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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.