Supporting nurse mentors to reduce the barriers to implementing alcohol Interventions and Brief Advice (IBA) in primary care

Note: This report was funded and/or written by our predecessor organisation Alcohol Research UK.

It is estimated that nine million people in England regularly drink above the Government’s previous sensible drinking guidelines¹. Alcohol, together with obesity and smoking are the three biggest lifestyle risk factors for disease and death in the UK².

There is a wealth of evidence that supports alcohol Identification and Brief Advice (IBA) in primary care as both effective and cost effective in reducing the risks associated with drinking alcohol and National Institute of Health and Care Excellence (NICE) guidance suggests that such prevention should be prioritised as ‘invest to save’ measures³. On average 1 in 8 higher or increasing risk drinkers receiving the intervention will reduce their alcohol consumption to lower risk levels, reducing the potential for alcohol-related harm.

Despite the strong evidence base for IBA there remain barriers to implementation of this relatively simple intervention in primary care including:

• Professional feelings of lack of role adequacy and role legitimacy, lack of knowledge and skills
• Perceived lack of support by staff
• Patient/ client/ staff reluctance to engage – in some circumstances because of concerns about confidentiality
• Lack of monitoring⁴

The delivery of IBA in primary care has been patchy despite incentivised schemes. The alcohol Direct Enhanced Service (DES) required that practices screen newly registered patients aged 16 or over, using one of two shortened versions of the World Health Organisation (WHO) Alcohol Use Disorders Identification Test (AUDIT) questionnaires: FAST or AUDIT-C. FAST has four questions and AUDIT-C has three questions, with each taking approximately one minute to complete. The DES stated that patients with a score of five or more with AUDIT-C should be given the full AUDIT and be offered brief advice for a score between eight and 19, or be considered for referral to specialist services for a score of 20 or more.

However, payment was based upon calculation of the number of newly registered patients, aged 16 or over in the financial year, who have been screened using either the FAST or AUDIT-C tool without the requirement for brief interventions/referral on to specialist services to be delivered, leading to questions about how effective the DES would be. During 2009–2010, Haringey practices participating in the alcohol DES identified just 2% of new patients as AUDIT positive even though an estimated 26% of Haringey residents drink above recommended limits⁵. In addition, over half of the practices didn’t identify any of their patients as AUDIT positive, whereas some practices identified all of their patients as AUDIT positive. A review found, to give just two examples, that 75% of practices were using incorrect screening questions, and that only 50% of practices were offering face-to-face brief advice. This would suggest that the systems used within primary care can play an important part in implementation of IBA.

The nurse mentor role

Nurse mentors have an important role in primary care leadership to support multi-agency learning, education and innovation in practice⁶. Nurse mentors also play an important role in developing newly qualified staff across all areas of patient care; and practice placements are acknowledged as being one of the most important aspects of a trainee’s educational experience in healthcare. However, nurse mentors are not usually identified to be trained in the specifics of alcohol IBA.

Project aims

This project aims to reduce barriers to the implementation of IBA in primary care by providing expert support to nurse mentors to:

• develop a leadership role in IBA including provision of ongoing training and support to staff members
• encourage ongoing evaluation of activity and outcomes in IBA

This project was conducted with a large city-based practice in Birmingham in an area of deprivation with a practice population of 9,500. There is a total of nine GPs, five nurses and four Health Care Assistants (HCA). The practice has a specialism in provision of drug and alcohol treatment.

Project plan

The project was designed to take place over a six-month period with the key activities and timescales as identified in table 1 below.

Table 1

Baseline audit

At month 1 an initial baseline audit was conducted.

• 1,298 AUDIT-Cs completed in a one year period in 2015/16
• 13% scored 5 or higher
• Of these, 30% went on to have a full AUDIT

Training session

A training session was provided at month 2 to the two nurse mentors identified to lead the project which outlined:

• The rationale for IBA including prevalence and types of problems resulting from alcohol-related harm
• The findings of the baseline audit
• How to use AUDIT-C and full AUDIT
• A new patient leaflet

The PowerPoint presentation used in the above was made available to the nurse mentors to provide training to the staff at the surgery. One nurse mentor went on long term sickness absence leave and the project was delayed but the remaining nurse mentor continued the project.

Training and awareness raising

Training was provided to all HCAs and nurses at the practice. The PowerPoint presentation had also been looked at and discussed at the doctor’s meetings so all clinical staff at the medical practice had been updated and trained.

Ongoing support was provided to the nurse mentor via phone/ email contact and a meeting at the end of the project was arranged to evaluate its impact. The email and phone contact with the nurse mentor was limited, as they felt confident to implement the project.

Evaluation

An evaluation session was carried out with one nurse mentor at the end of the project (the second nurse remained on sickness absence). The following were identified as positive impacts on the surgery:

Whilst it was felt by nurse mentors that the staff had good knowledge regarding alcohol it was felt that prior to the project staff had not been fully trained in the delivery of IBA and that this had increased confidence in discussing alcohol use with patients both in terms of knowledge and in confidence. Staff now felt that this was an effective intervention legitimate to their role. It was also felt that some simple changes to processes (an easier route to the full AUDIT and the provision of a patient leaflet) had made a significant difference to make delivery of IBA quick and easy.

A referral created by a nurse mentor during the project for onward referral which had increased confidence in signposting those with more complex alcohol problems.

The nurse mentors have decided that they would include an annual audit on IBA and an annual training update to all staff at the practice to deal with it as an ongoing issue within the medical practice. This was in recognition that with other competing initiatives awareness regarding IBA was likely to reduce over time.

End of project audit

At the project end the audit was repeated with the following findings:

• 290 AUDIT-Cs were completed in a four-month period during 2016/17
• 15% (44) had a score of five or more
• Of these 48% (21) went on to have full AUDIT.

This indicates that provision of brief interventions had increased by 18%. There had also been a modest increase in the numbers who were scoring five or more on the AUDIT-C screen from 13% to 15%. However, the number of AUDIT-C screens being completed appeared to have reduced from 108 to 73 per month. This may reflect the fact that there had been long term staff absence leave, and also the fact that Christmas and New Year fell over the period of the second audit, with more public holidays and annual leave being taken. Finally, the end of project audit was conducted over a four-month period and the baseline audit measured activity over a year long period. The end of project audit may not be as reliable regarding activity at the surgery as the baseline audit due to its considerably shorter time span.

The findings of this project suggest that providing a relatively low level of support to nurse mentors based in primary care leads to a significant increase in the delivery of IBA:

• There was a marked increase in the percentage of patients screening positive at an initial screening test going on to receive IBA, from 30% at the beginning of the project to 48% at the project end.
• There was a modest increase in the percentage of patients who received an initial screen being assessed as requiring a brief intervention from 13% at the beginning of the project to 15% at the project end indicating that clinicians were identifying increasing or higher risk drinkers more effectively.

Following the implementation of the project staff at the surgery appear to be more effective at identifying alcohol-related harm and at providing brief interventions to this group.

An unanticipated finding of this project was the nurse mentors’ unique position to provide leadership not just in terms of knowledge, encouragement and monitoring, but also their ability to identify and make positive changes to operational aspects of delivery.

This project indicates that by supporting nurse mentors in leading on the implementation of IBA there is potential for reducing alcohol-related harm within the existing resources of the surgery. This could support primary care in the practical implementation of an evidence based cost effective intervention which has experienced patchy uptake.

1 Her Majesty’s Government (2012) The Government’s Alcohol Strategy -2012

2 House of Commons Health Committee, 29012, Government’s Alcohol Strategy

3 National Institute for Health and Care Excellence (2012) Alcohol-use disorders: prevention Guideline PH24

4 Thom B. et al (2014) Delivering alcohol IBA: broadening the base from health to non-health contexts Alcohol insight number 116 Alcohol Research UK

5 PHE Alcohol Learning Resources

6 Event hosted jointly by the Royal College of GPs Foundation, the Committee of General Practice Education Directors (COGPED) and Health 6 6Education Wessex (HEW) November 2013 Nursing in Primary Care – ‘a roadmap to excellence’