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uring the past few years, the popularity of bareback sex within male homosexual communities in Western countries has increased, despite increased attention to health promotion campaigns in the era of AIDS and HIV. To address the issue of HIV and its legal ramications, this article focuses on the important issue of serological status disclosure prior to sexual contact. It should be noted that the social, cultural, economic, and gender differences that lead to the creation of HIV laws are beyond the scope of this article. Instead, our goal is to present a brief overview of particular sexual practicesbareback sex and two of its derivatives: bug chasing and gift givingas they relate to HIV sero-status and unprotected sexual contacts, as exemplied through current Canadian HIV laws. Because the legalities of HIV reporting, disclosure, and surveillance vary worldwide, it would be impossible to address more than one countrys HIV laws within the scope of a single article; therefore, we chose to focus on the legal aspects of bareback sex mainly from a Canadian perspective. However, our overall intent is to inform nurses of the legal and clinical implications of working with individuals who engage in bareback sex practices. It is

hoped that through this article, additional questions for clinical practice and research will emerge. BAREbACK SEX, BUG CHAsING, AND GIFT GIVING
Bareback Sex

Commonly dened as skin-to-skin sex or raw sex, the term bareback sex arose initially from the expression of bareback horse riding (i.e., riding a horse without a saddle) (Mansergh et al., 2002; Scarce, 1999). Put simply, bareback sex refers to voluntary unprotected anal intercourse and constitutes a sexual practice in which condom use is explicitly and consciously excluded. Its popularity has increased in recent years (Scarce, 1999). This trend is particularly perplexing to health care professionals because it occurs in the era of HIV/AIDS and is practiced by people who know (or should know) the risks associated with the sharing of particular body uids, such as semen (Wolitski, Ronald, Denning, & Levine, 2001). Recent reports from the U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC), and Health Canada indicate that HIV/AIDS diagnoses are increasing in the United

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States for the rst time in 10 years (CDC, 2006; Health Canada, 2005; Yee, 2003). Since HIV testing began in 1985, there have been 56,000 individuals diagnosed with HIV in Canada (Health Canada, 2005). In addition, it is estimated that 17,000 of these HIV-positive individuals are unaware of their HIV-positive serological status. This group of unaware HIV-positive individuals presents a public health concern because of their potential to unintentionally infect others. Although in Canada from the mid to late 1990s, the HIV rates for men having sex with men dropped from 75% to 37% of newly diagnosed HIV infections, during the past 4 years, this percentage has increased to 44.4% (Health Canada, 2005). This demonstrates that, although men having sex with men represents a relatively small proportion of new HIV infections, they still constitute the largest at-risk group and that the number of new infections within this population is again increasing (Health Canada, 2005). In response to these collective ndings, public health institutions across North America have responded by intensifying prevention campaigns aimed at limiting risky behavior in uninfected people and attempting to stop the transmission of HIV by already infected people. However, the effectiveness of such campaigns with individuals who choose to engage in bareback sex is unclear. Therefore, the ever-growing popularity of bareback sex has led to new research on this sexual practice (Bolton, McLean, Fitzpatrick, & Hart, 1995; Halkitis, Parsons, & Bimbi, 2001; Scarce, 1999; Suarez & Miller, 2001; Yep, Lovaas, & Pagonis, 2002). However, research based on epidemiological theoretical frameworks, for the most part, overlooks the impor28

tance of desires operating within the action itself (Tremblay, 2003) and fails to take into consideration sociocultural and psychological dimensions. For example, how important is it for some men to feel another man inside of them without a condom? What are the symbolic dimensions associated with semen exchange? How is silence in the face of risk a constitutive feature of being in the bareback sex community? How does violating health protocols make raw sex pleasurable? These are questions that must be addressed in order to gain a complete understanding of this practice. Meanwhile, nurses need to be knowledgeable regarding the complexity of issues that surround the act of bareback sex and those who engage in it, whether they are working in sexual health clinics in the community, community mental health settings, or institutional settings, such as forensic psychiatric and correctional facilities. Bareback sex is considered an extreme sexual practice that dees the public health and mental health discourse, and constitutes an undeniable indicator of the tensions between public health imperatives and individual desires. Therefore, nurses involved in detecting sexually transmitted infections and educating clients about them are charged with paradoxical responsibilities: supporting preventive measures regarding safer sex, while respecting patients personal decisions and choices. As agents of the state, nurses must support and convey the public health message, while simultaneously defending individual choices and needs, as dictated by their professional ethics. Currently, this radical sexual freedom movement, which involves bareback sex, is poorly understood by both American and Canadian nurses (Crossley, 2002; Mansergh et al., 2002; Ro-

fes, 1996). Therefore, individuals who engage in bareback sex pose special challenges to nurses whose intervention strategies often seem to be improvised through trial and error, rather than stemming from a specic, predetermined plan of action. This is a direct result of the lack of knowledge on the subject within the existing literature, especially scientic journals, a lack which is due to a scarcity of empirical research.
Bug Chasing

In addition to bareback sex, an even more extreme type of barebacking called bug chasing has been reported in the literature. In this practice, individuals seek to deliberately become infected with HIV through voluntary unprotected anal intercourse (Gauthier & Forsyth, 1999). The bug being chased is HIV. Condoms are deliberately not used because they would interfere with the premeditated interaction aimed at transferring HIV. The role of desire in bug chasing has been linked with the eroticization of HIV in certain subsets of gay culture. While this may seem to be a highly peculiar practice specic to HIV, this is not the rst time an illness has become intertwined with sexual desires. Historically, it was believed that tuberculosis consumed the individual and made him or her more romantic and sensitive (Sontag, 1989). The movie Moulin Rouge! (Luhrmann, 2001) clearly illustrates such an attitude. The main character, Satine, played by Nicole Kidman, is seductive, highly sexually charged, and has many men lusting after her. She also has rosy cheeks, pale skin, and a sonorous voice (all symptoms of tuberculosis) and nally collapses in a moment of extreme passiona death that maintains the myth of
Continued on page 29.

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Continued from page 28.

tuberculosis as being a consumptive and passionate illness. With HIV, similar eroticization has occurred in two ways. First, there has been an eroticization of the wasting body, in which the physical appearance of HIV/AIDS has become sexually appealing. The second relates to the semen of the HIV-positive individual, as the ejaculate holds the gift bug chasers desire. As discussed in both scientic and non-scientic literature, the practice of bareback sex may respond to two distinct nalities: to intensify the intimate connection between partners (Holmes & Warner, 2005) and to intentionally contract HIV (Mansergh et al., 2002). However, on its own, bug chasing is ineffectual if there is no viral source. Consequently, to acquire HIV, bug chasers must enlist the help of HIV-positive individuals, who are then viewed as gift givers.
Gift Giving

the gift of HIV through anal penetration is in a subordinate and passive position, thus eliminating his obligation to repay the HIVpositive donor.

tive outcomes; one never knows what results a gift might bring or what responses might be required. Taken to the extreme, individuals accept the gift of HIV from anonymous partners, about whom personal information is unknown. BAREbACK SEX AND THE LAW: DIsClOsURE OF HIV STATUs In Canada, specic laws to address the issue of HIV disclosure are non-existent. Instead, court decisions have set a precedent through case law. This means that the court has decided that existing laws within the Criminal Code are sufcient for addressing the legal exigencies presented by HIV. To date, there have been two signicant cases that have shaped HIV disclosure laws.
R. v. Currier

The case of greatest importance is R. v. Currier in 1998 (Canadian AIDS Society, 2004). The Supreme Court of Canada ruled that:
every HIV-positive person has a legal obligation to disclose his or her HIV status where he or she engages in a sexual activity that poses a signicant risk of serious bodily harm [italics added] (i.e., transmission of HIV) to another person. (Canadian AIDS Society, 2004, pp. 1-5)

The complement of bug chasing is gift givingthe gift being HIV. It should be noted that this label is applied by the bug chaser (the HIV-negative seeker), not the gift giver (HIV-positive donor). Gift giving is not the intentional infection of an unknowing individual by someone who is HIV positive. According to Mauss (1990), gifts between equals are not free; the act of giving is always coupled with that of receiving. In the case of subordinate relationships, inferiority negates the need for reciprocity (e.g., in child-parent relationships, gifts are given without the need of repayment). In the case of voluntary HIV infection, the individual who receives

Mauss (1990) further stated that gifts are not regarded as free of consequence; gifts produce anxiety. The story of the Trojan horse exemplies how any gift brings with it the risk of nega-

In this case, Currier was found guilty of aggravated assault for having engaged in unprotected sexual activity with another individual who was believed to be HIV negative prior to engaging in sexual contact with Currier. In this case, the Supreme Court of Canada provided three main guidelines (Canadian AIDS Society, 2004): l If a persons consent to engage in unprotected sexual activity is obtained either without 29

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informing them, or deliberately deceiving them about ones HIV status, then the consent is obtained fraudulently. l If the consent has been obtained fraudulently, then the HIVpositive individual can be charged with aggravated assault. l The application of the Criminal Code does not undermine public health policies regarding HIV/AIDS because the court held that such action will not deter marginalized groups from being tested. It was further believed that this application of law was for the purpose of protecting society, while not undermining the public health initiative that everyone is responsible for self-protection against the acquisition of HIV. Although the charges were determined, a signicant risk of serious bodily harm was not fully dened. Based on scientic evidence and risk estimation, the Canadian HIV/AIDS Legal Network attempted to provide an overview of what constituted a risky practice in order to provide adequate legal guidance, although in some cases, they found that the evidence was insufcient. Their recommendations were summarized by the Canadian AIDS Society (2004): l In the case of vaginal or anal intercourse without a condom, whether insertive or receptive, there is a signicant risk of causing bodily harm, and thus the duty to disclose is present. l A signicant risk exists with the sharing of sex toys, where the toy is inserted into the vagina or anus of the HIVpositive individual and then into the vagina or anus of the HIVnegative individual; again, disclosure is required. l For insertive and receptive anal and vaginal intercourse with condoms, the risk has been determined as low, but the duty to disclose is listed as unknown because a criminal case involving such 30

sexual practices has never come before the courts. l The same low risk and unknown duty to disclose applies to both parties engaged in unprotected cunnilingus, fellatio, and analingus, while the duty to disclose for these three activities when using a protective barrier is listed as probably not required but is not truly known. For self-protection, nurses advising HIV-positive clients who engage in bareback sex must be knowledgeable regarding current HIV disclosure laws specic to the jurisdiction in which they practice, and should be educated in the levels of risk associated with specic sexual practices. Therefore, HIV-positive clients who engage in bareback sex must be informed of the risk of criminal prosecution, and should be provided with information to enable them to continue a healthy sexual lifestyle. For example, one way clients can ensure that legal documentation of HIV disclosure to sexual partners has occurred is by consulting their nurse or other health care provider, as long as the discussion of status and risk occurs with the HIV-positive's sexual partner present. By charting the interaction and the observed disclosure, the nurse provides the HIV-positive client with a legal document that proves his or her duty to disclose was fullled. This could occur either prior to the rst sexual contact or after sexual contact had commenced, providing the partner also reports to the nurse or health care provider that HIVpositive status was disclosed prior to the rst sexual contact. In the case of casual partners, where such a meeting with a health care professional is highly unlikely, verbal disclosure is required and the client's partner must not engage in sexual activity under the inuence of alcohol, drugs, or coercion (Canadian AIDS Society, 2004).

R. v. Williams

The second important case in HIV law in Canada is the 2003 R. v. Williams (Canadian AIDS Society, 2004), in which Williams, although not charged with aggravated assault, was convicted of attempted aggravated assault because the court was unable to determine if, in fact, Williams partner had been HIV negative at the time of the sexual contact. The Supreme Court of Canada ruled unanimously that a person can be found guilty of aggravated assault if at the time of the sexual contact, the HIV status of the HIV-positive persons sexual partner could not be proven to be negative beyond a reasonable doubt. However, in such situations, the HIV-positive individual would be charged with attempted aggravated assault. Because it is possible that a sexual partner has been previously infected (and re-infection is not considered possible under the law), after a person is infected, they can no longer have bodily harm caused to them. However, engaging in what would constitute aggravated assault on an HIV-negative partner is not nullied if the partner is previously HIV positive, because a criminal offense has occurred nonetheless. In addition, in the Williams case (although this was never completely addressed in the case), the issue was raised that an absolute HIV test, through serology, is not required because the Crown Prosecutor need only show recklessness. Therefore, if an individual were to suspect that he or she could be HIV positive or has been identied as a contact of an HIV-positive individual, then HIV disclosure laws apply. In addition to informing serologically denite HIV-positive clients about HIV disclosure laws, potential HIV contacts must also be informed of their duty to disclose their HIV status to sexual partners prior to engaging in JULY 2006

sexual contact (Canadian AIDS Society, 2004). In addition to providing a precedent for the duty to disclose HIV status, these two landmark cases also resulted in the provision of legal guidelines for health care professionals, including nurses, caring for HIV-positive clients. Specically, health care professionals counseling HIV-positive clients have no legal obligation to inform the police if their clients were engaging in potentially criminal behavior (Canadian AIDS Society, 2004). However, two situations arise that could result in legal action against nurses counseling HIV-positive individuals. First, a nurse could have civil actions brought against him or her by the sexual partner of an HIVpositive client because the nurse did not take responsible steps to prevent the client from exposing the partner to HIV. Second, a nurse could be sued for breech of condentiality by an HIV-positive client. It must be noted that, to date, no cases have been tried regarding these two possibilities; therefore, it is impossible to predict whether a court would nd a nurse civilly liable (Canadian AIDS Society, 2004). The problem arising from breeching condentiality as a requirement, and the subsequent possibility of the nurse incurring civil action, is the result of two conicting laws: the public safety exception precedent and the condence law. A nurse might be released from the requirement of maintaining condentiality in cases where there is a risk of imminent danger, which could cause bodily harm or death to another individual. For example, if a nurses HIV-positive client refuses to disclose his or her HIV status before engaging in unprotected

intercourse, and the nurse knows the clients partner, the nurse could breech condentiality but has no legal obligation to do so. In addition, nurses duty to inform

a clients potential sexual partners of harm with the concomitant possibility of civil litigation does not require that nurses directly inform the clients partners. They may, instead, inform the public

health authorities that the clients sexual partner might be at risk and thereby fulll the duty to warn or prevent harm (Canadian AIDS Society, 2004). As a consequence, Canadian nurses must inform both serologically conrmed HIVpositive clients (and potentially HIV-positive clients) not only of the clients duty to disclose their status, but also of the limits to condentiality that exist regarding HIV. Additional factors that affect the maintenance of condentiality include the requirement to report HIV/AIDS under public health laws and the use of search warrants and subpoenas to obtain evidence. Clients should be informed at the outset that information disclosed to a nurse could potentially be used against them in a criminal investigation or prosecution because RNs are legally required to document their professional activities (Canadian AIDS Society, 2004). In comparison, due to the design of the American legal system, involving both federal and state laws, only a very broad overview of areas of concern can be provided for nurses working with individuals requesting HIV testing or who are already HIV positive and are engaging in sexual practices that permit transmission of HIV. A similarity is that HIV reporting is required in all 50 states; however, the methods by which HIV-positive individuals are reported and tracked differ. In approximately two thirds of the states, HIV reporting is achieved through condential naming in which the HIV-positive persons name is transferred condentially to the public health unit. In the remaining states, various methods, such as unique identiers or anonymous reporting, are used. Therefore, according to the Centers for Disease Control and Prevention 31

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(2001), it is each nurses responsibility to provide individuals requesting HIV testing with counseling regarding all benets and risks of testing, including the requirements of HIV reporting and the method by which this reporting is undertaken in the clients state of residence. In addition, nurses must become familiar with their state laws regarding partner notication (contact tracing) and be aware of recent changes in the Ryan White CARE Act Amendments of 2000, which now requires that all programs receiving Title III funds inform all HIV-positive clients that it is their duty to inform their partners of their HIV status. ClINICAl IMPlICATIONs With issues related to bareback sex and HIV, nurses are directly situated between the client and the public at large. In addition, practice in this domain intersects with the law; therefore, bareback sex is clearly a part of the forensic nursing domain, regardless of the setting in which a nurse practices. As a result of this emerging sexual practice, nurses working with clients who engage in bareback sex must clearly understand the legal and clinical implications involved. Both the clients needs and the nurses protection are critical. When dealing with individuals who are HIV positive, or those who are requesting serological testing for HIV, nurses must discuss the legal implications of a positive HIV test prior to testing, regardless of whether the nurse or client believes the level of HIV transmission risk is low and whether the test is being performed for the rst time. The nurses role is to ensure that clients receive proper counseling before testing and that informed consent is properly obtained. During pre-test counseling, nurses need to assess HIV risk, determine the window period (i.e., 32

the period between infection and the appearance of antibodies), provide information, explain the types of tests, and discuss their jurisdictional requirements for HIV recordkeeping (Canadian Medical Association [CMA], 1995). Testing should occur only when the patient (not the nurse) deems the advantages of testing to be greater than the disadvantages. Advantages include resolving uncertainty about HIV status, preventing further transmission, and obtaining appropriate HIV care. Disadvantages include psychological stress (being diagnosed with HIV has been shown to be implicated in depression and higher rates of suicide and suicidal ideation [Cooperman & Simoni, 2005]) and anxiety about keeping test results condential from friends and family. If risks of suicide, depression, or lack of support systems exist, testing should be deferred (CMA, 1995). Drawing on relevant legislation, recent legal documents, and court cases, nurses should know their responsibilities to inform both serologically conrmed HIV-positive and potentially HIV-positive clients of not only their duty to disclose their status to their partners, but also the limits of professional condentiality. In the case of HIV-positive clients who engage in bareback sex, nurses must discuss the risk of criminal prosecution and provide current information regarding the legal view of this sexual practice. To ascertain information about bareback sex, nurses must adopt a nonjudgmental, sensitive, matter-of-fact approach to establish rapport and engage clients in a therapeutic relationship. Any preamble that conveys a message of, Im embarrassed, and you should be too, should be disregarded (Clutterbuck, 2004). In addition, nurses should avoid making assumptions about the motivations

of individuals who engage in bareback sex and explore these motivations within the safety of the therapeutic relationship. Addressing the psychosocial issues related to bareback sex is an important task for nurses. Because many men experience erectile dysfunction, nurses need to be aware of male impotency issues, whether physiological or psychological in origin, that may arise due to condom use (Karlovsky, Lebed, & Mydlo, 2004). Nurses should also be sensitive to issues surrounding isolation. According to Gauthier and Forsyth (1999), some men intentionally engage in risky practices, such as bug chasing, due to a desire to belong. Because young gay men experience extremely high rates of suicide (Remafedi, 2002), addressing issues of loneliness and isolation is paramount. It is important that counseling about bareback sex should also include a discussion of pertinent public health laws and implications regarding partner notication, reporting, and the limits of condentiality. The complexity of issues that arise when working with clients who engage in bareback sex requires that nurses be knowledgeable and competent within the domain of both public health nursing and psychosocial nursing. In particular, nurses must possess a sound mastery of psychosocial nursing skills in order to fulll their professional responsibilities in working with those who engage in bareback sex. However, in cases where bareback sex is undertaken as an intentional practice and the individual is fully aware of the potential for HIV transmission (and related legal implications), it is important for nurses to avoid judging the individual. By remaining nonjudgmental, nurses foster the ongoing development of the therapeutic relationship and, thus, are in a better position JULY 2006

to help clients make informed choices and discuss the consequences of their actions. Making direct personal comments about the individuals sexual practices risks breaking this relationship, will further alienate the client, and may prevent the client from engaging in future health-seeking behaviors. CONClUsION The psyche of those who engage in bareback sex clearly challenges the traditional health promotion and illness prevention approaches embraced by nurses, and it may be that such health promotion campaigns are simply ineffective with this group. Clearly, questions related to the physical and psychological care surrounding those who engage in bareback sex are real concerns that need to be addressed through mutual problem solving. In doing so, it is hoped that together, nurses and clients can modify approaches and nd solutions that will protect all concerned. REFERENCEs
Bolton, M., McLean, J., Fitzpatrick, R., & Hart, G. (1995). Gay mens accounts of unsafe sex. AIDS Care, 7, 619-630. Canadian AIDS Society. (2004). Disclosure of HIV status after Currier: Resources for community-based AIDS organizations. Ottawa, Ontario: Health Canada. Canadian Medical Association. (1995). Counselling guidelines for HIV testing. Ottawa, Ontario: Author. Centers for Disease Control and Prevention. (2001). Revised guidelines for HIV counseling, testing, and referral. Morbidity and Mortality Weekly Report, 50(RR-19). Retrieved May 31, 2006, from http://www.cdc.gov/mmwr/pdf/rr/ rr5019.pdf Centers for Disease Control and Prevention. (2006). Cases of HIV infection and AIDS in the United States, 2004. Retrieved May 31, 2006, from http:// www.cdc.gov/hiv/topics/surveillance/ resources/reports/2004report/default. htm Clutterbuck, D. (2004). Specialist training in sexually transmitted infections and HIV. London, UK: Elsevier Mosby. Cooperman, N., & Simoni, J. (2005). Suicidal ideation and attempted suicide

KE Y POINT S
1. 2. Unsafe anal intercourse (bareback sex) is on the rise within the gay community. Barebacking constitutes a sexual practice with strong HIV-related legal implications. Nurses need to be aware of public health laws to be able to protect clients from undue legal prosecution. Nurses need to be aware of the components of HIV pretest counseling. Adopting a nonjudgmental, matter-of-fact approach is essential in establishing effective therapeutic relationships with clients who engage in bareback sex.
Do you agree with this article? Disagree? Have a comment or questions? Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com. We're waiting to hear from you! among women living with HIV/AIDS. Journal of Behavioural Medicine, 28, 149-156. Crossley, R. (2002). The perils of health promotion and the barebacking backlash. Health, 6(1), 47-68. Gauthier, D.K., & Forsyth, C.J. (1999). Bareback sex, bug chasers, and the gift of death. Deviant Behavior, 20, 85100. Halkitis, P.N., Parsons, J.T., & Bimbi, D.S. (2001). Intentional unsafe sex (barebacking) among gay men who seek sexual partners on the internet. Unpublished manuscript. Health Canada. (2005). HIV/AIDS epi updates. Ottawa, Ontario: Public Health Agency of Canada. Holmes, D., & Warner, D. (2005). The anatomy of a forbidden desire: Men, penetration and semen exchange. Nursing Inquiry, 12(1), 10-20. Karlovsky, M., Lebed, B., & Mydlo, J. (2004). Increased incidence and importance of HIV/AIDS and gonorrhea among men aged >/= 50 years in the US in the era of erectile dysfunction therapy. Scandinavian Journal of Urology and Nephrology, 38, 247-252. Luhrmann, B. (Director). (2001). Moulin rouge! [Motion picture]. United States: 20th Century Fox. Mansergh, G., Marks, G., Colfax, G.N., Guzman, R., Rader, M., & Buchbinder, S. (2002). Barebacking in a diverse sample of men who have sex with men. AIDS, 16, 653-659. Mauss, M. (1990). The gift: The form and reason for exchange in archaic societies. New York: Norton & Company. Remafedi, G. (2002). Suicidality in a venue-based sample of young men who have sex with men. Journal of Adolescent Health, 31, 305-310. Rofes, E. (1996). Reviving the tribe. New York: Haworth Press. Ryan White CARE Act Amendments of 2000, S. 2311, 106th Congress. (2000). Retrieved June 25, 2005, from http://www7.nationalacademies.org/ ocga/Laws/PL106_345.asp Scarce, M. (1999). A ride on the wild side. POZ, 52, 70-71. Sontag, S. (1989). Illness as metaphor and AIDS and its metaphors. New York: Picador. Suarez, T., & Miller, J. (2001). Negotiating risks in context: A perspective on unprotected anal intercourse and barebacking among men who have sex with menWhere do we go from here? Archives of Sexual Behavior, 30, 287-300. Tremblay, P. (2003). The seminal truth? Retrieved April 13, 2005, from http:// www.youth-suicide.com/gay-bisexual/ semen/01-semen-sperm-introduction. htm Wolitski, R.J., Ronald, O.V., Denning, P.H., & Levine, W.C. (2001). Are we headed for a resurgence of the epidemic among men who have sex with men? American Journal of Public Health, 91, 883-888. Yee, D. (2003, August 3). AIDS cases on the rise in United States. New York Times. Retrieved April 13, 2005, from http://www.aegis.com/news/ads/2003/ AD031563.html Yep, G.A., Lovaas, K.E., & Pagonis, A.V. (2002). The case of riding bareback: Sexual practices and the paradoxes of identity in the era of AIDS. Journal of Homosexuality, 42(4), 1-14. Dr. Holmes is Associate Professor, and Mr. OByrne is a doctoral candidate and a CIHR Doctoral Awardee, School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada. The authors disclose that they do not have signicant nancial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Dave Holmes, RN, PhD, Associate Professor, School of Nursing, Faculty of Health Sciences, University of Ottawa, 451 Smyth Road, Ottawa, Ontario, Canada K1H 8M5; e-mail: dholmes@uottawa.ca.

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