Table 4 Anticipated barriers to implementation of nurse-delivered screening, brief intervention, and referral to treatment

1. Nurses’ Lack of a

Alcohol-related Knowledge and Skills

“You know, I’m a pretty new nurse. I’m not real comfortable speaking to them about stuff like that (alcohol) yet. Just the whole being a nurse in an acute care setting, you know? Everything you have to do and all the responsibilities and all, it’s a lot of learning.”

“. . . [the nurse practitioner in the video] made [the patient in the video] feel like she was listening to her and not just coming, “Ok, here’s the question, what’s the answer? Here’s the question, what’s the answer?” So, not all nurses have that ability to do that. . .”

“…Some people have a bad taste in their mouth when it comes to dealing with somebody with an addiction. We all have a bad feeling about when, “Oh, he’s a drinker,” you know?” (multiple agreement) . . . So I think it needs to be somebody that’s more compassionate, that understands, that doesn’t have that stereotype.”

2. Limited Interdisciplinary Collaboration and Communication around Alcohol-related Care

You know, we can suggest [an addiction consultation] to some [doctors], but if I don’t know those doctors and I suggest [a consultation] just out of the blue, they’re not going to listen to me.

Sometimes I feel I pass things on and they never get anywhere, you know? Three days later you’re still passing things on, it’s like, c’mon, you know?

Calling the doctor and saying “Listen this guy’s abusing alcohol, this guy’s abusing marijuana” and they’re like, “Whatever”-

Nurse 1: I don’t think that [the physicians] really look at our notes. . . They don’t read, they don’t have time to read-

Nurse 2: And to be honest, too, I think with nurses, everybody looks to see if [the addiction consultation] has been done, and if it’s done, we just all move on.

3. Inadequate alcohol assessment protocols and poor integration with the EMR^b

“It’s hard because, I don’t feel there is a enough structured assessment tool for any of it (alcohol). And I feel like it just gets bypassed, especially in that group (risky drinkers).

“If they say [they don’t drink] and if they don’t show signs and symptoms (of alcohol withdrawal), it’s basically all just focused on what they’re there for.”

“All that the admission assessment is requires, “How many drinks have you had? When was the last drink?” It’s not detailed- not really tell us or how to follow or make any commitment and all.”

4. Concerns about negative patient reactions and limited patient motivation to address alcohol use

Nurse 1: Sometimes the patients can be temperamental. You don’t want to cause a problem that’s not there, like, get them riled up.

Nurse 2: And once get angry about one issue then they have trouble- they don’t want to take the meds for you, they don’t want to cooperate with anything else.

Nurse 1: . . . (the older alcoholics), I think a lot of them are so far gone, you know?

Nurse 2: That generation just doesn’t listen, especially to women.

Nurse 3: Yeah, and I’ve had a lot of patients just tell me that “This is all I know, this is all I do.”

Nurse 1: Our population is probably mid-50s to older--it’s something they’ve been doing for 25-30 years. . . at that point they don’t think they have a problem, it’s just normal to them.

Nurse 2: Or it’s already too long. They’ve already got the problems that go with it (alcohol use), and think, why bother?

5. Questionable compatibility of alcohol screening, brief intervention, and referral to treatment with the acute care paradigm and nursing role

If they’re in for, like, something not alcohol-related, like pneumonia or whatever- -sometimes I think if the alcohol is not going to be an issue, as in they’re not going to withdrawal, it kind of gets overlooked and you just treat what’s medically wrong with them.

. . .Sometimes it’s hard when they’re here for such a short period of time, to really get the big picture of what’s going on in their life, especially when a list of long medical problems that need to be addressed

As far as acute care nursing goes, I don’t know what else we could do as nurses, other than what we do.

And I hate to keep saying this but I really think that the people who are the professionals who are used to dealing with [alcohol] every day should be ones that are making goals with the patient.

I actually think us as nurses, we do [alcohol-related counseling] automatically. I mean, we don’t need to be told, “Help your patients stop drinking.” We may not have all the necessary tools and it might be not the appropriate place but to get him over that acute phase of withdrawal, but to talk to him and try to encourage him to stop drinking, we do that all the time anyway.

6. Logistical Issues (e.g., lack of time/privacy)

I think that we’re so busy, and a lot of times we’re talking about the discharges, it’s like they’re handing you two admissions that are coming in and saying, you know, “Get your patient out of here, this guy’s coming in.” So to take a half an hour to talk to them about their drinking habits, like, it’s not gonna happen, you know?

I don’t know if, as a nurse, on a typical day, I’d have that amount of time to sit with a patient--to build up a rapport back and forth (to discuss alcohol).

Especially in a semi-private room. Who wants to talk about the most personal things in their life with, you know, some complete stranger next to them?