Brief interventions - ’having a word’ at the right time - can be effective in making people reconsider their drinking behaviour and cut their alcohol intake significantly
Alcohol consumption has increased by over 19% in the UK over the last 30 years and alcohol-related conditions now cost the NHS over £2.7bn annually. A randomised controlled trial undertaken in maxillofacial clinics has shown that brief interventions delivered by nurses result in significant reductions in alcohol consumption in the long term. The Royal College of Surgeons, endorsed by the Royal College of Nursing, recommends that screening and brief interventions for alcohol misuse should be adopted as a routine part of clinical practice. Brief interventions - “having a word” in a structured format - are cost effective and could save health and social service providers £124.3m in England alone over the next 30 years. This article describes how a programme of nurse-led screening and brief interventions is being rolled out in maxillofacial and trauma clinics across Wales.
Citation: Bridgeman K et al (2012) Brief intervention for alcohol misuse. Nursing Times; 108; online issue.
Author: Kathryn Bridgeman is nurse manager at Cardiff University Health Board; Jonathan Shepherd is professor of oral and maxillofacial surgery and director of the Violence Research Group at Cardiff University; Paul Jordan is knowledge transfer associate at Cardiff University; Craig Jones is senior health promotion practitioner at Public Health Wales.
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Alcohol consumption has risen by 19% since 1980, and a quarter of England’s adult population now drink at hazardous levels. Alcohol-related conditions cost the NHS £2.7bn annually (Department of Health, 2008). Alcohol misuse has been identified as the third most important risk factor for ill health in Europe after tobacco use and high blood pressure (Gartner, 2009).
Over the past 10 years there has been a steady rise in alcohol-related hospital admissions in the UK. For example, in Wales between 1999 and 2009, the rate of hospital admissions directly attributable to alcohol misuse rose from 327 to 449 per 100,000 in men and from 172 to 236 per 100,000 in women, while alcohol-related health problems cost the NHS in Wales £70m-£85m per year.
Sensible drinking guidelines
Current recommendations are that women should not regularly (most days or every day) drink more than 2-3 units of alcohol a day; that equates to no more than a standard 175ml glass of wine a day, with two days per week without alcohol. Men should not regularly drink more than 3-4 units of alcohol a day, equating to not much more than a pint of strong lager, beer or cider, with two alcohol-free days per week (Change 4 Life, 2012).
Hazardous drinking levels are defined as drinking more than 22 units per week for men and 15 units for women. Drinking at these excessive levels contributes to a range of medical conditions including cancers, cardiovascular diseases, diabetes, gastrointestinal diseases and neuropsychiatric disorders, as well as accidental injury and violence (British Medical Association, 2008).
Screening and brief interventions
Guidance from the National Institute for Health and Clinical Excellence (2010) recommends that health professionals should routinely carry out alcohol screening as an integral part of their practice.
A position statement from the Royal College of Surgeons of England (2010), endorsed by the Royal College of Nursing, recommends brief, cognitive advice delivered by nursing staff as part of care for conditions resulting from alcohol misuse.
Along with evidence from numerous clinical trials and systematic reviews in a range of healthcare settings, trials conducted by the Violence Research Group at Cardiff University demonstrate the effectiveness of brief interventions.
One trial found that opportunistic brief interventions delivered by nurses while removing sutures in patients with alcohol-related facial injury resulted in significant long-term reductions in drinking in one in four young men consuming alcohol at hazardous levels (Smith et al, 2003).
These findings regarding the effectiveness of brief interventions for alcohol misuse have changed nursing practice in the Cardiff maxillofacial service. Brief intervention delivery has now been standard practice in Cardiff for 10 years without additional resources.
This nurse-led approach is now being rolled out in all trauma and maxillofacial clinics across the country with funding from the Welsh Government and the Technology Strategy Board (a non-departmental public body).
The FAST test
Although the elements of screening and brief interventions for alcohol misuse are well understood, implementation requires nurse leadership and determined management in specific clinical settings.
In Wales, patients complete the Fast Alcohol Screening Test (FAST) questionnaire before receiving wound care in the outpatient clinic (Fig 1). The questionnaire comprises four questions, asking patients how often they drink heavily, how often drinking has affected their memory, how often it has affected their ability to function, and whether anyone has expressed concern about their drinking or suggested they cut down (Hodgson et al, 2002).
This screening, which is designed to identify patients who drink excessively, takes less than 20 seconds to complete and can be completed by patients either in the waiting room or with the nurse. A combined score greater than two indicates hazardous drinking and should prompt a brief intervention. It should be noted that brief interventions are not designed for drinkers who are dependent on (that is, addicted to) alcohol, for example those who drink excessively on a daily basis. Such patients should be referred to specialist addiction services.
A brief intervention in this context is a structured conversation between patient and nurse; they are designed to motivate patients to change their drinking behaviour.
The intention is to prompt patients to recognise the harm their drinking has caused, especially the wound being treated; review their drinking; set themselves drinking limits; and make and act on decisions to reduce their hazardous drinking. These interventions will prompt some who have relapsed in their drinking behaviour to adopt sensible drinking once more.
Brief interventions should be personalised and offered in a supportive, non-judgemental manner using the FRAMES approach (Miller and Rollnick, 1991). This provides a simple outline and structure for the brief intervention conversation (Box 1). The conversation will comprise a combination of feedback and structured advice delivered in an empathetic matter. This will not be alien to nurses.
Brief interventions do work
Controlled trials indicate that on average, for every eight people drinking at hazardous levels who receive an alcohol brief intervention, one will reduce their drinking to within safe drinking limits.
Effectiveness seems to be even greater if the intervention is delivered at a particularly teachable moment (see below) in patients’ lives, for example while they are having their sutures removed five days after sustaining a weekend face laceration.
Since brief interventions can be opportunistic and incorporated into routine clinical work without the need for additional clinical resources, they represent a worthwhile use of nurses’ time and are therefore cost effective (Tariq et al, 2009). There is no need to label brief intervention as such in clinical settings; it should be incorporated into usual conversation during clinical contact, as described below by a nurse manager whose service uses this approach.
“The intervention starts as a normal conversation and it is only when it develops and the patient engages with you, they realise that there is a structure to the conversation and an agenda. At the point of realisation, it is important for the nurse to re-evaluate the engagement of the patient. It may be necessary to regroup
and assure the patient that you’re not being judgemental about their drinking habits. It is often at this point that full realisation dawns on the patient and the process of intervention can truly begin” (nurse manager).
Timing is crucial. Brief interventions work best in “teachable moments”. These are when individuals are faced with the consequences of their actions and are more receptive to the suggestion of behaviour change.
Nurses are best placed to deliver brief interventions for a variety of reasons. They often have a natural rapport with patients that doctors sometimes do not. Patients are known to respond to nurses because they see them as “non-threatening and approachable” (Mistral and Velleman, 1999), and providing a brief intervention is simply an extension of this role.
Some nurses might feel hypocritical delivering interventions if they themselves drink above the guidelines but, clearly, a professional approach to health risks for patients should include helping them to reduce these risks. Nevertheless, the screening and brief intervention process may perhaps be helpful to the health professionals themselves as a challenge to their own health behaviour.
Putting research findings into practice
In Wales, a knowledge transfer partnership between Cardiff University, the Welsh Government and Public Health Wales has been set up to deliver the alcohol brief intervention programme in all maxillo-facial and trauma clinics.
Following feedback from nurses and recognising the need for effective and efficient training arrangements, rather than the overly time-consuming and impractical training sometimes recommended, a dedicated two-hour brief intervention course has been developed and is accredited by the RCN and Agored Cymru. Public Health Wales is also delivering an alcohol brief-intervention training programme aimed at professionals across primary and social care, including GPs and youth workers.
Nurses can make a positive difference to the lives of their patients by leading and delivering screening and brief interventions for alcohol misuse during the provision of routine nursing care. In the great tradition of nursing, this “have a word” approach reaps great benefits for patients, their families and the community.
- Alcohol-related conditions cost the NHS over £2.7bn annually
- In one study, one in four patients receiving brief intervention reduced their drinking significantly
- Brief intervention works best at a “teachable moment” in a drinker’s life
- Nurses are well placed to deliver brief intervention because of their rapport with patients
- A simple framework can help nurses to structure interventions
British Medical Association (2008) Alcohol Misuse: Tackling the UK Epidemic. London: BMA.
Change 4 Life (2012) Alcohol Units and Guidelines.
Department of Health (2008) The Cost of Alcohol Harm to the NHS in England.
Hodgson R et al (2002) The FAST alcohol screening test. Alcohol and Alcoholism; 37: 1, 61-66.
Miller W, Rollnick S (1991) Motivational Interviewing: Preparing People to Change Addictive Behavior. New York, NY: Guilford Press.
Mistral W, Velleman R (1999) Are practice nurses an underused resource for managing patients having problems with illicit drugs? A survey of one health authority area in England. Journal of Substance Use; 4: 2, 82-87
National Institute for Health and Clinical Excellence (2010) Alcohol-Use Disorders - Preventing Harmful Drinking (PH24). London: NICE.
Royal College of Surgeons of England (2010) Reducing alcohol misuse in trauma and other surgical patients: position statement. London: RCS.
Smith A et al (2003) A randomized controlled trial of a brief intervention after alcohol-related facial injury. Addiction; 98: 1, 43-52.
Tariq L et al (2009) Cost-effectiveness of an opportunistic screening programme and brief intervention for excessive alcohol use in primary care. PLoS ONE; 4: 5, e5696.