research thesis literature review and research proposal by theresa lowry-lehnen specialist nurse...

ENQUIRING INTO HEALTH AND SOCIAL CARE PRACTICE

Specialist Nurse Practitioner Research Thesis

Theresa Lowry- Lehnen

Specialist Nurse Practitioner Surrey University 2005

Systematic Literature Review

&Research ProposalSCREENING AND BRIEF INTERVENTION FOR ALCOHOL MISUSE AND ITS IMPLEMENTATION BY PRACTICE NURSES IN PRIMARY CARE

ABSTRACT

Area of interest: Primary care nurses in the UK and screening and brief intervention (SBI) for alcohol misuse.

Objective: To explore practice-based experiences and views of primary care nurses in the UK with regard to the implementation of SBI for alcohol misuse and how it can be improved.

Research Question: What are the experiences of primary care nurses with regard to SBI for alcohol misuse?

Methodology: Study design is qualitative, using grounded theory approach to data collection and analysis. Semi-structured: in-depth interviews to be conducted with ten nurses from general practice within the Sutton and Merton Primary Care Trust.

Conclusions: The study focuses on the experiences of primary care nurses with regard to screening and brief intervention for alcohol misuse (SBI). It aims to achieve a view from inside, and its inductive approach should lead to concepts and theories about ways to improve the implementation of SBI. It also allows greater participation by nurses, benefiting from their experience in practice and inviting practice-based suggestions.


Surrey University 2005

Theresa Lowry- Lehnen

Specialist Nurse Practitioner

SYSTEMATIC LITERATURE REVIEW

SCREENING AND BRIEF INTERVENTION FOR ALCOHOL MISUSE AND ITS IMPLEMENTATION BY PRACTICE NURSES IN PRIMARY CARE

ABSTRACT


Objective: To identify major themes in the existing research by undertaking a systematic qualitative literature review before embarking on a research proposal.

Guiding question: How can primary care nurses implementation of screening and brief intervention (SBI) for alcohol misuse be improved?

Methods: Systematic literature review, qualitative.

Results: There is little research on the subject. However, a consensus emerges that while practice nurses work in an ideal setting to implement health promotion strategies, they are clearly an under-used resource with regard to screening and brief intervention for alcohol misuse. Why this should be is not entirely clear, but there appear to be certain barriers, such as training, knowledge, perception of the nursing role, and possible negative reaction from some patients.

Conclusions: Given how little research there is, it is not surprising that some of the results are unexpected or even appear to contradict common sense, such as that more training can lead to worse patient management with regard to SBI. However, if the health promotional role of the practice nurse is to be taken seriously, then it is clearly desirable to improve the implementation of SBI for alcohol misuse. How this can be done is not unequivocally clear from the existing research to date. Further research is necessary.

Systematic Literature Review Contents

Contents Page

1. Introduction

1

2. Background

1

Alcohol misuse: Definition and epidemiology

2

Screening and brief intervention (SBI)

3

3. Guiding Question

5

4. Search Strategy

5

5. Literature Review

9

Introduction

9

Background and qualifications of the researchers 10

Introductions and literature reviews

12

Methodology: Design, Strategy, Data collection/analysis

16

Results

20

Discussion and conclusions: Analysis of themes

21

6. Summary and Conclusions 25

Gaps identified in existing research

25

The way forward 25

7. Appendix 1 (Literature Review: Details of Studies)

28

8. Appendix 2 (Bibliography of related research studies)

33

9. Appendix 3 (Alcohol Use Disorders Identification Test)

35

10. References

36

1. INTRODUCTION

This analytical study focuses on screening and brief intervention for alcohol misuse and its implementation by primary care nurses in the UK. A qualitative systematic literature review will be undertaken (Polgar & Thomas 2000). It will identify major themes and gaps in the existing research. First some background and definitions will be given, before a guiding question is formulated and the criteria for the search strategy are set out.2. BACKGROUND

Excessive alcohol use causes immense problems to an individuals health and to the health of society. Up to 22,000 deaths each year are associated with alcohol misuse; nearly six million people in England drink above the governments recommended daily guidelines on some occasions; a quarter of children aged 11 to 15 drink an average of ten units of alcohol per week; 360,000 incidents of domestic violence and half of all violent crimes are alcohol-related, so are up to 17 million days absent from work; 150,000 hospital admissions each year are associated with alcohol misuse; about 70 per cent of A&E attendances between midnight and 5am on weekend nights are alcohol-related (DoH 2004). Alcohol-related health problems have been estimated to add 3 billion annually in secondary health care costs to the NHS (Royal College of Physicians 2001).

Health professionals play an important role in preventing, detecting and treating alcohol misuse. But Alcohol Concern (2003) has warned that six million heavy drinkers risk developing health problems because the primary care sector is not properly equipped.

The current Labour Government describes its Alcohol Harm Reduction Strategy as the first coordinated strategy on alcohol misuse in England. It points out the need to tackle alcohol problems at an early stage, emphasising screening and brief intervention in both primary care and hospital settings (Cabinet Office 2004).

Alcohol misuse: Definition and epidemiology

Alcohol misuse is defined as an over-reliance on alcohol for its mood-altering benefits or the repeated use of alcohol (without abuse or dependency) to cope with problems (Carter Martin et al. 1999). Alcohol abuse occurs when patients are unable to fulfil major role obligations. Alcohol dependency is defined by three or more of such symptoms as increased tolerance for alcohol, the development of withdrawal symptoms, uncontrolled use and persistent desire, a great amount of time spent using or recovering from alcohol use, reduced activities due to alcohol use, and continued use despite better knowledge (Carter Martin et al. 1999).

According to the Office of National Statistics (2000), 27 per cent of men and 15 per cent of women drink above the recommended number of weekly units for sensible drinking, and one in thirteen people is dependent on alcohol in Britain, twice as many as are dependent on all other forms of drugs. Alcohol misuse is estimated to account for between two and twelve per cent of total NHS expenditure on hospitals (Royal College of Physicians 2001).

While moderate alcohol consumption can provide some protection against coronary heart disease, heavy drinking leads directly to health problems, such as cirrhosis of the liver, and can contribute to certain cancers, to stroke, and to mental illness, quite apart from the effects it has on families and communities (DoH 1999).

Screening and brief intervention (SBI)

Babor and Higgins-Biddle (2000) define screening as a process to differentiate people who have, or are at risk of having, a medical condition from those who do not. In the context of this analysis, screening should detect drinking patterns that present a risk. The World Health Organisation (WHO) has developed an assessment tool designed for the early identification of risk drinkers: the Alcohol Use Disorder Identification Test (AUDIT), said to be the most studied screening tool for detecting alcohol-related problems in primary care settings (Appendix 3) (Bohn et al. 1995, USPSTF 2004).

Brief intervention means an activity directed at people who engage in risky drinking. Such activities (e.g. practical advice, health education) are of low intensity and short duration and are intended for early intervention. They are not to be confused with specialised treatment techniques (Babor & Higgins-Biddle 2000).

In 2001, an overview of brief interventions described them as one of the newer treatment modalities and pointed out their cost-effectiveness, but also stated that they are intended for those who present with less severe drinking problems (Osborn 2001).

The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioural counselling interventions in primary care settings to reduce alcohol misuse (USPSTF 2004). Many other sources assert the importance and effectiveness of SBI, e.g. Kaner et al. (2003), Alcohol Concern (2000). But there is also a dissenting voice; according to Beich et al (2003) screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. The authors meta-analysis raises questions about the feasibility of screening in general practice for excessive use of alcohol. However, it must be asked whether screening as a method is ineffective or whether screening is not carried out in an effective manner. To assess the effectiveness of SBI properly, it is necessary to consider the quantity and quality of screening. If SBI is done haphazardly, then its effectiveness must suffer.

A consensus has developed that SBI can have positive effects. Screening and brief intervention has been identified as a health promotion tool by the Department of Health as well as such organisations as Alcohol Concern. Early detection of potential risk-drinking seems to be the key to reducing alcohol-related problems (Cabinet Office 2004, Kaner et al. 2003, Alcohol Concern 2000, Alcohol Concern 2003).

3. GUIDING QUESTION

To summarise, screening and brief intervention by nurses in primary care will refer to the early identification of potential risk-drinking in patients presenting to the surgery and to the practical advice and health education which can typically be given in a routine appointment. Screening and brief intervention for alcohol misuse by nurses in primary care is said to be effective, but it does not seem to happen often enough (Kaner et al 2003, Alcohol Concern 2003).

How can primary care nurses implementation of SBI for alcohol misuse be improved?

4. SEARCH STRATEGY

Initial reading of related articles led to the identification of relevant keywords: alcohol, primary care, screening, intervention and nurses. A systematic approach, starting with the first keyword and then adding others, eliminated less relevant articles in the process. Table 1 shows the search engines accessed via the Athens password and the results for each combination of keywords in two successive searches. The second search shows results without the exclusion criteria full text only and research only. EBSCO Host did not offer a full text only option.TABLE 1: SEARCH RESULTS

BNICINAHL

Search engine First search Second searchSearch engine First search Second search

Alcohol1261420Alcohol5967546

+ Primary Care015+ Primary Care21195

+ Screening03+ Screening858

+ Intervention01+ Intervention222

+ Nurses00+ Nurses12

EBSCO HOST MEDLINE R

Search engine First search Search engine First search Second search

Alcohol1843Alcohol7174105,612




+ Nurses0+ Nurses15

PROQUESTPUBMED (via BioMed Central)

Search engine First search Second searchSearch engine First search Second search

Alcohol12,14512,987Alcohol3093486,015




+ Nurses56+ Nurses011

The first search revealed that the full text requirement was exclusive to a fault. Relevant studies were often available only in abstract form and accessing the full text required online subscriptions. For the final selection of literature, the results of the second search are therefore important. They include abstracts of research projects, and the full articles were obtained directly from the respective journals. To avoid overlooking relevant material, all articles and references were scanned once the search brought their number down to a manageable level.

Since the research interest in SBI with regard to nurses in primary care as well as the government initiatives mentioned in the introduction have been relatively recent, it was decided to limit the search to publications from the year 1995 onwards. Indeed, the earliest study which met the search criteria was undertaken in 1995 and not published until 1998 (Deehan et al. 1998).

Many articles were professional opinions, meta-analyses or summaries of previous studies. It was decided to base the literature review on original research in order to be able to determine the reliability and validity of the studies. This in turn led to the use only of articles published in professional journals.

It was also decided to concentrate on UK studies. Two studies are relevant in a wider sense. However, they concern primary care nurses in other countries (Aalto et al. 2001, Tomson et al. 1998), and not enough was known about the specific circumstances in those primary care sectors (e.g. government policies, guidelines, role of practice nurses) and how they compare to the UK.

Similarly, the main focus was to be on research directly relating to the role of nurses in primary care. Most of the research to date looks at the role of GPs. These studies are useful for background, and a list of the more relevant ones is included in Appendix 2. But their inclusion would have blurred the focus of the review. One other study concerned nurses but concentrated on a hospital ward setting and had only limited relevance (Brown et al. 1997). Table 2 lists the inclusion and exclusion criteria applied in this search.

TABLE 2: CRITERIA FOR INCLUSION AND EXCLUSION

INCLUSION CRITERIA

Studies relating to screening and brief intervention for alcohol misuse, as this is the focus of the literature review.

Original research only, to allow reliability and validity to be determined

Publication from 1995 onwards, to ensure currency.

British studies only, as the context of foreign studies may not be known.

Studies relating to role of primary care nurses only, as this is the focus of the review.

EXCLUSION CRITERIA

No studies relating to role of GPs, as they would blur the focus of this review.

No studies before 1995, as these would not take into account current policies.

No meta-analyses, summaries of studies, or professional opinions, in order to improve validity.

This literature review is therefore based on published research in the form of five articles (Table 3) giving an account of original studies concerning the role of primary care nurses in the UK with regard to screening and brief interventions for alcohol misuse. TABLE 3: STUDIES INCLUDED IN LITERATURE REVIEW

Deehan A, Templeton L, Taylor C, Drummond C, Strang J 1998 Are practice nurses an unexplored resource in the identification and management of alcohol misuse? Results from a study of practice nurses in England and Wales in 1995 Journal of Advanced Nursing September 1998, Vol 28, Issue 3: 592-597

Kaner E, Lock C, Heather N, McNamee P, Bond S 2003 Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial Patient Education and Counselling 2003, Vol 51: 277-284

Lock C, Kaner E, Lamont S, Bond S 2002 A qualitative study of nurses attitudes and practices regarding brief alcohol intervention in primary health care Journal of Advanced Nursing Vol 39, Issue 4: 333-342

Lock C, Kaner E 2004 Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice? Family Practice 2004, Vol 21, No 3: 270-275

Owens L, Gilmore IT, Pirmohamed M 2000 General practice nurses knowledge of alcohol use and misuse: a questionnaire survey Alcohol and Alcoholism 2000 Vol 35, No 3: 259-262

5. LITERATURE REVIEWIntroduction

Mulrow (1994) states that systematic literature reviews are invaluable scientific activities, efficiently integrating existing information and providing data for rational decision making. They are vital before embarking on a new study (Parahoo 1997). Mason (1993) describes it as good practice to be explicit about what previous researchers have done. Reviews serve to highlight both strengths and weaknesses in previous studies (Hek et al. 1996). They allow the reviewer to identify areas which may need further research.

According to Dooley (1984, cited by Polgar & Thomas 2000), a qualitative review selects key features of related publications which are presented in table form, while a quantitative review condenses results from several publications into a single statistic. Given the nature of the guiding question and the fact that the selected studies vary slightly in their focus and strategy, a qualitative approach has been chosen for this review.

There are a number of possible frameworks (Polgar & Thomas 2000, Mason 1993, Gould 1994, Hek et al. 1996). This review is based on the framework prepared by Maskell (2000): First, the background and qualifications of the researchers will be looked at. Then the introductions and the methodology sections, including design and strategy of the studies, will be examined. Finally, the results sections and the researchers conclusions will be analysed, allowing a detailed analysis of the themes emerging from the studies in relation to the guiding question. Appendix 1 shows a detailed presentation of the studies in table form.

Background and Qualifications of the Researchers

The selected studies have clear titles, giving good indications of their content. The background, qualifications, current posts and contact details of the researchers are clearly stated, and it appears that all researchers have sufficient expertise. They have academic backgrounds in health, are research specialists, and some are specialists in addiction studies.

All five studies are published in professional medical journals, indicating when they were received and accepted for publication. Kaner et al. (2003), Lock and Kaner (2004) and Owens et al. (2000) underwent some revision before publication.

Funding and grants were given by the government or other public bodies, and this is clearly stated in each study. Deehan et al. (1998) were supported by a grant from the Department of Health. Owens et al. (2000) received funding from Liverpool Health Authority and NHS Executive North West. The other three studies were supported by a grant from the Alcohol Education and Research Council. While there is no evidence of undue influence by any vested interest, one should keep in mind the source of the funding. Given that government and public funding is involved, it is legitimate to ask whether the researchers accept current government policies or whether they are inclined to question them, if appropriate. The current government, in its health frameworks and targets, wants SBI by primary care nurses to be part of national health promotion (DoH 2004).

Some of the researchers were involved in more than one study included in this review. Lock and Kaner are co-authors of three of the studies: Kaner et al. (2003), Lock and Kaner (2004), and Lock et al. (2002). Bond is a co-author of both Kaner et al. (2003) and Lock et al. (2002). This is not necessarily a problem even though for the purpose of this review a larger number of perspectives would have been preferable.

Introductions and Literature Reviews

All five studies include abstracts and set out clearly their reasons and aims. Previous studies, secondary literature as well as government publications and policies, where they are seen to be relevant, are mentioned. They appear to form an appropriate background.

It is helpful to look in some detail at the stated aims in order to be able to assess how they relate to the guiding question. This will be done in chronological order since it is assumed that each research project takes into account previous studies.

Deehan et al. (1998), state that their paper presents findings from the first national study of practice nurses work with alcohol misusers and presents the only data available currently on this issue. Indeed, their study, carried out in 1995, is cited by the other four research papers. Deehan et al. (1998) focus on government literature and policies with regard to health promotion targets and the role of the practice nurse, including detection and treatment of alcohol misuse. They ask whether practice nurses are an untapped resource in meeting government targets for the reduction of alcohol consumption.

Owens et al. (2000) also focus on government strategies for the NHS and health promotion as a key element of the primary care nurses role. With regard to SBI for alcohol misuse, they say that it is unclear whether practice nurses are willing and have the knowledge to take on such a role. Consequently, Owens et al. (2000) aim to determine knowledge and attitudes among primary care nurses with regard to SBI for alcohol misuse.

Lock et al. (2002) aim to explore primary health care nurses attitudes and practices regarding brief alcohol intervention in order to understand why it is under-exploited. They also state that their study is part of a wider programme aimed at promoting SBI by primary care nurses, and as has been pointed out three of the authors of this study have co-authored other research included in this review. The researchers state that there is strong circumstantial evidence suggesting that nurses can be effective at reducing excessive drinking in primary care patients.

Kaner et al. (2003) give as the purpose of their study an evaluation of the clinical impact and cost-effectiveness of an intervention to promote SBI by primary care nurses. Citing US and Australian studies, they say that nurse involvement in alcohol intervention remains low even though SBI by primary care nurses has been shown to be effective at reducing excessive drinking. While this appears to be an acceptable statement, it should again be pointed out that there is little UK-based evidence available which focuses on practice nurses. It is therefore no surprise that the authors have to resort to non-UK studies. However, better knowledge of the practices within the health services of other countries would be necessary in order to evaluate such studies properly and understand their relevance to the primary care setting in the UK. It is worth pointing out that the authors of this study have decided to include the question of cost-effectiveness. This may imply some outside, non-scientific interest. Best-available evidence should not be diluted by issues of cost-effectiveness, although financial considerations are of course important in the implementation of any health promotion.

Lock and Kaner (2004), aim to investigate whether non-clinical factors such as the characteristics of patients and nurses influence the provision of brief alcohol intervention. They cite evidence relating to GPs and say that much less is known about nurse practice.

Both Deehan et al. (1998) and Owens et al. (2000) emphasise current government policies and the developing role of the practice nurse. There is little or no discussion about previous studies examining the effectiveness of SBI. Instead, it is taken as given that the implementation of SBI in the primary care sector is desirable. Owens et al. (2000) in particular speak of the potential for primary care nurses to have a major role in the detection and treatment of alcohol misuse, without citing any relevant research studies. As we have seen, such research does exist, but there also appears to be conflicting, or at least ambiguous, evidence (Beich et al. 2003).

Lock et al. (2002), Kaner et al. (2003) and Lock and Kaner (2004) cite previous studies concerning the effectiveness of SBI and point out the lack of research concerning primary care nurse practice, especially in the UK. They accept that practice nurses should be more involved in SBI as part of their role in health promotion.

Deehan et al. (1998) as well as Lock and Kaner (2004) pose clear research questions in their titles, thus making their studies easily accessible to the reader and improving validity. While the other studies prefer to state aims and objectives, their statements are judged sufficiently clear not to reduce validity (Parahoo 1997).

The studies under review therefore focus on the implementation, or lack of implementation, of SBI by primary care nurses, who are seen to be an underused resource. Emphasis is given to attitudes and knowledge, possible barriers and promotion of brief alcohol intervention by nurses in primary care.

It appears that in each case the topic was chosen because there is a stated government policy to achieve a reduction in alcohol consumption by strengthening health promotion, and especially by promoting the implementation of SBI in the primary care sector. However, while there is some research concerning either the effectiveness of SBI or its implementation by GPs, very little evidence exists on this issue concerning the role of practice nurses in the UK. Therefore, each of the five studies aims to help fill a gap.

Methodology: Design, Strategy, Data Collection and Data Analysis

The methodology, including design, strategies and methods of collection and analysis of the data, is a crucial part of any study. According to Polgar and Thomas (2000), it should enable another researcher to replicate an investigation. It should also allow a judgement about reliability and validity.

Before considering the studies in more detail, it is useful to provide definitions of reliability and validity. Reliability refers to the consistency of a particular method in measuring or observing the same phenomena (Parahoo 1997: 38). Validity refers to the extent to which a method measures what it is supposed to measure (Parahoo 1997). Hek et al (1996) state that a valid instrument will therefore measure what it is supposed to measure, and a reliable instrument will always measure what it is supposed to measure. If a method is not reliable, it cannot be valid. On the other hand, if a method is not valid, then its reliability becomes irrelevant (Gibbons 1998).

All studies clearly describe their research question as well as their design and strategy. The researchers define the areas of their studies and also point out possible limitations. They describe the setting in which the research was undertaken, who the subjects were, how they were chosen, and the response rate, where appropriate. Only Kaner et al. (2003) mention approval of their study by an ethics committee.

Four of the studies apply a quantitative approach and are designed either as a postal survey or as an experimental trial, using questionnaires as the data collection tool. While this appears appropriate in most cases, Lock and Kaner (2004) admit that even though there was significant variation between nurses in their tendency to offer brief interventions, their study was unable to identify any independent nurse characteristics which could predict when an intervention would be offered. This has implications with regard to the validity of their study: The authors themselves state that a qualitative research design may be able to explore this area better. It therefore appears that their chosen research design has only limited validity with regard to the research question they have posed, namely: Do non-clinical factors influence practice? While their study answers this question in the affirmative, the research design does not allow the authors to explore the non-clinical factors in more detail.

A qualitative approach is chosen by Lock et al. (2002). They use semi-structured in-depth interviews for data collection and the grounded theory approach for analysis, and this is appropriate to their research aim, i.e. to explore primary health care nurses attitudes and practices regarding SBI.

The other studies mostly use questionnaires. The validity of a questionnaire is determined by the extent to which it addresses the research question, i.e. measures what it is supposed to measure. Its reliability refers to the consistency with which respondents understand, and respond to, all the questions (Parahoo 1997). Deehan et al. (1998) and Owens et al. (2000) clearly state that they have used pilot studies, thus allowing them to correct problems and revise their questionnaires in order to improve reliability and validity. However, as Parahoo (1997) points out, with self-administered questionnaires there is no opportunity to ask respondents to elaborate and little is known about the context in which the questions were answered. Although more time-intensive, a qualitative approach, using semi-structured interviews for data collection, may have provided deeper insight into why nurses are an under-used resource in the context of this review. The researchers acknowledge this and point out the need for further research.

Given the nature of the study by Deehan et al. (1998), their sample size is by far the biggest, with 4467 nurses of whom 1908 responded to a structured postal questionnaire. While Lock and Kaner (2004) use a sample of 128 nurses, their approach includes 5541 anonymized carbon copies of screening questionnaires carried out by the nurses over three months. The cluster randomised controlled trial undertaken by Kaner et al. (2003) is based on a sample divided into three groups: a control group provided with an SBI programme and guidelines, a group provided with additional training, and a group provided with both training and support. This study not only aims to research the clinical impact of SBI but also its cost-effectiveness. It uses anonymous copies of completed screening questionnaires as well as evaluation questionnaires for self-reporting by nurses.

The qualitative approach chosen by Lock et al. (2002), on the other hand, concentrates on a relatively small sample of 24 nurses. The researchers state that the nurses are based in practices previously involved in a GP-led brief alcohol intervention trial. It is difficult to determine whether this may have influenced the respondents and introduced some bias. It is possible that some of the respondents knowledge, views and attitudes may have been based on previous experience in a trial situation rather than in everyday clinical practice. However, the authors address this issue, stating that they obtained no data to suggest such bias. The authors also point out that the interviewer and main data analyst were different individuals. This may have implications for the validity of their study, but the researchers assert that they introduced measures to reduce the likelihood of misinterpretation.

It is worth pointing out some further potential limitations: Deehan et al. (1998) use a large sample, and while this provides a good overview, it is difficult to say whether regional characteristics should have been taken into account. Furthermore, the study presented in 1998 had been carried out in 1995, and it is difficult to judge how much may have changed in that period.

The other four studies concentrate on smaller geographical areas. Owens et al. (2000) look at the Liverpool area, whereas the other three studies focus on the Northeast of England. Indeed, Lock et al. (2002), Kaner et al. (2003) and Lock and Kaner (2004) not only concentrate on the same geographical area, there is also some overlap in their sample groups. Lock and Kaner (2004) make clear that their study is a follow-on from Kaner et al. (2003). This is not necessarily a problem. However, it must raise questions about how representative these studies are, not only because of their geographical limits, but also because at least some of the nurses will have taken part in previous, similar studies, and it is impossible to determine how this may have influenced both their knowledge of the research area and their responses to the questionnaires. Given that the study is part of a wider research project, the question must also be asked how much the researchers are influenced by the aims and results of previous studies. All this may have an impact on the rigour of the studies as it may have implications for avoiding bias (Parahoo 1997).

Results

The results section must give a clear account of the collected data in order to set the scene for their interpretation and any conclusions to be drawn from them. The data must also be relevant to the research question.

Given the qualitative approach chosen by Lock et al. (2002), they offer a more interpretative analysis of the data (Polgar & Thomas 2000). Each key section of their research area is described briefly, allowing other researchers to see how categories were identified. For example, the authors conclude that there are many opportunities to implement SBI for alcohol misuse in nurse practice and that nurses accept brief alcohol intervention as a legitimate part of their role. However, there appear to be some barriers, such as confusion about alcohol-related issues and nurses and patients reactions to the subject of alcohol and drinking behaviour. One nurse is quoted as saying that alcohol consumption is the hardest subject to tackle in practice.

Given the quantitative nature of the other studies, their results sections use tables and graphs to present data. However, a considerable knowledge in the field of statistics is necessary in order to evaluate the results in any great detail. Nonetheless, the data can be linked back to the original research question, they are presented clearly, and as far as can be judged, comprehensively.

While the results presented by Deehan et al. (1998) and Owens et al. (2000) appear to be relatively straightforward, both Kaner et al. (2003) and Lock and Kaner (2004) require more careful analysis. In the first case, the aim is not only to evaluate the clinical impact of SBI, but also its cost-effectiveness. In the latter case, the data refer to 5541 copies of completed screening tests as well as to questionnaires used by nurses for self-reporting. The results section therefore has to consider separate sets of data in order to answer the research question.

Discussion and Conclusions: Analysis of Themes

This final section both summarises the research undertaken and points the way forward. It is therefore helpful to look at the selected literature in some detail in order to identify and analyse major themes emerging from the studies and detect possible gaps in the research.

Deehan et al. (1998) state that primary care is an ideal setting for health promotion and that the role of the practice nurse as health promoter is important. However, based on the results of their study, they find that primary care nurses are an under-utilized resource within the wider political context of Health of the Nation(DoH 1992) alcohol targets. They identify training needs and the need for support services and for empowerment of practice nurses, and they point out that practice nurses need to be made aware of the value of their health promotion role. They also state that, at the time, their study presents the only available data on this issue. Their conclusions are therefore given in the context of the developing role of the practice nurse, and while this study is valuable in a pioneering sense, it is difficult to evaluate its significance in 2005, given that the role of the practice nurse has undergone significant changes and development since 1998. It is therefore difficult to say how much of this study still applies today.

Owens et al. (2000) refer to Deehan et al. (1998) at the beginning of their discussion. They conclude that while nurses are an unexplored resource in the identification and management of alcohol misuse, they are happy to give advice and want to become involved in the care of patients. However, many nurses also appear to lack the knowledge to give appropriate advice. The researchers point out that in their study only a small number of nurses from one health district were questioned. They therefore conclude that the results should be viewed as preliminary and similar surveys should be repeated elsewhere in the country. Like Deehan et al. (1998), they place their research within the context of the Health of the Nation document (DoH 1992), and they point out training needs for practice nurses as they identify a knowledge and skills gap in relation to advice given about alcohol consumption (Owens et al. 2000). That conclusion, and the recommendation for appropriate training, is consistent both with the results of their own survey and the research previously undertaken by Deehan et al. (1998). However, an updated study would be helpful to determine whether there have been changes in the last years.

Lock et al. (2002) have undertaken the only qualitative study in this literature review. Their approach also leads to the conclusion that more attention should be given to providing nurses with better preparation and support to carry out health promotion in the context of alcohol misuse. Lock et al. (2002) do not fail to point out that their study was conducted among nurses with previous experience of SBI, and from one geographical area, and that these factors may have influenced the responses and generalisability of the study. However, they add that they obtained no data suggesting this was the case, even though they admit that a replication of the study with a wider sample would be of merit.

The research undertaken by Kaner et al. (2003) marks a further step. Based on the previous studies, this research focuses on promoting SBI by primary care nurses and aims to evaluate both its clinical impact and cost-effectiveness. Their cluster randomised controlled trial shows that the use of more intensive promotional strategies has increased the extent that primary care nurses engaged in SBI. However, the researchers report that there was a trade-off: The control group showed the most appropriate patient management. In other words, nurses carrying out more SBI often did this less accurately (Kaner et al. 2003). The researchers say it is not clear why this was the case. They say their study has demonstrated a means of encouraging nurses to become involved in SBI but future research is needed to improve the appropriateness of brief intervention delivery. They also conclude that nurses can be a cost-effective option in the delivery of SBI.

It is interesting to note the conclusion that the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care (Kaner et al. 2003). This appears to contradict earlier conclusions that more specific training is necessary. It is not clear from the research undertaken by Kaner et al. (2003) why additional training appears to have had a counterproductive effect. Further research is necessary.

Finally, Lock and Kaner (2004) reinforce the point that there is a need to improve the accuracy of delivery of SBI. They conclude that both patient and nurse factors contribute to a selective provision of brief intervention in primary care. There may be concern among nurses about negative reactions from patients to receiving preventative advice. Only two thirds of risk drinkers identified by the nurses in this trial actually received an intervention. Ten per cent of non-risk drinkers were given an intervention. With regard to nurse characteristics influencing the delivery of SBI, the results are equivocal. The researchers point out limitations in saying that some characteristics which may offer an explanation may not have been measured in the study and that a qualitative research design may be able to explore this in more detail.

6. SUMMARY AND CONCLUSIONS

Gaps Identified in the Existing Research

This literature review has identified a number of gaps in the existing research, beginning with the fact that there is very little UK based research with regard to primary care nurses implementation of SBI for alcohol misuse. Owens et al. (2000), for example, point out that their results should be viewed as preliminary and other surveys should be repeated elsewhere in the country. Similarly Lock et al. (2002), state that a replication of their qualitative study would be of merit. This is true especially in the light of the developing role of the practice nurse. Little is known so far about how current government policies and publications with regard to SBI for alcohol misuse in the primary care sector have influenced the knowledge, skills and practices of primary care nurses in this field. Moreover, while there is a consensus that primary care nurses are an underused resource in this area, there is little conclusive evidence how this might be changed. While some studies highlight the need for more specific training (Deehan et al. 1998, Owens et al. 2000), others provide contradictory evidence with regard to training needs (Kaner et al. 2003).

The Way Forward

Given both the changing role of the practice nurse, in particular regarding health promotion, and concerns about excessive alcohol consumption, it is perhaps surprising that relatively little research has been undertaken in this field in the UK. One reason may be that there is a lack of funding for such research.

The primary care sector is an important setting for the early detection of alcohol misuse. There is also wide agreement that SBI in the primary care setting can have a positive impact. However, the existing research demonstrates that there is no consistent approach to the delivery of SBI by primary care nurses. While there appears to be a shortcoming with regard to training and support, there is no unequivocal evidence showing what kind of training and support would improve the implementation of SBI. In fact, studies dealing with this issue appear to produce unexpected results: Nurses who received training seem to have been less effective in the delivery of SBI than those who only received written guidelines (Kaner et al. 2003).

Practice nurses are aware of their health promotional role. They are also aware of the health risks of excessive alcohol consumption and of the tested methods for screening and brief intervention. However, various studies have concluded that practice nurses are an unexplored and under-utilized resource in this field and that better and more consistent training is necessary. That there is scope for further research is clear since some of the existing studies may by now be dated; others have yielded unexpected results which appear to contradict common sense, i.e. that more training can lead to worse results (Kaner et al. 2003).

It may be helpful to widen a meta-analysis like this one in order to include GPs in the UK and the experience of primary care nurses and GPs in other countries. It would be interesting to see whether such a wider analysis can lead to further conclusions.

For now, two major themes have been identified: the need for a more consistent approach to SBI by primary care nurses and the need for further qualitative research. Quantitative studies have been helpful in identifying problems. However, in the search for solutions they have produced equivocal results. A qualitative approach would allow greater nurse involvement, giving nurses a more active role and thus perhaps helping to identify some of the barriers which appear to exist with regard to SBI for alcohol misuse.

APPENDIX 1

LITERATURE REVIEW: DETAILS OF STUDIES:

Funding, Methodology, Reliability and Validity, Results, Main Themes/Implications for Practice

DATEAUTHORSTITLE/

SOURCEFUNDINGMETHODOLOGYRELIABILITY AND VALIDITYRESULTSMAIN THEMES/

IMPLICATIONS FOR PRACTICE

1998Deehan A, Templeton L, Taylor C, Drummond C, Strang JAre practice nurses an unexplored resource in the identification and management of alcohol misuse? Results from a study of practice nurses in England and Wales in 1995

Journal of Advanced NursingGrant from Department of Health Quantitative. Non-experimental. Data collected by postal questionnaire from nurses in a 50% random sample of 1852 practices.

43% of nurses responded from 62% of targeted practices, i.e. 1908 out of a total of 4467 nurses. Significance tests carried out by multiple regression analysisDraft of questionnaire was piloted for understanding, ambiguity and relevance, then revised. Questionnaire designed to collect data on practice policy, clinical work with patients, demographic profile of patients, attitudinal data. Study undertaken in 1995.Respondents reported identifying a mean of 3.1% patients per month who were drinking above recommended limits. These patients tended to be male, aged over 40. 51.5% of patients were identified during routine screening. Less than 5% were self-presenting.

Main methods used to detect alcohol misusing patients were assessment interviews and screening questionnaires.

Very little intervention undertaken by nurses except for referral to GP. Only 3.7% of patients were referred to specialist services. While identification rate is low, nearly 75% of patients are identified by nurses through screening methods.Primary care is ideal setting for early detection. But current levels of detection by practice nurses are low. Practices nurses are a major under-used resource for SBI within primary care. Work in identifying alcohol misuse among patients must be developed as a matter of urgency. More emphasis must be placed on valuable contribution practice nurses can make, particularly through use of screening instruments and brief interventions. Practice nurses should receive specific training. Clear objectives for professional development are necessary. There needs to be provision of support services. Empowerment of nurses, i.e. more autonomy, is necessary, to allow them to become more competent and confident when implementing SBI.

DATEAUTHORSTITLE/



2000Owens L, Gilmore I T, Pirmohamed MGeneral practice nurses knowledge of alcohol use and misuse: a questionnaire survey

Alcohol and AlcoholismFunding from Liverpool Health Authority and NHS Executive North West Quantitative. Non-experimental. Postal questionnaire survey of 132 practice nurses in Liverpool. 80 nurses (61%) returned questionnaire after first mailing, a further 21 nurses responded after second mailing. Final response rate is 76.5%. Data entered onto a Microsoft Access database for analysis.Questionnaire piloted in random sample of ten practice nurses. Designed to collect data on knowledge and views of nurses regarding sensible levels of alcohol consumption, current practice in dealing with alcohol misusing patients, attitudes towards getting involved in further care. Not all respondents answered every question. Only a number of nurses from one health district were questioned. Results therefore preliminary. Authors recommend similar surveys in other parts of the country94% of respondents felt that alcohol misuse is a common problem in the community. Almost all nurses take alcohol histories in the clinics they run. 53.5% felt they had sufficient knowledge to give advice on sensible drinking. However, of these, 65% (45%) indicated incorrect sensible limits for men (women), showing a knowledge gap. 92% of nurses would welcome specific training for alcohol misuse screening and intervention. 96% of nurses routinely gave advice on sensible levels of alcohol consumption, but only 34% (60%) gave advice to men (women) which was in keeping with guidelines specified by the Department of Health.Knowledge and skills gap exists in delivery of effective SBI. Most nurses requested further training to develop screening and health promotional roles and to become involved in management of alcohol misusing patients. Appropriate training and adequate back-up facilities are needed. Many nurses lack knowledge to give appropriate advice. Only one in four nurses knew correct limits for sensible drinking as recommended by the Department of Health at the time. Conflicting advice from different bodies may have led to confusion.

DATEAUTHORSTITLE/



2002Lock C A, Kaner E, Lamont S, Bond SA qualitative study of nurses attitudes and practices regarding brief alcohol intervention in primary care

Journal of Advanced NursingGrant from Alcohol Education and Research CouncilQualitative study design, using grounded theory approach to data collection and analysis. Semi-structured interviews were conducted with 24 nurses from practices previously involved in a GP-led brief alcohol intervention trial in the Northeast of England, with anonymised transcripts. Combination of convenience and purposive sampling. Initial sample of ten nurses who had been involved in previous trial was supplemented with a further 14 nurses, purposively sampled to provide range of new perspectives on issues emerging from on-going analysis, until data saturation was judged to have occurred.Study aims to examine primary care nurses attitudes towards alcohol intervention, including perceived barriers and facilitating factors. Sampling method provided sample with age range from 30 to 57, from urban, rural and mixed settings, with primary care experience ranging from 2 to 24 years, and experience of brief alcohol intervention judged to be none, low, medium or high. Authors assert that full and frank exchanges occurred during interviews, enhancing rigour. Report containing data analysis was sent to all nurses for further comment. Authors assert they obtained no data suggesting bias emerging from the fact that nurses had previous experience in an intervention trial. Interviewer and main data analyst were different individuals, but authors assert they introduced measures to reduce the likelihood of misinterpretation.Consensus exists about wealth of opportunities for screening and brief intervention in nurse practice. All nurses accepted SBI for alcohol misuse as part of their role. Nurses reported negative patient reactions, ranging from aggression to embarrassment and guilt. There was some confusion about alcohol issues, such as sensible limits and health effects. Most nurses reported having received no specific training.Most primary care nurses have received little or no preparation for implementing alcohol intervention. Nurses are therefore at a disadvantage since alcohol consumption is a confusing and emotive area for both health professionals and patients. Nurses recognise alcohol misuse as a health issue with great relevance to their work and SBI as a legitimate part of their role, but they need training in intervention skills, need to enhance their confidence regarding intervention and need support to help deal with negative patient reactions.

DATEAUTHORSTITLE/



2003Kaner E, Lock C, Heather N, McNamee P, Bond SPromoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial

Patient Education and CounselingGrant from Alcohol Education and Research CouncilQuantitative. Experimental. Cluster randomised controlled trial: written guidelines (controls, n=76); outreach training (n=68); training plus telephone-based support (n=68). Sample pool involved 312 practices from seven health districts in the North of England, of which nurses in 212 practices agreed to implement SBI. Nurses directed to use Alcohol Use Disorders Identification Test (AUDIT) and give brief intervention to all risk drinkers identified. Baseline questionnaire to record personal and workplace details, follow-up questionnaire after three months. After three months, anonymous carbon copies of screening questionnaires were collected. These were scored by research team to identify risk drinkers and patients receiving brief interventions. Ethical approval was obtained from relevant ethics committees.Study purpose is to evaluate clinical impact of three intensities of an intervention to promote SBI by nurses in primary care. Reliability and validity demonstrated by authors.After three months, only 39% of controls implemented SBI programme, compared to 74% of nurses in trained practices and 71% in trained and supported practices. But there was a trade-off between extent and appropriateness of brief intervention delivery: Controls displayed the least errors in overall patient management. More intensive promotional strategies increased implementation of SBI by nurses. But balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care. Nurses carrying out more SBI often did this less accurately. Reasons for this not made clear by study. Authors state that future research should be aimed at improving appropriateness of brief intervention delivery.

DATEAUTHORSTITLE/



2004Lock C A, Kaner EImplement-ation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?

Family PracticeGrant from Alcohol Education and Research CouncilQuantitative. Patient screening data provided by 128 practice nurses from general practices across Northern England. 5541 anonymized carbon copies of completed screening questionnaires collected after three months. Nurses were subjects of previous trial (reported by Kaner et al. 2003, see above). They were asked to screen patients aged over 16 and follow an identical structured protocol to give a brief intervention to all risk drinkers. Screening questionnaires analysed by logistic regression analysis.Study aims to investigate if patient characteristics, nurse characteristics and practice factors influence provision of brief alcohol intervention by primary care nurses. Authors state their study was unable to identify any independent nurse characteristics which could predict a brief intervention, even though there was significant variation between nurses in their tendency to offer interventions. This has implications with regard to validity of study given the stated aims. The authors themselves state that a qualitative research design may be able to explore this area in more detail.Screening identified 1500 risk drinkers, but only 962 (62%) received a brief intervention. In addition, 402 non-risk drinkers received an intervention. In total, 976 patients (18%) did not receive appropriate management. Study did not identify any independent nurse characteristics predicting implementation of brief intervention. Male risk drinkers were most likely to receive brief intervention.Patient and nurse factors contribute to selective provision of brief intervention in primary care. Accuracy of delivery must be improved. Authors state that research aimed at implementing evidence-based health care may need to take account of non-clinical factors influencing intervention delivery and that a qualitative research design may be able to explore this in more detail.

8. APPENDIX 2

Bibliography of related research studies which did not meet inclusion criteria

Kaner E, Heather N, Mc Avoy BR, Lock C, Gilvarry E 1999 Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners Alcohol and Alcoholism 1999, Vol 34, No 4: 559-566

Mc Cambridge J, Platts S, Whooley D, Strang J 2004 Encouraging GP alcohol intervention: pilot study of change-orientated reflective listening Alcohol & Alcoholism 2004 Vol 39, No 2: 146-149

Aalto M, Seppa K, Mattila P, Mustonen H, Ruuth K, Hyvarinen H, Pulkkinen H, Alho H, Sillanaukee P 2001 Brief intervention for male heavy drinkers in routine general practice: a three-year randomized controlled study Alcohol and Alcoholism 2001, Vol 36, No 3: 224-230

Anderson P, Kaner E, Wutzke S, Funk M, Heather N, Wensing M, Grol R, Gual A, Pas L 2004 Attitudes and managing alcohol problems in general practice: an interaction analysis based on findings from a WHO collaborative study Alcohol and Alcoholism 2004 Vol 39, No 4: 351-356

Fleming M, Lawton Barry K, Baier Manwell L, Johnson K, London R 1997 Brief physcian advice for problem alcohol drinkers: a randomized controlled trial in community-based primary care practices JAMA 2 April 1997, Vol 277, Issue 13: 1039-1045

Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR 1999 Brief physician- and nurse practitioner-delivered counselling for high-risk drinkers. Does it work? Archive of Internal Medicine 11 October 1999, Vol 159: 2198-2205

Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH 2003 Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention Annals of Internal Medicine 4 March 2003, Vol 138, No 5: 372-382

9. Appendix 3

The Alcohol Use Disorders Identification Test: Interview Version

Read questions as written. Record answers carefully. Begin the AUDIT by saying Now I am going to ask you some questions about your use of alcoholic, beverages during this past year. Explain what is meant by alcoholic beverages by using local examples of beer, wine, vodka, etc. Code answers in terms of standard drinks. Place the correct answer number in the box at the right.

1. How often do you have a drink

containing alcohol?

(0) Never [Skip to Qs 9-10]

(1) Monthly or less

(2) 2 to 4 times a month

(3) 2 to 3 times a week

(4) 4 or more times a week

6. How often during the last year have you

needed a first drink in the morning to get

yourself going after a heavy drinking

session?

(0) Never

(1) Less than monthly

(2) Monthly

(3) Weekly

(4) Daily or almost daily

2. How many drinks containing alcohol

do you have on a typical day when you

are drinking?

(0) 1 or 2

(1) 3 or 4

(2) 5 or 6

(3) 7, 8 or 9

(4) 10 or more


had a feeling of guilt or remorse after

drinking?

(0) Never


(2) Monthly

(3) Weekly


3. How often do you have six or more

drinks on one occasion?

(0) Never


(2) Monthly

(3) Weekly


Skip to Questions 9 and 10 if Total

Score for Questions 2 and 3 = 0


been unable to remember what happened

the night before because you had been

drinking?

(0) Never


(2) Monthly

(3) Weekly


4. How often during the last year have

you found that you were not able to

stop drinking once you had started?

(0) Never


(2) Monthly

(3) Weekly


9. Have you or someone else been injured as

a result of your drinking?

(0) No

(1) Yes, but not in the last year

(2) Yes, during the last year

5. How often during the last year have you failed to do what was normally expected from you because of drinking?

(0) Never


(2) Weekly


10. Has a relative or friend or a doctor or

another health worker been concerned

about your drinking or suggested you cut

down?

(0) no

(1) Yes, but not in the last year

(2) Yes, during the last year

Record total of specific items here.

If total is greater than recommended cut-off, consult Users Manual.

Source: AUDIT- The Alcohol Use Disorders Identification Test (WHO 2001) Theresa Lowry- Lehnen

Specialist Nurse Practitioner


Surrey University 2005

Research Proposal

SCREENING AND BRIEF INTERVENTION FOR ALCOHOL MISUSE AND ITS IMPLEMENTATION BY PRACTICE NURSES IN PRIMARY CARE

ABSTRACT


Objective: To explore practice-based experiences and views of primary care nurses in the UK with regard to the implementation of SBI for alcohol misuse and how it can be improved.

Research Question: What are the experiences of primary care nurses with regard to SBI for alcohol misuse?

Methodology: Study design is qualitative, using grounded theory approach to data collection and analysis. Semi-structured in-depth interviews to be conducted with ten nurses from general practice within the Sutton and Merton Primary Care Trust.

Conclusions: The study focuses on the experiences of primary care nurses with regard to screening and brief intervention for alcohol misuse (SBI). It aims to achieve a view from inside, and its inductive approach should lead to concepts and theories about ways to improve the implementation of SBI. It also allows greater participation by nurses, benefiting from their experience in practice and inviting practice-based suggestions.

Research Proposal

Contents

Contents Page

1. Introduction 1

2. Background

2

- Alcohol misuse and SBI: Current policies and practices in the UK 2

- AUDIT and Brief Intervention

4 3. Theoretical Framework 6

4. Research Aim

9

5. Research Question

11

6. Methodology: Rigour of the Study

11

- Design and Strategy, Sampling, Data Collection, Pilot Study

11

- Ethical Considerations 16

- Method of Data Analysis 17

- Limitations of Study

19

- Time Schedule

20

- Budget Proposal 21

- Funding/Sponsoring

21

- Presentation of Study 21

7. Conclusion 22

8. Appendix 1

25

Table 1(a) Letter to Practice Nurses

25

Table 1(b) Initial Audit 26

Table 2 Semi-structured Interview / Interview schedule 27

9. Appendix 2 : Glossary / Definitions

28

10. References

29

1. Introduction

The primary care sector has been identified as an ideal setting for screening and brief intervention (SBI) with regard to alcohol misuse (Cabinet Office 2004, Kaner et al. 2003, Alcohol Concern 2000, Alcohol Concern 2003). However, as a systematic review of the relevant research literature has shown, there is little up-to-date information about the implementation of SBI by primary care nurses in the UK. There is a consensus that nurses are an under-used resource in this area, but the literature review in Part One has identified some conflicting or inconclusive evidence. For example, Kaner et al. (2003) conclude that nurses who received training were less effective in the delivery of SBI than those who only received written guidelines. Furthermore, there is at least one meta-analysis which questions the suitability of universal screening (Beich et al. 2003). However, it is not entirely clear whether screening as a method is ineffective or whether screening is not carried out in an effective manner. As we have seen, the U.S. Preventive Services Task Force (USPSTF 2004) recommends screening and behavioural counselling interventions in primary care settings to reduce alcohol misuse.

It is clearly useful to examine how the implementation of SBI by primary care nurses can be improved. This research proposal will aim to do so, using a qualitative approach. Semi-structured, in-depth interviews using a grounded theory approach will help to identify some current problems in the implementation of SBI as well as ways to improve it. Indeed, some research reviewed in Part One identified the need for more qualitative research in this field (Lock & Kaner 2004). The research proposal presented here has direct relevance to clinical practice. It focuses on the experiences and views of primary care nurses and thus is a valuable addition to the debate about SBI for alcohol misuse.

2. Background

For the purpose of this research proposal, it is useful to look more closely at the Alcohol Use Disorders Identification Test (AUDIT), already mentioned in Part One, and the recommendations published by the World Health Organisation with regard to Brief Intervention. However, first, it is necessary to describe in more detail current policies and practices with regard to SBI in the UK, before providing the theoretical framework for this research proposal.

Alcohol misuse and SBI: Current policies and practices in the UK

The current Government published its Alcohol Harm Reduction Strategy for England in March 2004. Among the measures to reduce alcohol-related harms the document lists improved and better targeted education and communication as well as better identification and treatment of alcohol problems. It states further that failing to identify and treat those experiencing alcohol problems can affect an individuals health, family and work, and can also lead to crime, disorder and anti-social behaviour. It also warns that alcohol problems are not always identified and appropriate referral or treatment does not always occur (Cabinet Office 2004). Although people with alcohol problems can present at any point of the health service, their problems may not be picked up for a number of reasons, including the absence of a clear identification process and lack of staff training (Cabinet Office 2004). The document also points out that there are often pressures on staff time and possible unease about a problem which carries a strong stigma (Cabinet Office 2004).

The government paper identifies two types of alcohol screening: universal and targeted screening. Universal screening includes all patients in a GP surgery, clinic, outpatient department or other setting. However, the strategy paper states that recent research has raised questions about the value and effectiveness of universal screening, which means that it is difficult to advance a sound case for this type of screening (Cabinet Office 2004). Although the document does not offer any source for this statement, we have seen that Beich et al. (2003) raise such doubts regarding universal screening. Targeted screening, on the other hand, is aimed at people who may be drinking in a problematic way. It would therefore concentrate on those who present to the health service with symptoms and conditions which may be linked to problematic drinking.

With regard to brief intervention following screening, the strategy document cites evidence that drinkers may reduce their consumption by as much as 20 per cent as a result of a brief intervention (Cabinet Office 2004). But it points out that the research evidence on brief interventions draws heavily on small-scale studies carried out outside the UK, and more information is needed on the most effective methods of targeted screening and brief interventions, and whether the successes shown in research studies can be replicated within the health system in England (Cabinet Office 2004).

Nonetheless, the Cabinet Office stresses the importance of early identification of alcohol problems and announces pilot schemes for the year 2005 to test how best to use a variety of models of targeted screening and brief intervention (Cabinet Office 2004).

In providing the background for this research proposal, it is also useful to keep in mind the changing role of the general practice nurse, identified by the Department of Health as a first contact for assessment, treatment and referral and as important in the implementation of health protection and promotion programmes (DoH 2002).

AUDIT and Brief Intervention

The World Health Organisation (WHO) supports an assessment tool designed for the early identification of risk drinkers: the Alcohol Use Disorder Identification Test (AUDIT) (Babor et al. 2001, see Part One, Appendix 3). It is said to be the most studied screening tool for detecting alcohol-related problems in primary care settings (Bohn et al. 1995, USPSTF 2004). Babor et al. (2001) state that it is brief, rapid and flexible, has been specifically designed for primary health care workers and validated on primary health care patients in six countries. The authors state that all patients should be screened for alcohol use, preferably annually, and that if health workers screen only those they consider most likely to have a drinking problem, the majority of patients who drink excessively will be missed (Babor et al. 2001). This clearly contradicts the doubts expressed by the Governments strategy paper, mentioned above, about the value and effectiveness of universal screening (Cabinet Office 2004). Beich et al. (2003) conclude on the basis of their meta-analysis that although even brief advice can reduce excessive drinking, screening in general practice does not seem to be an effective precursor to brief interventions targeting excessive alcohol use. However, they relate their conclusion to the feasibility of screening in general practice. They are also primarily concerned with screening undertaken by GPs, and the studies included in their meta-analysis were conducted in a variety of countries. They identify a screening effect of 2.6 per 1000 patients screened, in other words between two and three patients out of 1000 can be expected to have reduced their alcohol consumption to below recommended maximum levels after 12 months, and while a positive net benefit is still possible () screening for excessive drinking is in keen competition with other proposals for screening (Beich et al. 2003: 538-539). In other words, while screening leads to brief intervention and reduced alcohol consumption in some patients, the authors conclude that the involved workload is not entirely justified by the result. This of course does not necessarily prove the case against screening. It may rather be an argument in support of the need for further research, especially given the assertion by Babor et al. (2001) that AUDIT has fulfilled many expectations and that its reliability and validity have been established in research conducted in a variety of settings and in many different nations and the conclusion of trials such as the one conducted by Ockene et al. (1999) that there is evidence that screening and brief intervention as part of routine primary care significantly reduces alcohol consumption by high-risk drinkers.

While the feasibility of screening is obviously under debate, there seems to be less controversy concerning brief intervention. The consensus seems to be that, once a high-risk drinker has been identified, brief intervention can have a positive effect. Beich et al. (2003) and Babor and Higgins-Biddle (2001), as well as other researchers, are in agreement that even brief advice can reduce excessive drinking.

According to a manual published by the World Health Organization, brief interventions are low in cost, have proven effective across the spectrum of alcohol problems, and are increasingly used by health workers and policymakers. They are seen as treatment for hazardous and harmful drinkers and as a way to facilitate referral of more serious cases (Babor & Higgins-Biddle 2001). The same manual states that training is simple and easy, the relatively short time spent on SBI is more than justified given the importance of alcohol use to the health of many patients, and fears of antagonizing patients are exaggerated since harmful and hazardous drinkers are rarely uncooperative (Babor & Higgins-Biddle 2001).

3. Theoretical Framework

A systematic literature review, as undertaken in Part One, serves as a foundation on which to build a research proposal. It also helps the researcher to develop a theoretical framework about the problem to be investigated (Hek 1994).

Hek et al. (1996) point out that having made a decision regarding the overall nature of the study, a researcher may choose a theoretical framework to guide and underpin the study. Parahoo (1997) states that a framework guiding a study can draw on concepts from various theories and research findings.

The systematic review in Part One has identified the need for more qualitative research. Leach (1990) states that qualitative research concerns the interpretative understanding of nursing situations. Similarly, Playle (2000) suggests that qualitative research in nursing can be useful since much of the profession is concerned with understanding the complexity of human experience. We have seen how the studies reviewed in Part One have produced some contradictory or unexpected evidence. This research proposal focuses on a very complex issue, namely the implementation of SBI for alcohol misuse. We have already encountered a number of problems associated with this area: individual decisions to implement SBI, the need for training, the need for interpretation, the possible unease about opening discussions on alcohol misuse, the reaction of patients.

When it comes to finding ways of improving the implementation of SBI and searching for reasons why nurses are an under-used resource in this area, a view from inside, focusing on meanings, values and the beliefs of individuals, seems preferable. Such an inductive approach should lead to concepts and theories about ways to improve the implementation of SBI for alcohol misuse (Hek et al. 1996; Parahoo 1997). It would also allow greater participation by nurses, benefiting from their experience in practice and inviting practice-based suggestions.

While the focus is on the experiences of individual nurses (phenomenology), it is impossible to consider those experiences outside the nurses environment, i.e. the primary care sector, or more generally the health service (ethnography). In grounded theory, it matters little if individuals are studied in isolation or as part of their cultural and social environment since the focus is on the generation of theories from data (Parahoo 1997). Grounded theory is according to Parahoo (1997), useful for studying phenomena for which little or no theory has been developed. It may generate theories which can then be tested deductively, by quantitative methods (Glaser & Strauss 1967).

When investigating a complex issue involving the views, practices, experiences and reactions of individuals, it is important to avoid an approach which places too many restrictions on the researcher. However, it is equally important to use tested and accepted methods. As the Department of Health in its Research Governance Framework points out, research which duplicates other work unnecessarily or which is not of sufficient quality to contribute something useful to existing knowledge is in itself unethical (DoH 2001).

It is therefore suggested that a grounded theory approach may be the most suitable in the light of the research objectives which will be stated next, prior to a detailed account of the proposed methodology.

4. Research Aim

In formulating a research proposal, it is important to state clearly its objective and its guiding question. As Parahoo (1997) points out, most research ultimately aims to improve practice, but the purpose of a study relates to the particular questions for which data can be collected. Polgar and Thomas (2000) state that for qualitative research, holding clear cut hypotheses may prejudice the investigation. It is all the more important to set out clear aims and objectives and to show their relevance, in order to give focus and direction to the research study (Hek et al. 1996).

Nursing is a practice based profession, and practice should therefore influence the identification of problems and questions to be researched (Hek et al. 1996). It may be added that relevant policies and the social context also need to be considered and that the overall aim of any research study should be to improve evidence-based practice. A researchable problem can therefore be said to be one where the current method of addressing the problem is unsatisfactory to the nurses or patients, or both (Hek et al. 1996). It can also come from the results of previous research which has identified some new problems (Hek et al. 1996).

Both the problems and the relevance of any research into the implementation by primary care nurses of SBI for alcohol misuse can be deducted from the literature review undertaken in Part One and the Background section of this research proposal. Not only does alcohol misuse cause individual health problems, it is also estimated to account for between two and twelve per cent of total NHS expenditure on hospitals (Office of National Statistics 2000, Royal College of Physicians 2001). Furthermore, there are high social costs associated with alcohol misuse (Cabinet Office 2004). Evidently, a research study aimed at improving ways in which the health service deals with high-risk drinkers has a high social relevance. It is also very much relevant to current policies, as the Government has identified the reduction of alcohol misuse as one of its health targets (Cabinet Office 2004, DoH 2004). More specifically, since the Government has announced pilot schemes for 2005 with regard to targeted screening and brief intervention in primary and secondary healthcare settings (Cabinet Office 2004), there is a direct relevance for nursing practice.

Furthermore, the need for additional research is a direct outcome from the literature review, on which this research proposal is based. While primary care nurses have been identified as an under-used resource with regard to the implementation of SBI for alcohol misuse (Deehan et al. 1998; Owens et al. 2000), UK-based research has not yet provided any clear guidance for improvement, e.g. with regard to training needs (Lock et al. 2002; Kaner et al. 2003; Lock & Kaner 2004). The literature review has identified two major themes: the need for a more consistent approach to SBI by primary care nurses and the need for further qualitative research. The aim of this proposed research is therefore twofold: to explore ways to improve the implementation of SBI by primary care nurses, and to do so by taking into account the experiences, views and ideas of the nurses.

5. Research Question

This leads to the formulation of the research question: What are the experiences of primary care nurses with regard to SBI for alcohol misuse?

6. Methodology: Rigour of the Study

Design and Strategy, Sampling, Data Collection, Pilot Study

The methodology section of a research proposal is essential to establish the rigour of a study. It must give a clear account of how, when and where data are to be collected and analysed. It must show the research approach, the sampling and method of data collection, the time, place and source of the data, data collection tools and the method of data analysis (Parahoo 1997; Hek et al. 1996). This proposal also includes a pilot study, considerations about reliability and validity, ethical considerations, limitations of the study, and a budget proposal.

The approach chosen for this research study is a qualitative, grounded theory approach. Glaser and Strauss (1967), state that in this approach the joint collection, coding and analysis of data is the underlying operation. It is therefore a constant comparative method, which codes and analyses data to develop concepts (Polgar & Thomas 2000). Parahoo (1997) adds that this approach allows the study of phenomena from the viewpoint of respondents and is characterised by organising information and identifying patterns, developing ideas, and drawing and verifying conclusions. Given the aim of this research, i.e. exploring nurses experiences in the field of SBI for alcohol misuse, this approach is judged to be the most suitable.

The study to be undertaken is descriptive, with regard to the experiences and views of nurses concerning SBI for alcohol misuse. From the collected data, topics and patterns will emerge, and the emphasis of this study is on the description of these topics and patterns, i.e. the experiences and views of primary care nurses. The study design is retrospective, relying on nurses experiences to date in order to explore why nurses are an underused resource in the area of study and how this may be changed.

In order to achieve a wide range of perspectives the study is cross-sectional, including nurses in a variety of primary care settings and at different stages of experience with regard to SBI for alcohol misuse (Parahoo 1997).

To improve validity, a combination of volunteer and purposive sampling will be used. While volunteer sampling gives the researcher little initial control, it is deemed important to achieve an interested and cooperative sample in the first instance, since the research approach and the use of semi-structured interviews for data collection depend on cooperative respondents (Parahoo 1997; Barriball & White 1994). Purposive sampling will be applied in order to ensure a wide range of experiences and perspectives among respondents. In particular, as the study progresses, further nurses may be purposively sampled to provide new perspectives on issues emerging from the ongoing analysis (Glaser & Strauss 1967). While the aim of volunteer sampling is to recruit cooperative respondents, purposive sampling will be applied to achieve a broad range of nurses ages, experiences and practice settings.

The sample consists of nurses from general practices in the Sutton and Merton PCT. While this involves a geographical limitation, the PCT comprises affluent areas as well as areas of high social deprivation (Sutton and Merton Primary Care Trust 2003). Thus a cross-sectional sample can be achieved.

Interviewees will be chosen from among those who have indicated their interest and willingness in their response to an initial letter. This will be sent to all primary care nurses in Sutton and Merton Primary Care Trust (PCT). There are 58 general practices in this area, according to the Sutton and Merton Primary Care Trust website. To establish the parameters of existing provisions in the PCT, the letter will include a small number of questions, in the form of an brief audit, allowing the researcher to estimate how common a practice SBI for alcohol misuse is in the Sutton and Merton area. This approach may allow some triangulation between quantitative and qualitative data. It will also aid the purposive sampling. The letter, including a pre-stamped return envelope, will ask the primary care nurse whether he/she would be willing to take part in an interview as part of the qualitative research. The letter will also give assurances about confidentiality, asking for a name and contact only if the respondent is willing to be interviewed. The letter will state clearly the aim of the research study, who is conducting it, and who is supporting it. A time-frame of one month is proposed for gathering the responses, although this may have to be revised if answers are not returned within that period. Tables 1(a) and 1(b) (Appendix 1) show the proposed letter and initial audit.

Given that the chosen approach is time-intensive, the study will aim for an initial sample of ten nurses from the Sutton and Merton PCT area. The initial sample may be augmented through purposive sampling in the course of the ongoing analysis, as described above. A time-frame of one month is expected for conducting the interviews, although this may have to be revised. It is expected that the interviews will take place at the respective general practices and last up to about one hour.

Given the aim and the qualitative approach chosen for this research proposal, data will be collected by semi-structured, in-depth interviews, as the most suited format to explore the experiences and views of practice nurses with regard to SBI. Barriball and While (1994), state that semi-structured interviews are well suited for the exploration of the perceptions and opinions of respondents.

To increase validity, the interviews will be tape-recorded and then transcribed for coding and analysis. Group interviews have been considered, but these may be difficult to organise and interaction within the group may distort the data. Therefore, the interviews will be individual. Whenever possible, face to face interviews will be conducted, although telephone interviews may be considered if a meeting proves difficult to organise.

The tool of data collection in semi-structured interviews is the interview schedule, which can be said to contain elements of quantitative and qualitative research in that it stresses the notion of standardization while at the same time allowing the researcher some flexibility (Parahoo 1997). Table 2 (Appendix 1) shows the draft for the semi-structured interview with questions based on the research objective and the research question.

The interview schedule will be tested in a pilot study, to identify and correct any problems, especially regarding clarity, and thus improve reliability and validity. The pilot study will allow the researcher to make any necessary improvements. Barriball and While (1994), recommend that a pilot draft should be judged for its content validity by a number of experts to assess appropriateness and completeness. Such a final draft should then be exposed to the rigours of the field under conditions similar to those anticipated in the main study (Barriball & While 1994). This will be achieved by piloting the interv

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