Introduction: Hospitals can be dangerous environments for patients who are dependent on criminalized drugs, due to stigma and written or unwritten substance use policies. A group of health care providers and community partners in Halifax have worked to implement harm reduction practices including opioid agonist therapy, needle and syringe distribution, and take-home naloxone kits. In this study, we sought to understand the experiences of health care providers trying to implement harm reduction-oriented care without institutional policy support.

Methods: 10 semi-structured interviews were conducted between October 2024 and January 2025 with purposively selected QEII Hospital staff. People with lived experience using drugs in hospital and hospital staff were engaged throughout the research process. Interview guides were informed by Normalization Process Theory, which considers how beliefs, behaviours, and context impact the implementation of interventions. Data was analyzed using thematic analysis.

Results: We identified themes related to context, mechanisms, and outcomes affecting implementation of harm reduction practices. Contextual factors included medical paternalism, fear, in-hospital resource barriers, and strong community resources. Mechanisms included collective organization, leveraging existing tools, and workarounds. Implementation outcomes affecting practice change include improved provider awareness of resources and champions, culture change, and observation of improved patient experiences and outcomes.

Conclusion: We identified several factors that have impacted the partial implementation of harm reduction practices in a hospital in Halifax. Grassroots groups of healthcare providers and community partners identified workaround mechanisms, reflecting contextual barriers and facilitators. Other institutions can learn from this model of enacting change while waiting for institutional support.