Alcohol misuse: a detoxification project

This article describes the structure and philosophy of an innovative unit for detoxifying clients suffering from alcohol misuse. It attempts to provide treatment in partnership with the people it was designed to serve. The author discusses the various aspects of the project and reviews the way it has developed since its inception. He emphasises the nursing-led approaches employed to meet the needs of clients who use its facilities and expertise.

Transcending alcoholic denial

Denial is a characteristic of alcoholism and other drug addictions that must be appreciated in order to understand the recovery process. The purpose of this field study was to describe the internal processes that alcoholics experience as they transcend denial. Grounded theory methods guided data collection and analysis. The author observed and interviewed 42 patients in an inpatient alcoholism treatment facility, then followed 30 participants over a 3-year period. Using the constant comparison method of data analysis, a basic social process theory of transcending alcoholic denial emerged. The theory has five progressive stages: reacting to the critical event; role disaffiliation; ambiguous anticipation; peer affiliation; and acceptance. The theory also elucidates consequences of unresolved stages.

[Decision to join a mutual aid group]

Alcoholism affects not only the alcoholic but the entire family. Spouses of alcoholics often withdraw emotionally and their health deteriorates. This unhealthy adaptive behavior to the drug dependency of another is defined as co-dependency. Some spouses reach for help while others do not. Support groups, like Al-Anon, have been known to help spouses disengage from a co-dependent relationship. Based on the Miller decision-making model, this study focuses on the psychological, environmental and cognitive factors involved in deciding to participate in a support group. The differences between the two groups of spouses are highlighted. Those who choose to participate have a higher level of preoccupation with family life, a higher incidence of health problems and a longer period of exposure to alcoholic behavior. They have also received support from various drug addiction centres, giving them a better knowledge of the disease and a positive view of support groups. The non-participants are mostly younger, have less exposure to their spouses' alcoholic behavior, are less educated and give the impression of knowing everything about alcoholism and group support. They also feel they do not need treatment for themselves. The author explores ways nurses can reach this population.

Staff perceptions of organization change of treatment delivery on an addiction unit

The Work Environment Scale was used to assess staff perceptions of a change in a treatment programme for problem drinkers. A more cost-effective 2-week research-based day-patient programme, which included the concept of matching, replaced a 5-week cognitive behavioural in-patient programme. The maintenance of a positive work environment was attributed to the meeting of staff expectations, a cognitive behavioural ideology, and the establishment of a research culture. The study highlights the importance of the thorough preparation of staff for change, and their active involvement in the process in settings where work satisfaction is already above the average level for mental health facilities.

The Winner's Group: A Self-Help Group for Homeless Chemically Dependent Persons

The homeless chemically addicted person presents many unique problems that cannot be addressed in standard treatment programs. Homeless clients are difficult to track and are not consistent in follow-up care. The health and mental health conditions found in this population are straining the resources of drug treatment programs, hospitals, the criminal justice system, and social agencies that serve the homeless (Bassuck, 1991). The Winner's Group located in an inner city soup kitchen demonstrates the adaptability and flexibility of nursing practice. The nurses exhibited creativity in developing methods to meet the diverse needs of homeless chemically addicted persons. The goals and objective that were achieved were neither successes nor failures, they were reflections of efforts to make lifestyle changes. Some of those persons responded in a very positive manner, while others continued to deteriorate. An overall desire was to instill a seed of hope and knowledge that there is always a potential for change and that recovery from chemical dependency is possible. Nurses who work with the homeless must be knowledgeable and realistic about the impact and importance of substance abuse. Nontraditional programs that meet the unique needs of a particular setting and a particular population can provide an opportunity to gain access to health care providers.

Brief intervention as an advanced practice strategy for seriously injured victims of multiple trauma

Trauma is the leading cause of death during the first 4 decades of life. Approximately 40-50% of seriously injured patients who require hospitalization have an alcohol-related injury. The traumatic injury offers nurses in advanced practice roles a unique opportunity to discuss the relation between the patients' traumatic injuries and their alcohol use. One strategy that has shown promise in recent research is the Brief Intervention, a simple and quick clinical tool used to motivate patients to consider the consequences of their alcohol-related behavior. The Brief Intervention technique uses a screening instrument, the Alcohol Use Disorders Test, to determine whether the patient is a sensible, heavy, or dependent drinker. A counseling session, focusing on reducing alcohol use in the nondependent drinker, follows while the patient is still acutely injured. Through the use of Brief Intervention, the nurse has an opportunity to motivate trauma patients to change their patterns of drinking and limit their risk for repeated injuries. If nurses can prevent future injuries, the potential savings in lives lost and dollars spent are huge.

Family nurse practitioner clinical competencies in alcohol and substance use

The prevalence of substance use among patients presenting to primary health care settings mandates clinical competency in the area for nurse practitioners (NPs). An educational intervention with an evaluation component is described. The effect of incorporating substance use content into a Family Nurse Practitioner (FNP) curriculum was tested with a convenience sample of 16 FNP students and 8 practicing NPs. Students' knowledge increased significantly; however, differences in students' and practicing NPs' knowledge did not reach significance. Students' clinical competency increased significantly, as demonstrated by standardized patient clinical evaluations, and was significantly better than the practicing NPs in the skill domains of evaluation and record keeping. Educational intervention can improve NP identification of substance-abusing patients in primary health care settings.

The challenge of change: rethinking alcohol abuse

Nurses usually conceptualize alcohol abuse and dependence as a progressive disease that can be managed but never cured. Yet there are millions of Americans for whom this approach is not helpful. Impressive results have been reported by the alcohol research community with interventions that are guided by the assumption that many alcohol problems are learned habits that can be changed. This article reviews the clinical research in the area of brief interventions and moderation training with alcohol abusers. Nursing's vital role in advocating for and delivering such interventions is identified. Resistance to implementing alternative approaches for the treatment of alcohol problems is explored.

Identification of at-risk drinkers in an orthopaedic inpatient population

The prevalence of hazardous drinking of alcohol in orthopaedic inpatients and its impact on patient management was determined. A prospective survey was performed on acute and arranged admissions in the orthopaedic wards at St Vincent's Hospital, Melbourne, over a 3 month period. At-risk drinking was measured by the AUDIT questionnaire, a score of eight or more suggesting hazardous drinking and a score of 20 or more suggesting dependence. A separate questionnaire recorded relevant details of the admission, complications during hospital stay, degree of difficulty nursing the patient and any past history of alcohol problems. Thirty-four (36%) of 94 patients were drinking at hazardous levels. Of these, 62% gave no prior history of problems with alcohol. Thirty-four per cent of 53 acute admissions and 39% of 41 arranged admissions were harmful drinkers suggesting that trauma may not be the only contribution to problem drinking in the orthopaedic setting. Hazardous drinking occurred in both male and female groups aged less than 55 years and in males greater than 55 years. Hazardous drinking was associated with more inpatient complications (chi 2 = 6.6, d.f. = 1, P = 0.01) and greater nursing difficulty (chi 2 = 5.5, d.f. = 1, P = 0.02). A third of the patients in the orthopaedic wards drink alcohol at hazardous levels, whether they are acute or arranged admissions. Hazardous drinking is associated with more complications and greater difficulty in nursing patients.

Early detection and intervention for the hidden alcoholic: assessment guideline for the clinical nurse specialist

Among hospitalized patients, it is estimated that between 20% and 35% have significant alcohol problems that remain largely undetected. Alcohol abuse is a risk factor for a variety of disorders, including diabetes mellitus, gastrointestinal problems, hypertension, liver disease, and stroke. In an era of health care cost containment, early detection, intervention, and referral of alcohol-abusing or -dependent patients by the CNS may significantly impact the cost effectiveness of hospital care. In this article, a guideline is described that can be used by the CNS relative to the assessment, intervention, and referral of alcohol-abusing or -dependent patients in the general hospital setting.

Alcoholism in homeless veterans: a historical overview

The department of Veterans Affairs uses a variety of approaches to assist homeless veterans suffering from alcoholism, including outreach and domiciliary programs. The history of alcoholism and homelessness is discussed in this article and characteristics of homeless veterans are delineated. Cultural considerations, treatment options, and the role of the CNS working with this population are presented. Implications for further research are included.

The Alcoholism Denial Assessment Tool (ADAT): a study of interrater reliability

The purpose of this study was to develop and test a tool for assessing alcoholic denial. The primary author devised the Alcoholism Denial Assessment Tool (ADAT) based on 2 years of experience. The tool was tested for interrater reliability using chart data of 42 recently discharged alcoholism patients. The test for significance of a proportion, using z scores, indicated significance at the .001 level. Item analysis showed strong interrater reliability on all but 1 of the 16 tool items. The ADAT provides nurses with a practical assessment tool that can be used daily to monitor progress. Recognition that a patient is in denial can allow meaningful and appropriately planned treatment.

Lesbians recovering from alcohol problems: an ethnographic study of health care experiences

The findings of this ethnographic study of 35 San Francisco lesbians in long-term alcohol recovery describe their identification of alcohol problems, help-seeking experiences, and barriers to recovery in health care interactions. Multiple addictions and "core difficulties," such as childhood trauma, were common yet poorly addressed by health care providers. Lesbian clients mistrusted culturally ignorant providers who often inappropriately reversed therapeutic roles. Provider-client conceptual incongruence about alcohol problems often impeded recovery, while providers' persuasive styles (paternalistic, maternalistic, confrontational, and influential) were pivotal to recovery. The confrontational approach caused the most problems. It could precipitate crises, be interpreted by the women as social ostracism, and retraumatize those who had histories of childhood trauma. Consensus favored the influential style, characterized by flexibility, negotiation, support, and avoidance of ultimatums. Conclusions challenge the assumptions that alcoholics are manipulative, "in denial," and require coercion to attain and maintain recovery.

The alcoholic family: a nursing diagnosis validation study

This study was designed to develop and validate a new nursing diagnosis, altered family processes: alcoholism. The Delphi technique was used to obtain nurse experts' (N = 201) ratings of terms for the definition, related factors, and defining characteristics. Degree of consensus was determined by analyzing the mean, frequencies, and Fehring's (1987) Diagnostic Content Validity Index for items. Findings supported a proposed definition and related factors including family history of alcoholism and lack of problem-solving skills. Defining characteristics were grouped into three categories: feelings (e.g. mistrust, insecurity, powerlessness, unhappiness), roles, and relationships (e.g. disturbed family dynamics, inconsistent parenting, marital problems), and behaviors (e.g. impaired communication, dependency, denial). Future research includes the proposal and testing of nursing interventions for alcoholic families.

Understanding alcoholism relapse. A case study illustrating the integration of two theories

The potential for relapse is a continuous threat for recovering alcoholics, most of whom will relapse within the first few years following treatment. Although relapse prevention is a challenge to nurse practitioners and clinical specialists, having an understanding of the factors leading to relapse can assist nurses in planning individualized care. This article presents a unique perspective on alcoholism relapse by integrating two theories--the interactional approach theory and the theory of recovery and goal setting. Case studies illustrate this perspective.

An exploration of women's perceptions of the major factors that contributed to their alcohol abuse

The purpose of this research was to explore the interviewees' perceptions of the major factors that contributed to their alcohol abuse. The research was carried out by interviewing seven women who were identified by community mental health professionals. The research was qualitative and exploratory. The semi-structured tape-recorded interview technique was used as an enquiry tool. The tapes were then transcribed and coded, and the findings were scrutinized and scanned for emerging themes and concepts using an interactive and cyclical process of data-reduction techniques, data display and verification of findings. The findings suggest that the majority of the interviewees could identify and isolate specific life events and past-life crises that contributed to an increase in their alcohol intake. Results also indicate that there is a need to consider the efficacy of the current models of primary, secondary and tertiary care as well as relapse-prevention programmes of care in order to facilitate women to have every opportunity to make informed and rational health choices about their drinking behaviours, and to maintain abstinence, for the promotion of positive mental health and for enhancing the quality of their lives.

How lesbians recognize and respond to alcohol problems: a theoretical model of problematization

To determine how one specific at-risk population problematizes alcohol use and responds to alcohol-related difficulties, findings from an ethnographic interview study of lesbians recovering from alcohol problems were used to develop a theoretical model of problematization. Problematization consists of two phases: recognition and response. Recognition involves problem indicators varying by type (cumulative vs immediate) and source (personal vs environmental). Movement from recognition to response is hindered by perceptual and environmental constraints. Response consists of interrelated processes of construction, interaction, action, and validation. On the basis of validation, problems are reconstructed and new problems are recognized as the cycle continues.