Research Thesis Literature Review and Research Proposal by Theresa Lowry-Lehnen Specialist Nurse Practitioner Surrey University 2005

Specialist Nurse Practitioner
Research Thesis
Theresa Lowry- Lehnen
Surrey University 2005
Systematic Literature Review

&
Research Proposal
SCREENING 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.

Research Thesis
SYSTEMATIC LITERATURE
REVIEW
ALCOHOL MISUSE AND ITS IMPLEMENTATION BY
PRACTICE NURSES IN PRIMARY CARE
ABSTRACT
alcohol misuse.
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
2. Background
Alcohol misuse: Definition and epidemiology
Screening and brief intervention (SBI)
3. Guiding Question
4. Search Strategy
5. Literature Review
Introduction
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

The way forward
25
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 & HigginsBiddle 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

BNI
CINAHL
Search engine
First
search
Second
search
Search engine
First
search
Second
search
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
126
0
0
0
0
1420
15
3
1
0
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
596
21
8
2
1
7546
195
58
22
2
EBSCO HOST
MEDLINE R
Search engine
First
search
Search engine
First
search
Second
search
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
1843
23
7
5
0
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
7174
86
28
8
1
105,612
750
220
59
5
PROQUEST
PUBMED (via BioMed Central)
Search engine
First
search
Second
search
Search engine
First
search
Second
search
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
12,145
184
60
23
5
12,987
217
71
28
6
Alcohol
+ Primary Care
+ Screening
+ Intervention
+ Nurses
3093
4
0
0
0
486,015
1059
481
87
11
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: 277284
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 REVIEW
Introduction
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 semistructured 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 costeffectiveness. 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
DATE
1998
AUTHORS
Deehan A,
Templeton L,
Taylor C,
Drummond
C, Strang J
TITLE/
SOURCE
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
FUNDING
METHODOLOGY
RELIABILITY
AND VALIDITY
Grant from
Department
of Health
Quantitative. Nonexperimental.
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
analysis
Draft 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.
RESULTS
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 selfpresenting.
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.
MAIN THEMES/
IMPLICATIONS FOR PRACTICE
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.
DATE
2000
AUTHORS
Owens L,
Gilmore I T,
Pirmohamed
M
TITLE/
SOURCE
General
practice nurses
knowledge of
alcohol use and
misuse: a
questionnaire
survey
Alcohol and
Alcoholism
FUNDING
METHODOLOGY
Funding
from
Liverpool
Health
Authority
and NHS
Executive
North West
Quantitative. Nonexperimental.
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.
RELIABILITY AND
VALIDITY
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 country
RESULTS
94% 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.
MAIN THEMES/
IMPLICATIONS FOR
PRACTICE
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.
DATE
2002
AUTHOR
S
TITLE/
SOURCE
Lock C A,
Kaner E,
Lamont S,
Bond S
A qualitative
study of nurses
attitudes and
practices
regarding brief
alcohol
intervention in
primary care
Journal of
Advanced
Nursing
FUNDING
METHODOLOGY
RELIABILITY AND VALIDITY
RESULTS
Grant from
Alcohol
Education
and
Research
Council
Qualitative 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.
MAIN THEMES/
IMPLICATIONS FOR
PRACTICE
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.
DATE
2003
AUTHORS
Kaner E,
Lock C,
Heather N,
McNamee
P, Bond S
TITLE/
SOURCE
Promoting brief
alcohol
intervention by
nurses in primary
care: a cluster
randomised
controlled trial
Patient
Education and
Counseling
FUNDING
Grant from
Alcohol
Education
and
Research
Council
METHODOLOGY
Quantitative. Experimental.
Cluster randomised
controlled trial: written
guidelines (controls, n=76);
outreach training (n=68);
training plus telephonebased 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.
RELIABILITY AND
VALIDITY
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.
RESULTS
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.
MAIN THEMES/
IMPLICATIONS FOR
PRACTICE
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.
DATE
AUTHORS
2004
Lock C A,
Kaner E
TITLE/
SOURCE
Implement-ation
of brief alcohol
interventions by
nurses in primary
care: do nonclinical factors
influence
practice?
Family Practice
FUNDING
Grant from
Alcohol
Education
and
Research
Council
METHODOLOGY
Quantitative. 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.
RELIABILITY AND
VALIDITY
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.
RESULTS
Screening identified
1500 risk drinkers,
but only 962 (62%)
received a brief
intervention. In
addition, 402 nonrisk 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.
MAIN THEMES/
IMPLICATIONS FOR
PRACTICE
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 evidencebased 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

been unable to remember what happened
the night before because you had been
drinking?
(0) Never
(2) Monthly
(3) Weekly
Score for Questions 2 and 3 = 0

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
failed to do what was
normally expected from you because of drinking?

(0)
(1)
(2)
(3)
Never
Less than monthly
Weekly
Daily or almost daily
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)


Research Thesis
Research Proposal
ALCOHOL MISUSE AND ITS IMPLEMENTATION
BY PRACTICE NURSES IN PRIMARY CARE
ABSTRACT
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.
Research Proposal
Contents
Contents
Page
1. Introduction
2. Background
- Alcohol misuse and SBI: Current policies and practices in the UK
- AUDIT and Brief Intervention
3. Theoretical Framework
4. Research Aim
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

Table 1(b) Initial Audit
Table 2 Semi-structured Interview / Interview schedule
9. Appendix 2 : Glossary / Definitions
10. References
25
26
27
28
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 smallscale 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 & HigginsBiddle 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 timeframe 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
interview schedule with a group of volunteers from among primary care
nurses in the Sutton and Merton PCT.
Although Parahoo (1997) states that the concepts of reliability and validity
belong to quantitative research and as such have been criticised as having
little relevance to qualitative studies and Glaser and Strauss (1967) assert
that the presentation of grounded theory, developed through analysis of
qualitative data, is often sufficiently plausible to satisfy most readers, any
study must allow others to make judgements about the reliability and validity
of the chosen methods.
The validity of such a tool as a semi-structured interview 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).
Unlike self-administered questionnaires, interviews offer the opportunity to ask
respondents to elaborate (Parahoo 1997). Barriball and White (1994) add that
the willingness of respondents to be good informants has implications for the
validity of the data. They also state that approach and manner towards
respondents can help enormously with securing validity and reliability, that
field notes made by the interviewer about each interview can provide
information about the data collection which can enhance the validity and
reliability of the research findings and that audio taping helps validate the
accuracy and completeness of the collected information (Barriball & White
1994). Consideration must also be given to the skills of the interviewer since
securing validity and reliability of the data is a big challenge to interviewers
and depends on thorough training (Moser & Kalton 1986 cited by Barriball and
While 1994).
Ethical Considerations
Polgar and Thomas (2000) assert that a research process is judged to be
ethical if it conforms to relevant standards and conventions. Important ethical
considerations include the benefits of the research (which for this proposal
have been established) as well as the dignity, informed consent, protection
and privacy of participants (Polgar & Thomas 2000; Parahoo 1997; DoH
2001). Participants must be fully informed about the purpose of the research
and privacy and confidentiality must be maintained.
Although this research proposal does not directly involve patients, it may be
possible that information about some patients could come to light, and in that
case there would have to be full compliance with data protection and privacy
issues (DoH 2001, Hek et al. 1996).
It is proposed that this research design will be submitted to the appropriate

Ethics Committee.
Method of Data Analysis

Data analysis will be conducted using the grounded theory approach as a
constant comparative method, coding and analysing the information gained
from the interviews. Glaser and Strauss (1967) give a detailed description and
examples for this method. Strauss and Corbin (1990 cited by Parahoo 1997)
state that research conducted using the grounded theory approach allows
topics and patterns to emerge which are relevant to the area of study.
The area of study has been identified as the experiences of primary care
nurses with regard to SBI for alcohol misuse. The semi-structured, in-depth
interview has been identified as a suitable tool for data collection in this
approach. Systematic analysis of the collected data will allow the discovery
and development of a theory with regard to the implementation of SBI by
primary care nurses.
While the research aim has marked the area of study, analysis of the collected
data will yield information about such areas as:
Where do nurses learn about alcohol misuse and how much do they
know?
Where do nurses learn about SBI and how much do they know?
Is there sufficient knowledge and training about alcohol misuse and SBI?
Is there a screening tool readily available, and which screening tool is

being used, e.g. AUDIT or others?
Do nurses believe that SBI is worthwhile?
In the view of the nurses, is screening for alcohol misuse in the course of a
routine appointment feasible?
Under which circumstances is it not feasible?
What are the benefits and drawbacks of universal versus targeted

screening from the nurses point of view?
What barriers exist from the nurses point of view with regard to screening?
What barriers exist with regard to brief intervention as a follow-up to

screening?
How can nurses measure the effectiveness of SBI for individual patients?
What improvements could be made?
Coding and analysis of the data collected in the semi-structured interviews will
allow the organisation of the information, the identification of patterns and the
development of ideas and conclusions during the ongoing process of data
analysis in which, as Parahoo (1997) points out, emerging hypotheses are
constantly being reviewed.
Limitations of Study
While a proper account of the limitations of a research study can only be
given after its conclusion, some possible limitations can already be pointed
out.
In order to achieve a realistic proposal, the research study is confined

to a small geographical area, i.e. the area covered by a primary care
trust.
Since interviews will be conducted with those who have volunteered,

there is the possibility of some bias, i.e. it may be that only those
particularly interested in the subject will agree to participate. However,
it is hoped that a cross-section of views and experiences can be
achieved, by combining volunteer and purposive sampling. A more
detailed judgement on possible bias may be possible in the course of
the actual study.
It may be preferable to conduct a thorough quantitative research within

the chosen area, before embarking on the qualitative study. However,
such an approach would be much more time-intensive. It is hoped that
the chosen approach can help to combine quantitative and qualitative
data at least to some extent and thus open up the possibility of
triangulation.
Another limitation may lie in the research topic itself: Not only is alcohol
misuse a very complex and emotive issue, the literature review has
shown that some issues surrounding SBI for alcohol misuse remain
unclear. Indeed, that is the reason for proposing this research study.
As Parahoo (1997) points out when more than one interviewer is used,
it is possible that some are more able than others to extract
information. In addition, a unified approach cannot necessarily be
guaranteed. It would therefore be preferable to use only one
interviewer. However, this may lead to a limited view. Parahoo (1997)
also cautions that the presence of the interviewer may introduce some
bias.
Possible limitations with regard to reliability and validity and ways to

minimise those limitations have been described above.
Time Schedule
Table 3 summarises the proposed time schedule for this research study.
While an attempt has been made to give a realistic time-frame, it may be
necessary to revise the schedule during the actual study.
TABLE 3: TIME SCHEDULE

Initial letter and response
1 month
Analysis of response, selection of participants, pilot
1 month
study
Revision to enhance validity and reliability
2 weeks
Interviews
1 month
Analysis
2 weeks
Preparing presentation
2 weeks
TOTAL
4 months 2 weeks
Budget Proposal
Table 4 shows an estimate of the cost of this research study.
TABLE 4: BUDGET
Researcher and Interviewer (100 hrs at 15) 1,500
Secretarial support (10 hrs @ 10)
100
Printing, posting, telephone, contingency costs
200
TOTAL
1,800
Funding/Sponsoring
Given the relevance of the research proposal with regard to current policy, it is
proposed that funding/sponsoring is sought from public bodies such as
interested Primary Care Trusts and from organisations such as Alcohol
Concern.
Presentation of Study
It is proposed that the completed study will be presented in a research report.
In the first instance, the final report should be made available to the sponsors,
the participants in the study, and the general practices in the Sutton and
Merton PCT. Consideration should also be given to a wider publication of the
research, e.g. local and regional newsletters, nursing publications and
professional journals.
7. CONCLUSION
This research proposal 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.
The study area is clearly relevant in the light of current government policies
which identify the reduction of alcohol misuse as a key target and the primary
care sector as an important setting for the early detection and treatment of
alcohol misuse. The literature review has provided insights into the subject
area and also shown the need for further research because even though the
concept of SBI is widely accepted, its implementation, especially by primary
care nurses, is much more problematic. By focusing on the views and
experiences of primary care nurses, this research proposal has direct
relevance with regard to clinical practice, health promotion policies, and
patient health care. It explores why primary care nurses are an under-used
resource in the context of SBI for alcohol misuse, and it identifies problems
and possible ways to resolve them by drawing directly on the experiences and
views of nurses. For example, findings may include the suitability of using
AUDIT in the course of routine appointments, the feasibility of SBI for alcohol
misuse in everyday practice, possible barriers to implementing SBI, such as

pressure on staff time or lack of knowledge, training and confidence in raising
the problem of alcohol misuse when it carries a strong social stigma. Another
benefit of the chosen approach is increased communication among nurses,
leading to a stronger awareness of the subject area. There are also wider
social benefits beyond the immediate practice area since 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 (Cabinet Office 2004).
The aim of this study has determined a qualitative approach, using semistructured in-depth interviews and grounded theory for data collection and
analysis. It has been demonstrated that this approach is suitable for
identifying patterns, developing ideas and drawing conclusions about how SBI
for alcohol misuse can be effectively implemented by primary care nurses. It
has also been shown how the research strategy and the collection and
analysis of data have been designed in order to ensure the validity of the
study.
Thus the proposed study can help fill a gap in the existing research and
provide starting points and direction for future studies. In particular, the
findings of the proposed research can be translated directly into practice
based knowledge and thus make a valuable contribution to the ongoing
development of an effective health service.
As a personal learning outcome, the systematic research of a subject area

can enhance knowledge in that it provides a strong theoretical base, thus
increasing the understanding of problems in clinical practice. The assignment
has also been beneficial in teaching the value of properly designed research
and how it can help to explore complex issues and thus improve practice.
8. Appendix 1
TABLE 1(a): LETTER TO PRIMARY CARE NURSES
Faccini House Surgery
Middleton Road
Surrey
SM5 3LQ
05/05/2005
Tel: 0208 6405372
Dear Practice Nurse,
This letter is inviting you to take part in a research project aimed at exploring the
experiences of primary care nurses with regard to screening and brief intervention for
alcohol misuse (SBI). The study will be carried out by a local research team and is
supported by the Sutton and Merton PCT.
Government policy identifies the primary care sector as a key part of the health
service in the detection and early treatment of alcohol misuse. Yet little is so far
known about the implementation of SBI in general practices.
If you are interested in taking part in the research project, please indicate so on the
enclosed form. We will then contact you to arrange a time for an interview asking you
about your experiences and views with regard to SBI. The interview will last about
one hour.
Whether you decide to take part or not, it would be a great help if you could find the
time to answer a few questions on the enclosed form and return it to us in the prestamped addressed envelope. All the information you give us either now or in a later
interview will be treated confidently and anonymously.
Yours sincerely
Theresa Lowry-Lehnen
TABLE 1(b) INITIAL AUDIT

Place the correct answer number in the box.
1. How would you describe your knowledge/training about screening and brief
intervention for alcohol misuse?
(1) No knowledge
(2) Some knowledge
(3) Good knowledge
(1) No training
(2) Some training
(3) Good training
2. Is a screening tool for alcohol misuse readily available in your practice?

(1) Yes
(2) No
3. Do you use screening for alcohol misuse during routine appointments with
patients aged over 18?
(1) Never
(2) Sometimes
(3) Often
(4) Always
4. If you use screening for alcohol misuse, which patients aged over 18 do you
screen?
(1) Only new patients
(2) Only patients who mention concerns about their own alcohol consumption
(3) Only patients presenting with symptoms which may suggest alcohol
misuse
(4) All patients at least occasionally
5. How many times have you used screening for alcohol misuse in the past
year? Please estimate.
(1) Daily
(2) Weekly
(3) Monthly
(4) Other (Please specify)
6. How many times have you given a brief intervention, meaning health advice
about alcohol misuse, in the past year? Please estimate.
(1) Daily
(2) Weekly
(3) Monthly
(4) Other (Please specify)
7. Please indicate whether you would be happy to take part in an interview with
a researcher, lasting about 60 minutes, as part of a research study, about
your experiences and views on the implementation of screening and brief
intervention of alcohol misuse.
(1) Yes (Contact Name/ Phone Number)..
(2) No
TABLE 2:
SEMI-STRUCTURED INTERVIEW / INTERVIEW SCHEDULE
1. How much does your training prepare you to deal with patients who misuse
alcohol, meaning those who regularly drink above recommended limits
without being dependent on alcohol?
2. Do you have a useful screening tool available for alcohol misuse?
3. Do you think that screening for alcohol misuse is feasible?
4. Do you think it should be universal or targeted?
5. Do you think screening is effective?
6. Do you think that brief intervention can be effective?
7. What are your specific experiences with SBI with regard to patients?
8. What would prevent you from implementing SBI?
9. Do you think SBI is worthwhile?
10. Does SBI by nurses in primary care need to be improved, and if yes, how
can it be improved?
APPENDIX 2
Glossary / Definitions
Alcohol misuse is defined as an over-reliance on alcohol for its moodaltering benefits or the repeated use of alcohol (without abuse or dependency)
to cope with problems (Carter Martin et al. 1999: 16).
Universal Screening is defined 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. (Babor & Higgins-Biddle 2000: 678).
Targeted Screening is defined as being aimed at people who may be

drinking in a problematic way. It concentrates on those who present to the
health service with symptoms and conditions which may be linked to
problematic drinking (Cabinet Office 2004: 38).
Screening Tool in this context is defined as a brief questionnaire designed to

detect harmful drinking patterns in patients, such as AUDIT (Babor et al. 2001)
Brief intervention is defined as an activity directed at people who engage in

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Research Thesis Literature Review and Research Proposal by Theresa Lowry-Lehnen Specialist Nurse Practitioner Surrey University 2005

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Specialist Nurse Practitioner

Surrey University 2005

Systematic Literature Review

Specialist Nurse Practitioner

Systematic Literature Review Contents

Alcohol misuse: Definition and epidemiology

Screening and brief intervention (SBI)

Background and qualifications of the researchers

Introductions and literature reviews

Methodology: Design, Strategy, Data collection/analysis

Discussion and conclusions: Analysis of themes

6. Summary and Conclusions

Gaps identified in existing research

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

8. Appendix 2 (Bibliography of related research studies)

9. Appendix 3 (Alcohol Use Disorders Identification Test)

Health professionals play an important role in preventing, detecting and

The current Labour Government describes its Alcohol Harm Reduction

Alcohol misuse: Definition and epidemiology

for sensible drinking, and one in thirteen people is dependent on alcohol in

While moderate alcohol consumption can provide some protection against

Screening and brief intervention (SBI)

Brief intervention means an activity directed at people who engage in risky

The U.S. Preventive Services Task Force (USPSTF) recommends screening

TABLE 1: SEARCH RESULTS

PUBMED (via BioMed Central)

Many articles were professional opinions, meta-analyses or summaries of

It was also decided to concentrate on UK studies. Two studies are relevant in

TABLE 2: CRITERIA FOR INCLUSION AND EXCLUSION

This literature review is therefore based on published research in the form of

TABLE 3: STUDIES INCLUDED IN LITERATURE REVIEW

According to Dooley (1984, cited by Polgar & Thomas 2000), a qualitative

Background and Qualifications of the Researchers

Introductions and Literature Reviews

It is helpful to look in some detail at the stated aims in order to be able to

Consequently, Owens et al. (2000) aim to determine knowledge and attitudes

scientific interest. Best-available evidence should not be diluted by issues of

The studies under review therefore focus on the implementation, or lack of

implementation of SBI in the primary care sector. However, while there is

implementation by GPs, very little evidence exists on this issue concerning

Before considering the studies in more detail, it is useful to provide definitions

The other studies mostly use questionnaires. The validity of a questionnaire is

The other four studies concentrate on smaller geographical areas. Owens et

Discussion and Conclusions: Analysis of Themes

It is interesting to note the conclusion that the balance of evidence favoured

al. (2003) why additional training appears to have had a counterproductive

6. SUMMARY AND CONCLUSIONS

The Way Forward

It may be helpful to widen a meta-analysis like this one in order to include

RELIABILITY AND VALIDITY

Qualitative study design,

Study aims to examine

Kaner E, Heather N, Mc Avoy BR, Lock C, Gilvarry E 1999 Intervention for

Mc Cambridge J, Platts S, Whooley D, Strang J 2004 Encouraging GP alcohol

Aalto M, Seppa K, Mattila P, Mustonen H, Ruuth K, Hyvarinen H, Pulkkinen H,

Anderson P, Kaner E, Wutzke S, Funk M, Heather N, Wensing M, Grol R,

Fleming M, Lawton Barry K, Baier Manwell L, Johnson K, London R 1997

6. How often during the last year have you

2. How many drinks containing alcohol

7. How often during the last year have you

3. How often do you have six or more

8. How often during the last year have you

Score for Questions 2 and 3 = 0

9. Have you or someone else been injured as