Art & science health promotion

42 august 14 :: vol 27 no 50 :: 2013 NURSING STANDARD / RCN PUBLISHING

Abstract
The negative effects of alcohol consumption are increasingly being
recognised in the UK, with statistics highlighting the health and social
problems associated with the misuse of alcohol. Consequently, nurses
need to consider their role in educating and advising patients about
safe drinking limits. This article identies some of the problems with
adhering to such safe drinking limits, for example, the miscalculation
of alcohol units. In addition, the article highlights nursing interventions
that can be used with all patients, not just those presenting with
alcohol-related problems, to increase awareness of the negative
effects of harmful alcohol consumption.
Authors
Anne Govier
Clinical nurse specialist, Cardiff and Vale University Health Board,
Cardiff.
Colin Rees
Lecturer, School of Nursing and Midwifery Studies, Cardiff University,
Cardiff.
Correspondence to: reescb@cf.ac.uk
Keywords
Alcohol consumption, alcohol misuse, health promotion and
education, nursing interventions
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Reducing alcohol-related
health risks: the role of the nurse
Govier A, Rees C (2013) Reducing alcohol-related health risks: the role of the nurse.
Nursing Standard. 27, 50, 42-46. Date of submission: August 7 2012; date of acceptance: June 10 2013.
THE HEALTH CONSEQUENCES associated
with alcohol consumption in the UK have
continued to rise, with an increase in
alcohol-related liver disease from 9,231 cases
in 2001 to 11,575 cases in 2009 (Public Health
England 2012). Globally, health problems
resulting from harmful alcohol consumption
have been recognised and account for 4% of
deaths (World Health Organization (WHO)
2011). In the UK, alcohol consumption is the third
largest lifestyle risk factor for disease and death
following smoking and obesity (HM Government
2012). Alcohol misuse in the UK is estimated
to cost 18-25 billion per year in terms of
alcohol-related disorders, crime, loss of
productivity in the workplace and social effects
(HM Government 2010). Therefore, it is essential
to tackle the negative effects associated with
harmful alcohol consumption (Glasper 2012).
Controlling alcohol consumption is complex,
and there are many social and cultural aspects
involved. Alcohol plays a role in many social
events, such as celebrations. In the UK, it is
consumed in homes, bars and restaurants, and
is purchased in supermarkets by 72% of adults
(Lader and Steel 2010). Previous attempts to
control alcohol consumption in the UK have been
met with resistance, particularly the governments
attempt to introduce minimum pricing (HM
Government 2012).
The health promotion approach focuses on
lifestyle changes, ensuring consumption levels
are within safe limits. Early initiatives, such as
the Sensible Drinking Campaign (Department
of Health (DH) 1995), recommended maximum
consumption of 21 units of alcohol per week
for men and 14 units for women. In the UK,
one unit is dened as a measure of alcoholic
drink containing 8g or 10mL of ethanol,
although this can vary depending on the total
percentage of alcohol in the drink and its total
volume (National Institute for Health and Care
Excellence (NICE) 2010).
More recently, the method of calculating
recommended maximum levels of alcohol
consumption has changed from weekly levels to
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recommended daily allowances of 3-4 units for
men and 2-3 units for women (DH 2007, Royal
College of Psychiatrists 2011). This change is
aimed at providing an easier and more immediate
time period over which to monitor consumption. It
also highlights episodes of binge drinking, dened
as large amounts of alcohol consumed in one
drinking session or over a short space of time, such
as one day (Institute of Alcohol Studies 2010). The
focus on daily consumption also relates to advice
from the House of Commons (2012) for regular
drinkers to have at least two alcohol-free days per
week to protect against kidney damage.
Role of the nurse
Although there may be a potential role for the
nurse in increasing public awareness of the
issues relating to harmful alcohol consumption,
there is a lack of clarity on what exactly nurses
could do to reduce signicantly alcohol-related
problems. Glasper (2012) suggested that the lack
of agreement on the nurses role in this area has
resulted in a confusing and controversial situation
for nurses and patients alike in terms of actions
to be taken by the nurse and willingness to take
action by the nurse.
Nurses in all clinical settings should be aware of
the consequences of alcohol misuse to ensure that
they can provide clear and accurate information
to motivate and support patients to maintain safe
levels of alcohol consumption (DH 2012, Glasper
2012, Kiernan et al 2012).
The health burden associated with harmful
alcohol consumption is signicant and with levels
of consumption increasing in the UK, individuals
need to consider lifestyle changes to minimise
harm. The potential for nurses to be more active in
this process by motivating, assessing and educating
patients has been recognised (Phillips 2011). The
role of the nurse is promoted in The Governments
Alcohol Strategy (HM Government 2012), which
highlights missed opportunities for assessing and
supporting individuals exposed to alcohol-related
health risks. The newly formed Public Health
England also emphasises that nurses can play a
major role in improving the health and wellbeing
of the public by making each contact with a patient
count (Ford 2013).
Since nurses are already in contact with patients
at risk of particular diseases and disorders,
they are ideally placed to provide low level, but
high-impact interventions to encourage safe
consumption of alcohol (Mably and Jones 2010,
NICE 2011, House of Commons 2012, Mdege et
al 2013). However, nursing involvement requires
careful consideration. While it is acknowledged
that current and competing demands make it
difcult for nurses to take on additional roles,
scope exists for nurses to have a more proactive
role in increasing awareness of the harmful effects
of excessive drinking when the opportunity arises.
The rst step is for nurses to be able to identify
individuals who may benet from this type of
advice and support.
Identifing individual risk
For those who drink alcohol regularly, levels of
consumption vary throughout the lifespan and
are inuenced by environmental factors such
as the sale of cheap alcohol, and socioeconomic
factors such as social drinking patterns, education,
income and coping mechanisms (WHO 2011).
It is, therefore, difcult to identify those who are
potentially vulnerable.
At present, there is concern about underage
and young adult drinkers, as patterns of early
consumption and learnt behaviours can continue
into adulthood, and pose long-term health and
social problems (DH 2007). Interestingly, the
populations receiving less attention are those in
midlife and older, and these individuals may be at
increased risk of alcohol misuse. The Royal College
of Psychiatrists (2011) cautions that older adults
are often overlooked when screening for harmful
levels of alcohol consumption. This is supported
by Parkes et al (2011) and Wilson et al (2011)
who suggested that older people do not meet the
stereotypes associated with problem drinkers and
are not thought to drink alcohol at levels that are
considered harmful to health. Similarly, women
are frequently under-represented in studies on
alcohol consumption and its associated problems
(Heather et al 2008). This is a signicant omission
as women who have high incomes and those living
in deprived areas are particularly vulnerable to
drinking in excess of daily limits (Boniface and
Shelton 2013).
Nursing interventions
Calculating alcohol consumption
Assessing levels of consumption is often left
to the individual. However, these calculations
are not without their problems and can lead to
underestimations. Comparison between what
people claim to consume and annual alcohol sales
gures, reveals that sales are up to 40% higher
than claimed consumption levels (Boniface and
Shelton 2013). It is acknowledged that self-reporting
methods may be partly responsible for this gap, and
that individuals may not provide accurate gures,
either intentionally or unintentionally.
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Art & science health promotion
If survey gures are adjusted to take into
account underestimates, Boniface and Shelton
(2013) calculated that weekly guidelines on
alcohol are likely to be exceeded by over one
third of adults, and daily limits are exceeded by
over three quarters of adults. This suggests that
a signicant number of people may be at risk of
harmful alcohol consumption.
One explanation for the underestimation of
the amount of alcohol consumed is the difculty
in accurately estimating the alcohol volume of
drinks. For example, Gill and OMay (2007)
found misunderstandings regarding unit values
were inuenced by the different size and shape
of glasses. In their study, a sample of 297 people
were presented with a range of different sizes of
glass sold as small and asked to select what they
estimated would provide a one unit measure of
alcohol. The sample chose glasses with capacities
varying between 250mL and 360mL, which is
more than double the recommended small glass
size of 125mL (DH 2007). Consumption of
alcohol based on such decisions would result in
individuals consuming double the recommended
units of alcohol.
Gill and OMay (2007) asked participants to
pour the equivalent of their usual drink and tested
their knowledge of unit allowances. The results
showed that 49% of participants did not know
the recommended daily allowance. In addition,
the glass size appeared to have an effect on the
amount of alcohol dispensed, with more alcohol
being poured into large volume glasses compared
to smaller glasses. Men poured larger amounts of
red wine than women, resulting in high unit levels
of alcohol consumed per drinking session. The
study concluded that people visually calculate one
unit of alcohol based on the size of the glass in
which it is served; this is often an underestimate
and does not consider the percentage of alcohol
present in the drink. This evidence suggests that
individuals calculating how much alcohol they
consume may underestimate the degree of risk
they are exposed to.
An alternative system is for the nurse to work
with individuals to calculate alcohol consumption
using online tools such as the Drinkaware Unit
Calculator (tinyurl.com/drinkaware-unit-
calculat). The nurse or patient can select the type,
brand, alcohol by volume (ABV) and quantity
of alcoholic drinks consumed in one day or one
week. The calculator then displays the number
of units and calories consumed, and minutes of
exercise (running) required to use up the calories.
The calculator also displays the risk level of alcohol
affecting your health. Use of the calculator can take
place during any nurse-patient encounter where
access to a computer or online facilities, such as
smart telephone or tablet, is available.
Teachable moments
In a systematic review, Mdege et al (2013)
identied that individuals often do not seek help
for high levels of alcohol consumption as they do
not see themselves as being at risk. If exploration
of alcohol consumption is part of the general
assessment or general health encounter, patients
may be prepared to explore the topic, providing
this is approached in a sensitive manner.
Where an individual recognises that such
assessments suggest they are at risk of harmful
alcohol consumption and associated health and
social problems, the nurse is provided with a
teachable moment. Teachable moments are
naturally occurring events in health encounters
when individuals are open to suggestions for
behavioural change. In this instance, the nurse
can provide alcohol brief advice as suggested
by Mably and Jones (2010). This is described as
a short, evidence-based, structured discussion
between the nurse and patient that focuses on
alcohol consumption. It is aimed at motivating
and supporting individuals to consider, and where
appropriate, plan changes to drinking patterns
to reduce the risk of harm. The key to such
discussions is to ensure individuals feel they are
being invited to think about the topic rather than
pressurised or criticised when confronting current
drinking patterns.
Although nursing time is limited, this approach
supports the current emphasis on providing
alcohol advice rather than avoiding sensitive
topics, and has parallels with other risk reduction
activities such as smoking cessation, which also
involves major changes in lifestyle that some
nurses may be reluctant to discuss with patients
(McBride et al 2003, Rice and Stead 2008). Such
discussions would also only take place when
deemed appropriate by the nurse.
Although there are concerns about appropriate
preparation for such discussions, free online
training in this area is available from Public
Health England (tinyurl.com/ALC-eLearning)
and is accredited by the Royal College of Nursing.
This online resource provides 20-minute learning
sessions and a nal assessment with a printable
record of achievement. The sessions include
step-by-step guides to carrying out an assessment,
using different assessment tools and providing a
brief intervention.
A useful guide to structuring conversations
with patients is provided by the FRAMES
(Feedback, Responsibility, Advice, Menu of
options, Empathetic interviewing, Self-efcacy)
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framework recommended by NICE (2010) and
Mably and Jones (2010) (Table 1). Conversations
using the FRAMES framework for motivational
intervention ensure that the individual does not
feel pressurised and always feels in control. If the
patient prefers not to discuss the issue, then the
nurse does not insist on taking this further, but
always tries to emphasise that he or she is available
to discuss this in greater detail at a later date.
Use of risk levels
The use of varying risk levels based on units of
alcohol consumed per week for males and females
has also been helpful in supporting those who need
to take action (Table 2). Written information is
given to individuals so that they can reect on what
has been discussed (NICE 2010, 2011, Davies
2011). Where individuals need more specialised
advice or guidance, they are referred directly to
the nearest specialist alcohol service. It has been
estimated that 4% of the UK population are
dependent on alcohol and require specialist
referral (NICE 2011).
In the authors experience, since using the
Drinkaware Unit Calculator and the online
training from Public Health England, individuals
have shown motivation to reduce the volume of
alcohol consumed. Several individuals have also
reported complying with the suggested minimum
of two alcohol-free days per week.
TABLE 1
FRAMES famework for motivational intervention
FRAMES Implementation
Feedback Level of risk identied in a non-judgemental,
informative way, with additional written supporting
information.
Responsibility of
the person
The person is responsible for wanting to make the
change in behaviour.
Advice to change Factual information regarding the need for change
is provided.
Menu of change
strategies
Options available to make a change such as altering
the strength of the beverage are identied.
Empathetic
counselling style
A person-centred, non-judgemental and
non-confrontational approach is adopted.
Self-efcacy
enhancement
Condence and support are provided, using positive
language.
(Marshall et al 2010)
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et al (2012) in maxillofacial clinics. In this setting,
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Art & science health promotion
training from Public Health England, will help
healthcare professionals tackle the growing public
health problem of harmful alcohol consumption
and associated complications.
Conclusion
Given that harmful alcohol consumption is
associated with signicant health burden, and
social and nancial implications, nurses have
a responsibility to support individuals to make
informed choices about their health. Because of
the inaccuracies associated with self-reporting
and self-calculation of alcohol consumption, the
use of online tools, such as the Drinkaware Unit
Calculator, guided by a nurse may be helpful.
It is essential that nurses support patients to
make positive and successful lifestyle changes by
providing encouragement and appropriate advice
in a non-judgemental manner NS
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TABLE 2
Risk levels based on units of alcohol per week for males and females
Adults who regularly drink Level of risk
21 units per week or less (men)
14 units per week or less (women)
Low-risk drinkers
22-50 units per week (men)
15-35 units per week (women)
Increased-risk drinkers
50+ units per week (men)
35+ units per week (women)
High-risk drinkers
(National Institute for Health and Clinical Excellence 2010)
Having A Word, which emphasises the informality
of the style of conversations.
It is recommended, therefore, that other clinical
areas should be proactive in incorporating such
conversations in their practice. It is hoped that
use of the Drinkaware Unit Calculator and online
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