Problem drinkers in accident and emergency: health promotion initiatives

Problem drinkers in Accident and Emergency: health promotion initiatives T. Lockhart Problems caused by excessive alcohol consumption often contribute to Accident and Emergency attendances, giving possible health promotion opportunities to this client group. These could include screening, health education (verbal or written), brief intervention and referral to alcohol services. Accident and Emergency staff rarely take these opportunities. A knowledge of alcohol problems, possible health promotion initiatives and services available alter attitudes and increase the likelihood of staff giving health promotion. Health promotion to problem drinkers should be a routine in Accident and Emergency departments. \

INTRODUCTION

Tim Lockhart BSc, RGN, Staff Nurse, Accident & Emergency Department, Cardiff Royal Infirmary, Newport Road, Cardiff; UK

Manuscript accepted 22 May 1996

The Public Health Report (1993) shows 25% of men and 12% of women drink excess alcohol, and alcohol consumption is one of the areas targeted in the governments health promotion policy As a staff nurse in an urban Accident and Emergency (A & E) department, having previously worked in alcohol dependency nursing, the author was aware of health problems caused by excess alcohol consumption, often contributing to A & E attendances. A study of the literature and an informal survey of staff corn the author’s department (staff were asked to complete a simple questionnaire) showed attitudes to this problem. It was found that health promotion to those who may have an alcohol problem was rarely given in A & E

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departments. Staff attitudes and their lack of knowledge were possible barriers to health promotion for this client group. Health promotion initiatives and barriers to such initiatives were considered in order to see how health promotion to problem drinkers, by A & E staff, could be improved.

SCREENING AND DETECTION OF PROBLEM DRINKERS In surveys of those attending A & E, over 10% of attenders (Walsh & Macleod 1983) have been drinking alcohol, and up to 40% of those attending in the evenings (Holt et al 1980). It has been found that 11% of those attending A & E had an alcohol problem although only 2% had received help for their problem (Redmond et al 1987). If alcohol problems are treated early prior to more chronic problems, the results are likely to be more positive (Chick et al 1985, Green et al 1993). For many with alcohol problems A & E may be the first point of entry to health care (Green et al 1993). There was found to be a higher rate of drinking amongst A & E attenders than the general population (Wright 1994). For these reasons it is suggested that A & E could be used to screen for problem drinkers and therefore detect them early (Holt et al 1980, Yates et al 1987, Wright 1994). Screening all clients would be impractical and intrusive but many with alcohol problems can be identified, and staff need to be able to identify them. Blood alcohol levels (BALs) are more accurate than clinical judgement at indicating those who are intoxicated (Holt et al 1980). It may not always be convenient to measure BAL, and breath smell is the most reliable of clinical methods (Holt et al 1980). Some patients, such as those claiming to have been assaulted, have often been drinking (Keech 1992, Dowey 1993). It is good clinical practice to detect those who are intoxicated (Rutherford 1977). Although many intoxicated clients were seen to have alcohol problems (Glynn & O’Neill1974), they are not necessarily problem drinkers (Yates et al 1987, Redmond et al 1987). Those with a BAL over 200% should be considered to have an alcohol problem (Yates et al 1987). Asking about their drinking is the most effective way of determining problem drinkers (Yates et al 1987). Questionnaires such as the ‘CAGE’ questionnaire (Table l), and Michigan Alcohol Screen Test can be effective in detecting problem drinkers (Redmond et al 1987, Paton 1989). The more questions asked the more effective they are at detecting problem drinkers (Redmond et al 1987). A self-administered

Problem

0 0

l 0

Have you ever felt you should Cut down on your drinking? Have people ever Annoyed you by criticizing your drinking? Have you ever felt Guilty about your drinking? Have you ever had a drink first thing in the morning (Eye-opener)?

questionnaire can be used (Dewey 1993). These questionnaires can be timely for an A & E department; the most relevant questions can be used (Redmond et al 1987). Routine questions that determine how much, how often, patterns of drinking and problems that result are recommended (Paton 1989). It has been shown that nurses can perform well at screening for those with alcohol problems (Rowland & Maynard 1989). It is suggested that screening alone may be beneficial for problem drinkers. In a survey of those admitted to hospital, Watson (1992) found that there was a reduction of alcohol consumption and alcohol problems amongst those asked about their drinking, regardless of whether they received further advice or education. However, it could be that the reason for their hospital admission resulted in lifestyle changes. The reduced alcohol consumption may lead on from these changes and not from the questioning about their drinking. It is recommended that general practitioners (GPs) are informed of those found to have an alcohol problem (XValsh & McLeod 1983, Yates et al 1987).

Brief intervention Several brief intervention health promotion strategies have been suggested. Cards with information on treatment agencies can be given to patients. One study found that 30% of those given cards subsequently attended these agencies (Brooks cited by Green et al 1993). A leaflet with advice (e.g. units and safe limits - Table 2) and services can be given to those with alcohol problems or friends and relatives accompanying patients (Tether 1985, Keech 1992, Dowey 1993). Leaflets are thought to be more effective when given with verbal advice (Williams et al 1987). Health advice about alcohol should be mandatory if alcohol is the cause of their attendance (Paton 1989). If the patient is receptive further intervention methods such as drink diaries can be used (Keech 1992). Similar brief intervention has been shown to be effective on medical wards (Chick et al 1985). Counselling by an experienced staff member can be given (Tether 1985). St Mary’s Hospital, Paddington, A & E Department, offered clients

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I unit of alcohol f pint of ordinary beer, lager or cider Single spirit Small glass of wine Small sherry Sensible drinking limits Women: up to 2 I units spread throughout the week Men: up to 28 units spread throughout the week

found to have an alcohol problem the opportunity to return for health education advice; 43% of those identified took this opportunity (Green et al 1993). It was noted, however, that the numbers targeted were much less than the likely numbers of problem drinkers who attend A & E. The numbers returning for advice showed that there could be benefit for a specialist worker to be attached to an A & E department (Green et al 1993, Wright 1994). It has been suggested that alcohol treatment services (which offer counselling and withdrawal) should be integrated with A & E (Holt et al 1980). Glynn et al (1974) found that those attending A & E intoxicated had significant social problems, and suggested that A & E departments can be used for crisis intervention by social workers. With limited resources it is likely that social services can intervene only when social problems are identified.

STAFF KNOWLEDGE ATTITUDES

AND

Cooper (1993) states ‘Every nurse should be committed to combating the health problems associated with overuse of alcohol’. The reality is often very dii?&rent. A & E deparnnents often have no policy for those found to have been drinking heavily; there is no questioning about their drink ing, no assessment and no follow-up (Glynn & O’Neill 1974, Holt et al 1980). There are clearly barriers that prevent or discourage staff 6om providing health promotion to this client group. Health promotion interventions can be given by doctors and nurses even though they are not alcohol specialists (Keech 1992). This paper concentrates on intervention by nurses; however, Paton (1989) recognized that doctors failed regarding health promotion. He found alcohol problems were frequently undetected; doctors did not accept they had an obligation to look after those who misused alcohol. They concentrated on a medical model - treating only diseases caused by alcohol, by which time it is often too late for effective treatment. They considered enquiring about alcohol to be intrusive, embarrassing and producing untruthful

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responses. They often failed to examine their own attitude to drinking and newly qualified doctors were poor at taking an alcohol history. The following eight points give reasons for nurses not promoting health to those with alcohol problems.

I. Lack of knowledge Nurses have anxieties about how adequate their information and skills are in recognizing and responding to drinkers (Cooper 1993). Conventional nurse training offers little education on alcohol misuse (Hagemaster et al 1993). Watson (1992) notes that limitations in nurses’ knowledge prevented them being effective in both detecting problems and delivering health education. Watson found 63% had not been taught what advice to give to problem drinkers. They were, however, shown to be better informed about alcohol problems than the general public. In the author’s department staff believed further education would be beneficial. Educating nurses increases their confidence and the number of interventions they make (Rowland & Maynard 1989).

2. Not their

role

Nurses are anxious about whether this role is within their remit (Cooper 1993). Nurses comprise the largest group of health professionals and are, therefore, in a good position to offer health education (Rowland & Maynard 1989, Watson 1992). The majority of nurses thought health education should be offered (Rowland & Maynard 1989). Watson (1992) showed that 88% of nurses felt they had a role in giving health education advice; however, only 10% said they always gave advice. Rowland and Maynard (1989) found 59% of nurses thought it was important to screen for alcohol problems, and views in the author’s department are similar. It is, therefore, not the uncertainty as to the legitimacy of offering health promotion that is a barrier for most nurses.

3. Unsure

4. Attitude It has been shown that many nurses have a negative and moralistic attitude to those with alcohol problems (Roth 1972, Rowland & Maynard 1989, Hagemaster et al 1993). Clients labelled as drunks are treated as less deserving, not believed, treated in an abusive or jocular manner or ignored. Staff often comment on how they hate to take care of drunks (Roth 1972). Intoxicated people can be violent, abusive or antisocial and it would be unrealistic to expect staff not to find these clients difficult. Nurses in the author’s department often found clients with alcohol problems a nuisance, particularly if drunk, although their attitude to them tended to depend on the behaviour of the client. Nurses find some patients easier than others (Rowland & Maynard 1989). The negative attitude that nurses have may be accounted for by those people who present as drunk or chronic ‘alcoholics’ (Rowland & Maynard 1989). These experiences reinforce the commonly held stereotypes like ‘down and outs’ and violent drunks, while in reality the majority of alcohol-related problems are caused by ‘social drinkers’ - those drinking on a regtlar basis or getting intoxicated from time to time (Rowland & Maynard 1989). It has been shown that heavy drinkers are as likely to attend during the day (often sober) as in the evening (possibly intoxicated); however, it is the latter group that is more readily identified as being problem drinkers, again reinforcing negative attitudes (Wright 1994). Problem drinkers include not only stereotypes but anyone irrespective of age, sex, employment or social group (Keech 1992). Nurses also felt that light drinkers were more open about their drinking than heavy drinkers, who they felt were defensive and lied about their drinking. However, research shows that nurses can obtain accurate drink histories (Rowland & Maynard 1989). Cheripitel, cited by Wright (1994), found that people with positive BAL nearly always admitted to having been drinking. Education can affect nurses’ attitudes to become more permissive and less judgmental (Hagemaster et al 1989).

of support

Nurses are concerned about further help and advice being available (Cooper 1993). In the author’s department, some nurses were uncertain or unaware of services that are available; they expressed concern that some services were unavailable outside normal working hours. Health education material is available when requested (although sometimes at a cost) and there are numerous services assisting those with alcohol problems. Any staff education programme should include knowledge about local services.

5. Not accident

and emergency

role

The suggestion is made that some people attending A & E did not recognize their problems and were reluctant to answer questions. Therefore, it was felt A & E was not a good site to motivate changes in drinking (Robertson cited by Green et al 1993). Others suggested that attending A & E may help those with drink problems recognize their problems and therefore become more ready for change (Green et al 1993).

Problem

As previously shown, large numbers of problem drinkers attend A & E. It is likely that they are going to be in different stages of change, some more ready to contemplate change than others. It is sometimes inappropriate to give health education and advice, for example to those who are heavily intoxicated, abusive or reluctant to recognize their problems (Keech 1992). If GPs are informed of these problem drinkers, health promotion opportunities may arise at a later date.

6. Unsure

of effectiveness

Nurses were unconvinced of the long-term benefits of education to those who drink to excess (Rowland & Maynard 1989). As previously mentioned, health promotion initiatives have been shown to have some (if sometimes limited) success: nurses can screen effectively for alcohol problems (Rowland & Maynard 1989); asking about drinking may result in a reduction of alcohol consumption (Watson 1992); patients will attend follow-up services (Brooks cited by Green et al 1993); A & E attenders will return for follow-up health education advice (Green et al 1993); and brief intervention can be effective in reducing altoho1 consumption (Chick et al 1985). Rowland and Maynard (1989) found only 7% of nurses thought alcohol education was not worthwhile although many qualified their response, questioning its lasting effectiveness. It was felt likely to be more effective for those who ask for assistance with their drinking problems (Rowland & Maynard 1989). It must be accepted that health education may not always produce results; no health education is likely to produce fewer results. If only a few are helped it may be very beneficial for those individuals.

7. Lack of resources Extra funds for alcohol treatment in an A & E department are not usually available (Green et al 1993). Preventative health care can be cost effective in the long run and health promotion is clearly an important aspect of preventative health care for those who drink excessive alcohol. Health education need not be expensive.

8. Lack of time Time is often a constraint in areas like A & E departments (Paton 1989). In A & E time is at a premium; health education to those who are not always responsive is sometimes considered not the best way of using that time (Dowey 1993). The author found nurses in his department indicated time was a barrier to health education. As thought earlier, an alcohol

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history can be taken in only a short time (Paton 1989), but if health education becomes routine practice, it need not take a lot of time.

STAFF

NEEDS

To be able to promote health alcohol problems staff should:

to those with

1. Be able to recognize those with alcohol problems. 2. Be able to give health education advice to those with alcohol problems. 3. Be aware of services available to those with alcohol problems. These abilities needed by staff are similar to those identified by the Advisory Committee on Alcoholism (cited by Cooper 1993). To be able to recognize those with alcohol problems, staff need knowledge about the problems alcohol causes (medical, psychological and social), safe drinking limits (Table 2), and injuries and conditions with which those with alcohol problems are likely to attend A & E. The staff need to be able to identity not just stereotype problem drinkers, such as intoxicated clients and chronic alcoholics, but other problem drinkers. To be able to give health education advice, as well as information about alcohol problems, staff need to know about intervention methods and services available, to increase their confidence and make them more likely to give advice and offer referrals. Health education for those with alcohol problems needs a higher priority; it should be a routine part of treatment (Chick et al 1985, Rowland & Maynard 1989). Paton (1989) recommends education for all professionals to encourage this process. It has been found that education workshops can increase knowledge, change attitudes and belief in treatment (Hagemaster et al 1993). Watson (1992) found that nurses had a good knowledge of health problems caused by alcohol but are less knowledgeable about alcohol limits and sensible drinking limits. Nurses need to know what injuries or conditions are likely to result in A & E attendances. These include those assaulted (or involved in a fight), gastritis, previous accidents, self-inflicted injuries and a vague history of the accident (e.g. amnesic or partially amnesic about the night before) (Keech 1992). This knowledge should affect staff attitudes; staff should be non-judgmental (Paton 1989, Keech 1992). Health promotion intervention Clients may resent the suggestion that they have a problem, and being non-confrontational

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is important (Keech 1992). The aim is for the clients to make the connection between their drinking and their accident or condition: motivational interviewing is needed to encourage the client to see their need for change. The client can be asked to describe the accident in detail with open questions about what happened before the injury, including drinking prior to the injury - where, how much, what and if intoxicated? It should be established if this is a regular drinking pattern. The client can be asked ‘How do you think your drinking may tie in with your accident?’ (Keech 1992). Similar questions can be asked about previous accidents. The client should be reassured that alcohol-related accidents are not uncommon (Keech 1992). Staff should recognize that clients are unlikely to make sudden or major changes. The most that can be expected is change not recognizing from precontemplation, they have a problem, to contemplation where they consider the possibility of a need to change their lifestyle. If they are already considering a lifestyle change they may be prompted to take some action. If staff have realistic expectations they are less likely to be discouraged.

that most problem drinkers do not fit these stereotypes and are more likely to be susceptible to health education. A greater belief in the effectiveness of health education increases the likelihood of nurses giving health education. Health education to those with alcohol problems needs to be a routine part of treatment, only then will staff find the required time and resources. Education to staff improves knowledge, changes attitudes and increases the likelihood of staff making health promotion interventions.

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J, Lloyd G, Crombie E 1985 Counselling problem drinkers in medical wards: a controlled study. British

Medical Journal 290: 965-967 Cooper D 1993 Education on the rocks. 89(29):

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Dewey KF 1993 Alcohol related attendances at an Accident and Emergency department. The Ulster Medical Journal 62(l): 58-62 J, O’Neill F 1974 Social intervention intoxicated patients seen in an accident

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393-395 Hagemaster J, Handley S, Plumlee A, Sullivan 1993 Developing educational programmes that meet today’s Education Today

CONCLUSION A large number of problem drinkers attend A & E, giving an opportunity for health promotion to this group. Health promotion initiatives that could be offered in A & E include screening and detection of problem drinkers, health education given verbally and with leaflets and advice about where further help can be obtained. The benefits of early health promotion can be demonstrated. Despite this health promotion opportunities are rarely taken inA&E. Nurses are ideally placed to provide health education, being the largest group of health care workers and having a lot of patient contact. There are several barriers to nurses giving health education. These include lack of knowledge, their attitude to problem drinkers, lack of belief in the effectiveness of health education and lack of time and resources. Traditional nurse training gives little attention to alcohol problems or health promotion; lack of knowledge often results in lack of confdence in giving health education. Nurses’ attitudes are often based on negative experiences of those with alcohol problems such as abusive drunks and ‘down and outs’. Health education to these stereotypes is thought, probably realistically, to be ineffective. Nurses need to recognize

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