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Facilitators and barriers to intervening for problem alcohol use

Yun-Fang Tsai, Mei-Chu Tsai, Yea-Pyng Lin, Chih-Erh Weng, Ching-Yen Chen & Min-Chi Chen
Accepted for publication 28 January 2010

Correspondence to: Y.-F. Tsai: e-mail: yftsai@mail.cgu.edu.tw Yun-Fang Tsai PhD RN Professor School of Nursing, Chang Gung University, Tao-Yuan, and Associate Director, Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan Mei-Chu Tsai MS RN Supervisor Department of Nursing, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan Yea-Pyng Lin MS RN Supervisor Department of Nursing, Mennonite Christian Hospital, Hualien, Taiwan Chih-Erh Weng BS RN Supervisor Department of Nursing, Chang Gung Memorial Hospital, Keelung, Taiwan Ching-Yen Chen MD Physician Department of Psychiatry, Chang Gung Memorial Hospital, Linkou, Tao-Yuan, Taiwan Min-Chi Chen PhD Associate Professor School of Medicine, Chang Gung University, Tao-Yuan, Taiwan

TSAI Y.-F., TSAI M.-C., LIN Y.-P., WENG C.-E., CHEN C.-Y. & CHEN M.-C. ( 2 0 1 0 ) Facilitators and barriers to intervening for problem alcohol use. Journal of Advanced Nursing 66(7), 14591468. doi: 10.1111/j.1365-2648.2010.05299.x

Abstract
Title. Facilitators and barriers to intervening for problem alcohol use. Aim. This article is a report of a study exploring nurses perceived facilitators and barriers to conducting brief interventions for problem alcohol use. Background. Excessive alcohol use has been associated with health, social and legal problems. Healthcare providers worldwide need help to detect and intervene with hazardous/harmful drinkers. Methods. For this cross-sectional study, ten hospitals were randomly selected throughout Taiwan during 2007. Nurses (N = 741) were selected from the emergency department, and psychiatric and gastrointestinal medical-surgical units where most patients with alcohol problems are seen. Data collected using facilitator and barrier scales and a demographic information form were analysed by descriptive statistics and stepwise, multiple linear regression analysis. Results. Nurses identied the top facilitator to intervening for problem alcohol use as patients drinking problems are related to their illness. Top barriers were patients lack motivation to change and patients express no interest in receiving intervention. Perceived facilitators were associated with nurses work unit, intention to intervene for problem alcohol use, and age. Perceived barriers were associated with work unit, experience in intervening for problem alcohol use, and having attended a training course. Conclusion. Source of perceived barriers reected cultural inuences. Taiwanese nurse education needs to be strengthened in terms of brief interventions for problem alcohol use. Emergency department nurses need to become more aware of their important role in alcohol intervention. Alcohol-related education is needed for the general population and hospital policymakers to enhance facilitators and reduce barriers to intervening for problem alcohol use. Keywords: alcohol, barriers, facilitators, brief intervention, nursing

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Introduction
There is a causal relationship between alcohol consumption and more than 60 types of disease and injury. Alcohol is estimated to cause about 2030% worldwide of oesophageal cancer, liver cancer, cirrhosis of the liver, homicide, epilepsy and motor vehicle accidents (World Health Organization 2009).

thought that drugs corrupted the young and that drug misusers should be cared for only in specialized units (Carroll 1995). Moreover, they viewed drug misusers as a threat to society due to HIV/AIDS and agreed that they should be compulsorily tested for HIV infection (Carroll 1995).

Nursing interventions
Few researchers have explored nurses perspectives on barriers to and facilitators for providing alcohol interventions. A study of Finnish nurses and general practitioners (GP) revealed six possible obstacles to providing alcohol interventions, i.e. confusion about the meaning of early-phase heavy drinking, lack of self-efcacy for helping problem drinkers, perceived lack of time to carry out brief interventions, lack of simple guidelines for brief interventions, perceived difculty identifying early-phase heavy drinkers and uncertainty about justifying a discussion on alcohol issues with patients (Aalto et al. 2003b). A qualitative study of primary health care nurses in the UK (Lock et al. 2002) showed that although nurses have many opportunities to intervene for problem alcohol use, most are poorly prepared for this work. Facilitators for nurse involvement in alcohol interventions were recognition of the problems relevance to their work, many opportunities, and role legitimacy. Barriers for these nurses included their attitudes towards alcohol use, negative patient reactions, nurse confusion about alcohol issues (e.g. standard drink units, limits), lack of training, and other priorities for nurses and patients. The authors concluded that nurses should be better trained and supported in carrying out alcohol interventions (Lock et al. 2002).

Background
Diagnosis and treatment of alcohol-related problems
Healthcare providers play important roles in detecting and treating patients with alcohol problems. However, physicians in primary care settings in Western countries have been found to avoid conducting brief alcohol interventions. For example, physicians in the United States of America (USA, Conigliaro et al. 2000, Vinson et al. 2000), United Kingdom (UK, Kaner et al. 1999a, 2001), Australia (Rydon et al. 1992, Richmond & Anderson 1994) and Finland (Aalto et al. 2003a) frequently feel reluctant to screen and counsel patients in relation to problem alcohol use. General practitioners are in a position to provide continuity of care for dened populations, but they have been reported to deliver brief alcohol interventions inconsistently (Kaner et al. 1999b). The most common reasons given for not providing alcohol counselling are lack of time, inadequate training, fear of antagonizing patients, the perceived incompatibility of alcohol counselling with primary health care, and the belief that alcoholics do not respond to interventions (Kaner et al. 1999b, Babor et al. 2001). Nevertheless, US physicians in family practice are more likely to diagnose problem drinking and to perform brief alcohol interventions after a training programme (Seale et al. 2005). Moreover, 72% of US physicians report preferring to transfer patients with problem alcohol use to nurses for further treatment (Spandorfer et al. 1999). Thus far, most nursing studies have focused on exploring psychiatric (mental health) nurses attitudes about caring for patients with drug or substance abuse problems (Pinikahana et al. 2002, Wadell & Ska rsa ter 2007). However, some researchers have examined the attitudes of general nurses, midwives, or special unit nurses [e.g. Emergency Department (ED) nurses] towards patients with substance use (Carroll 1995, Happell & Taylor 2001, Raeside 2003). Nurses attitudes are thought to affect their emotional responses and the subsequent care they give to patients (Carroll 1995). Indeed, nurses have been shown in several studies to have judgmental and punitive attitudes towards substance users (Carroll 1995, Happell & Taylor 2001, Raeside 2003). They
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The Taiwanese context

Individuals with alcoholism in Taiwan have been shown to have a poor prognosis. For example, only 153% had completely stopped drinking alcohol in the second year after diagnosis, while 626% had more serious alcohol-related conditions and 221% had already died (Hsu et al. 1999). These ndings suggest that once individuals become alcohol dependent, they have a low probability of being successfully treated and recovering from alcoholism. Hazardous or harmful alcohol use has also been implicated in many social and legal problems (Babor et al. 2001, Taiwan Ministry of Transportation and Communication 2005). Of the 156 thousand trafc accidents that caused injury in Taiwan in 2005, 4735 resulted in death (Taiwan Ministry of Transportation and Communication 2005). Among these accidents, 54% were caused by drunk drivers (the sixth top cause), but the top cause of accidents that resulted in death
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(189%) was drunk driving. Alcohol, which is a legal and accessible substance in many Asian countries, plays an important role in Chinese culture where it is viewed as an acceptable drink for relieving stress and enhancing socialization (Li & Wang 1996). As a result, drinking problems are easily ignored. As problems with alcohol consumption accumulate gradually, hazardous or harmful drinkers should be detected and treated at an early stage (Babor et al. 2001). Helping health care providers to deal with this challenge is an important worldwide issue (Babor & Higgins-Biddle 2001). Most nurses in Taiwan work in hospital settings (Department of Health, Executive Yuan 2007a) and identify health promotion as their professional duty and responsibility (Department of Health, Executive Yuan 2007b). The most common health-risk behaviours in Chinese society are smoking, heavy drinking and chewing betel nuts (Tsai et al. 2002). As health care providers in Western countries are reluctant to intervene for problem alcohol use, it is likely that Taiwanese healthcare workers have a similar reluctance. Moreover, thus far, no study has explored issues related to brief alcohol interventions by Taiwanese healthcare workers. As nurses have more frequent contact with patients than physicians, they might recognize problem drinkers more often. Thus, it is important to understand the factors that facilitate and hinder their willingness to briey intervene for problem alcohol use.

questionnaires distributed, 743 were returned giving a return rate of 856%. Two returned questionnaires were incomplete; thus, 741 questionnaires were used in the analysis.

Data collection
The principal investigator sent a letter to each unit explaining the study and inviting nursing staff to participate. All nurses who wished to participate were asked to sign a consent form and complete a self-report questionnaire that included facilitator and barrier scales and a demographic form. Participants could leave their questionnaires in a box at each nursing station. One week later, a research assistant collected the questionnaires from each unit. The questionnaire was anonymous.

Facilitator and barrier scales

These scales were developed from the results of a pilot study in which 15 nurses were individually interviewed about facilitators and barriers they perceived when intervening for problem alcohol use. The scales were tested for content validity by a panel of ve Taiwanese experts. These experts included a nurse who had conducted research in alcohol assessment and intervention, two physicians with expertise in treating patients alcohol problems, a medical-surgical nursing teacher and a psychiatric nursing teacher. The experts suggested only minor modications of item wording. These scales also were tested for internal consistency (Cronbachs a) and testretest reliability (Pearsons r) with a group of 30 nurses. Internal consistencies of the facilitator and barrier scales were 087 and 088 respectively. Two-week testretest reliabilities for these scales were 080 and 082 (both P < 001) respectively. In this study, internal consistencies for the facilitator and barrier scales were 088 and 089 respectively. The results of validity and reliability testing indicated that these scales were generally suitable to measure nurses perceived facilitators and barriers to intervening for hazardous or harmful alcohol use. The nal facilitator scale has 12 items, and the barrier scale has 27 items. Responses to both scales are rated on a 5-point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). The scores for each scale are computed by calculating the sum of responses for all items in each scale. The total possible scores on the perceived facilitator and barrier scales are 60 and 135 respectively.

The study
Aim
The aim of this study was to exploring nurses perceived facilitators and barriers to conducting brief interventions for problem alcohol use.

Design
A cross-sectional design was used and the data were collected during 2007.

Participants
The data were derived from a large, alcohol-training programme for physicians and nurses in Taiwan. Participants were recruited from ten hospitals randomly selected according to their locations and geographical distribution throughout Taiwan (north: middle: south: east= 4:2:3:1). As most patients with alcohol problems are seen in EDs, psychiatric and gastrointestinal (GI) medical-surgical units (Huange 2007), nurses who worked in these units (including both inpatient and outpatient units) were selected within each hospital. Of 866
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Demographic information
A demographic information form was used to record nurses age, gender, formal nursing education, work unit, drinking
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and smoking habits, experience with intervening for problem alcohol use and previous training in alcohol-related interventions. In addition, participants were asked one question about their intention to intervene for problem alcohol use. Responses to this question were rated on a 5point Likert-type scale, ranging from 1 (strongly disagree) to 5 (strongly agree). These scales were also tested for content validity by the same panel of ve experts who veried the facilitator and barrier scales. No modications were suggested.

Table 1 Participant demographics (N = 741)

Variable n %

Ethical considerations
This study was approved by institutional review boards at the study hospitals.

Data analysis
SPSS for Windows Version 12.0 (SPSS Inc., Chicago, IL, USA) was used for data analysis. Descriptive statistical analysis (frequency, percentage, mean and standard deviations) was used to analyse facilitator, barrier and demographic variables. Associations of demographic and professional characteristics with facilitators and barriers were evaluated by stepwise, multiple linear regression analysis.

Gender Male 9 12 Female 732 988 Educational level Certicate in nursing 21 29 Associate degree in nursing 464 631 Bachelor degree or higher 441 341 Marital status Never married 469 633 Married 266 359 Divorced 6 08 Have a child No 523 706 Yes 218 294 Drinking habit No 438 591 Yes 303 409 Smoking habit No 724 977 Yes 17 23 Attended a training course in intervening for problem alcohol use No 733 989 Yes 8 11 Due to missing data, n may not equal to 741.

Results
Participant demographics
The 741 participating nurses were on average 291 years old (SD = 59, range = 2058 years) and worked in the ED (417%) or on GI medical-surgical (424%) and psychiatric (159%) units. Their average length of general clinical care experience was 917 months (SD = 709, range = 1432) and their average length of clinical care experience in the current unit was 552 months (SD = 526, range = 1343). A majority (778%) reported having intervened for problem alcohol use with clients. They commonly suggested abstaining (943%) and gave support to families (790%). In general, participants expressed a slightly positive intention to intervene for a drinking problem (mean = 33, SD = 08). Other details about the nurses demographics can be found in Table 1.

nurses moderately agreed with items on the perceived facilitator scale. Examination of mean item ratings for the perceived facilitator scale indicated that most nurses agreed on all facilitator items (Table 2).

Nurses perceived barriers to intervening for problem alcohol use

The average overall perceived barrier score to intervening for a drinking problem was 954 (SD = 154), indicating that nurses moderately agreed with items on the perceived barrier scale. Examination of mean item ratings in the perceived barriers scale indicated that these nurses believed that major barriers originated from three sources: patients and their families, nurses and the environment. The top barrier from patients and their families was perceived by a majority of nurses as lack of patient/family motivation for changing. The top barrier from the nurse source was perceived as personal worries about not being able to resolve patients economic problem. The top barrier from environmental sources was perceived as concern over the lack of professionals to assist and to whom patients could be referred for further consultation (Table 3).
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Nurses perceived facilitators to intervening for problem alcohol use

The average overall perceived facilitator score for intervening for a drinking problem was 463 (SD = 62), indicating that
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Table 2 Nurses perceived facilitators for intervening for problem alcohol use (N = 741)
Strongly disagree, n (%) 4 (05) 4 (05) Disagree, n (%) 8 (11) 15 (20) Neutral, n (%) 91 (123) 102 (138) Agree, n (%) 527 (711) 504 (680) Strongly agree, n (%) 111 (150) 116 (157)

Item Patients drinking problems are related to their illness Patients family expressed that they want to improve patients drinking problems Patients expressed that they want to improve their drinking problems Patients drinking problems can inuence their treatment outcomes Patients become uncomfortable about withdrawal syndrome Having a good nurse-patient relationship Having a positive outcome for previous patients after performing alcohol intervention After expanding knowledge base about alcohol interventions Having a private environment. After enhancing communication skills After designing a systematic way to perform alcohol interventions as well as formalizing as a guideline After intervening for problem alcohol use was added into the nursing routine

Mean

SD

41 06 40 07

40 07

5 (07)

17 (23)

101 (136)

504 (680)

114 (154)

40 06

6 (08)

10 (13)

102 (138)

522 (704)

101 (136)

39 07 39 06 39 07

6 (08) 2 (03) 6 (08)

17 (23) 13 (18) 19 (26)

113 (152) 127 (171) 132 (178)

508 (686) 505 (682) 488 (659)

97 (131) 94 (127) 96 (130)

38 07 38 07 38 07 37 07

3 (04) 4 (05) 5 (07) 8 (11)

19 (26) 20 (27) 16 (22) 22 (30)

155 (209) 172 (232) 191 (258) 195 (263)

483 (652) 469 (633) 454 (613) 446 (602)

81 (109) 76 (103) 75 (101) 70 (94)

36 08

15 (20)

48 (65)

225 (304)

397 (536)

56 (76)

1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Relationships between nurses demographics and perceived facilitators and barriers

Nurses demographic and professional characteristics were analysed by stepwise, multiple linear regression analysis to determine their associations with perceived facilitators. Perceived facilitator scores were statistically signicantly and positively associated with work unit, intention to intervene for problem alcohol use, and age (Table 4). These results indicate that nurses age and intention were associated with perceived facilitators for intervening for problem alcohol use. In addition, nurses who worked in psychiatric units perceived more facilitators for intervening for problem alcohol use than ED nurses. Nurses demographic and professional characteristics were also analysed by stepwise multiple linear regression analysis to evaluate their associations with perceived barriers.
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Perceived barrier scores were statistically signicantly and negatively associated with work unit, experience in intervening for problem alcohol use, and having attended a training course (Table 5). These results indicate that fewer barriers to intervening for problem alcohol use were perceived by nurses if they worked in psychiatric and GI medical-surgical units, had experience in intervening for problem alcohol use, and had attended a training course in intervening for problem alcohol use.

Discussion
Study limitations
This study had two limitations. First, no information could be obtained about non-participants, making it difcult to estimate differences between nurses who joined the study and
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Table 3 Nurses top two perceived barriers to intervening for problem alcohol use by three sources (N = 741)
Strongly disagree, n (%) Disagree, n (%) Neutral, n (%) Agree, n (%) Strongly agree, n (%)

Item Patients and their families Patients lack motivation to change Patients express no interest in receiving intervention Nurses Worry about being unable to resolve patients economic problems because of inexperience Worry about being unable to resolve patients psychological problems because of inexperience Environment Lack of professionals to assist and refer patients Lack of a role model for discussing drinking problems with patients

Mean

SD

40 07 40 07

2 (03) 2 (03)

22 (30) 25 (34)

97 (131) 105 (142)

468 (632) 482 (650)

152 (205) 127 (171)

36 09

10 (13)

100 (135)

180 (243)

372 (502)

79 (107)

35 10

12 (16)

119 (161)

169 (228)

376 (507)

65 (88)

37 08 36 08

6 (08) 12 (16)

62 (84) 65 (88)

137 (185) 171 (231)

446 (602) 436 (588)

90 (121) 57 (77)

1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree.

Table 4 Associations between nurses demographic and professional characteristics and perceived facilitators to intervening for problem alcohol use (N = 741) Variable Work unit Emergency department Psychiatry Gastro-intestinal medicine-surgery Intention to intervene Age B t P

Table 5 Associations between demographic and professional characteristics and perceived barriers to intervening for problem alcohol use (N = 741)
Variable Work unit Emergency department Psychiatry Gastro-intestinal medicine-surgery Experience intervening for alcohol abuse No Yes Attended a training course No Yes B t P

Reference 186 083 259 009

285 171 950 235

<001 009 <001 002

Reference 601 342

367 289

<001 <001

those who chose not to participate. However, our surveys acceptable response rate supports the generalizability of the ndings. Second, self-report measures were chosen to obtain a general overview of Taiwanese nurses perceived facilitators and perceived barriers about performing a brief alcohol intervention. With such a large number of nurses participating, measures based on observation would have been too time-consuming within the timeframe of the study. In interpreting the results of the study, the limitations of selfreport measures have to be taken into account as they may not reect nurses actual practice.

Reference 568 Reference 2135

518

<001

399

<001

Discussion of results
This study is the rst to explore perceived facilitators and barriers to brief alcohol interventions in a representative
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sample of 741 nurses in Taiwan. Perceived facilitators were associated with nurses work unit, intention to intervene for problem alcohol use and age. Perceived barriers were associated with work unit, experience in intervening for problem alcohol use and having attended a training course. These nurses perceived that the major facilitators to intervening for problem alcohol use were patients drinking problems are related to their illness, patients or patients family expressed that they wanted to improve the patients drinking problems, and patients drinking problems can inuence their treatment outcomes. Similar ndings were
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reported when Taiwanese nurses were asked about their perceived facilitators of taking a sexual history (Tsai & Hsiung 2003, Tsai 2004). However, about one-third of nurses in the present study either disagreed or felt neutral about having a private environment, after enhancing communication skills or after designing a systematic way to perform alcohol interventions as well as formalizing a guideline as facilitators. These results differ from those with UK nurses (Lock et al. 2002), who perceived that conducting alcohol interventions was facilitated by recognition that problem alcohol use was a relevant health issue, having many opportunities to identify and intervene for problem drinking, and the legitimacy of alcohol interventions as part of nurses health promotion role. Moreover, about 40% of nurses in the present study either disagreed or felt neutral about after intervening for problem alcohol use was added into the nursing routine as a facilitator. These data may reect a unique phenomenon in Taiwan. A statistically signicant proportion of these nurses did not perceive that their performing an alcohol intervention was inuenced by the environment or administration (e.g. having a guideline or a nursing routine). The ndings suggest that these nurses also felt comfortable with their communication skills for making such an intervention. They were more concerned about the relationship of problem alcohol use to patients illness and treatment. Thus, effective continuing education programmes should be developed to address and emphasize nurses knowledge about alcohol and its impact on illness and treatment. Our nurses perceived barriers mainly came from patients and their families. This differs from reports about Western healthcare providers, who seem to perceive barriers as more related to themselves, e.g. lack of time, inadequate training, fear of antagonizing patients, perceived incompatibility of alcohol counselling with primary health care and the belief that alcoholics do not respond to interventions (Kaner et al. 1999b, Babor et al. 2001). This difference in perceived barriers may reect a cultural difference between Asians and Westerners. Asians, especially Chinese, tend to be more concerned about relationships, particularly among family members, whereas Westerners are more individualistic and self-centred, thinking of the effect of their behaviour on themselves and their careers. As we focused on Taiwanese nurses in this study, further research is needed to explore whether this difference is found with healthcare providers from other Asian countries. In addition, these Taiwanese nurses considered that they had not been adequately prepared for the challenges of performing brief interventions for problem alcohol use. Their
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inexperience hindered them from implementing an alcohol intervention. Moreover, their work environment did not provide any role models to learn from or any experts to consult. About one-fourth of nurses also thought that their supervisors would not support their making alcohol interventions with their patients. As a result, most Taiwanese nurses may not actively perform alcohol interventions. Thus, it would be very difcult to expect these nurses to help their clients implement any lifestyle changes. Changing nurses ideas about alcohol problems in Taiwan will take time. However, it is extremely important to help these nurses understand their pivotal role in promoting their clients health. Indeed, role support, in terms of appropriately skilled staff readily available for consultation and advice, was recently found to be the most important predictive factor for nurses therapeutic attitude towards patients using illicit drugs (Ford et al. 2008). These ndings may explain the importance of environmental factors in nurses clinical practice. We found that more facilitators were perceived by nurses who were older and had greater intention to intervene. Nevertheless, no statistically signicant relationship was found between perceived barrier and intention scores. This suggests the importance of increasing nurses perceived facilitators to intervening for problem alcohol use. In addition, nurses who had experienced performing an alcohol intervention had lower perceived barrier scores about making another alcohol intervention than those who did not. Those who had attended training courses had lower perceived barriers scores about performing an alcohol intervention than those who did not. Relevant training experience and longer average practice consultations have been found to predict intentions to perform brief alcohol interventions among British general practitioners (Kaner et al. 2001) and US paediatricians and family practitioners (Marcell et al. 2002). These previous studies support the importance of alcohol training courses and clinical practice experiences for performing alcohol interventions. As we did not explore causal relationships, further studies are needed to explore the impact of past experience and training on perceived barriers in Taiwanese nurses. Comparison of nurses work units indicated that nurses who worked in psychiatric units had higher perceived facilitator scores than nurses who worked in the ED. Moreover, nurses who worked in psychiatric units had the lowest perceived barrier scores and nurses who worked in the ED had the highest perceived barrier scores. These results suggest that ED nurses perceived the lowest facilitators and highest barriers among nurses in all three workunit groups. Careful examination of barrier scores found
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What is already known about this topic

Excessive alcohol use has been associated with health, social and legal problems. Healthcare providers worldwide need help to detect and intervene with hazardous/harmful drinkers.

What this paper adds

Nurses perceived facilitators to intervening for problem alcohol use were patients drinking problems are related to their illness, patients or patients family expressed that they wanted to improve the patients drinking problems, and patients drinking problems can inuence their treatment outcomes. Perceived barriers mainly came from patients and their families, whereas Western healthcare providers perceived barriers seem more related to themselves, demonstrating a cultural difference in this issue. Among emergency department, psychiatric and medical-surgical nurses, emergency department nurses perceived the lowest facilitators and highest barriers to intervening for problem alcohol use.

knowledge decit in relation to intervention strategies (Kelleher & Cotter 2009). Similar ndings for ED nurses were reported in the USA (Howard & Chung 2000), suggesting that this is an international phenomenon for ED nurses. Thus, it is crucial to help Taiwanese ED nurses understand their role and overcome barriers to alcohol interventions. Our study focused on nurses attitudes towards intervening for problem alcohol use, unlike most studies in the literature on nurses attitudes towards substance users (Carroll 1995, Happell & Taylor 2001, Pinikahana et al. 2002, Raeside 2003, Wadell & Ska rsa ter 2007). Rather than assuming that nurses attitudes could affect their emotional responses and the subsequent care they gave to patients (Carroll 1995), our purpose was to explore nurses perceived facilitators and barriers to intervening for alcohol problem use. Understanding nurses perceived facilitators and barriers can help in developing education programmes to increase nurses willingness to briey intervene for problem alcohol use. Our ndings can be used not only to develop an alcohol education programme for Taiwanese nurses but also as a reference for other countries to encourage their nurses to intervene for problem alcohol use.

Implications for practice and/or policy

Educational programmes are needed to enhance nurses alcohol knowledge and emphasize the impact of alcohol abuse on illness and treatment to facilitate intervening for problem alcohol use. It is crucial to help nurses understand their role, especially Taiwanese emergency nurses, in intervening for problem alcohol use. Alcohol-related education is also needed for the general population and hospital policy makers to enhance facilitators and reduce barriers to intervening for problem alcohol use. that ED nurses had statistically signicantly higher perceived barrier scores in all environmental items than those in other work-unit groups. Indeed, only 152% of ED nurses in the present study agreed that drinking problems are a major problem for patients in their unit, even though 94245% of admissions to EDs in Taiwan are related to alcohol misuse (Huange 2007). Over one-third of ED nurses had been told by their supervisors that performing alcohol interventions was the least important aspect of nursing care. Our results are similar to a recent report that a majority of ED doctors and nurses in Ireland had never received any specic training regarding substance use, with a particular
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Conclusion
The implications for clinical practice can be summarized as follows: First, education programmes should target knowledge about alcohol, its impact on illness and treatment, and enhance facilitators and reduce barriers to intervening for problem alcohol use. Role-playing in training programmes would give nurses opportunities to practise their skills. The outcomes of such education programmes should be examined to determine their effectiveness. A second critical issue would be to encourage ED nurses to become aware of their important role in alcohol assessment and intervention as part of providing better care to ED patients. Finally, alcoholrelated education is also needed for the general population and hospital policy makers to enhance facilitators and reduce barriers to intervening for problem alcohol use.

Acknowledgements
This study was funded by the National Science Council, an agency of the Taiwan government (NSC-95-2314-B-182034-MY2).

Conict of interest
No conict of interest has been declared by the authors.
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Facilitators and barriers to alcohol intervention Kaner E.F., Lock C.A., McAvoy B.R., Heather N. & Gilvarry E. (1999a) A RCT of three training and support strategies to encourage implementation of screening and brief alcohol intervention by general practitioners. The British Journal of General Practice 49(446), 699703. Kaner E.F., Heather N., McAvoy B.R., Lock C.A. & Gilvarry E. (1999b) Intervention for excessive alcohol consumption in primary health care: attitudes and practices of English general practitioners. Alcohol & Alcoholism 34(4), 559566. Kaner E.F., Heather N., Brodie J., Lock C.A. & McAvoy B.R. (2001) Patient and practitioner characteristics predict brief alcohol intervention in primary care. The British Journal of General Practice 51(471), 822827. Kelleher S. & Cotter P. (2009) A descriptive study on emergency department doctors and nurses knowledge and attitudes concerning substance use and substance users. International Emergency Nursing 17(1), 314. Li Y.C. & Wang F.L. (1996) Alcohol abuse and the family of alcoholism. Medical Digest 23, 404409. Lock C.A., Kaner E., Lamont S. & Bond S. (2002) A qualitative study of nurses attitudes and practices regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing 39(4), 333342. Marcell A.V., Halpern-Felsher B., Coriell M. & Millstein S.G. (2002) Physicians attitudes and beliefs concerning alcohol abuse prevention in adolescents. American Journal of Preventive Medicine 22(1), 4955. Pinikahana J., Happell B. & Carta B. (2002) Mental health professionals attitudes to drugs and substance abuse. Nursing & Health Sciences 4(3), 5762. Raeside L. (2003) Attitudes of staff towards mothers affected by substance abuse. The British Journal of Nursing 12(5), 302 310. Richmond R.L. & Anderson P. (1994) Research in general practice for smokers and excessive drinkers in Australia and the UK. III. Dissemination of interventions. Addiction 89(1), 4962. Rydon P., Redman S., Sanson-Fisher R.W. & Reid A.L. (1992) Detection of alcohol-related problems in general practice. Journal of Studies on Alcohol 53(3), 197202. Seale J.P., Shellenberger S., Boltri J.M., Okosun I. & Barton B. (2005) Effects of screening and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- postintervention assessment. BMC Family Practice 6, 46. Spandorfer J.M., Israel Y. & Turner B.J. (1999) Primary care physicians views on screening and management of alcohol abuse: inconsistencies with national guidelines. The Journal of Family Practice 48(11), 899902. Taiwan Ministry of Transportation and Communication (2005) Social Indicators. Retrieved from http://eng/stat/gov.tw/public/data/ dgbas03/bs2 on 3 March 2007. Tsai Y.F. (2004) Nurses facilitators and barriers for taking a sexual history in Taiwan. Applied Nursing Research 17(4), 257264. Tsai Y.F. & Hsiung P. (2003) Aboriginal nurses perception of facilitators and barriers for taking a sexual history in Taiwan. Public Health Nursing 20(4), 281286. Tsai Y.F., Wong T.K.S. & Chen S.C. (2002) Prevalence and related risk factors of areca quid chewing among junior high students in Eastern Taiwan. Public Health 116(4), 190194.

Author contributions
YFT, MCT, YPL, CEW, CYC and MCC were responsible for the study conception and design. MCT, YPL, CEW and CYC performed the data collection. YFT and MCC performed the data analysis. YFT, MCT, YPL, CEW, CYC and MCC were responsible for the drafting of the manuscript. YFT, MCT, YPL, CEW, CYC and MCC made critical revisions to the paper for important intellectual content. MCC provided statistical expertise. YFT obtained funding.

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