The views of nurses to the conduct of a randomised controlled trial of problem drinkers in an accident and emergency department

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Abstract

The Trent Regional Health Authority funded a study in 1995 to train nurses in an accident and emergency (AandE) department to screen all adult attendees for alcohol problems with a view to identifying a sample of problem drinkers to participate in a randomised controlled trial (RCT). In the RCT identified drinkers were to be assigned either to health education plus brief counselling intervention or, as controls, to health education alone. Despite 16 654 attendances at AandE during the recruitment phase of the study only 20% of attendees were screened of whom a further 19% were identified as problem drinkers by the CAGE screening questionnaire. Less than half of the problem drinkers were, however, provided with feedback by the nurses, leaving a small group of 264 eligible for entry to the RCT. The great majority of this subgroup refused an initial appointment at the specialist clinic and so the trial was abandoned. A number of in-depth interviews were undertaken with the nurses in an attempt to understand ways in which the overall conduct of the study might have been improved. This paper outlines in some detail some of the reasons for the lack of success with the study which include; general environmental factors that undoubtedly led to stress and poor morale amongst the nursing team, the differences in perception between managers and clinical nurses concerning the value of research and the inadequacy of the initial training programme. The paper concludes that there are problems in the NHS which do not provide a helpful backcloth to the successful conduct of health services research.

Section snippets

Background

Excessive intake of alcohol can lead to many public health problems including premature mortality (Gronbaek et al., 1995), physical and psychological ill-health, marriage and family breakdown (Buchan et al., 1981) and child neglect and abuse (Bijur et al., 1992). Drinkers are also known to have a higher number of health problems and accordingly consult general practitioners frequently (Buchan et al., 1981).

However, in the context of this report it is important to note that those attending

Objectives of the study

  • 1.

    To demonstrate that problem drinkers could be routinely identified through screening by triage nurses in an AandE department.

  • 2.

    To assess the outcome of brief intervention for problem drinkers subsequently referred to a clinical nurse specialist following opportunistic screening in an AandE department.

  • 3.

    To examine the attitudes of nurses, working in an AandE department, to problem drinkers following a short training which included use of an appropriate screening instrument.

Screening by the triage nurse

All patients presenting at

Screening attendees in the AandE department

Over the 6 month period of the study a total of 16 654 adults attended the AandE department of whom 28% (n=4663) were recorded, i.e. a screening form was prepared. Of this group, 25% (1162) were judged unable to complete the questionnaire although a reason for this was not generally given. Thus, only 20% of all adult attendees were screened (3398/16 654) by triage nurses. 19% (n=645) of this smaller subsample screened positive inasmuch as they either drank in excess of government guidelines or

Discussion

This study was funded to examine the impact of screening for alcohol problems in a population of AandE attendees. Nurses were trained to play a key role in the research through the provision of screening and feedback at triage. Furthermore, the efficacy of brief intervention provided by clinical nurse specialists was to have been examined in a randomised controlled trial for those identified through screening as problem drinkers.

Although the research team planned this research in an energetic

Acknowledgements

We are grateful to NHS-Executive, Trent who funded this study and who encouraged us to persist with the research despite the difficulties.

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