Key learning points:
- Nurses are one of the most effective providers of brief alcohol interventions
- An intervention in primary care can begin with simple feedback using a motivational approach
- There are several benefits for nurses who incorporate alcohol screening questionnaires into everyday practice
A recent systematic review found brief interventions delivered by nurses to be the most effective at reducing alcohol consumption when compared with other provider groups.[1] Such findings coincide with increasing the visibility of nurses leading preventive interventions and improving population health2 for a range of public health priorities, including reducing harmful drinking.[3]
There are many opportunities for effective brief conversations about alcohol for health improvement and chances to have them in partnership with people, supporting and promoting individual choice and personal autonomy.[4]
Such conversations are commonly referred to as alcohol screening and brief interventions [5] or alcohol identification and brief advice (IBA).[6] More recently, they have been defined within a more integrated approach to health improvement called ‘Making Every Contact Count’ (MECC).[7]
Harmful drinking
The UK Chief Medical Officer’s current low-risk drinking guidelines are reflective of the latest evidence that has accumulated since the last review over 20 years ago [8]. Drinking patterns above low-risk levels are internationally defined [9] as hazardous (negative effects not yet evident with an increasing likelihood of future health harm) or harmful (existing negative effects evident with a higher risk of further harm and developing alcohol dependence).
UK Chief Medical Officer’s Low Risk Drinking Guidelines [8]
This applies to adults who drink regularly or frequently ie most weeks.
The Chief Medical Officer’s guideline for both men and women is that:
- To keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis.
- If you regularly drink as much as 14 units per week, it is best to spread your drinking evenly over three or more days. If you have one or two heavy drinking episodes a week, you increase your risks of death from long-term illness and from accidents and injuries.
- The risk of developing a range of health problems (including cancers of the mouth, throat and breast) increases the more you drink on a regular basis.
- If you wish to cut down the amount you drink, a good way to help achieve this is to have several drink-free days each week.
In support of improving health literacy and effective communication between professionals and the public, risk-based terminology of ‘increasing risk’ and ‘higher risk’ drinking is used interchangeably with ‘hazardous’ and ‘harmful’ drinking respectively.[6] Harmful drinking is currently reported as the third leading risk factor for disease and early death in the UK,[10] with a causal link identified for over 200 acute and chronic conditions.[11]
Major health problems commonly associated with harmful drinking overlap with a range of priorities in primary care, including but not limited to: preventing accidents and injuries; reducing risk factors for cardiovascular disease, liver disease, cancers and common mental health problems; as well as improving the quality of life for people with long-term physical and mental health conditions.[10-12] Understanding the relevance can help guide a nurse to routinely identify opportunities to initiate discussions about alcohol use.
The negative effects of alcohol are much more far reaching when also considering the impact on wider relationships. For example, a survey of 1,200 adults in the North West of England [13] showed that as many as one in five people knew of a child or children who had been negatively affected as a result of someone else’s drinking. This so-called ‘hidden harm’ could affect as many as one third of children across the UK who are living with a parent or carer drinking hazardously or harmfully.[14] This highlights the equally important role and relevance for nurses supporting and promoting the health and wellbeing of the whole family.
Public Health England estimates that there are 10.8 million adults drinking at increasing or higher risk levels, with an estimated 1.6 million adults drinking at mild, moderate or severely dependent levels.[10]
While there is a continued need to improve tertiary prevention interventions and primary care pathways for those with alcohol dependence,[15] these population health figures highlight the demand for brief secondary prevention interventions,[15] with potentially 20-30% of regular attenders to primary care services.[16] This suggests that adults who regularly drink alcohol above the low-risk guideline levels frequently come into contact with a wide range of nurses in primary healthcare roles.
Brief interventions
NICE guidelines recommend that the nurse’s starting point is to identify at-risk individuals by integrating alcohol ‘screening’ and brief interventions in everyday practice.[5]
As an umbrella term, brief interventions can vary in length from very brief (less than five minutes) to extended (20-30 minutes or more).[17]
Recent studies have found that the choice of screening tool and length of brief alcohol intervention may not significantly affect the outcome,[1,16] suggesting that nurses could trust that any effort made, however short, will increase the likelihood of behaviour change.
For anyone identified as hazardously or harmfully drinking, options for behaviour change could consist of a reduction in drinking towards 14 units per week, spreading out alcohol use over three or more days a week as well as aiming for several drink-free days each week to reduce the long-term health risks.[8] Practical ideas to take away to reduce the short-term health risks could include a plan to set a personal limit on any single occasion, drinking more slowly, drinking alongside food, alternating with water, or staying with people you trust and arranging how to get home when not drinking at home.[8]
For anyone identified as potentially alcohol dependent, the focus of the conversation should be to promote access and referral to specialist alcohol triage or comprehensive assessment depending on local provider services.[5]
There are a number of screening questions available for nurses to choose from, depending on the time available for the brief intervention.[5] The range of questionnaires have evolved from the original full-length Alcohol Use Disorder Identification Test (AUDIT) containing 10 questions as the ‘gold standard’, which is estimated to take two to four minutes to complete.[18]
Shorter, abbreviated alcohol screening tools could be used [5,6,16] with a choice of four questions (FAST), three questions (AUDIT-C), or when time is very limited, a single alcohol screening question (M-SASQ).
Introducing a screening questionnaire as routine and explaining the benefits to the person provides a platform for the nurse to support and promote individual choice and autonomy from the outset.[4]
Seeking permission from the person to opt into the brief intervention sets the scene for collaboration and working in partnership with the person.
Alcohol screening
There are several benefits for nurses who incorporate alcohol screening questionnaires into everyday practice. Studies suggest that shortened alcohol screening questionnaires provide an effective structure for a conversation based on simple feedback and exchanging information.[1,16] Ultimately, having a conversation is at the heart of any brief intervention with a focus on what is most important and relevant to the person to enhance motivation.[5,6,7,19]
One advantage to the questionnaires is that the design of questions and cut-off scores have been validated to have high sensitivity and specificity, supporting efficient early identification of adults at risk of health harm across the spectrum of drinking patterns.[5,16,18]
Additionally, the scoring systems can provide a structure for nurses to offer personalised feedback and exchange information as well as suggest when to step up the offer of support to specialist alcohol services.
The FRAMES principle
This practical delivery of a five-to-15-minute conversation can be arranged around the motivational principles of brief interventions known as ‘FRAMES’.[5]
There are six effective elements in a brief intervention when using the FRAMES model:
- Offering Feedback on current risk level.
- Emphasising that change is the individual’s Responsibility.
- Providing clear Advice when requested.
- Offering a Menu of a variety of options to choose from to support behaviour change.
- Being Empathic.
- Supporting Self-efficacy to build confidence to change.
Public Health England’s Alcohol Learning Resources include downloadable alcohol screening questionnaires with UK unit conversions, reminding practitioners to explore ‘units of alcohol’, not ‘drinks’, alongside visual material to support the conversation using FRAMES.[15]
The aim of the conversation may be to increase the person’s knowledge of the benefits of drinking less, or the conversation could aim to increase awareness of the small changes that can make a big difference to lowering risk.[5,7] For example, if long-term health is important to the person, exchanging information about the links between alcohol and cancer may be of benefit.
References
1. Platt L, Melendez-Torres GJ, O’Donnell A et al. How effective are brief interventions in reducing alcohol consumption: do the setting, practitioner group and content matter? Findings from a systematic review and meta-regression analysis. BMJ Open. 2016; 6:e011473. doi:10.1136/bmjopen-2016- 011473 (accessed 28 November 2016).
2. Public Health England. All Our Health: personalised care and population health. gov.uk/government/collections/all-our-health-personalised-care-and-population-health (accessed 28 November 2016).
3. Public Health England. From evidence into action: opportunities to protect and improve the nation’s health. PHE publications gateway number: 2014404, 2014. gov.uk/government/publications/from-evidence-into-action-opportunities-to-protect-and-improve-the-nations-health (accessed 28 November 2016).
4. Nursing and Midwifery Council. Standards for competence for registered nurses, 2014. nmc.org.uk/standards/additional-standards/standards-for-competence-for-registered-nurses/ (accessed 28 November 2016).
5. National Institute for Clinical Excellence. Alcohol-use disorders: prevention, 2010. nice.org.uk/guidance/ph24 (accessed 28 November 2016).
6. Lavoie D. Alcohol Identification and Brief Advice in England: A major plank in alcohol harm reduction policy. Drug and Alcohol Review. 2010; (29)608-611. Doi: 10.1111/j.1465-3362.2010.00224.x (accessed 28 November 2016).
7. Public Health England, NHS England and Health Education England. Making Every Contact Count (MECC): Consensus Statement. gov.uk/government/publications/making-every-contact-count-mecc-practical-resources (accessed 28 November 2016).
8. Department of Health. UK Chief Medical Officers’ Low Risk Drinking Guidelines, 2905649. Crown Copyright: 2016.
9. World Health Organization. Lexicon of alcohol and drug terms published by the World Health Organization (accessed 28 November 2016). who.int/substance_abuse/terminology/who_lexicon/en/.
10. Public Health England. Health Matters: Harmful drinking and alcohol dependence. Weblog. publichealthmatters.blog.gov.uk/2016/01/21/health-matters-harmful-drinking-and-alcohol-dependence/ (accessed 28 November 2016).
11. World Health Organisation. Alcohol Factsheet 2015. who.int/mediacentre/factsheets/fs349/en/ (accessed 28 November 2016).
12. NHS England. NHS Outcomes Framework 2016-2017 at a glance. gov.uk/government/publications/nhs-outcomes-framework-2016-to-2017 (accessed 28 November 2016).
13. DrinkWise. Let’s Look Again At Alcohol: Alcohol and Childhood Don’t Mix, 2014. eurocare.org/library/updates/alcohol_and_childhood_don_t_mix_campaign (accessed 28 November 2016).
14. Manning V, Best D, Faulkner N et al. New estimates of the number of children living with substance misusing parents: results from UK national household surveys. BMC Public Health 2009;9:33-99. doi:10.1186/1471-2458-9-377.
15. Public Health England. Alcohol CLeaR resource pack: Good practice guidance and resources, 2016 alcohollearningcentre.org.uk/ (accessed 28 November 2016).
16. Kaner E, Bland M, Cassidy P et al. Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial. BMJ. 2013; 346. bmj.com/content/346/bmj.e8501 (accessed 28 November 2016).
17. National Institute for Clinical Excellence. Behaviour change: individual approaches, 2014. nice.org.uk/guidance/ph49 (accessed 28 November 2016).
18. Babor T, Higgins-Biddle J, Saunders J et al. AUDIT – The Alcohol Use Disorders Identification Test: Guidelines for use in primary care. 2nd ed. Geneva: World Health Organization, 2001. who.int/substance_abuse/publications/alcohol/en/.
19. NHS England. Personalised care and support planning handbook: The journey to personalised care, 2016. england.nhs.uk/resources/resources-for-ccgs/out-frwrk/dom-2/ltc-care/ (accessed 28 November 2016).
Resources
How are you? Quiz and Drinks Tracker – nhs.uk/oneyou.
Public Health England Alcohol Learning Resources – alcohollearningcentre.org.uk .
Alcohol Concern – alcoholconcern.org.uk.
