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Table 2 Coding tree for anticipated barriers and facilitators associated with nurse-delivered screening, BI a and RT b

From: A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center

BARRIERS  
  Patient-level
  ➢ Concerns about negative patient reaction and limited patient motivation to address alcohol use
    · Patient expressions of anger, denial, dishonesty, offense, aggression, disinterest in changing
      Alcohol-dependent patients
         -- Challenging behavior
         -- Repeated admissions
      Sex and age-related differentials between nurse and patient
  Provider-level
  ➢ Lack of nurse training and skills in alcohol screening, BI, and RT
    · Alcohol-related knowledge
      Conceptual definitions, clinical criteria, established standards/recommendations
    · Alcohol-related skills
      Effective therapeutic communication techniques
      Goal-setting for consumption reduction
  ➢ Limited interdisciplinary collaboration and communication around alcohol-related care
    · Differences in prioritization and attention to alcohol issue across provider disciplines
      Physician resistance/reluctance to address alcohol use or withdrawal
    · Lack of effective communication with physicians, specialists
    · Lack of shared care planning with physicians, specialists
  ➢ Questionable compatibility of alcohol screening, BI, and RT with the nursing role
    · Competing priorities, goals
    · Nursing advocacy and autonomy
  System-level
  ➢ Inadequate alcohol assessment protocols and poor integration with the EMRc
    · Brevity of alcohol-related content in admission assessment
    · Despite admission template, lack of standardization in alcohol assessment across nurses
    · Limits of EMR regarding alcohol-related care planning
      Lack of detailed patient care templates
      Lack of guidance on follow-up actions
      Inappropriately-generated automatic prompts for consults
  ➢ Questionable compatibility of screening, BI, and RT with the acute care paradigm
      Competing priorities, goals
  ➢ Logistical issues
    · Lack of time
      Task prioritization
      Uninterrupted time
    · Lack of patient privacy
FACILITATORS
  Patient-level
    · N/A
  Provider-level
  ➢ Improved provider knowledge, skills, communication, and collaboration
    · Alcohol and screening, BI, RT education for nurses and doctors
      General knowledge, brief intervention skills, communication techniques
    · Shared assessment, care planning, sense of responsibility
      Inclusion of all disciplines’ professional perspectives
  System-level
  ➢ Enhanced EMR features for alcohol-related care
    · Electronic templates and scoring for patient screening, assessment
    · Clinical decision making algorithms/electronic reminders
    · Consultation orders linked to assessment
    · Patient education resources
  ➢ Expanded processes of care and nursing roles
    · Autonomy to initiate addiction specialist consultations
    · Specialized nurse educators/specialist team focused on BI and patient education
  1. Notes: a BI = brief intervention; b RT = referral to treatment; c EMR = electronic medical record.