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In the spring of 2014, a meeting took place to discuss a shared dream. What would it look like to develop a community-based service that could provide meaningful care to marginalized populations, supporting and supplementing existing resources, and providing a unique practice training space for university students in the health professions? Equally important, the vision involved all of this being done through a social justice lens which emphasizes equality, fairness, respect, and inclusion as core organizational and service delivery characteristics (Hemphill, 2015; O’Brien, 2011).

Cyndi Hall, the Dalhousie School of Social Work (SSW) Field Education Coordinator and Jeff Karabanow, Professor in the SSW met to determine whether a commitment to starting a community clinic together was feasible. Both social work faculty members have experiences and shared leadership styles and skills that are complementary and necessary to foster and promote change. These include characteristics such as visible and engaged leadership, adept at stakeholder engagement, and clinical and change champions (Clinical Adoption Team Canada Health Infoway, 2015). Jeff co-created and continues to co-coordinate a community-based emergency winter homeless shelter. Through these experiences, Jeff recognized there were few services to provide case management and supportive counseling in an unconditional, immediate fashion to those who are poor, marginalized, precariously housed or un-housed; individuals most often experiencing deep and unresolved trauma. In Cyndi’s experiences, there are significantly more challenges in securing quality student placements for education and training. Several factors contribute to this issue but are largely due to growing competition among universities for student placements, increasing enrolments at universities, and organizational fatigue from the volume of learners and placements at sites. There are also few sites that are explicit in their social justice work. Lastly, most interprofessional placement opportunities were within traditional hospital settings.

These observations and concerns regarding social work practice and locating related field education practicums have been previously reported. Evidence shows the current neo-liberal climate has led to limited time and quality of engagement between service providers and service users, bringing about increased marginalization of service users (Preston, George, & Silva, 2014). In addition, within this neoliberal agenda of reduced resources and increased caseloads, agencies are struggling to meet their daily functions and are more hesitant to take on student supervision (Bogo, 2005; Perlman, 2016; Poulin, Silver & Kaufman, 2006). Contrastingly, the World Health Organization has requested health professions adopt a foundation in social accountability, as well as a focus on interprofessional education and care (Dugani & McGuire, 2011). Based on these observations, the proposed clinic was viewed as a possible mechanism to reduce these challenges, to better serve communities, and to bring different disciplines together in a community setting through the Dalhousie University School of Social Work Community Clinic (SWCC).

Evidence Base for Clinic Structure

To explore the evidence base for the proposed clinic, an environmental scan was conducted. Based on our findings, most university supported-community clinics follow traditional medical models of care. In these models, other health profession students serve as adjunct supports and many are student-run clinics (SRC) (Meah, Smith & Thomas, 2009; Schutte et al., 2015). Ambrose and colleagues (Ambrose, Baker, Mahal, MicFlikier & Holmqvist, 2015) write: “although [student-run clinics] were initially staffed solely by medical students and physicians, Canadian SRCs are increasingly adopting an interprofessional framework involving students and mentors from a variety of disciplines” (p. 2). This sentiment is shared by Wang and Bhakta (2013), reiterating that medical students and faculty are generally at the lead of these clinics and that bringing multiple professional schools together “is more reflective of a truly interprofessional mission” (p. 1). Our desire to have social work practitioners lead this Clinic was surprisingly novel and fits within the shifting approach to interprofessional practices found in the literature.

We identified only one other community-based agency created by a social work school. This program, developed within West Texas A&M University, espouses a dual purpose of providing social services to underserved populations and providing practicum and service learning opportunities to social work students (Nino, Cuevas & Loya, 2011). In addition to these two core purposes highlighted above, we wanted to focus on building a social work based foundation with a deep social justice/anti-oppressive landscape. We also planned to develop an interprofessional approach based on the presenting needs of the clients who were being referred to the Clinic. Moreover, our model involved paid staff (MSW graduates) who would provide case management, supportive counselling and student supervision.

Evidence Base for Clinic Philosophy

From an anti-oppressive (AOP) and social justice stance, issues impacting individuals are informed by social structures and processes that oppress and marginalize members of certain groups over others (Baines, 2011). Anti-oppressive work involves a commitment towards a more socially-just society as well as learning about the complexity of engaging in this work, both as individuals and organizations. A commitment toward AOP practice means using our power in our efforts toward social justice while being mindful of how privilege can make us complicit in the oppression of others.

A review of existing literature about AOP organizational dynamics (Ramsundarsingh & Shier, 2017) found there is limited research that looks at the intersection of service-user experience of oppression and social service organizations. This is complex and relatively uncharted territory. However, from the research we do have (Barnoff, 2011; Karabanow, 2004; Ramsundarsingh & Shier, 2017; Strier & Binyamin, 2009, 2014), we know some key characteristics of AOP organizations. First and foremost, AOP organizational structures embrace notions of “locality development” – providing immediate and meaningful services ‘on the ground’ to those in need – in a compassionate and empowering fashion (Karabanow, 2004). In addition, AOP organizations are committed to ongoing exploration of power and privilege, and toward ethical use of this privilege (Barnoff, 2011; Ramsundarsingh & Shier, 2017; Strier & Binyamin, 2009, 2014). This exploration of power and privilege incorporates reflexivity and dialogue; processes that are embedded within a culture of learning, with a focus on ongoing education and training, and an orientation toward innovation, risk taking, and collaborative work (Barnoff, 2011; Strier & Binyamin, 2014). Another significant organizational AOP characteristic identified is the expansion beyond individual work toward social action (Barnoff, 2011; Karabanow, 2004; Ramsundarsingh & Shier, 2017; Strier & Binyamin, 2009). This fits with an understanding that human challenges are impacted by societal oppression and champions the development of a commitment to working toward a more socially-just society. Lastly, the literature identifies an ongoing analysis of how organizational policies and procedures as a whole fit within an AOP approach (Barnoff, 2011), up to and including policies and procedures that impact employees. The rationale is that “if the workplace itself is oppressive to the workers, the workers will in turn be oppressive to those whom they are serving” (Ramsundarsingh & Shier, 2017, p. 14). Some examples of AOP organizational policies include a commitment toward inclusion and diversity, both in workforce and clientele (Barnoff, 2011; Karabanow, 2004), and working toward more egalitarian organizational structures (Karabanow, 2004; Strier & Binyamin, 2009, 2014). AOP organizational structures can be understood as dynamic and containing uncertainty and discomfort, where bumps are expected, where new issues emerge and are transformed rather than resolved (Barnoff, 2011). Based on our scan of AOP literature, there is no one method to follow for successful integration of AOP principles in practice and more research is required to determine how to fully and successfully incorporate AOP principles within an organization.

Stakeholder Engagement

We consulted with non-governmental organizations (NGOs) in the community who provide services to clients whom would also serve as the SWCC’s population. Previous community development experiences pointed to challenges of engaging in large-group discussions and led to the decision to connect individually with a variety of organizations. Through this more intimate process we worked to explain the SWCC philosophy and activities, along with the proposed teaching and learning model. Community dialogues in the development stage of this new initiative provided insight into the needs of the community, while ensuring that existing services would not be duplicated; an approach the literature has noted as important (Clark, Melillo, Walace, Pierrel & Buck, 2003; George, Moffatt, Barnoff, Coleman, & Paton, 2009).

During this important preparatory stage, we were careful and deliberate in fostering relationships with other agencies—demonstrating our unique qualities (i.e., training ground for health profession students) and our commitment to AOP values and methods. We were deliberate in avoiding the duplication of services, while complementing and supporting the existing formal and informal systems. This approach allowed us to be viewed as an ally rather than a threat or competitor for shrinking resources. This strategy culminated in the Clinic gaining wide support, which encouraged us to continue our development.

Strategic Alliances

During our very early preparations, a newly-appointed Dalhousie University president had embarked on the development of a new university strategic plan that embraced a renewed sense of “service to community,” “innovative teaching,” and “community partnerships” (Dalhousie University, 2014). The Clinic aligned with these mandates: providing a creative, unique, and dynamic practice setting for students, and building a space for community and university engagement.

We intentionally and strategically sought to place the Clinic outside the university campuses and closer to the city centre as a way to be more accessible to both clients and partner agencies. The first proposed Clinic location was in a shared pro-bono church-owned property in the centre of Halifax, near major transit routes (bus and ferry).

An advisory committee was created in 2013 consisting of colleagues from the faculties of Law, Pharmacy, Nursing, Occupational Therapy, and Social Work. The role of the advisory committee, which meets approximately twice per year, is to provide broader interprofessional and organizational perspectives on the Clinic’s operations. Jeff and Cyndi serve as Directors. The main source of our funding for the clinic came from the School of Social Work and from the University President’s Office, through short term allocations and a salary replacement.

The Clinic Becomes a Reality

The Dalhousie SWCC opened in May 2014. A grand opening was held in June through support from both the School of Social Work, and the Faculty of Health Dean’s Office. The opening involved the University’s President, the Dean of Health, the Director of the School of Social Work, colleagues, students, and a wide variety of representation from community and government. With minimal funding, the Clinic opened; with deep humility we worked on its development and watched to see whether it would emerge as a needed service and a site of excellence for teaching and learning.

Our Clinic has three main goals:

Case management and provision of efficient, accessible and innovative delivery of primary care. We are working collaboratively to fill the gaps and provide essential support to Halifax’s most marginalized individuals. In a climate of increasing demands for service and limited resources (George et al., 2009), collaboration works to ease some of the responsibility placed on other programs by minimizing waitlists and fostering cooperative case management. Moreover, the Clinic has served as an important bridge, building relationships between Dalhousie University and the Halifax Community. The Clinic supports and enhances existing connections between the University and the Community by building partnerships with community members and service delivery agencies. Providing services in the community can allow the University to be more meaningful in the presence of diverse communities.

Social work placements in an AOP/social justice environment. As mentioned earlier, there is a shortage of quality field settings (Bogo, 2005; Perlman, 2016; Poulin et al., 2006), particularly those providing opportunities for our students to experience AOP theoretical approaches being demonstrated in practice. The Clinic has been able to provide these opportunities. In addition, we see potential to expand student involvement to include community development practicums (e.g., aligning with a variety of social action activities, building new community partnerships, etc.) and research experiences (e.g., evaluation, case study, etc.), augmenting what is being taught in the practice classes. To date, one student research-project evaluation has been completed based on the Clinic.

Creating an interprofessional culture of learning and service delivery in a non-medical setting. The Clinic currently provides opportunities for students to engage in community-based learning in two main ways: practicums/experiential learning, and service learning. Practicums, which are also referred to as field placements or clinical rotations, are generally stand-alone elements of a student’s education. Service learning tends to be shorter, project-based and is an intentional component of course-based learning activities (Taylor et al., 2016).

Referrals

We started very intentionally, taking referrals from a small number of organizations that we had consulted with and had worked with in the past; a legal aid clinic affiliated with Dalhousie, the shelter system, including the emergency winter shelter Jeff is affiliated with, a women’s program, and an immigration and settlement centre. The Departments of Community Services and Health were informed of our intention to open the community clinic. Unbeknownst to us, the selected referrals would not be contained and, soon after we opened our doors, referrals started to come from several locations within and outside of the formal health system. Thus far, we have worked with over 450 clients and more than 40 organizations. The Clinic employs a case-management platform to support our clients who are, for the most part, individuals living in poverty in Nova Scotia.

Building an Interprofessional Platform

Coordinated and supervised by MSW graduates from our School, the Clinic not only complements and supplements existing resources in the Halifax Regional Municipality, but is also a field placement site for BSW and MSW Social Work students and students from other disciplines. We have provided practice and volunteer experiences to approximately 75 undergraduate and graduate students from eight different disciplines: Social Work, Occupational Therapy, Psychology, Nursing, Nutrition, and Pharmacy engaging in practicum learning and service delivery. Students from Medicine and Management have also completed project-based and service-learning opportunities with the SWCC.

Our approach stresses the importance of including the University’s strategic interests of student engagement and experiential learning: we are providing alternative educational opportunities for Dalhousie students to engage within the community while meeting the needs of their academic programs. It is especially heartening to see the Clinic’s structural analysis strengthened by students and health professionals from other disciplines through their involvement at the Clinic.

This aligns with literature that identifies student-run clinics in Canada as using innovative approaches to deliver interprofessional education through the clinic-based collaborations amongst clinic engaged professions (Haggarty & Dalcin, 2014). Plans are underway to include a Nurse Practitioner student, and we are strengthening our learning objectives around interprofessional collaborative practice development. We have worked to incorporate other professions as needs evolve, and we are developing meaningful relationships with these professional schools around field experiences and client services. We are pleased to be able to provide students with practicums that offer interprofessional-learning opportunities within a community-based setting that is rooted in an AOP practice framework.

The creation of the advisory committee provided a network of contacts in other professions that supported the gradual addition of these other professions into the Clinic. The first additional profession to join was Pharmacy and was the result of advisory committee involvement by a pharmacist and the observation by the Clinic’s social workers during client in-take that many people presented with a complex medication history. A meeting was held between the Directors of the SWCC, the School of Social Work and the College of Pharmacy. One staff member from the College of Pharmacy, and one faculty member, joined the Clinic for one half-day per week. Pharmacy was chosen for several reasons. First, research has shown that re-hospitalizations for mental health are reduced when Social Work and Pharmacy work together (Gil, Mikaitis, Shier, Johnson & Sims, 2013). Second, Pharmacy in Nova Scotia has expanded its scope of practice and can offer more services to clients. Third, there is strong interest within Pharmacy to explore innovative approaches to providing primary care, particularly for marginalized populations experiencing chronic mental health issues. Non-dispensing community-based roles for pharmacists have not been fully funded or optimized yet in many parts of Canada (Kennie-Kaulbach, Whelan, Burgess, Murphy & Davies, 2017).

The pharmacists at the Clinic have secured funding support from the Dalhousie Pharmacy Endowment Fund to conduct a scoping review to help inform the pharmacist practice at the clinic (Peters et al., 2015; Arksey & O’Malley, 2005). Pharmacy student academic involvement is somewhat limited in terms of meeting current accreditation standards for completing practicum hours, but we do have two pharmacists from our Faculty of Health involved, seeing clients and collaborating on cases. In addition, the College of Pharmacy is embarking on launching a new entry to practice Doctor of Pharmacy degree in 2020 and is working toward offering the Clinic as an interprofessional rotation elective practice site. To this day, the combination of social work and pharmacy has shown a successful interlinking of multi-dimensional support to clients and exciting professional sharing between the two disciplines.

We are also expanding our interprofessional approach beyond the health professions. Our partnership with Dalhousie Legal Aid has also enhanced our Clinic. A lawyer and a law student have come for one afternoon per week to meet with clients and advise them on legal matters. In the future this may lead to regularly hosting law students, adding to the exciting venture to foster a more holistic vision of community care. Moreover, we have begun to work with other disciplines such as medical and business students to support aspects of the Clinic. For example, a medical student, as part of service learning, worked on our website and management students, as part of a course project, explored databases for our data collection and file management.

Through structured and intentional interprofessional case rounds (students reviewing files together), article discussions (chosen articles concerning diverse aspects of our work being shared with all students and then discussed), and consistent explorations/discussions (critical reflections) we are beginning to see the ways in which we can learn from one another, celebrate the unique contributions of diverse professions, and reflect upon how working together can build deeper understandings of social justice work. Existing research notes the benefits of collaboration and integration of multiple professional approaches in the process of working toward a truly interprofessional approach to practice (Wang & Bhakta, 2013). As an example, through interprofessional learning, students can gain greater respect for the contributions of other professions (Dacey, Murphy, Anderson & McCloskey, 2010).

Funding Sustainability

Funding challenges were and are a consistent focus for the Clinic. Clinic finances include salaries, rent, insurance, utilities, supplies, technological support, and programmatic resources, approximating $180,000 per year. Over 60 community and foundation proposals for grant-based funding have been written and, to date, we have received two Community Health Board grants. These are used to support emergency funds for clients.

In 2016, the Department of Labour and Advanced Education (LAE) provided significant funds for our operation. This is due, in part, to their timely assessment review of the School of Social Work’s approaches to preparing students for practice. The Clinic was viewed as an excellent way to enhance the teaching of practice and preparation of our students for the workplace. The Department of Community Services (DCS) has been approached on several occasions, both in formal meetings and informal dialogues. While communicating they are impressed with the Clinic, they turned down requests for funding until the fall of 2017. At that time, they agreed to provide equal funding to that provided by the LAE. This is encouraging given the fact that a large portion of the Clinic casework is with DCS clients. To date, the Department of Health and Wellness has not been a partner, but informal conversations continue regarding the work of the clinic.

Although the University supported the Clinic in principle and with some resources (e.g., money, staffing repositioning), sustainable funding is not guaranteed. Since the inception of the Clinic, we have navigated through networking and meeting with various key leaders in the University and have recently engaged the Office of Advancement (alumni fundraising) to develop a strategic marketing campaign. The complex path to securing support from our institution reflects the contradictory location that field education programming inhabits within universities (Taylor, 2016). Literature suggests that this contradiction reflects the tensions between the privileging of academic knowledge over community knowledge and university concerns about preparing students for entry into the workforce (Taylor, 2016).

Location and Space

For the first year, the SWCC remained in the first proposed location, which was a free space at a downtown church. As the Clinic evolved, we realized that the operation required a larger and more private space, and a non-secular environment. In December 2015, the Clinic moved to Veith House, a community hub in the North End of Halifax. Veith House is situated close to a large public-housing project, and the organization supports several poverty reduction initiatives and rents space to a nonprofit childcare centre and to other NGOs. The North End is a diverse neighbourhood with a noteworthy history including complete destruction during the 1917 Halifax Explosion, as well as containing Africville, a historic black neighbourhood that was forcibly relocated by the city of Halifax in the early 1970s to build a bridge across the harbour. Today the North End contains a mixture of public housing and gentrified streets. In the space at Veith House, two private offices, two large meeting rooms, and a dedicated student space allowed for further expansion of the Clinic. From the beginning, we had conceived the potential for partnering on future joint community development projects and collaborating on specific grant proposals, and our new space could help accomplish this. The larger space also helped us take steps toward realizing our goals for increasing the interprofessional teaching culture. Due to continued growth and a need for better accessibility, the Clinic has since relocated to a central Halifax street in an accessible street-level office space near convenient transit routes.

Work at the Clinic

Case management is a continuous and collaborative process where clients, and their community supports, identify needs and goals. Case management within the Clinic works to connect marginalized individuals to the social and healthcare systems from which they are often excluded. Rooted in the accompaniment approach to practice, our program serves as a resource centre for marginalized individuals who may not fit into traditional support settings, or those who are not yet connected to the already existing network of social service agencies in Halifax.

The concept of accompaniment emerged in Latin America within the liberation theology of Roberto Goizueta and Gustavo Gutierrez (Watkins, 2015). Accompaniment is “rooted in an interdependent understanding of psychological and community well-being, not in an individualistic paradigm of psychological suffering” (Watkins, 2015, p. 327). It involves taking a stance to ‘walk with’ those we work with, resisting western notions of individualism and power-over. This approach helps us to reach out and connect with individuals who have experienced barriers while attempting to access services, allowing for the centering of their experience and knowledge, reducing alienation, and fostering connection and hope.

Employing a case management model, the Clinic incorporates system navigation, supportive counseling, resource support, community outreach, advocacy, group work, as well as needs assessments. Further, working in partnership with other organizations, this Clinic fills in gaps in services while working towards the reduction of the high caseloads and waitlists of existing agencies as discussed above.

Students completing practicums at the Clinic can analyze different system structures and policies and how they affect clients’ lives. The broad core curriculum goals of field placement for both BSW and MSW are met through the day-to-day activities in the Clinic. In addition, each student develops and works to meet their personal learning objectives.

Learning objectives of social work students while completing a placement at the Clinic include development of their case management and supportive counseling skills, including:

  • Observing/shadowing of the intake process and individual needs assessments

  • Increasing their knowledge of community resources and programs

  • Participating in case planning and coordination of services among community partners

  • Advocacy

  • Basic counselling skills

  • Participating in group supervision

  • Interprofessional collaboration

  • Developing a structural and political analysis of social problems

Ongoing Community Engagement and Staff Development

Another core dimension of our work has been knowledge mobilization. We are forming partnerships with community agencies by sharing what we are doing and learning from what others are doing. We engage in case planning around client issues and are forming alliances to advocate for greater access/more equitable services for those with whom we work. The Clinic is involved in numerous round table meetings with government, NGOs and/or community advocacy groups, to fight for increased or better supports for those in need. We are also committed to community outreach—meeting clients in their own communities if they feel more comfortable that way. Clinic staff and students regularly meet clients in private meeting rooms booked within the Halifax Public Library System or at another public meeting place agreed to by the client.

Each year we have invited colleagues to come and provide training to our staff and students—ranging from trauma informed care, motivational interviewing, and brief solution focused therapy. Knowing the Clinic is still in a development phase, these trainers have donated their time and expertise to support our growth and they are provided with an honorarium. We are also building community capacity by inviting one or two of our partner agencies to participate in each training session. Furthermore, several graduate students in the capacity of a research course, have conducted an informal evaluation on the Clinic—looking into how well our day to day operations fit our mandate and philosophy. In addition, a graduate student from another Canadian university has explored our Clinic in her thesis. We believe there are many opportunities for research within the context of the Clinic that could further grow this body of knowledge.

Throughout our work, we have presented at numerous conferences and have had interest/visits from other universities intrigued by our initiative. During a poster presentation at the Canadian Association of Social Work Education’s (CASWE) 2016 annual conference, several schools talked about their desire to replicate our program. Participants stated that some schools had attempted to create a clinic but faced many challenges to launching. Some of the barriers shared during the presentation included: legal and liability issues, space challenges, not having the support of the university, financial barriers, and not having the human resources to establish a model and then support its growth over the long term. Our challenges were similar, but we have been able to succeed, in large part, because of the support of Dalhousie University’s leadership and the knowledge, commitment, and dedication of Jeff, Cyndi, our Clinic Coordinators, and our willing interprofessional collaborators.

Conclusion

At a time when the state of field education in Canada is reaching a crisis proportion, with service delivery structures overwhelmed, strained, financially fragile, and with the decreased capacity to provide services and offer field education, we are grateful to become a part of the solution; solidifying our relevance in teaching, learning, and serving community.

Many factors created the climate for us to be able to develop our Clinic. The Dalhousie context was influential with changes in leadership and strategic planning that highlights community engagement and innovative teaching. Our own Faculty of Health has embraced interprofessional learning and teaching. The climate of government and their increasing vigilance of professional schools created the opportunity to promote our approach to practice learning that significantly enhances readiness for practice. The Dalhousie School of Social Work, where both Clinic directors are employed, supported the development both financially and through flexible work deployment.

It has been a very organic, flexible, and adaptive process. We continue to learn as we go. Overall, as directors, we are mindful of the importance of providing ongoing oversight and support to the Clinic as it grows, evolves, and becomes established in the community. This oversight has been identified as the key to ensuring the populations that we serve are adequately and ethically supported, and that students receive education that fits within their educational goals (Buchanan & Witlen, 2006).

We have much to celebrate with this initiative—its community development roots, its social justice framework, its anti-oppressive emblems, and its accompaniment philosophy. While indeed a work in progress, the Clinic signals a social work initiative that can embrace an interprofessional lens, be a bridge between the worlds of community and university, focus upon meeting the needs of our clientele, and provide thoughtful and meaningful training grounds for emerging health professionals. There are constraints as well, of course. We continue to seek consistent and sustainable funding to maintain the Clinic’s operations and eventually expand to newer offerings (e.g., drop in, therapeutic supports). Moreover, we are continually working to balance our service delivery platform with true community development and advocacy orientations of AOP. We want to continue to be a community focused organization that leads in providing client focused services— we must maintain our social justice lens and work with our communities to advocate for a more just and equitable society. We are diligent in our efforts to maintain our unique philosophy and offer transformative learning opportunities for students.