Pieces of the jigsaw :

Transcription

1 Pieces of the jigsaw : what support do rural multi-skilled emergency nurses need to deliver alcohol brief intervention education in a small rural Emergency Department?

2 Elizabeth A. McCall, RN.,RM., BHSc (Nursing), MHSc Nurse Manager Byron District Hospital Byron Bay NSW Australia

3 THIS RESEARCH WAS FUNDED BY THE HEALTH RESEARCH AND TRAINING INSTITUTE (HETI) UNDER THE AUSPICES OF THE RURAL RESEARCH CAPACITY BUILDING PROGRAM AND SUPPORTED BY NNSWLHD. ADDITIONAL IN-KIND SUPPORT TO COMPLETE THIS PROJECT WAS PROVIDED BY THE AUTHOR S HEALTH FACILITY.

4 BACKGROUND WHILE ALCOHOL MISUSE IS PREVALENT INTERNATIONALLY, THE MAJORITY OF STUDIES ON ALCOHOL BRIEF INTERVENTIONS IN THE EMERGENCY DEPARTMENT HAVE FOCUSED ON EFFECTIVENESS OF THE BRIEF INTERVENTION (BI).

5 LITTLE HAS BEEN WRITTEN REGARDING THE KNOWLEDGE AND SYSTEMS SUPPORT REQUIRED FOR EMERGENCY NURSES TO SUCCESSFULLY IMPLEMENT ALCOHOL BI

6 WHAT IS AN ALCOHOL BRIEF INTERVENTION? Alcohol brief interventions are short education sessions delivered prior to patient discharge from the health facility.

7 THE EMERGENCY NURSES IN THIS STUDY: WERE MULTI-SKILLED WORKED IN THE GENERAL WARD AREA AS WELL AS THE EMERGENCY DEPARTMENT OFTEN CARED FOR PATIENTS WHO HAD BEEN ADMITTED FOR ALCOHOL-RELATED INJURY, ILLNESS OR FOR WITHDRAWAL TREATMENT IN THE WARD AREA. HAD EXPERIENCE IN COMPLETING A SUBSTANCE USE HISTORY HAD ACCESS TO ONGOING CONTINUING EDUCATION REGARDING ALCOHOL MISUSE TREATMENT AND EDUCATION.

8 EMERGENCY NURSES ARE WELL PLACED TO BE AT THE FOREFRONT OF BI IMPLEMENTATION AS THEY SPEND SO MUCH TIME WITH PATIENTS.

9 STUDY DESIGN PHENOMENOLOGICAL STUDY DATA COLLECTED BY FOCUS GROUPS & IN-DEPTH INTERVIEWS 21 PARTICIPANTS INTERPRETATIVE THEMATIC ANALYSIS

10 EMERGENCY NURSES EXPERIENCES

11 MANY BURDENS IN DIFFERENT DIRECTIONS PARTICIPANTS TALKED ABOUT THE PUBLIC HEALTH BURDENS EXCESSIVE ALCOHOL USE PLACES ON SOCIETY:

12 I M THINKING MORE OF THE BURDEN ON THE DEPARTMENT THE COST OF WHAT THE PRESENTATION MAY BE ON THE PERSON AND THEIR FAMILY - THE COMMUNITY, THE HOSPITAL. SO IT HAS A WIDE-RANGING EFFECT ON A LOT OF PEOPLE. I MEAN LOOK AT NEW YEAR S EVE TAKE OUT THE ALCOHOL RELATED PRESENTATIONS AND WE HAD FOUR SICK PEOPLE. SO YES THERE ARE MANY BURDENS IN DIFFERENT DIRECTIONS (I 2).

13 OTHERS SPOKE OF THEIR FEELINGS OF DISQUIET REGARDING THE LEARNED BEHAVIOURS OF ALCOHOL- INTOXICATED PATIENTS:

14 YOU KNOW MOST OF THESE PEOPLE COMING TO ED THEY VE PROBABLY WITNESSED THEIR PARENTS & OLDER SIBLINGS DOING THE SAME THING SO IT S JUST A TUMBLING CYCLE (F3 1).

15 THE NEED TO ADDRESS THE SOCIETAL ACCEPTANCE OF ALCOHOL MISUSE SO APPARENT IN CONTEMPORARY SOCIETY WAS DISCUSSED VOCIFEROUSLY:

16 ALL WE RE DOING IS PICKING UP PIECES THERE S A LOT OF MONEY SPENT ON PICKING UP THE PIECES WHEN THAT MONEY COULD BE USED TO PUT IN SOMETHING AT THE VERY BEGINNING TO HELP I DON T KNOW SOME SORT OF PREVENTION (F2 4).

17 TWO GROUPS GAVE ASTUTE OPINIONS ABOUT THE POLITICAL ISSUES OF CHANGING HOTEL CLOSING HOURS AS A WAY TO REDUCE ALCOHOL RELATED INJURIES THAT MIRRORED THOSE OF COMMUNITY GROUPS:

18 AND THEN I THINK IT S SHUTTING THE GATE AFTER THE HORSE HAS BOLTED THAT BECOMES A POLITICAL ARGUMENT THEN ARE THEY GOING TO STOP SELLING ALCOHOL?... BUT THEN IT BECOMES POLITICAL TO CLOSE ALL THE DOORS (F2 6). AND IT DOESN T HELP THESE DISCOS/NIGHTCLUBS OPEN TIL 3AM & THAT S JUST RIDICULOUS AND ONCE AGAIN THAT S WHEN YOUR STAFFING LEVELS ARE AT THEIR LOWEST WHEN THE PROBLEMS OCCUR (F3 7).

19 IT S ALL VERY ACCEPTABLE PARTICIPANTS TALKED ABOUT AUSTRALIAN MORES AND THE COMPARISONS WITH THEIR EUROPEAN EXPERIENCES:

20 WELL THEY RE SITTING DOWN AT DINNER WITH US WHILE WE RE DRINKING WINE... IT S ALL VERY ACCEPTABLE ISN T IT? TWENTY YEARS AGO WHEN WE HAD SCHOOLIES WEEK NOT EVERYBODY WOULD GO (F3 2). THAT S THE CULTURE AUSTRALIA DAY WE ALL GET DRUNK, NYE WE ALL GET DRUNK, BIRTHDAYS WE ALL GET DRUNK (F3 3).

21 OTHERS EXTENDED THE CONVERSATION CONCERNING FAMILY ATTITUDES, REFERENCING EXAMPLES OF OTHER POSSIBLY MORE ACCEPTABLE CULTURAL MORES REGARDING THE CONSUMPTION OF ALCOHOL:

22 IN EUROPE IT S A SOCIAL THING - THEY DRINK & EAT AT THE SAME TIME IT S A COMBINATION WHEREAS I THINK AUSTRALIANS JUST DRINK. YOU DON T FEEL UNSAFE WALKING DOWN THE PARTY STREETS IN PARIS OR MADRID OR BARCELONA (F3 1). IN FRANCE THEY DO THAT ALL THE TIME (F3 7). EVERYBODY S OUT THE OLDER PEOPLE ARE OUT LATE AT NIGHT TOO SO IT S A TOTALLY DIFFERENT CULTURE (F3 5).

23 INDIGNATION WAS EXPRESSED THAT YOUNG PEOPLE IN PARTICULAR HAD AN EXPECTATION OF TREATMENT RELATED TO ALCOHOL ILLNESS AND INJURY WITHOUT TAKING ANY RESPONSIBILITY FOR THEIR BEHAVIOURS:

24 THEY RE ACTUALLY TEACHING THE KIDS IF THEY START VOMITING OR START TO LOSE CONSCIOUSNESS GET TO THE HOSPITAL. THE EDUCATION THEY RE TAKING IN ISN T DON T DO IT OR MODIFY YOUR DRINKING OR ANYTHING LIKE THAT IT S HOW TO HANDLE IT IT S OK TO DO IT - IT S OK TO GET DRUNK BUT THIS IS WHAT IS WHAT YOU DO WHEN THINGS ARE FALLING APART (F3 6).

25 JUST THAT ONE WORD IN RECOGNITION OF PATIENT VULNERABILITY AND THE DESIRE FOR THEIR PRACTICE TO BE ETHICAL THE MAJORITY OF PARTICIPANTS EXPRESSED AN UNEQUIVOCAL WISH TO BE: COMPASSIONATE COMPETENT KNOWLEDGEABLE

26 THAT S WHY I LIKE WORKING IN ED ITS THAT THE BRIEFEST INTERACTION CAN MAKE SUCH A DIFFERENCE TO SOMEONE S LIFE. THAT S THE REAL BEAUTY OF WORKING IN ED (F1 6). AND I FIND BY THE MORNING AND THEY RE STARTING TO COME BACK TO THEMSELVES AND YOU REALISE OH THIS YOUNG GIRL IS LOVELY SHE S JUST A GIRL AND SHE S GONE OUT (F2 3).

27 WE RE MISSING SOME MAJOR POINTS DESPITE THIS WISH, SOME PARTICIPANTS DID NOT HAVE THE ABILITY TO RECOGNISE THE USEFULNESS OF THE KNOWLEDGE THEY HAD GAINED IN ONE SETTING AND HAVE THE SKILLS OR CONFIDENCE TO TRANSFER IT TO ANOTHER SETTING

28 OBVIOUSLY WE RE MISSING SOME MAJOR POINTS HERE BECAUSE WE HAVEN T DONE THE RESEARCH OR THE STUDY (F2 4). COS YOU NEED TO FEEL CONFIDENT TO SAY BECAUSE OTHERWISE THEY RE JUST LOOKING AT YOU THINKING YOU THINK I M AN ALCOHOLIC. IF YOU HAD THE EDUCATION TO SAY IT RIGHT (F2 6).

29 IT S NOT MY JOB SOME FELT THEY DIDN T HAVE THE KNOWLEDGE DESPITE: CARING FOR ALCOHOL AFFECTED PATIENTS IN THE WARD AREA HAVING REGULAR CONTINUING EDUCATION

30 I DON T HAVE THE EMPATHY TO ACTUALLY SIT WITH THEM AND TALK AND DISCUSS WHAT S GONE DOWN IN THEIR LIFE. I THINK IT S NOT MY JOB AS AN ED NURSE. IT S ACTUALLY SOMEONE ELSE S JOB IT S DRUG AND ALCOHOL BECAUSE I M NOT TRAINED IN THAT (F1 3).

31 YOU CAN PUT THE DOTS TOGETHER WHEN ASKED WHETHER THEY THOUGHT THAT INCREASED EDUCATION WOULD ASSIST IN THE ACQUISITION OF SKILLS AND CONFIDENCE TO INITIATE ALCOHOL BRIEF BI EDUCATION IN THE ED SOME PARTICIPANTS AGREED THAT BRIEF INTERVENTIONS COULD WORK.

32 YOU RE NOT GOING TO HEAL YOU RE NOT GOING TO DO THE WHOLE THING BUT YOU CAN PUT THE DOTS TOGETHER (F1 3).

33 SAY THIS PERSON S WILLING TO TALK TO ME I WILL TAKE THE TIME AND SAY IT LOOKS LIKE THIS CRISIS THIS PROBLEM HAS BEEN RESOLVED AND THERE ARE SOME THINGS YOU CAN DO AND SEE WHETHER THEY RE WILLING TO (F1 5)

34 THEY RE STILL HALF OUT OF IT SOME WERE MORE PESSIMISTIC:

35 I KEEP THINKING ABOUT PEOPLE THAT COME IN WITH INJURIES THE DAY AFTER THEY THEY VE BEEN DRINKING. TO ME, TO GIVE THEM ANY INFORMATION THEY HAVE TO BE AWARE OF WHAT S GOING ON A LOT OF THEM THEY RE STILL HALF OUT OF IT (F3 6). AND ALSO SOMEONE OF THEM DON T HAVE THE COGNITIVE FUNCTION THEY VE GOT BRAIN DAMAGE (F3 7).

36 I DON T HAVE THE TIME OTHER PARTICIPANTS WERE ADAMANT THAT THEY DID NOT HAVE THE TIME OR SUPPORT TO PROVIDE BI EDUCATION:

37 I DON T HAVE THE TIME (F1 3). IT S ALWAYS WHEN YOU HAVEN T GOT TIME YOU DON T HAVE THE STAFF TO SUPPORT (F3 5). IT S JUST NOT PRACTICAL IN AN ED (F1 2).

38 WORKPLACE CHALLENGES ARE BARRIERS TO SUCCESSFUL BI IMPLEMENTATION: KNOWLEDGE DEFICITS DEDICATED TIME DEDICATED SPACE IN ELECTRONIC MEDICAL RECORDS INADEQUATE STAFF.

39 CONCLUSION EMERGENCY NURSES ARE OFTEN TOO STRESSED, BUSY AND UNDERSTAFFED TO CONTEMPLATE PROVIDING ALCOHOL BI EDUCATION IN THE ED.

40 RECOMMENDATIONS MANAGERS NEED TO ACKNOWLEDGE WORKPLACE CHALLENGES RELATED TO CARING FOR ALCOHOL-INTOXICATED PATIENTS

41 EDUCATION THAT ENHANCES BOTH THE KNOWLEDGE AND CONFIDENCE OF EMERGENCY NURSES MAY ASSIST IN THE IMPLEMENTATION OF ALCOHOL BI EDUCATION IN THE ED

42 THE ELECTRONIC MEDICAL RECORD USED IN THE ED REQUIRES SYSTEMS REDESIGN TO INCORPORATE A DISTINCT MANDATORY ICON TO PROMPT EMERGENCY NURSES TO OBTAIN A SUBSTANCE USE HISTORY FROM ALL PATIENTS PRESENTING TO THE ED

43 STUDY LIMITATIONS FINDINGS MAY BE DIFFICULT TO GENERALISE GIVEN THE DYNAMIC NATURE OF INTERPRETIVE ANALYSIS AND THE SPECIFICITY OF BOTH THE LOCALE AND PARTICIPANTS. IT IS ALSO ACKNOWLEDGED THAT PARTICIPANT FEELINGS MAY CHANGE OVER TIME. THERE IS A NEED FOR REPLICATION OF THIS STUDY TO DETERMINE THE EXPERIENCES OF OTHER RURAL AND URBAN EMERGENCY NURSES

44 Ac k n o w l edgements T h e a u t hor wo u l d l i k e t o t h ank:. T h e e m ergency n u r ses wh o b r a vely ve n t ured i n t o u n k nown t e r r i t ory. E m m a W ebster, a n d D a vid S c h m i dt, H E T I. D r Richard Lakeman, S e n ior L e c turer, S C U. L u C o o ney, R N., B yron D i s t r i ct H o s pital

45 THANK YOU