Research Article: 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

Date Published: May 2, 2012

Publisher: BioMed Central

Author(s): Lauren Matukaitis Broyles, Keri L Rodriguez, Kevin L Kraemer, Mary Ann Sevick, Patrice A Price, Adam J Gordon.


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.

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.

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.

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.

Partial Text

Unhealthy alcohol use includes the spectrum of alcohol consumption ranging from risky drinking, defined as >14 standard drinks/week or >4/occasion for men, and >7 standard drinks/week or >3/occasion for women and healthy individuals age 65 or older, to alcohol use disorders, defined as alcohol abuse and alcohol dependence [1-3]. Unhealthy alcohol use contributes to substantial morbidity, mortality, and social problems, but often goes unrecognized and unaddressed by healthcare providers [4-6]. A set of clinical strategies referred to collectively as alcohol screening, brief intervention, and referral to treatment (SBIRT) is recommended for improving the identification and management of unhealthy alcohol use [2,7-10]. Screening determines the extent of alcohol use and identifies the appropriate level of intervention needed, if any. Brief Intervention (BI) is a non-confrontational, patient-centered approach to risky alcohol use which involves a five- to fifteen-minute semi-structured motivational discussion raising awareness of alcohol-related consequences and motivating a patient toward behavior change [7]. This personalized patient-provider discussion provides the patient with feedback on his/her alcohol use, individualizes the relevant alcohol-related risks, explores readiness to cut-down or quit altogether, and explores concrete self-selected strategies for doing so [7]. BI has been shown to significantly reduce alcohol consumption, morbidity, and healthcare utilization in primary care patients [11,12], and has demonstrated potential, but inconclusive efficacy for patients in emergency and trauma care settings [13-16]. Referral to Treatment (RT) provides those complex patients who need more extensive alcohol-related treatment with referral to specialty care (e.g., addiction medicine/psychiatry providers, detoxification services, outpatient counseling, and self-help groups) [7]. To date, the clinical practices that have been studied most extensively are screening and BI, and evidence in support of RT among patients whose unhealthy alcohol use is identified by population-based screening is lacking. As a result, screening and BI (as opposed to RT) are most widely recommended, and most previous implementation studies have focused on implementation of screening and BI only. Specifically, alcohol screening and BI is included in primary care clinical practice guidelines issued by the United States (U.S.) Preventive Services Task Force, the U.S. Department of Veterans Affairs/Department of Defense [2,8], practice statements issued by the American College of Obstetricians and Gynecologists [17], and trauma center accreditation standards issued by the American College of Surgeons [9].

Alcohol screening, BI, and RT is a set of clinical strategies for the identification and management of unhealthy alcohol use. To date, early attempts to implement alcohol screening and BI have mainly occurred in primary care and have involved substantial challenges [52,53]. Other similar, federally-funded programmatic initiatives have been carried out in emergency/trauma settings [14,54]. Engaging direct healthcare providers in discussions and partnerships early is imperative for effective and sustained implementation of alcohol screening and BI in these and other potential healthcare settings [34]. Inpatient nurses in our study anticipated numerous provider-, patient-, and system-level barriers to nurse-led implementation of alcohol screening, BI, and RT, but also proactively suggested a variety of provider- and system-level facilitators of their delivery as well. To our knowledge, this study is one of only two U.S.-based studies exploring the potential implementation of alcohol screening, BI, and RT by nurses in hospital settings [55], and the only study to explicitly and comprehensively explore the perspectives of front-line providers for the purposes of BI trial design.

Nurse-delivered alcohol screening, BI, and potentially, RT, may be a novel approach to addressing risky alcohol use among hospitalized inpatients in the U.S. Despite anticipated patient-, provider-, and system-level barriers to implementation, nurse-delivered BI may constitute part of a viable model for BI delivery in the inpatient care setting after additional efficacy and effectiveness research is conducted. Calls have been issued for BI researchers to evaluate BI delivery models which are feasible at the pragmatic and economic levels [32]. Front-line healthcare providers can provide valuable perspectives informing the design, feasibility, and delivery of RCT interventions which can facilitate future translation of alcohol screening and BI into inpatient care delivery. Ongoing partnerships between health services researchers and nurses providing direct patient care in inpatient settings will facilitate the development, testing, and potential implementation of rigorous interventions designed to improve the identification, management, and prevention of unhealthy alcohol use in hospitalized patients.

The authors declare that they have no competing interests.

LMB conceived of the study, participated in its design and coordination, performed data analysis/interpretation, and helped to draft, edit, and finalize the manuscript. KLR participated in the design of the study and focus group guide, moderated the focus groups, performed data analysis/interpretation, and helped to draft, edit, and finalize the manuscript. KLK helped to conceive the study, and helped to edit and finalize the manuscript. PAP assisted with data collection, analysis, and interpretation, and helped to edit and finalize the manuscript. MAS assisted with data interpretation and helped to edit and finalize the manuscript. AJG helped conceive the study, assisted in its coordination, and helped to edit and finalize the manuscript. All authors read and approved the final manuscript.

LMB is a Research Health Scientist at the Center for Health Equity Research and Promotion (CHERP), and the VISN 4 Mental Illness Research, Education, and Clinical Center (MIRECC) at the VA Pittsburgh Healthcare System in Pittsburgh, Pennsylvania, USA. She also serves as an Assistant Professor of Medicine at the University of Pittsburgh. Dr. Broyles is the recipient of a 5-year VA Career Development Award from the Health Services Research & Development service of the U.S. Department of Veterans Affairs. She is also the 2009 Council for the Advancement of Nursing Science/American Nurses Foundation (CANS/ANF) Scholar, and serves as at Member-at-Large on the Executive Committee of the Association for Medical Education and Research in Substance Abuse (AMERSA).