A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care

BACKGROUND: Excessive alcohol consumption causes significant mortality, morbidity, economic and social problems in the United Kingdom (UK). Despite strong evidence for the effectiveness of brief intervention to reduce excessive drinking in primary health care, there is little indication that such intervention routinely occurs. AIMS: This study aimed to explore primary health care nurses' attitudes and practices regarding brief alcohol intervention in order to understand why it is underexploited. METHODS: The study design was qualitative, using a grounded theory approach to data collection and analysis. Semi-structured in-depth interviews were conducted with 24 nurses from practices that had previously been involved in a General Practitioner (GP) led brief alcohol intervention trial in the North-east of England. A combination of convenience and purposive sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. RESULTS: It was clear that although primary health care nurses have many opportunities to engage in alcohol intervention, most have received little or no preparation for this work. This has left nurses at a disadvantage as alcohol consumption is a confusing and emotive area for both health professionals and patients. An analysis of factors influencing nurse involvement in alcohol intervention outlined a requirement for clear health messages about alcohol, training in intervention skills, facilitation to enhance confidence regarding intervention and support to help deal with negative patient reactions. CONCLUSIONS: As current health policy is to encourage, sustain and extend the health promotion and public health role of primary care nurses, more attention should be given to providing them with better preparation and support to carry out such work.     

Cost-utility of collaborative nurse-led self-management support for primary care patients with anxiety,depressive or somatic symptoms: A cluster-randomized controlled trial (the SMADS trial)

BackgroundAnxiety, depressive and somatoform disorders are highly prevalent and cause a huge economic burden. A nurse-led collaborative care intervention has been set up in order to improve self-management of patients with these mental disorders in primary care in Hamburg, Germany. The aim of this study was to determine the cost-utility of this nurse-led intervention from the health care payer perspective.MethodsThis analysis was part of a 12-month cluster-randomized controlled trial aiming to increase perceived self-efficacy of primary care patients with anxiety, depressive or somatic symptoms by collaborative nurse-led self-management support compared with routine care. A cost-effectiveness analysis using quality-adjusted life years was performed. Net-monetary benefit regressions adjusted for baseline differences for different willingness-to-pay thresholds were conducted and cost-effectiveness acceptability curves were constructed.ResultsIn total, n = 325 patients (intervention group: n = 134; control group: n = 191) with a mean age of 40 from 20 primary care practices were included in the analysis. The adjusted differences in quality-adjusted life years and mean total costs between intervention group and control group were +0.02 and +€1145, respectively. Neither of the two differences was statistically significant. The probability for cost-effectiveness of the complex nurse-led intervention was 49% for a willingness-to-pay of €50,000 per additional quality-adjusted life year. The probability for cost-effectiveness did not exceed 65%, independent of the willingness-to-pay.ConclusionThe complex nurse-led intervention promoting self-management for primary care patients with anxiety, depressive or somatic symptoms did not prove to be cost-effective relative to routine care from a health care payer perspective.     

Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial

OBJECTIVE: To determine the effectiveness of specialist nurse-led clinics for hypertension and hyperlipidemia provided for diabetic patients receiving hospital-based care. RESEARCH DESIGN AND METHODS: This study was a randomized controlled implementation trial at Hope Hospital, Salford, U.K. The subjects consisted of 1,407 subjects presenting for annual review with raised blood pressure(>or=140/80 mmHg), raised total cholesterol (>or=5.0 mmol/l), or both. Individuals with diabetes were randomized to usual care or usual care with subsequent invitation to attend specialist nurse-led clinics. Nurses provided clinics for participants, with attendance every 4-6 weeks, until targets were achieved. Lifestyle advice and titration of drug therapies were provided according to the locally agreed upon guidelines. Patients with both conditions were eligible for enrollment in either or both clinics. At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register. Data relating to deaths were obtained from the national strategic tracing service. The primary outcome was the odds ratio of achieving targets in hypertension and hyperlipidemia, attributable to the specialist nurse-led intervention. RESULTS: Overall, specialist nurse-led clinics were associated with a significant improvement in patients achieving the target after 1 year (odds ratio [OR] 1.37 [95% CI 1.11-1.69], P = 0.003). This primary analysis revealed a borderline difference in effect between the two types of clinics (test for interaction between groups: P = 0.06). Secondary analysis, consistent with the prior beliefs of the health care professionals involved, suggested that targets were achieved more frequently in patients enrolled in the specialist nurse-led clinic for hyperlipidemia (OR 1.69 [1.25-2.29], P = 0.0007) than for hypertension (OR 1.14 [0.86-1.51], P = 0.37). Intervention (enrolled to either or both clinics) was associated with a reduction in all-cause mortality (OR 0.55 [0.32-0.92], P = 0.02). CONCLUSIONS: This study provides good evidence to support the use of specialist nurse-led clinics as an effective adjunct to hospital-based care of patients with diabetes. If the standards of care recommended in the National Service Framework for Diabetes are to be achieved, then such proven methods for delivering care must be adopted.     

Nurse practitioner alcohol intervention for people with viral hepatitis: Randomised controlled trial

BackgroundIn Australia, alcohol use is accountable for 5.1% of the total burden of disease and injury along with being responsible for 24% of the burden as a result of chronic liver disease. There is a paucity of quality evidence-based programmes for alcohol use management and the chronic viral hepatitis population.AimsTo evaluate the effectiveness of an alcohol brief intervention for ambulatory patients with chronic viral hepatitis C attending a hepatology clinic.MethodsA randomised controlled trial determined the effectiveness of: a brief intervention and routine care (Group 1) compared to routine care only (no formalised intervention) (Group 2). Alcohol reduction is the primary outcome measure. Reduction in risky drinking and quality of life were also measured. Data was collected at three-time points, baseline prior to randomisation, four weeks and eight weeks.FindingsAlcohol intake reduced in both groups at 4 weeks, with 57% (intervention) and 41% (control) having a 50% reduction in alcohol (p = 0.295). This reduction was maintained by both groups at 8 weeks with 53% (intervention) and 43% (control) (p = 0.536). The intervention group showed a greater reduction over time, but this was not statistically significant.DiscussionIncreasing nurse led models of care, such as nurse practitioners specialising in hepatology, could provide an effective response for managing people with chronic viral hepatitis C and alcohol misuse.ConclusionAssessing for alcohol use using the AUDIT C and TLFB_A and providing a brief intervention with routine care by the Nurse Practitioner, Hepatology is an acceptable and useful intervention to reduce alcohol consumption in this population.     

The effect of screening and brief intervention for risky drinking on health care utilization in managed care organizations

OBJECTIVE: We sought to estimate the effect of screening and brief intervention (SBI) for risky alcohol use on the health care utilization of risky drinkers in 4 managed care organizations. RESEARCH DESIGN: A quasi-experimental group design was implemented in which 12 participating primary care clinics randomly were assigned to 1 of 3 study conditions. In one condition, physicians, physician assistants, and nurse practitioners delivered the brief intervention. In another condition, midlevel professionals (usually nurses) performed the brief intervention. In the third condition, SBI was not performed. Using administrative claims data, we estimated the effect of SBI on individual-level annual days of total and inpatient health care utilization; annual outpatient visits; annual emergency room visits; and annual visits related to alcohol, drug, or mental health conditions. Negative binomial regression models were used to control for other factors that may affect health care utilization. RESULTS: Across all categories of care, the pre- to postintervention change in average health care utilization among risky drinkers in the intervention clinics was not significantly different from that of risky drinkers in the comparison clinics. CONCLUSIONS: Our findings suggest that there is no effect of SBI on the health care utilization of risky drinkers in the year following the intervention. Although SBI does not appear to reduce health care utilization, previous studies find that it significantly reduces the alcohol consumption of risky drinkers. Because these reductions presumably improve patients' overall health and well-being, managed care organizations may still find it beneficial to implement SBI on a broad scale.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

Trial study design to test a bilingual digital health tool for alcohol use disorders among Latino emergency department patients

We describe an emergency department (ED)-based, Latino patient focused, unblinded, randomized controlled trial to empirically test if automated bilingual computerized alcohol screening and brief intervention (AB-CASI), a digital health tool, is superior to standard care (SC) on measures of alcohol consumption, alcohol-related negative behaviors and consequences, and 30-day treatment engagement. The trial design addresses the full spectrum of unhealthy drinking from high-risk drinking to severe alcohol use disorder (AUD). In an effort to surmount known ED-based alcohol screening, brief intervention, and referral to treatment process barriers, while addressing racial/ethnic alcohol-related health disparities among Latino groups, this trial will purposively use a digital health tool and seek enrollment of English and/or Spanish speaking self-identified adult Latino ED patients. Participants will be randomized (1:1) to AB-CASI or SC, stratified by AUD severity and preferred language (English vs. Spanish). The primary outcome will be the number of binge drinking days assessed using the 28-day timeline followback method at 12 months post-randomization. Secondary outcomes will include mean number of drinks/week and number of episodes of driving impaired, riding with an impaired driver, injuries, arrests, and tardiness and days absent from work/school. A sample size of 820 is necessary to provide 80% power to detect a 1.14 difference between AB-CASI and SC in the primary outcome. Showing efficacy of this promising bilingual ED-based brief intervention tool in Latino patients has the potential to widely and efficiently expand prevention efforts and facilitate meaningful contact with specialized treatment services.     

The safety and effectiveness of a nurse-led anticoagulant service

AIM: The aim of this study was to compare the safety and effectiveness of anticoagulant nurses and a consultant haematologist in managing anticoagulant patients in a hospital outpatient setting. BACKGROUND: Nurses are increasingly developing roles traditionally undertaken by medical staff. As a result nurse-led practice has expanded in many areas including anticoagulant services. Previous studies have attempted to demonstrate the effectiveness of using other professionals to manage anticoagulant clinics over short periods of time. This research evaluates the safety and effectiveness of a consultant-led and a nurse-led service over two sequential 18-month periods. RESEARCH METHODS: A nonexperimental design was adopted. Data were collected retrospectively, from a random sample of 197 patients, who had been managed by both the consultant-led and nurse-led service. Two main outcome measures were selected: anticoagulant control between professional groups and interval between outpatient clinic appointments. RESULTS: No statistically significant difference in anticoagulant control was found between professional groups (P=0.137). There was evidence that patients attended anticoagulant clinics on significantly fewer occasions with nurse-led management (P < 0.0005). CONCLUSION: At the department within which this research was conducted, anticoagulant nurses were found to be at least as safe and effective as the consultant haematologist in managing outpatient anticoagulant patients over the study period. These findings are of importance in both shaping the future provision of anticoagulant care and also contributing to the wider area in evaluating the impact of nurse-led practice within health care.     

Brief interventions for high-risk drinkers

Aims and objectives. The purpose of this paper is to explore the literature on brief alcohol intervention and to review the literature that examines the status of the clinic nurse in the delivery of these interventions. The objective is to review critically the literature on brief intervention to create links for nurse developed and delivered brief intervention to high‐risk drinkers. Background. Population estimates suggest that more than one‐third of North Americans drink excessively with even higher rates for individuals treated in primary care settings. Alcohol use has been identified as the third leading cause of mortality in the United States. This problem is not unique to the US and, worldwide, agencies and governmental offices and ministries have issued recommendations to screen patients for alcohol misuse and deliver brief interventions to individuals considered to be high‐risk drinkers. Numerous randomized controlled trials and recent meta‐analyses have supported the use of screening and brief intervention for reducing alcohol consumption in primary healthcare settings. The vast majority of studies reporting on brief interventions have focused on the role of the physician with minimal if any involvement of the clinic nurse. A scant number of studies have been conducted that define and assess the role or potential role of the clinic nurse in providing screening and brief intervention to high‐risk drinkers in the primary care setting. Methods. Systematic review. Results. Six systematic reviews and meta‐analyses from an international base of studies support the use of brief intervention in the primary care setting. Three randomized control trials have highlighted the role of the staff or clinic nurse but there are no meta‐analyses addressing nurse‐delivered brief interventions. Numerous studies have explored factors effecting the implementation of brief intervention into the primary care setting. Conclusion. Brief intervention is recognized as a legitimate nursing role but little has been done to develop and define the role of the nurse in delivering brief interventions to high‐risk drinkers. This represents a major lacuna in both the nursing and alcoholism literature, where only a handful of studies have investigated nurse‐delivered brief intervention. Relevance to clinical practice. As health screening and health promotion are hallmarks of nursing care, nurses need to explore the use of brief intervention in their daily practice.     

A cluster randomized trial of a primary palliative care intervention (CONNECT) for patients with advanced cancer: Protocol and key design considerations

BackgroundThe addition of specialty palliative care to standard oncology care improves outcomes for patients with advanced cancer and their caregivers, but many lack access to specialty care services. Primary palliative care—meaning basic palliative care services provided by clinicians who are not palliative care specialists—is an alternative approach that has not been rigorously evaluated.MethodsA cluster randomized, controlled trial of the CONNECT (Care management by Oncology Nurses to address supportive care needs) intervention, an oncology nurse-led care management approach to providing primary palliative care for patients with advanced cancer and their family caregivers, is currently underway at 16 oncology practices in Western Pennsylvania. Existing oncology nurses are trained to provide symptom management and emotional support, engage patients and families in advance care planning, and coordinate appropriate care using evidence-based care management strategies. The trial will assess the impact of CONNECT versus standard oncology care on patient quality of life (primary outcome), symptom burden, and mood; caregiver burden and mood; and healthcare resource use.DiscussionThis trial addresses the need for more accessible models of palliative care by evaluating an intervention led by oncology nurses that can be widely disseminated in community oncology settings. The design confronts potential biases in palliative care research by randomizing at the practice level to avoid contamination, enrolling patients prior to informing them of group allocation, and conducting blinded outcome assessments. By collecting patient, caregiver, and healthcare utilization outcomes, the trial will enable understanding of the full range of a primary palliative care intervention's impact.     

Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review

OBJECTIVE: To review systematically the available literature on implementation of brief alcohol interventions in primary healthcare in order to determine the effectiveness of the implementation efforts by the health are providers. KEY QUESTION: To what extent have the efforts to implement brief alcohol interventions in primary healthcare environments been successful? METHOD: Literature search from Medline, Cinahl, PsychLIT, Cochrane. SETTING: Primary healthcare. MATERIAL: A total of 11 studies encompassing 921 GPs, 266 nurses, 88 medical students, and 44 "non-physicians" from Europe, the USA, and Australia. MAIN OUTCOME MEASURES: Material utilization, screening, and brief intervention rates. ANSWER: Intervention effectiveness (material utilization, screening, and brief intervention rates) generally increased with the intensity of the intervention effort, i.e. the amount of training and/or support provided. Nevertheless, the overall effectiveness was rather modest. However, the studies examined were too heterogeneous, not scientifically rigorous enough, and applied too brief follow-up times to provide conclusive answers.     

Minor illness education for parents of young children

BACKGROUND: A number of previous studies on minor illness have concentrated on nurse-led clinics and the role of nurse practitioners. This study examines the effect of a minor illness education programme which aimed to increase parents' confidence and knowledge in managing childhood illnesses. AIM: The primary aim of this study was to evaluate the effectiveness of a home visit and booklet in providing education to parents about minor infant illnesses. DESIGN: A randomized controlled trial was conducted. The intervention involved a home visit to discuss parents' concerns and provide advice and information, and a booklet advising parents what to do and when to consult about infant illnesses. METHOD: A total of 120 parents of 6 week old babies were identified over a 6 month period, using health visitors' caseloads, and randomized to an intervention group (60), that received a visit and a booklet, or a control group (60) that received standard care. Groups were compared on entry to the study and at 7 months, in terms of parental knowledge and confidence about childhood illnesses, the intended use of home care activities, intention to consult professionals and actual use of health services. Data were collected by self-completed questionnaire and case note review. FINDINGS: The educational intervention resulted in a reduction in visits to the child health clinic but had little effect on use of other services. Parents in the intervention group showed a general trend towards greater certainty about the home care options they would choose, and a reduction in intention to consult a doctor. However, they also indicated a feeling of reduced confidence and knowledge. CONCLUSION: The trial showed no effect on use of services but did demonstrate reduction in parents' intentions to consult a doctor, which appeared to be because of increased certainty about home care. However, it is of concern that they indicated feeling less confident and knowledgeable. It is not possible to clarify whether this represented anxiety that was constructive, enhancing decision-making or was destructive. Further work into the role of education in parental decision-making, anxiety levels and enhancement of confidence is required.     

Postoperative pain: strategy for improving patient experiences

BACKGROUND: Many patients continue to suffer moderate pain following surgery. Much of this may be unnecessary and could be alleviated with careful strategic pain management. It appears that the knowledge and attitudes of both health care professionals and patients are pivotal to patients' pain experiences. AIM: This paper reports the introduction and evaluation of a nurse-led intervention to improve pain management after surgery. METHODS: The study design was experimental (pretest-post-test), comparing patients' pain scores in a control and an intervention hospital over time. The control hospital was included to assess if temporal effects reduced pain scores during the study period. A convenience patient sample was used, and patients' pain scores were measured in two phases (n = 800). Baseline data were compared with subsequent data collected after the introduction of the nurse-led intervention. The intervention included education for nurses in the form of short pain courses, introduction of regular pain assessment and profiling of pain at hospital level. RESULTS: Introduction of the nurse-led intervention reduced patients' pain scores. This reduction, in the order of 0.73 cm (7.3%) on a visual analogue scale (0-10 cm), was statistically significant for day of surgery and 2 days postsurgery (P < 0.05) in the intervention hospital. A reduction was not seen in the control hospital. CONCLUSION: Improvements in pain management can be made by embracing basic pain management principles.     

Nurse-led brief psycho-education on self-stigma among clients with schizophrenia and affective disorders: - Solomon four-group design

BackgroundThe negative impact of self-stigma among clients with mental illness is well documented. Psychoeducation was found to be an effective measure for managing the treatment gap by reducing the stigma associated with the illness.PurposeThe present study investigated the effectiveness of a nurse-led brief psycho-education in reducing self-stigma among clients in the remittent stage of schizophrenia and affective disorders.MethodsThis study used Solomon- four-group design and was carried out at the Institute of mental health, Rohtak, India. A total of 80 participants were consecutively recruited using the block randomization method and as per the sampling criteria. A trained nurse delivered a 30-min individual-based brief psycho-education to the intervention group as per the standard module. The outcome measure was the reduction in the stigma based on a standardized stigma scale during a 1-month follow-up period.ResultsThe mean age of the participants was 40.48 years (SD = 3.55). Overall, the study observed a significant reduction of stigma scores in the intervention group in the alienation, stereotype endorsement, social withdrawal domain of ISMI during 1-month follow-up (p < 0.001). No interaction effect was found between intervention and pre-test except the social withdrawal domain (p = 0.034).ConclusionsThe nurse-led brief psycho-education has the potential to reduce stigma among clients with mental illness. Our findings open an area of discussion for placing greater attention on nurse-led brief psycho-education in this setting. The study provides pioneer research evidence regarding the involvement of nurses as brief psycho-education therapists among clients attending the tertiary mental health care unit of a lower-middle-income country. Considering the short-term effect of this study, more studies should be conducted in similar settings for an evidence base to advocate supportive nursing care practices in the routine mental health setting.     

Opportunistic screening and clinician‐delivered brief intervention for high‐risk alcohol use among emergency department attendees: A randomized controlled trial

Objective: To evaluate the feasibility and efficacy of routine opportunistic screening and brief intervention (BI) by ED staff to reduce high‐risk alcohol consumption. Methods: This was an open, randomized controlled trial with allocation blinding performed over 12 months. Using the Paddington Alcohol Test, adult patients were screened for high‐risk alcohol use. Consenting patients who were screened positive were eligible for randomization to no counselling (standard care, SC), same‐day BI by an emergency nurse or doctor or motivational intervention (MI) within 1 week by off‐site drug and alcohol counsellors. Telephone follow up was performed at 1 and 3 months. The primary outcome was maximum self‐reported daily standard drinks consumed. Analysis was by intention to treat. Results: Of 32 965 eligible patients, 10 274 were screened, 1043 were positive, 468 consented to the study, and 161, 159 and 148 were allocated to SC, BI and MI, respectively. In the MI group, 133 declined intervention or failed to attend. At 3 months, 96, 81 and 74 participants in the SC, BI and MI groups, respectively, were contactable and consented to telephone interview. Overall, maximum daily alcohol consumption decreased from a median of 13.5 standard drinks at enrolment to 9.25 drinks at 3 months. At 3 months, SC participants reported fewer drinks than those randomized to MI. Conclusion: In the present study, neither BI nor MI was better than SC in reducing high‐risk alcohol consumption. Uptake of opportunistic screening by ED staff was poor, as was patient compliance with off‐site counselling.     

Are practice nurses an unexplored resource in the indentification and management of alcohol misuse? Results from a study of practice nurses in England and Wales in 1995

Changes in the health promotional work undertaken in primary care, including the work needed to meet the 'Health of the Nation' alcohol targets, have led to a rapid expansion of the number of practice nurses in England and Wales. However, there has been little evaluation of this role. This study provides data, for the first time at a national level, about practice nurses' work in identifying and managing patients drinking above recommended sensible guidelines. Data were collected by postal questionnaire from all nurses in a 50% random sample of 1852 practices (drawn from a general practitioner (GP) national study, undertaken at the same time). 43% of nurses responded from 62% of the targeted practices. Respondents reported identifying a mean of 3·1 patients per month who were drinking above recommended sensible guidelines. These patients tended to be male, above 40 years of age and in contact with the nurse for the first time about this problem. Most patients were categorized as having a potential alcohol problem; few were classified as currently dependent. Very little intervention work was undertaken by nurses except for referral to the GP. If real progress is to be made in meeting the 'Health of the Nation' targets on population alcohol consumption, then primary care work in identifying alcohol misusing patients needs to be developed as a matter of urgency. The patients identified by practice nurses are those patients relevant to the 'Health of the Nation' alcohol targets. More emphasis needs to be placed on the valuable contribution practice nurses can make, particularly through the use of screening instruments and brief interventions.     

Improving insomnia in primary care patients: A randomized controlled trial of nurse-led group treatment

BackgroundInsomnia is a common health problem, and most people who seek help for insomnia consult primary care. In primary care, insomnia treatment typically consists of hypnotic drugs, although cognitive behavioral therapy for insomnia is the recommended treatment. However, such treatment is currently available to few primary care patients.ObjectivesTo evaluate the effects of a group treatment program for insomnia led by nurses in primary care.Outcomeswere the Insomnia Severity Index, a 2-week sleep diary, and a questionnaire on frequency of hypnotic drug use.DesignA randomized controlled trial with pre- and post-treatment assessment and a 1-year post-treatment follow-up of the intervention group.SettingsRoutine primary health care; 7 primary care centers in Stockholm, Sweden.ParticipantsPatients consulting primary care for insomnia were assessed for eligibility. To be included, patients had to have insomnia disorder and be 18 years or older. Patients were excluded if they if they worked night shifts or had severe untreated somatic and/or mental illness, bipolar disorder, or untreated sleep disorder other than insomnia. One-hundred and sixty-five patients 20 to 90 years were included. Most were women, and many had co-existing somatic and/or mental health problems. The post-treatment dropout rate was 20%.MethodsThe intervention was a nurse-led group treatment for insomnia based on the techniques of cognitive behavioral therapy for insomnia. The nurses had 2 days of training in how to deliver the program. Ninety patients were randomized to the intervention and 75 to the control group (treatment as usual). Data from 82 in the intervention and 71 in the control group were analyzed in accordance with intention-to-treat principles. Fifty-four of the 72 in the intervention group who participated in the group treatment program were followed up after 1 year.ResultsMean Insomnia Severity Index score decreased significantly from 18.4 to 10.7 after group treatment but remained unchanged after treatment as usual (17.0 to 16.6). The effect size was large (1.23). Group treatment also resulted in significant improvements in all sleep diary variables (sleep onset latency, total sleep time, time awake after sleep onset, number of awakenings, and sleep quality). It also reduced hypnotic drug use. Improvements were maintained 1-year post-treatment.ConclusionsPatients with insomnia can be treated successfully with a nurse-led group treatment program in primary health care. The results support implementation of the treatment program, particularly given the need for increased access to non-pharmacological insomnia treatments.     

Nurses' attitudes, beliefs and confidence levels regarding care for those who abuse alcohol: impact of educational intervention

Alcohol abuse is a worldwide public health concern. Nurses, representing the largest body of health care providers, are a potential resource to provide screening and brief intervention for patients with alcohol problems. This study evaluates the effect of an educational intervention on the attitudes, beliefs, and confidence levels of nurses regarding screening and brief intervention for alcohol problems. One hundred eighty-one students at Vanderbilt University School of Nursing participated in a four-hour educational intervention to train providers in brief negotiated intervention (BNI) for screening, early detection and brief treatment of alcohol problems. Participants completed questionnaires before and after this training. Analysis of the data using paired t-test and one-way analysis of variance showed statistically significant positive change in the nurses’ attitudes, beliefs, and confidence levels regarding alcohol abuse and its treatment after the educational intervention. For example, the percentage of nurses who reported always having confidence in assessing patients’ readiness to change their behavior increased from 8.3% to 23.5% after training. In conclusion, the BNI educational intervention can be effective in promoting positive changes among nurses in attitudes, beliefs, and confidence levels regarding alcohol abuse and its treatment.     

Secondary prevention for coronary heart disease: a qualitative study

The many responsibilities of primary care, cardiac rehabilitation and secondary prevention of coronary heart disease is a growing concern. Demanding standards have been given to primary care in the National Service Framework for Coronary Heart Disease. This article reports an evaluation of an intervention to support primary care service providers in this responsibility. A part-time specialist nurse and a part-time exercise worker were appointed to work in a group of 11 GP practices in a primary care trust in a city in the north of England. The evaluation component reported here is a qualitative study of the perceptions of health professionals on secondary prevention of coronary heart disease. Interviews were conducted with 18 primary care staff from practices in both intervention (n = 11) and control (n = 11) groups. The evaluation revealed support for the development of nurse-led clinics, increased confidence and skills development among practice nurses, but some concern about competing demands on practice nurses' time. Primary healthcare professionals found their resources stretched by competing demands on their time from government initiatives.