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Innovations in primary care: small Ontario town adopts big-city approach by offering street nursing service

Housing crisis fuels homelessness and increases need for helping people where they are

By Ellen Buck-McFadyen, Sean Lee-Popham, & Alexandria Sayegh
June 13, 2024
It is essential to recognize that clients are using substances and experiencing homelessness in communities of all sizes. As the housing and cost-of-living crisis continues to push more people into precarious situations, we must offer innovative solutions to meet the needs of our most vulnerable residents where they are, from city streets to small towns and their back roads.

This article is part of the Canadian Nurse series, Harm Reduction Saves Lives.

Street nurses offer services to people where they’re at, removing barriers to care and promoting health or reducing harm for some of Canada’s most marginalized populations.

This work has historically occurred within the country’s largest urban centres, where nurses engage clients in streets, alleys, shelters, drop-in centres or public parks. Yet as a housing crisis has deepened in recent years, a growing number of rural residents have been pushed into unsheltered homelessness, and encampments are popping up in small towns across the country. The need for street nursing is no longer confined to cities.

While homelessness has been considered an urban phenomenon, recent analysis of homelessness data from 55 rural regions across Canada revealed that approximately half of these regions experienced per capita rates of homelessness that were higher than those of the country’s three largest cities (Schiff et al., 2022).

In this article, we highlight the need for offering street nursing in rural areas by focusing on the experience of one small town in eastern Ontario.

About the town

With a population of approximately 4,000, the community lies in cottage country, where there is a high rate of poverty, few opportunities for post-secondary education or year-round employment, limited health and social services, no specialty services (such as inpatient withdrawal management), and limited public transit. The closest mid-sized cities are 1.5 hours by car.

Similar to other tourist towns, conversion of long-term rentals into Airbnbs and an influx of people moving to the country during the pandemic have inflated housing costs, reduced an already-low housing stock, and pushed the lowest-income residents out of the housing market altogether. When demand for housing is high, landlords can be selective about to whom they rent, and in a small town, where reputations and stigma are often entrenched, it can be nearly impossible for people who are homeless or experiencing mental illness or addiction to find employment or accommodation (Buck-McFadyen, 2022).

About the residents

Despite the challenges associated with rural living, residents often demonstrate resilience as they fill the gap in formal services and rally around local issues.

As the housing and homelessness crisis was becoming visible in the area, several community-led attempts to create emergency shelters were initiated, including at a church and motel. Although these shelters lasted only a few weeks due to the complexities of serving a vulnerable population with limited resources and training, they created awareness of the extent of the crisis and the need for more sustainable supports in the community.

A non-profit organization gradually expanded its services to support the growing number of vulnerable residents. The organization collaborated with the county to host an overnight shelter that applied lessons learned from the previous shelters by including a mix of volunteers, hot food, and paid security.

These responses demonstrate the innovation and perseverance required in underserviced rural regions often left to fend for themselves. The community’s innovative approach to supporting its residents includes integrating outreach and harm reduction services that are essential in primary care, where nursing practice must be adapted to address needs and service gaps.

Adapting the nursing role to meet community needs

In 2020, the town’s family health team developed a new harm reduction nurse position to meet the increasingly complex needs in the community. In this role, a registered nurse (RN) is employed for 32 hours per week to offer outreach, primary care, and harm reduction services to clients experiencing homelessness, mental health challenges and substance use — essentially, street nursing in the countryside.

Funding for this position is shared by the family health team and the Canadian Mental Health Association’s Mental Health and Addictions Services, a non-governmental organization offering community-based mental health care in Ontario.

The RN works out of the family health team’s office and manages their own caseload. Frequently, clients are not rostered patients of the team due to a shortage of physicians, and the RN is their main point of contact with the health-care system.

The nurse visits clients where they are, including in the street, in the woods, in encampments, at the drop-in centre or in abandoned buildings, trailers and homes in desperate need of repair across the region. This outreach builds trust, provides insight into the circumstances in which clients are living, and offers care that is unlikely to occur when vulnerable individuals are expected to seek services and show up on time for scheduled appointments.

What does street nursing in a rural context look like?

The role of the harm reduction nurse overlaps in many ways with the role of the street nurse in urban centres, although some aspects may be unique to the underserviced rural setting.

  • Primary care: Most commonly, care involves assessment, dressing a wound, following up on medication changes or opioid agonist therapy, and offering harm reduction supplies and education.
  • Follow-up care: Vulnerable clients can easily get lost for follow-up care, so checking in after ED visits, making sure antibiotic prescriptions are filled and taken, and monitoring wound healing may be needed.
  • System navigation: At other times, advocacy and system navigation are required to support clients to get to their appointments or convince providers not to cancel services when appointments are missed. They may book appointments on behalf of clients with no phone or fixed address, visit clients to remind them of their upcoming appointments, or even accompany clients to appointments as part of this outreach role.
  • Problem solving: Nurses in this role are keenly aware of how the social determinants of health impact their clients and collaborate with community partners to identify solutions to complex challenges around income, housing and transportation. For example, the RN initiated and chaired a steering committee of service providers, decision-makers and clients with lived experience of homelessness to share information and discuss strategies for addressing the housing and homelessness crisis.
  • Advocacy: Advocacy occurs at the individual, community and societal levels and requires the nurse to be intimately in touch with the realities of their clients. The outreach role and relationships developed create an understanding of the downstream effects of health and social policies that position the nurse well for advocacy on upstream solutions.
  • Collaboration: Collaboration is also essential and involves a range of partners in health-care and social services. Given the scarcity of formal services, it also includes less traditional partners, such as grassroots non-profit organizations, faith groups, and community volunteers.
  • Autonomy: Flexibility and innovation are important aspects of the nurse’s role, as are autonomy and working to the full scope of practice to meet the needs of complex clients in an underserviced rural area.


The harm reduction nurse has interacted with increasing numbers of marginalized clients in the community as trust has been built and outreach services have expanded. The number of annual client interactions has grown from fewer than 100 in 2020 to 284 face-to-face visits and 762 indirect visits in 2022.

Our experience demonstrates how street nursing can be implemented in the rural context to facilitate access to primary care and harm reduction services. Although a more formal evaluation is required to examine its impact on outcomes such as hospital visits and overdoses, evaluation metrics do not easily capture the informal interactions, advocacy and community education that lead to prevention of or reduction in harms or the relationships built over time between nurse and clients. This relationship with a consistent health-care provider may facilitate improved client well-being and restore the trust that has been eroded through negative interactions within the health-care system for so many individuals experiencing multiple intersecting vulnerabilities.


This innovative and rewarding role is not without its challenges. Being able to visit clients where they are offers a unique perspective into their lives and builds relationships with clients that are not otherwise possible. However, being the only RN working in this role, without colleagues to rely on for support or guidance, can be isolating.

Exposure to the suffering of clients who experience trauma, social exclusion, and immense poverty can lead to worry and feelings of frustration about system failures and government inaction.

Finally, in a small town with low population density and little anonymity, it is difficult to separate the personal role from the professional role when encountering clients in public spaces or being confronted by community members with opposing views on harm reduction. Self-care and strategies that maintain boundaries are particularly important for nurses who live and work in small communities.

Looking ahead

Despite the challenges associated with this role, it is essential to recognize that clients are using substances and experiencing homelessness in communities of all sizes. In the absence of an outreach and harm reduction program, how are these vulnerable people currently being served? Are we sending rural residents to the city (the “Greyhound solution”)? Are they relying on EDs to meet their health-care needs? Clearly, some are falling through the cracks, with approximately 20 overdose deaths per day across Canada in 2022 (Government of Canada, 2023).

As the housing and cost-of-living crisis continues to push more people into precarious situations, we must offer innovative solutions to meet the needs of our most vulnerable residents where they are, from city streets to small towns and their back roads.


Buck-McFadyen, E. (2022). Rural homelessness: How the structural and social context of small-town living influences the experience of homelessness. Canadian Journal of Public Health, 113(3), 407–416. doi:10.17269/s41997-022-00625-9

Government of Canada. (2023, June). Opioid- and stimulant-related harms in Canada. Ottawa: Public Health Agency of Canada. Retrieved from

Schiff, R., Wilkinson, A., Kelford, T., Pelletier, S., & Waegemakers Schiff, J. (2022). Counting the undercounted: Enumerating rural homelessness in Canada. International Journal on Homelessness, 3(1), 1–17. doi:10.5206/ijoh.2022.2.14633

Ellen Buck-McFadyen, RN, PhD, is an assistant professor in the Trent/Fleming School of Nursing, Trent University.
Sean Lee-Popham, RN, BScN, and Alexandria Sayegh, RN, BScN, are harm reduction nurses.