders Treatment Providers

Guideline Objective(s)

To provide an overview of principles, resources, and structures for delivering evidence-based supervised injection services (SIS)
To support best practices and decision making for nurses, health workers, and health systems leaders
To develop a guideline for nurses, health workers, and decision-makers on the most effective approaches for SIS delivery to people who inject drugs

Target Population

All people who inject drugs

Note : Unless specified, the recommendations in this Guideline generally apply to all people who inject drugs. The Registered Nurses’ Association of Ontario (RNAO) expert panel, however, identified sub-populations of people who inject drugs who have unique circumstances, experiences, and health inequities that need to be considered when providing support and services. These groups include:

Indigenous people
Lesbian, gay, bisexual, transgendered, queer, two-spirit, and intersex (LGBTQ2I) people
Women
Pregnant persons

Interventions and Practices Considered

Developing trusting relationships with people who inject drugs
Use of reflective practice to recognize and acknowledge health inequities
Promoting and engaging in shared decision making
Designing educational programs that incorporate multiple methods and strategies for health workers and students
Incorporating people with lived experience and practice experts in the delivery of education programs
Modifying format and structure of educational programs
Integrating peer workers into the programming of supervised injection services
Integrating comprehensive services into the programming of supervised injection services
Embedding harm reduction programs that including supervised injection services into existing health and social settings
Aligning the location, physical space, and operating hours to the needs of the local population and making operational improvements and structural redesign
Advocating for legislation and regulations to support ethical policies and procedures

Major Outcomes Considered

Engagement
Participation in care
Respect
Inclusion
Trust
Well-being and self-esteem
Safety
Increased knowledge, skill, and confidence
Improved attitudes
Experience with people who use drugs and harm reduction
Access to services
Comprehensive programming
Health equity
Appropriate resources
Staffing

Methodology

Methods Used to Collect/Select the Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Guideline Review

The Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline Development Team searched an established list of websites for guidelines and other relevant content published between January 2011 and August 2016. The resulting list was compiled based on knowledge of evidence-based practice Web sites and recommendations from the literature. RNAO expert panel members also were asked to suggest additional guidelines (see Figure 3 in the original guideline document). Detailed information about the search strategy for existing guidelines, including the list of Web sites searched and the inclusion criteria used, is available in the search strategy document (see the “Availability of Companion Documents” field).

Systematic Review

A comprehensive search strategy was developed by RNAO’s research team and a health sciences librarian based on inclusion and exclusion criteria created with the RNAO expert panel. A search for relevant research studies only published in English between January 2011 and April 2017 was applied to the following databases: Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE, PsycINFO, and EMBASE. Expert panel members were asked to review their personal libraries for key studies not found through the above search strategies (see Figures 4, 5, and 6 in the original guideline document).

Detailed information on the search strategy for the systematic review, including the inclusion and exclusion criteria and search terms, is available in the search strategy document (see the “Availability of Companion Documents” field).

Studies were independently assessed for relevance and eligibility by the Guideline Development Lead and a nursing research associate based on the inclusion and exclusion criteria. Any disagreements were resolved through tiebreaking by a second nursing research associate.

Number of Source Documents

Six guidelines and 88 studies were included. See the Guidelines Review Process Flow Diagram and the Article Review Process Flow Diagrams in Appendix D in the original guideline document for more information on the review process.

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Levels of Evidence

Ia Evidence obtained from meta-analysis or systematic reviews of randomized controlled trials, and/or synthesis of multiple studies primarily of quantitative research.

Ib Evidence obtained from at least one randomized controlled trial.

IIa Evidence obtained from at least one well-designed controlled study without randomization.

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study without randomization.

III Synthesis of multiple studies, primarily of qualitative research.

IV Evidence obtained from well-designed non-experimental observational studies, such as analytical studies, descriptive studies, and/or qualitative studies.

V Evidence obtained from expert opinion, committee reports, or clinical experiences of respected authorities.

Adapted by the RNAO Best Practice Guideline Development Team from: Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developer's handbook. Edinburgh: Scottish Intercollegiate Guidelines Network; 2011; and Pati D. A framework for evaluating evidence in evidence-based design. Health Environments Research and Design Journal. 2011;21(3):105-12.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

Guideline Review

The Guideline Development Lead and a nursing research associate appraised seven international guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II). Guidelines with an overall score of four or below were considered low and were excluded. Guidelines with a score of five were considered moderate, and guidelines with a score of six or seven were considered high.

Refer to the original guideline document for a list of the selected guidelines.

Systematic Review

Quality appraisal scores for 25 studies (a random sample of 20 percent of the total studies eligible for data extraction and quality appraisal) were independently assessed by the Guideline Development Lead and a nursing research associate. Quality appraisal was assessed using the Critical Appraisal Skills Programme (CASP) for primary studies, Assessment of Multiple Systematic Reviews (AMSTAR) for systematic reviews, and the Registered Nurses’ Association of Ontario’s (RNAO’s) scoring system that rates studies as low, moderate, or high (see Table 2 in the original guideline document).

An acceptable inter-rater agreement (kappa statistic, K=0.86) was reached, which justified proceeding with quality appraisal and data extraction for the remaining studies. The remaining studies were divided equally for quality appraisal and data extraction. Research summaries of literature findings were completed and used to describe the results in narrative form. The comprehensive data tables and research summaries were provided to all expert panel members for review and discussion.

A complete bibliography of all full text reviews screened for inclusion is available (see the “Availability of Companion Documents” field).

Methods Used to Formulate the Recommendations

Expert Consensus (Delphi)

Description of Methods Used to Formulate the Recommendations

Guideline Development Process

For this guideline, the Registered Nurses’ Association of Ontario (RNAO) assembled a panel of experts who represent a range of sectors and practice areas. A systematic review of the evidence—based on the purpose and scope of this guideline, and supported by the three research questions listed below—was conducted to capture relevant peer-reviewed literature published between January 2011 and April 2017. The following research questions were established to guide the systematic review:

How do health workers provide trauma-informed and culturally safe harm reduction care to people who are injecting drugs or accessing services in supervised injection services (SIS) facilities?
What are effective educational strategies to increase the knowledge, attitudes, and skill that health workers need to work with people who inject drugs or access services in SIS facilities?
What organizational and health system policies are required to support health workers in providing high-quality care in SIS facilities?

The RNAO Best Practice Guideline Development Team and expert panel work to integrate the most current and best evidence, and to ensure the validity, appropriateness, and safety of the guideline recommendations with supporting evidence and expert panel consensus.

A modified Delphi technique was employed to obtain expert panel consensus on the recommendations in this Guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

As a component of the guideline development process, feedback was obtained from participants across a wide range of health-care organizations, practice areas, and sectors. Participants include nurses, health workers, people with lived experience, knowledgeable administrators and funders of health-care services. Stakeholders representing diverse perspectives also were solicited for their feedback.

Stakeholder reviewers for the Registered Nurses’ Association of Ontario (RNAO) best practice guidelines (BPGs) are identified in two ways. First, stakeholders are recruited through a public call issued on the RNAO Web site. Second, individuals and organizations with expertise in the guideline topic area are identified by the RNAO guideline development team and the expert panel, and are directly invited to participate in the review.

Stakeholder reviewers are individuals with subject matter expertise in the guideline topic or those who may be affected by the implementation of the guideline. Reviewers may be nurses, health workers, administrators, researchers, educators, nursing students, or persons and family. RNAO aims to solicit stakeholder expertise and perspectives representing diverse health-care sectors, roles within nursing and other professions (e.g., clinical practice, research, education, or policy), and geographic locations.

Reviewers are asked to read a full draft of the guideline and to participate in the review prior to its publication. Stakeholder feedback is submitted online by completing a survey questionnaire. The stakeholders are asked the following questions about each recommendation:

Is this recommendation clear?
Do you agree with this recommendation?
Is the discussion of evidence thorough and does the evidence support the recommendation?

Public Advisors are reviewers who have lived experience. They participate in focus groups and interviews facilitated by RNAO expert panel members to provide feedback on the guideline. Public Advisors are asked the following questions about each recommendation:

Do you agree with this recommendation?
Will this recommendation meet your needs?

All reviewers have the opportunity to include comments and feedback for each section of the guideline. Reviewer submissions are compiled and feedback is summarized by the RNAO Best Practice Guideline Development Team. Together with the expert panel, RNAO reviews and considers all feedback and, if necessary, modifies the guideline content and recommendations prior to publication to address the feedback received.

Stakeholder reviewers have given consent to the publication of their names and relevant information in this Guideline. Public Advisors review and sign a consent form prior to participating in focus groups or interviews, indicating whether they want to be acknowledged as an individual or group (such as a patient advisory council) or if they wish to remain anonymous.

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the “Major Recommendations” field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate implementation of supervised injection services (SIS)

Refer to the “Benefits and Harms” sections in the original guideline document for benefits of specific information.

Potential Harms

People who inject drugs are at risk for stigmatization, disrespect and judgments during training sessions when engaging with learners that may be inexperienced at applying the principles of harm reduction, cultural safety, and trauma-informed practices. The unique needs of priority populations (such as Indigenous people) need to be considered in the context of including them in educational programs in order to prevent any potential harm associated with interacting with learners.
Peer workers are at risk for harm (e.g., psychological distress) if requisite supports are not provided to manage any issues associated with their involvement in supervised injection services (SIS).
There is a risk of harm to priority populations of people who inject drugs if the services offered are not relevant or effective for their specific health and social requirements (see Appendix F in the original guideline document). For example, services offered to Indigenous peoples should be provided by an individual or organization that understands the needs of this population.
There is potential harm for people who inject drugs if there has not been a considerable assessment of the diverse needs of people who inject drugs in the region (such as rural Indigenous people) and the resources available in a region (including access to nurses with specialized knowledge and skills), or if there had not been careful planning around the implementation of a new SIS or the expansion of an existing one.
There is a potential for harm if the unique needs of youth are not considered in the programming of services and supports. It also is important to recognize and consider the complex ethical issues that nurses and health workers may face when they are expected to participate in assisted injection; doing so will help to mitigate those issues prior to implementing a new policy.

Qualifying Statements

These guidelines are not binding on nurses, other health-care providers, or the organizations that employ them. The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses’ Association of Ontario (RNAO) gives any guarantee as to the accuracy of the information contained in them or accepts any liability with respect to loss, damage, injury, or expense arising from any such errors or omission in the contents of this work.
This nursing best practice guideline (BPG) is a comprehensive document that provides an overview of principles, resources, and structures for delivering evidence-based supervised injection services (SIS). It is not intended to be a manual or “how-to” guide; rather, it supports best practices and decision making for nurses, health workers, and health system leaders. This Guideline should be reviewed and applied in accordance with individual SIS facilities and the needs and preferences of persons accessing SIS. This document provides evidence-based recommendation statements and descriptions of (a) pragmatic practice, education, and policy considerations, (b) benefits and harms, and (c) values and preferences. This Guideline predominantly focuses on policy issues related to SIS and highlights relevant supporting documents that directly address clinical practices.

Implementation of the Guideline

Description of Implementation Strategy

Implementation Strategies

Implementing guidelines at the point of care is multi-faceted and challenging. It takes more than awareness and distribution of guidelines for practice to change: guidelines must be adapted for each practice setting in a systematic and participatory way to ensure that recommendations fit the local context. The 2012 Registered Nurses’ Association of Ontario’s (RNAO’s) Toolkit: Implementation of Best Practice Guidelines provides an evidence-informed process for doing this. It can be downloaded at the RNAO Web site.

The Toolkit is based on emerging evidence that successful uptake of best practices in health care is more likely when the following occur:

Leaders at all levels are committed to supporting guideline implementation
Guidelines are selected for implementation through a systematic, participatory process
Stakeholders for whom the guidelines are relevant are identified and engaged in the implementation
Environmental readiness for implementing guidelines is assessed
The guideline is tailored to the local context
Barriers and facilitators to using the guideline are assessed and addressed
Interventions to promote use of the guideline are selected
Use of the guideline is systematically monitored and sustained
Evaluation of the guideline’s impact is embedded in the process
There are adequate resources to complete all aspects of the implementation.

The Toolkit uses the “Knowledge-to-Action” framework to demonstrate the process steps required for knowledge inquiry and synthesis. It also guides the adaptation of the new knowledge to the local context and implementation. This framework suggests identifying and using knowledge tools, such as guidelines, to identify gaps and begin the process of tailoring the new knowledge to local settings.

RNAO is committed to widespread deployment and implementation of its best practice guidelines (BPGs). RNAO uses a coordinated approach to dissemination, incorporating a variety of strategies, including the following:

The Nursing Best Practice Champion Network®, which develops the capacity of individual nurses to foster awareness, engagement, and adoption of BPGs.
Nursing order sets, which provide clear, concise, and actionable intervention statements derived from the practice recommendations of clinical BPGs that can be readily embedded within electronic medical records, but which may also be used in paper-based or hybrid environments.
The Best Practice Spotlight Organization® (BPSO®) designation, which supports implementation at the organization and system levels. BPSOs focus on developing evidence-based cultures with the specific mandate to implement, evaluate, and sustain multiple RNAO BPGs.

In addition, RNAO offers annual capacity-building learning institutes on specific BPGs and their implementation. Information about our implementation strategies can be found at:

RNAO Best Practice Champions Network®: https://RNAO.ca/bpg/get-involved/champions
RNAO Nursing Order Sets: http://rnao.ca/ehealth/nursingordersets
RNAO BPSO®: https://RNAO.ca/bpg/bpso
RNAO capacity-building learning institutes and other professional development opportunities: https://RNAO.ca/events

Implementation Tools

Foreign Language Translations
Resources
Tool Kits

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Staying Healthy

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Registered Nurses Association of Ontario (RNAO). Implementing supervised injection services. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2018 Feb. 104 p. [134 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2018 Feb

Guideline Developer(s)

Registered Nurses’ Association of Ontario - Professional Association

Source(s) of Funding

This work is funded by the Ontario Ministry of Health and Long-Term Care. All work produced by the Registered Nurses’ Association of Ontario (RNAO) is editorially independent from its funding source.

Guideline Committee

Registered Nurses’ Association of Ontario (RNAO) Expert Panel

Composition of Group That Authored the Guideline

Expert Panel Members

David McKeown, MDCM, MHSc, FRCPC
Panel Co-Chair
Public Health Physician
Toronto, ON

Marjory Ditmars, RN, BScN
Panel Co-Chair
Registered Nurse
Insite Supervised Injection Site and Outreach Mental
Health and Addictions
Vancouver, BC

Jason Altenberg, BSc, MSW
Director of Programs and Services
South Riverdale Community Health Centre
Toronto, ON

Raffi Balian (see Dedication in the original guideline document)
Project Coordinator
South Riverdale Community Health Centre
Toronto, ON

Rosalind Baltzer Turje, RN, BScN, MA
Director of Clinical Programs, Research and Evaluation
Dr. Peter Centre
Vancouver, BC

Petrina Barbas, BHSc, BScN
Nursing Student
Ryerson University
Toronto, ON

Alexander Caudarella, MDCM, CCFP
ABAM (Dipl)
Addiction Medicine and Family Physician
St. Michael’s Hospital
Toronto, ON

Cori Chapman, BA, MHSc
Family Advocate and Retired Registered Nurse
Mississauga, ON

Luc Cormier, RN, MScN
Nursing Team Leader, Supervised Injection Services
Sandy Hill Community Health Centre
Ottawa, ON

Anne-Marie DiCenso, MSW, RSW
Director of Urban Health Services
Parkdale Queen West Community Health Centre
Toronto, ON

Marilou Gagnon, RN, PhD
Associate Professor, Faculty of Health Sciences
University of Ottawa
Ottawa, ON

Shaun Hopkins, BSW
Manager, Needle Exchange Program
The Works, Toronto Public Health
Toronto, ON

Cathryn Hoy, RN
Vice-President, Region 2
Ontario Nurses’ Association
Toronto, ON

Bernadette Pauly, RN, PhD
Associate Professor, School of Nursing
University of Victoria; Scientist
Canadian Institute for Substance Use
Victoria, BC

Juanita Rickard, RN, BScN
Vice President
Canadian Indigenous Nurses Association
Ottawa, ON

Amy Wright, BSW (student)
Harm Reduction Worker/SIS Peer
The Works, Toronto Public Health
Toronto, ON

Financial Disclosures/Conflicts of Interest

Declarations of competing interests that might be construed as constituting an actual, potential, or apparent conflict were made by all members of the Registered Nurses’ Association of Ontario (RNAO) expert panel, and members were asked to update their disclosures throughout the guideline development process. Information was requested about financial, intellectual, personal, and other interests and documented for future reference. No limiting conflicts were identified. Details regarding disclosures are available from the RNAO Web site.

Guideline Endorser(s)

Canadian Indigenous Nurses Association (CINA) - Nonprofit Organization
Canadian Nurses Association - Professional Association
Canadian Public Health Association - Nonprofit Organization
Sigma Theta Tau International Honor Society of Nursing - Nonprofit Research Organization
The Canadian Harm Reduction Network - Nonprofit Organization

Guideline Status

This is the current release of the guideline.

This guideline meets NGC’s 2013 (revised) inclusion criteria.

Guideline Availability

Available from the Registered Nurses’ Association of Ontario (RNAO) Web site.

Availability of Companion Documents

The following are available:

Registered Nurses’ Association of Ontario – Clinical Best Practice Guidelines Program: Implementing supervised injection services. Systematic review search strategy. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2018 Feb. 3 p. Available from the Registered Nurses’ Association of Ontario (RNAO) Web site.
Registered Nurses’ Association of Ontario – Clinical Best Practice Guidelines Program: Implementing supervised injection services. Bibliography and quality appraisal scores. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2018 Feb. 8 p. Available from the RNAO Web site.
Insite 2010 cookbook. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2010. 16 p. Available from the RNAO Web site.
Declarations of competing interests. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2018 Feb. 2 p. Available from the RNAO Web site.
Toolkit: implementation of best practice guidelines, second edition. Toronto (ON): Registered Nurses Association of Ontario (RNAO); 2012 Sept. 154 p. Available in English and French from the RNAO Web site.

Mobile versions of RNAO guidelines are available from the RNAO Web site.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 5, 2018. The information was verified by the guideline developer on May 15, 2018.

This NEATS assessment was completed by ECRI Institute on April 12, 2018. The information was verified by the guideline developer on May 15, 2018.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses’ Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses’ Association of Ontario (2018). Implementing supervised injection services. Toronto (ON): Registered Nurses’ Association of Ontario.

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