A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center

Addiction Science & Clinical Practice

Lauren Matukaitis Broyles³  Keri L Rodriguez²  Kevin L Kraemer⁴  Mary Ann Sevick⁴  Patrice A Price¹  Adam J Gordon⁴ 

[1] Critical Care Service Line, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

[2] Veterans Engineering Resource Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA

[3] Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

[4] Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA

关键词: Focus groups;    Qualitative research;    Counseling;    Screening;    Implementation;    Nurses;    Nursing;    Inpatients;    Alcoholism;    Alcohol consumption;   

Others  :  789377
DOI  :  10.1186/1940-0640-7-7

 received in 2011-09-23, accepted in 2012-05-02,  发布年份 2012

【 摘 要 】

Background

Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients.

Methods

We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting.

Results

A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features.

Conclusions

RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.

【 授权许可】

   
2012 Broyles et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]National Institute on Alcohol Abuse and Alcoholism: Helping patients who drink too much: a clinician's guide. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf webcite
• [2]U.S. Preventive Services Task Force: Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm webcite
• [3]Saitz R: Unhealthy alcohol use. N Engl J Med 2005, 352:596-607.
• [4]Tracy SW, Trafton JA, Weingardt KR, Aton EG, Humphreys K: How are substance use disorders addressed in VA psychiatric and primary care settings? Results of a national survey. Psychiatr Serv 2007, 58:266-269.
• [5]Brown RL, Leonard T, Saunders LA, Papasouliotis O: The prevalence and detection of substance use disorders among inpatients ages 18 to 49: an opportunity for prevention. Prev Med 1998, 27:101-110.
• [6]Smothers BA, Yahr HT, Ruhl CE: Detection of alcohol use disorders in general hospital admissions in the United States. Arch Intern Med 2004, 164:749-756.
• [7]Sullivan EFM: TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration; DHHS Publication No. (SMA) 97–3139; 1997.
• [8]Department of Veterans Affairs: Substance use disorders (SUD) VA/DoD clinical practice guidelines. http://www.healthquality.va.gov/Substance_Use_Disorder_SUD.asp webcite
• [9]American College of Surgeons Committee on Trauma: Resources for Optimal Care of the Injured Patient. Chicago: American College of Surgeons; 2006.
• [10]Substance Abuse and Mental Health Services Administration: SBIRT: screening, brief intervention, and referral to treatment. http://www.integration.samhsa.gov/clinical-practice/sbirt webcite
• [11]Wilk AI, Jensen NM, Havighurst TC: Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med 1997, 12:274-283.
• [12]Whitlock EP, Polen MR, Green CA, Orleans T, Klein J: Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004, 140:557-568.
• [13]D'Onofrio G, Degutis LC: Preventive care in the emergency department: screening and brief intervention for alcohol problems in the emergency department: a systematic review. Acad Emerg Med 2002, 9:627-638.
• [14]Bernstein E, Bernstein JA, Stein JB, Saitz R: SBIRT in emergency care settings: are we ready to take it to scale? Acad Emerg Med 2009, 16:1072-1077.
• [15]Nilsen P, Baird J, Mello MJ, Nirenberg T, Woolard R, Bendtsen P, et al.: A systematic review of emergency care brief alcohol interventions for injury patients. J Subst Abuse Treat 2008, 35:184-201.
• [16]Havard A, Shakeshaft A, Sanson-Fisher R: Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries. Addiction 2008, 103:368-376.
• [17]Committee on Health Care for Underserved Women ACoOaG: At-risk drinking and alcohol dependence: Obstetric and gynecologic implications. Obstet Gynecol 2011, 118:383-388.
• [18]The Joint Commission: Tobacco and alcohol measures. http://www.jointcommission.org/tobacco_and_alcohol_measures/ webcite
• [19]The Joint Commission: Specifications manual for national hospital inpatient quality measures. http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures/ webcite
• [20]Kuehn BM: Despite benefit, physicians slow to offer brief advice on harmful alcohol use. JAMA 2008, 299:751-753.
• [21]Higgins-Biddle J, Hungerford D, Cates-Wessel K: Screening and Brief Interventions (SBI) for Unhealthy Alcohol Use: A Step-By-Step Implementation Guide for Trauma Centers. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2009.
• [22]Addiction Technology Transfer Center Network (ATTC): The Change Book: A Blueprint for Technology Transfer. 2nd edition. Kansas: ATTC National Office; 2004.
• [23]Fahy P, Croton G, Voogt S: Embedding routine alcohol screening and brief interventions in a rural general hospital. Drug Alcohol Rev 2011, 30:47-54.
• [24]Groves P, Pick S, Davis P, Cloudesley RCR, Forsythe M, Pilling S: Routine alcohol screening and brief interventions in general hospital in-patient wards: acceptability and barriers. Drug Educ Prev Polic 2011, 17:55-71.
• [25]Griffiths RD, Stone A, Tran DT, Fernandez RS, Ford K: Drink a little; take a few drugs: do nurses have knowledge to identify and manage in-patients at risk of drugs and alcohol? Drug Alcohol Rev 2007, 26:545-552.
• [26]Brooker C, Peters J, McCabe C, Short N: The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department. Int J Nurs Stud 1999, 36:33-39.
• [27]Happell B, Carta B, Pinikahana J: Nurses' knowledge, attitudes and beliefs regarding substance use: a questionnaire survey. Nurs Health Sci 2002, 4:193-200.
• [28]Lock CA, Kaner E, Lamont S, Bond S: A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care. J Adv Nurs 2002, 39:333-342.
• [29]Nygaard P, Aasland OG: Barriers to implementing screening and brief interventions in general practice: findings from a qualitative study in Norway. Alcohol Alcohol 2011, 46:52-60.
• [30]Johnson M, Jackson R, Guillaume L, Meier P, Goyder E: Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Oxf) 2011, 33:412-421.
• [31]Babor TE, Higgins-Biddle J, Dauser D, Higgins P, Burleson JA: Alcohol screening and brief intervention in primary care settings: implementation models and predictors. J Stud Alcohol 2005, 66:361-368.
• [32]Nilsen P: Brief alcohol intervention–where to from here? Challenges remain for research and practice. Addiction 2010, 105:954-959.
• [33]Broyles LM, Gordon AJ: SBIRT implementation: moving beyond the interdisciplinary rhetoric. Subst Abus 2010, 31:221-223.
• [34]Kaner E: Brief alcohol intervention: time for translational research. Addiction 2010, 105:960-961.
• [35]Saitz R: Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: advocacy or evidence-based practice? Ann Intern Med 2010, 153:40-43.
• [36]Saitz R: Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals. Ann Intern Med 2011, 154:73-74.
• [37]Strauss A, Corbin J: Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2nd edition. Thousand Oaks: Sage; 1998.
• [38]Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC: Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Impl Sci 2009, 4:50. BioMed Central Full Text
• [39]Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, et al.: The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med 2006, 21(Suppl 2):S1-S8.
• [40]Bradley KA, Williams EC, Achtmeyer CE, Volpp B, Collins BJ, Kivlahan DR: Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care 2006, 12:597-606.
• [41]Lapham GT, Achtmeyer CE, Williams EC, Hawkins EJ, Kivlahan DR, Bradley KA: Increased documented brief alcohol interventions with a performance measure and electronic decision support. Med Care 2012, 50:179-187.
• [42]Bradley KA, Williams EC, Achtmeyer CE, Hawkins EJ, Harris AH, Frey MS, et al.: Measuring performance of brief alcohol counseling in medical settings: a review of the options and lessons from the Veterans Affairs (VA) health care system. Subst Abus 2007, 28:133-149.
• [43]Broyles LM, Rodriguez KL, Price PA, Bayliss NK, Sevick MA: Overcoming barriers to the recruitment of nurses as participants in health care research. Qual Health Res 2011, 21:1705-1718.
• [44]Administrative Personnel, 5 C.F.R: Part 2635, Subpart B, Gifts from Outside Sources. http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=e62a2086dab40719f9b70b63a58695eb&rgn = div5&view=text&node=5:3.0.10.10.9&idno=5#5:3.0.10.10.9.2 webcite
• [45]BNI-ART Institute: SBIRT for alcohol use: college student. http://www.bu.edu/bniart/sbirt-in-health-care/sbirt-educational-materials/sbirt-videos/ webcite
• [46]Patton MQ: Qualitative Interviewing. In Qualitative Research & Evaluation Methods. Thousand Oaks: Sage; 2002:339-428.
• [47]Miles MB, Huberman AM: Making good sense: drawing and verifying conclusions. In An Expanded Sourcebook: Qualitative Data Analysis. 2nd edition. Thousand Oaks: Sage; 1994:245-287.
• [48]Lincoln YS, Guba EG: Naturalistic Inquiry. Beverly Hills: Sage Publications; 1985.
• [49]Kaner E, Rapley T, May C: Seeing through the glass darkly? A qualitative exploration of GPs' drinking and their alcohol intervention practices. Fam Pract 2006, 23:481-487.
• [50]Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM: Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Brit J Addict 1989, 84:1353-1357.
• [51]U.S. Department of Veterans Affairs: National center for veterans analysis and statistics. http://www.va.gov/vetdata/index.asp webcite
• [52]Williams EC, Johnson ML, Lapham GT, Caldeiro RM, Chew L, Fletcher GS, et al.: Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review. Psychol Addict Behav 2011, 25:206-214.
• [53]Nilsen P, Aalto M, Bendtsen P, Seppa K: Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review. Scand J Prim Health Care 2006, 24:5-15.
• [54]Substance Abuse and Mental Health Services Administration: Cooperative agreements for screening, brief intervention and referral to treatment. http://www.samhsa.gov/grants/2011/ti_11_005.aspx webcite
• [55]Desy PM, Perhats C: Alcohol screening, brief intervention, and referral in the emergency department: an implementation study. J Emerg Nurs 2008, 34:11-19.
• [56]Dill PL, Wells-Parker E, Soderstrom CA: The emergency care setting for screening and intervention for alcohol use problems among injured and high-risk drivers: a review. Traffic Inj Prev 2004, 5:278-291.
• [57]VHA Office of Health Information: CPRS demo. http://www.ehealth.va.gov/CPRS_Demo.asp webcite
• [58]Crothers CE, Dorrian J: Determinants of nurses’ attitudes toward the care of patients with alcohol problems. [http://article ID 821514] webciteISRN Nursing 2011.
• [59]Willaing I, Ladelund S: Nurse counseling of patients with an overconsumption of alcohol. J Nurs Scholarsh 2005, 37:30-35.
• [60]Friedmann PD, McCullough D, Chin MH, Saitz R: Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists. J Gen Intern Med 2000, 15:84-91.
• [61]Lock CA, Kaner EF: Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice? Fam Pract 2004, 21:270-275.
• [62]Beich A, Gannik D, Malterud K: Screening and brief intervention for excessive alcohol use: qualitative interview study of the experiences of general practitioners. BMJ 2002, 325:870.
• [63]Owens L, Gilmore IT, Pirmohamed M: General practice nurses' knowledge of alcohol use and misuse: a questionnaire survey. Alcohol Alcohol 2000, 35:259-262.
• [64]Seale JP, Shellenberger S, Clark DC: Providing competency-based family medicine residency training in substance abuse in the new millennium: a model curriculum. BMC Med Educ 2010, 10:33. BioMed Central Full Text
• [65]Skinner N, Roche AM, Freeman T, McKinnon A: Health professionals' attitudes towards AOD-related work: moving the traditional focus from education and training to organizational culture. Drug_Educ Prev Polic 2009, 16:232-249.
• [66]Miller PM, Thomas SE, Mallin R: Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol 2006, 41:306-310.
• [67]Schermer CR, Bloomfield LA, Lu SW, Demarest GB: Trauma patient willingness to participate in alcohol screening and intervention. J Trauma 2003, 54:701-706.
• [68]Broyles LM, Rosenberger E, Hanusa BH, Kraemer KL, Gordon AJ: Hospitalized patients' acceptability of nurse-delivered screening, brief intervention, and referral to treatment (SBIRT). Alcohol Clin Exp Res 2012, 36(4):727-731.
• [69]New York Department of Health: Medicaid expands coverage for screening, brief intervention, and referral to treatment (SBIRT). http://www.health.ny.gov/health_care/medicaid/program/update/2011/2011-06.htm webcite
• [70]Williams EC, Achtmeyer CE, Kivlahan DR, Greenberg D, Merrill JO, Wickizer TM, et al.: Evaluation of an electronic clinical reminder to facilitate brief alcohol- counseling interventions in primary care. J Stud Alcohol Drugs 2010, 71:720-725.
• [71]Committee of the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute of Medicine: The future of nursing: leading change, advancing health. http://thefutureofnursing.org/IOM-Report webcite
• [72]Sandelowski M: Sample size in qualitative research. Res Nurs Health 1995, 18:179-183.