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Abstract

Alcohol-intoxicated patients in the emergency department (ED) can be very challenging. That is why nursing staff need different kind of skills to promote effective healthcare to these patients. The aim was to describe nursing staff's self-assessed skills concerning the care of acutely ill alcohol-intoxicated patients in EDs. A descriptive quantitative survey was used to measure Finnish ED nursing staff's (N = 1220, n = 252) skills in this area. The data were analysed statistically. The staff had the best skills in the care of acutely ill alcohol-intoxicated patients in security and safety issues. The skills related to follow-up treatment were the poorest area. The background factors that had a statistically significant association with the skills were work experience in psychiatric nursing or intoxicant care as well as alcohol use related training. Work experience increases ED staff's skills in alcohol intoxicant care, but with updating education these skills would possibility be better to acquire earlier in a nurse's working career.

Keywords

alcohol competence emergency department staff emergency nursing skills

Introduction

People with adverse alcohol use have a lot of health problems and are often treated in emergency departments (Eds) around the world. It has been estimated that about 6–45% of ED patients are under the influence of alcohol or are alcohol abusers.¹ Acute injuries, serious diseases and death are consequences of hazardous use of alcohol worldwide in healthcare.^2–5 In addition, these problems entail high costs to society and healthcare organizations.⁶ Alcohol abusers often use emergency services repeatedly because, for example, they have been injured while drunk or have an alcohol-related disease.⁷ It has been stated that alcohol screening and brief interventions are effective in primary care settings,⁸ but early interventions in EDs among this patient group might also reduce costs.⁹ By using early interventions, it is possible to prevent alcohol risk users from becoming addicted.¹⁰

Background

Alcohol-related problems are part of everyday life in the ED, but management of problems of this kind is not routine among ED staff. The staff often perceive alcohol abusers as a challenging patient group to care for, adding to the workload of an already busy staff.^11–13 A significant proportion of staff indicate that lack of patient motivation makes providing alcohol interventions very difficult.¹⁴ It has been reported that compared with physicians, nurses are more likely to believe that alcohol-related rehabilitation is ineffective.¹⁵ The challenges of providing care may be related to the hectic ED environment,¹⁶ but also to nursing staff's lack of knowledge and skills in identifying and addressing substance misuse.¹⁷ In addition, nurses may become frustrated because the patients do not necessarily engage in care and may discharge themselves against professional advice.¹⁸ Occasionally, nurses who work in the ED feel that they are not adequately trained to care for alcohol-intoxicated patients.¹⁵

Few emergency physicians screen for alcohol or substance abuse despite evidence showing that screening and brief interventions are effective also in the ED.¹⁹ Nursing staff may be a key professional group dealing with patients who misuse alcohol and seek help from the emergency department.²⁰ Nurses do not necessarily have enough knowledge about how they could use alcohol screening tools,²¹ or the tools are not available in the department.²² However, it has been reported that, for example, the use of the Alcohol Use Disorders Identification Test (AUDIT) may give valuable information on patients' risk drinking.²³ When professionals combine the alcohol use evaluation with a motivational interview, this intervention may stimulate patients to reduce their alcohol use.²⁴

Stigma and substance misuse are closely linked. Nurses should encounter patients without stigmatization or showing negative attitudes.¹¹ However, the situations with the patients may sometimes be very challenging. It has been reported that, particularly in emergency settings, nurses may experience both verbal and physical violence from intoxicated patients. This can occur so frequently that nurses accept it as part of the job.^25,26 The nursing staff need skills to control violent situations and encounter the patient professionally even in these circumstances.²⁷ This requires systematic training for nurses as well as clear instructions on how to act with violent patients.²⁶

When alcohol-intoxicated patients seek emergency care it is important to find out whether the patient's situation requires follow-up care in intoxicant services. This requires individual evaluation of patients' needs and knowledge on suitable service producers on the part of nursing staff.^15,14 It is not always possible to dispatch patients immediately to follow-up care, but nursing staff can motivate patients to take care of their health²⁸ as well as giving instructions on how they can later seek appropriate care on their own.²⁹ Intensive collaboration between ED staff, social workers and drug and alcohol workers is required when striving to reduce patients' alcohol use and ED attendance.²⁹

The care of acutely ill or injured patients who are also intoxicated requires wide-ranging competence of nursing staff working in EDs. Training healthcare staff to ask and talk about alcohol use with patients is an ongoing challenge.¹⁷ It is important to develop nursing staff's knowledge related to alcohol use and misuse and to enhance skills in working with patients who have alcohol-related problems.³⁰ The directors of EDs should ensure that their staff have sufficient knowledge about this nursing area and that nurses have a positive attitude towards this kind of work.

Methods

Aims and research questions

The aim was to describe nursing staff's self-assessed skills concerning the care of acutely ill alcohol-intoxicated patients in EDs. The detailed research questions were as follows:

What kind of skills do nursing staff have concerning the care of acutely ill alcohol-intoxicated patients in EDs?

How do nursing staff's background factors associate with staff's skills?

Design and setting

A descriptive quantitative self-assessment survey design was used to describe nursing staff's skills to care for acutely ill alcohol-intoxicated patients in EDs. Finland is geographically divided into 20 hospital districts. Each hospital district has a central hospital; five of them are university hospitals. Each central hospital has at least one ED.

Sample and data collection

The data were collected among nursing staff working in EDs in Finland. The sampling frame (N = 1220) consisted of the total nursing staff working in these departments. The contact person in each study organization distributed questionnaires to the eligible staff members via email. The questionnaire was accompanied by an introductory letter with information about the aim of the study and assurance of anonymity and confidentiality. The response time was three weeks. Reminder emails were sent once during the data collection time. Out of the 1220 eligible participants in the sampling frame, 252 returned a completed questionnaire (total response rate 20.7%). The rule of thumb was used to ascertain how many participants were needed for the results to be reliable. According to that, five participants would be sufficient for each proposition on the scale.^31,32 There were 49 propositions in the developed competence scale; the reliable number of ED staff that needed to participate was thus n = 245.

Instrument

A mixed-method design was used to develop the instrument. First, a Delphi-type technique was used. Five nurses and a social worker working in an ED participated in three Delphi rounds. The round one was an email survey, rounds two and three were group interviews. Second, an integrative literature review was conducted,³³ and finally, six personal interviews were performed with nurses working in the ED. The findings from each phase were combined and competence scales and contents for the instrument were formed. A pilot study was conducted among nurses working in the ED in a district hospital that did not belong to the target group of the study. The aim of the feasibility study was to ensure that the instrument was comprehensible and easy to answer. Minor improvements to the instrument were made based on nurses' suggestions.

The instrument consisted of seven scales: 1) alcohol risk use evaluation skills (11 items), 2) interaction skills (6 items), 3) ethical skills (7 items), 4) counseling and education skills (7 items), 5) security and safety skills (9 items), 6) teamwork and network skills (5 items), and 7) follow-up treatment skills (4 items). The instrument consisted of five-point Likert-type items. The participants self-evaluated their skills using the alternatives 1 = extremely poor, 2 = reasonably poor, 3 = reasonably good, 4 = good, and 5 = extremely good. The nurses' background factors included organization, position, work experience in healthcare, work experience in emergency care, work experience in psychiatric nursing, work experience in intoxicant care, participation in alcohol use related training, and participation in substance abuse related training.

Data analysis

Frequencies, percentages, means and standard deviations as well as medians were used to describe the background data. Seven mean sum variables were formed from the scales of the instrument. If a participant had more than two missing items in any section of the sum variable, the whole answer was left out from the sum variables. Associations between background factors and sum variables were analyzed using the Kruskal–Wallis test. All statistical tests were performed as two-tailed, with a significance level set at 0.05.³⁴ The analyses were performed using SAS System, version 9.4 for Windows (SAS Institute Inc., Cary, NC, USA).

Ethical considerations

In the study, ethical decisions followed general ethical guidelines and legislation on healthcare research.³⁵ The study was approved by the Ethics Committee of the University of Turku, Finland (Decision 30/2015, 8 September 2015). Permission for sampling was obtained from the nursing directors or medical directors following the conventions of each organization. The participation of nursing staff was voluntary, and the data were treated in confidence. Participants received written information about the research by email. Responding to the survey was considered as giving informed consent to participate in the study.³⁶

Results

Background information

Altogether, 252 candidates participated in the research. Over half of the participants (57.4%) worked at the ED in a central hospital. Most of the nursing staff who participated were nurses (85.3%) and half of them had more than ten years of work experience (49.2%). A third (31.2%) had worked for longer than ten years in the ED while more than a fifth (22.8%) had worked there for less than two years. Less than a quarter (23.0%) of the staff had experience in psychiatric nursing and 12.0% had worked in intoxicant care. Of the whole sample, 30.2% had received alcohol use related training during their career, and 13.9% had received it during the last year. Almost half (41.0%) had received substance abuse related training during their career, and about a fifth (18.3%) of that training had taken place during the last year (Table 1).

Table 1.

Background factors.

Background factor	n (%)
Organization
Central hospital	144 (57.4)
University hospital	107 (42.6)
Position
Nurse manager/assistant nurse manager	10 (4.0)
Registered nurse	215 (85.3)
Practical nurse	16 (6.3)
Other	11 (4.4)
Work experience in healthcare
<2 years	24 (9.5)
2–5 years	38 (15.1)
>5 years–10 years	66 (26.2)
>10 years	124 (49.2)
Work experience in emergency care
<2 years	57 (22.8)
2–5 years	51 (20.4)
>5 years–10 years	64 (25.6)
>10 years	78 (31.2)
Working in psychiatric nursing
Yes	58 (23.0)
No	194 (77.0)
Work experience in psychiatric nursing
<2 years	42 (72.4)
2–5 years	9 (15.5)
>5 years–10 years	6 (10.4)
>10 years	1 (1.7)
Working in intoxicant care
Yes	30 (12.0)
No	221 (88.0)
Work experience in intoxicant care
<2 years	16 (53.3)
2–5 years	9 (30.0)
>5 years–10 years	4 (13.4)
>10 years	1 (3.3)
Alcohol use related training during the last year
Yes	35 (13.9)
No	217 (86.1)
Alcohol use related training during career
Yes	76 (30.2)
No	176 (69.8)
Substance abuse related training during the last year
Yes	46 (18.3)
No	205 (81.7)
Substance abuse related training during career
Yes	103 (41.0)
No	148 (59.0)

Nursing staff's skills and related factors

The nursing staff estimated how good their different skills were in the area of the care of alcohol-intoxicated patients. In this evaluation, they considered that they had the best skills in security and safety issues (Mean 3.97, Md 3.89, SD 0.55) while ethical skills in alcohol-intoxicated patient care were the second-best area (Mean 3.90, Md 4.00, SD 0.58). The competence in alcohol risk use evaluation skills was quite poor (Mean 3.07, Md 3.09, SD 0.71) while follow-up treatment related skills were the poorest area (Mean 2.56, Md 2.50, SD 0.83) (Table 2).

Table 2.

Nursing staff's skills concerning the care of acutely ill alcohol-intoxicated patients in the emergency department.

Skills (sum variables)	N	Mean	Median	SD	Cronbach's alpha value
Alcohol risk use evaluation skills	250	3.07	3.09	0.71	0.912
Interaction skills	251	3.59	3.67	0.61	0.877
Ethical skills	250	3.90	4.00	0.58	0.866
Counseling and education skills	249	3.26	3.29	0.67	0.880
Security and safety skills	248	3.97	3.89	0.55	0.878
Teamwork and network skills	249	3.60	3.60	0.74	0.896
Follow-up treatment skills	250	2.56	2.50	0.83	0.907

Connections between research participants' background factors and self-evaluated skills considering care of alcohol-intoxicated patients were statistically analysed using the Kruskal–Wallis test. The organization where the participant worked had an association with their ethical skills (Chi² 3.951, DF 1, p = 0.047). Nursing staff working in central hospital evaluated their ethical skills as being higher (Mean 3.95, SD 0.63) than did those who worked in university hospital (Mean 3.84, SD 0.51). Position had statistical significance when nursing staff estimated their teamwork and network skills (Chi² 11.81, DF 3, p = 0.008). Nurse managers/assistant nurse managers had higher means (Mean 4.32, SD 0.46) in this area than nurses (Mean 3.57, SD 0.72), practical nurses (Mean 3.67, SD 0.71) or others (Mean 3.56, SD 1.12). Work experience in healthcare also had statistical significance in terms of teamwork and network skills (Chi² 13.49, DF 3, p = 0.004). Those who had worked in healthcare for between five and ten years had the best self-evaluated teamwork and network skills (Mean 3.79, SD 0.65) (Table 3).

Table 3.

Associations between background factors and sum variables using Kruskal-Wallis test.

	Alcohol risk use evaluation skills Mean (SD)	Chi² DF p	Interaction skills Mean (SD)	Chi² DF p	Ethical skills Mean (SD)	Chi² DF p	Counseling and education skills Mean (SD)	Chi² DF p	Security and safety skills Mean (SD)	Chi² DF p	Teamwork and network skills Mean (SD)	Chi² DF p	Follow-up treatment skills Mean (SD)	Chi² DF p
Organization		0.445 1 0.505		0.931 1 0.335		3.951 1 0.047		0.884 1 0.347		2.406 1 0.121		0.491 1 0.483		1.574 1 0.210
Central hospital	3.10 (.75)		3.62 (.64)		3.95 (.63)		3.29 (.68)		4.02 (.53)		3.63 (.75)		2.61 (.86)
University hospital	3.03 (.64)		3.54 (.57)		3.84 (.51)		3.22 (.65)		3.92 (.57)		3.56 (.74)		2.47 (.79)
Position		5.378 3 0.146		1.949 3 0.583		2.351 3 0.503		0.651 3 0.884		4.487 3 0.214		11.81 3 0.008		0.582 3 0.901
Nurse manager/ assistant nurse manager	2.90 (.65)		3.63 (.47)		4.00 (.48)		3.23 (.69)		3.87 (.62)		4.32 (.46)		2.50 (.83)
Nurse	3.10 (.69)		3.58 (.61)		3.90 (.58)		3.27 (.66)		3.96 (.53)		3.57 (.72)		2.55 (.81)
Practical nurse	3.20 (.62)		3.73 (.69)		4.02 (.57)		3.31 (.59)		4.12 (.58)		3.67 (.71)		2.66 (.82)
Other	2.53 (.94)		3.53 (.75)		3.75 (.79)		3.01 (.93)		4.16 (.73)		3.56 (1.12)		2.66 (1.21)
Work experience in healthcare		1.612 3 0.657		4.057 3 0.255		5.912 3 0.116		4.790 3 0.188		6.762 3 0.080		13.49 3 0.004		4.027 3 0.259
<2 years	2.98 (.50)		3.44 (.50)		3.89 (.46)		2.98 (.62)		3.69 (.55)		3.21 (.51)		2.26 (.79)
2–5 years	3.13 (.65)		3.66 (.58)		3.28 (.51)		3.28 (.51)		3.98 (.53)		3.50 (.66)		2.46 (.71)
> 5 years–10 years	3.14 (.71)		3.69 (.59)		3.34 (.67)		3.34 (.63)		3.96 (.47)		3.79 (.65)		2.64 (.81)
> 10 years	3.04 (.76)		3.54 (.65)		3.82 (.62)		3.27 (.71)		4.03 (.58)		3.61 (.82)		2.60 (.88)
Work experience in emergency care		5.747 3 0.125		1.684 3 0.640		3.901 3 0.272		3.204 3 0.361		9.531 3 0.023		5.988 3 0.112		4.028 3 0.259
<2 years	3.14 (.72)		3.61 (.62)		3.97 (.58)		3.13 (.69)		3.79 (.57)		3.45 (.63)		2.45 (.88)
2–5 years	3.19 (.58)		3.66 (.52)		3.98 (.50)		3.33 (.55)		3.94 (.43)		3.56 (.71)		2.47 (.69)
> 5 years–10 years	2.97 (.72)		3.63 (.68)		3.94 (.56)		3.32 (.69)		4.03 (.58)		3.72 (.78)		2.54 (.89)
>10 years	3.02 (.76)		3.49 (.61)		3.77 (.64)		3.25 (.70)		4.06 (.55)		3.64 (.81)		2.55 (.83)
Working in psychiatric nursing		7.980 1 0.005		5.201 1 0.023		4.197 1 0.041		2.100 1 0.147		0.074 1 0.785		0.165 1 0.685		3.439 1 0.064
Yes	3.33 (.73)		3.75 (.66)		3.99 (.73)		3.40 (.74)		4.00 (.46)		3.63 (.83)		2.78 (.96)
No	3.00 (.68)		3.54 (.59)		3.88 (.53)		3.22 (.64)		3.96 (.57)		3.60 (.72)		2.49 (.78)
Working in intoxicant care		13.160 1 <0.001		8.171 1 0.004		7.194 1 0.007		8.414 1 0.004		1.530 1 0.216		2.589 1 0.108		5.562 1 0.018
Yes	3.58 (.71)		3.92 (.57)		4.19 (.48)		3.64 (.74)		4.11 (.47)		3.83 (.66)		2.95 (.98)
No	3.01 (.68)		3.55 (.61)		3.87 (.58)		3.22 (.64)		3.96 (.54)		3.58 (.75)		2.51 (.80)
Alcohol use related training during the last year		4.211 1 0.040		1.439 1 0.230		0.154 1 0.695		2.337 1 0.126		2.897 1 0.089		0.152 1 0.696		3.063 1 0.080
Yes	3.28 (.58)		3.69 (.58)		3.88 (.73)		3.41 (.68)		4.13 (.47)		3.69 (.72)		2.80 (.78)
No	3.04 (.72)		3.57 (.62)		3.91 (.56)		3.24 (.67)		3.95 (.56)		3.59 (.75)		2.52 (.84)
Alcohol use related training during career		11.552 1 <0.001		1.239 1 0.266		0.102 1 0.729		7.504 1 0.006		3.218 1 0.073		4.502 1 0.034		14.572 1 <0.001
Yes	3.32 (.66)		3.66 (.59)		3.92 (.57)		3.44 (.67)		4.07 (.48)		3.77 (.68)		2.85 (.79)
No	2.97 (.70)		3.56 (.62)		3.90 (.59)		3.18 (.66)		3.93 (.57)		3.54 (.76)		2.43 (.82)
Substance abuse related training during the last year		10.808 1 0.001		7.321 1 0.007		1.614 1 0.204		13.136 1 < 0.001		11.360 1 <0.001		7.658 1 0.006		13.929 1 <0.001
Yes	3.40 (.65)		3.82 (.53)		4.02 (.54)		3.61 (.66)		4.24 (.49)		3.93 (.71)		2.99 (.82)
No	3.01 (.70)		3.54 (.62)		3.88 (.59)		3.19 (.65)		3.92 (.54)		3.55 (.71)		2.47 (.80)
Substance abuse related training during career		6.370 1 0.012		0.956 1 0.328		0.041 1 0.839		11.840 1 <0.001		4.003 1 0.045		8.805 1 0.003		18.234 1 <0.001
Yes	3.23 (.71)		3.64 (.60)		3.91 (.57)		3.43 (.69)		4.07 (.51)		3.77 (.72)		2.81 (.79)
No	2.97 (.69)		3.56 (.62)		3.90 (.59)		3.15 (.63)		3.91 (.56)		3.49 (.74)		2.39 (.82)

Note. statistically significant p values are shown in bold.

Work experience in emergency care was associated with security and safety skills (Chi² 9.531, DF 3, p = 0.023). Those who had worked in emergency care for more than ten years evaluated their security and safety skills highest (Mean 4.06, SD 0.55). In turn, working in psychiatric nursing had statistical significance in alcohol risk use evaluation skills (Chi² 7.980, DF 1, p = 0.005), interaction skills (Chi² 5.201, DF 1, p = 0.023) and ethical skills (Chi² 4.197, DF 1, p = 0.041). Nursing staff who had worked in psychiatric nursing thought that they had better skills in all these three areas (alcohol risk use evaluation skills Mean 3.33, SD 0.73; interaction skills Mean 3.75, SD 0.66; ethical skills Mean 3.99, SD 0.73) than those who had not worked in psychiatric nursing (alcohol risk use evaluation skills Mean 3.00, SD 0.68; interaction skills Mean 3.54, SD 0.59; ethical skills Mean 3.88, SD 0.53). Working in intoxicant care also had a positive association with alcohol risk use evaluation skills (Chi² 13.160, DF 1, p < 0.001), interaction skills (Chi² 8.171, DF 1, p = 0.004) and ethical skills (Chi² 7.194, DF 1, p = 0.007). In addition, it was also associated with counseling and education skills (Chi² 8.414, DF 1, p = 0.004) and with follow-up treatment skills (Chi² 5.562, DF 1, p = 0.018) (Table 3).

The participants who had received alcohol use related training over the past year estimated their alcohol risk use evaluation skills higher (Mean 3.28, SD 0.58) than did those who had not taken part in such training (Mean 3.04, SD 0.72). It also had statistical significance (Chi² 4.211, DF 1, p = 0.040) in participants' skills in alcohol risk use evaluation regardless of whether they had received the above training or not. Participants were also asked whether they had received alcohol use related training during their career, substance abuse related training during the last year, or substance abuse related training during their career. All these types of training had a connection with many of the respondents' self-evaluated skills. The training type that had the most statistical significance with different competencies was substance abuse related training during the last year (Table 3).

Those who had been in that type of training during the last year evaluated their skills higher in alcohol risk use evaluation skills (had training Mean 3.40, SD 0.65; did not have training Mean 3.01, SD 0.70), interaction skills (had training Mean 3.82, SD 0.53; did not have training Mean 3.54, SD 0.62), counseling and education skills (had training Mean 3.61, SD 0.66; did not have training Mean 3.19, SD 0.65), security and safety skills (had training Mean 4.24, SD 0.49; did not have training Mean 3.92, SD 0.54), teamwork and network skills (had training Mean 3.93, SD 0.71; did not have training Mean 3.55, SD 0.71), and follow-up treatment skills (had training Mean 2.99, SD 0.82; did not have training Mean 2.47, SD 0.80) than those who had not taken part in the training. All these skills also had a connection with training: higher in alcohol risk use evaluation skills p = 0.001, interaction skills p = 0.007, counselling and education skills p < 0.001, security and safety skills p < 0.001, teamwork and network skills p = 0.006, follow-up treatment skills p < 0.001. Ethical skills were the only area that did not show a connection with this kind of training (p = 0.204) even if participants who had taken part in the training estimated their skills to be higher in this domain as well (had training Mean 4.02, SD 0.54; did not have training Mean 3.88, SD 0.59) (Table 3).

Discussion

Discussion of the results

The registered nurses had the most skills in the security and safety section and in ethical questions. Longer experience in emergency care was associated with better security and safety skills. New nurses should also have these skills because it is clear that patients who are alcohol-intoxicated can cause unsafe situations in the EDs²⁵ and it is therefore important that nurses know better how to deal with violent patients.²⁷ Patients’ behavior can cause annoyance among nursing staff; in such cases, nurses have to make sure that their actions remain professional. Most participants had worked in EDs for more than five years, so it seems that ethical skills might also improve with longer work experience. Nurses may confront ethical problems when they have to maintain the nurse's role and provide high-quality care despite the patient's misbehavior. In addition, nurses have to ensure the safety of other patients and sometimes request the presence of guards. It is important that there are clear instructions on how to act in unsafe situations in the emergency department and that the whole staff is trained to follow the instructions. The directors of the department are responsible for the instructions.

Compared to other areas, follow-up treatment skills and alcohol risk use evaluation skills were evaluated as having the lowest means by the participants. Even though these means are good, this shows that the nurses felt that they had fewer skills in this competence area. In order to have this kind of expertise nurses must have specific knowledge on how to care for alcohol misusers¹⁷ and ED nurses do not always have good skills when, for example, they need to use alcohol screening tools.²¹ Security and safety issues and ethical problems are present in all domains of the healthcare system and are part of all nursing areas, which is why it is understandable that nurses feel that they have better skills in this kind of knowledge. Follow-up treatment skills and alcohol risk use evaluation skills have a very important role when treating acutely ill alcohol-intoxicated patients in the ED.²⁴ Emergency department directors should be aware of this fact and offer alcohol use or substance abuse related training to nurses who work in the ED. However, it is not enough that these facts have been taken account in the ED. These patients often have follow-up care in primary healthcare after visiting the ED. The staff of the primary healthcare also have to have competence in the care of the alcohol abusers. Cooperation between ED and primary healthcare is necessary in order for the patient to receive the best and continuous care. In addition, it must be possible that ED staff are able to consult the experts of intoxicant care and mental healthcare.³⁷

According to the results of this research, substance abuse related training is of great importance to skills related to substance abuse nursing. Working in psychiatric nursing or in intoxicant care also had an effect on these kinds of skills. Sometimes ED staff start working in the ED immediately after graduating from nursing school, with no previous work experience from any other care areas. That is why targeted educational interventions can improve the skills and attitudes of nursing staff who take care of alcohol-intoxicated patients in the ED. In addition, updating training interventions can also have a positive impact on nurses' attitudes towards alcohol-intoxicated patients.^30,38 Nurses who have been working in the ED for some time feel that they are not adequately trained to care for alcohol-intoxicated patients, so it is important that they receive more training in this area which is, after all, part of their everyday work.^17,15

Reliability and limitations

Our statistical analyses indicated that the instrument is usable and reliable in measuring nursing staff's skills concerning the care of acutely ill alcohol-intoxicated patients in EDs. The homogeneity of the items in different sum variables (sub-scales) using Cronbach's alpha values varied from 0.866 to 0.912 (see Table 2). The alpha value for the whole instrument was 0.957.

The study has some limitations. The total response rate for the study was 20.7%, which is quite low. Emergency departments are very busy environments and it is possible that nursing staff did not have much time to concentrate on answering our questions. The questionnaire had so many items that it might take quite a long time to answer in full. In addition, it is known that ED nursing staff's attitudes towards the care of intoxicated patients is not always very positive,^20,11 which is why it is possible that many nurses were not very interested in our topic. However, we think that our findings give some evidence of what kind of skills nursing staff have concerning the care of acutely ill alcohol-intoxicated patients in the ED.

The generalizability of our findings may be limited because of the special setting of Finnish emergency care. On the other hand, it is known that, internationally, the number of alcohol-intoxicated patients treated in EDs in Western countries is consistent.^39,40 In addition, the reasons for which alcohol-intoxicated patients come into EDs are also similar.^41,42 Thus, care in different EDs requires similar skills of the nursing staff.

Conclusion

Education in intoxicant care has a connection with the skills associated with the care of acutely ill alcohol-intoxicated patients in EDs. Substance abuse related training received by the nursing staff during the past year is of key significance for the competence mentioned earlier. Work experience also makes a difference in terms of knowledge of alcohol-intoxicated patient treatment skills in the ED. The skills in different areas that nurses need in this kind of work are rated as higher if the nurse has work experience from psychiatric nursing or intoxicant care.

Relevance to clinical practice

Alcohol use related training is an important factor for ED nurses' skills to care for acutely ill alcohol-intoxicated patients. Emergency department directors should organize updating education for nursing staff on this area of care. Understanding the importance of this kind of training is relevant to clinical practice because it would improve the quality of care and also improve nursing staff's motivation in their work when they have more skills and knowledge to care for this patient group in the ED. It might even lower healthcare costs if follow-up care to these patients could be more effective and less alcohol-intoxicated patients would enter EDs.

Footnotes

Funding

The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article: The study was funded by the Satakunta Hospital District (Government Research Financing 81902, Decision 57/2016) and the Hospital District of Southwest Finland (Government Research Financing 81902, Decisions 7/2015 and 15/2016).

Declaration of conflicting interests

The authors declare that there is no conflict of interest.

References

Clarke

Gonzalez

Pereira

, et al. The impact of knowledge on attitudes of emergency department staff towards patients with substance related presentations: a quantitative systematic review protocol. JBI Database System Rev Implement Rep 2015; 13(10): 133–145.

Hankin

Haley

Baugher

, et al. Kiosk versus in-person screening for alcohol and drug use in the emergency department: patient preferences and disclosure. West J Emerg Med 2015; 16(2): 220–228.

World Health Organization (WHO). Status report of alcohol and health in 35 European countries 2013. WHO Regional Office for Europe, http://www.euro.who.int/__data/assets/pdf_file/0017/190430/Status-Report-on-Alcohol-and-Health-in-35-European-Countries.pdf (2013, accessed 23 March 2019).

Chen CM and Yi H. Trends in alcohol-related morbidity among short-stay community hospital discharges, United States, 1979–2010. Surveillance Report #94 of National Institute on Alcohol Abuse and Alcoholism, https://pubs.niaaa.nih.gov/publications/Surveillance94/HDS10.pdf (2012, accessed 23 March 2019).

World Health Organization (WHO). Alcohol and injury in emergency department: summary of the report from the WHO collaborative study of alcohol and injuries. World Health Organization. Report ISBN 978 92 4 159485 1, http://www.who.int/substance_abuse/publications/alcohol_injury_summary.pdf (2007, accessed 23 March 2019).

Rehm

Mathers

Popova

, et al. Global burden of disease and injury and economic cost attributable to alcohol and alcohol-use disorders. Lancet 2009; 379(9682): 2223–2233.

Holzer

Minder

Rosset

, et al. Patient characteristics and patterns of intoxication: one-time and repeated use of emergency ambulance services. J Stud Alcohol Drugs 2013; 74(3): 484–489.

Kraemer

. The cost-effectiveness and cost–benefit of screening and brief intervention for unhealthy alcohol use in medical settings. Subst Abus 2007; 28(3): 67–77.

Barbosa

Cowell

Bray

, et al. The cost-effectiveness of alcohol screening, brief intervention, and referral to treatment (SBIRT) in emergency and outpatient setting. J Subst Abuse Treat 2015; 53: 1–8.

10.

National Institute of Drug Abuse, USA. Understanding drug use and abuse, https://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction (2018, accessed 23 March 2019).

11.

Henderson

Stacey

Dohan

. Social stigma and the dilemmas of providing care to substance users in a safety-net emergency department. J Health Care Poor Underserved 2008; 19(4): 1336–1349.

12.

Ahern

Stuber

Scalea

. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend 2007; 88(2–3): 188–196.

13.

Hoskins

Salmon

Binks

, et al. A study exploring drug use and management of patients presenting to an inner city emergency department. Accid Emerg Nurs 2005; 13(3): 147–153.

14.

Indig

Copeland

Conigrave

, et al. Attitudes and beliefs of emergency department staff regarding alcohol-related presentations. Int Emerg Nurs 2009; 17(1): 23–30.

15.

Warren

Sena

Choo

, et al. Emergency psysicians' and nurses' attitudes towards alcohol-intoxicated patients. J Emerg Med 2012; 43(6): 1167–1174.

16.

Wood

Green

Dargan

. Five-year trends in self-reported recreational drugs associated with presentation to a UK emergency department with suspected drug-related toxicity. Eur J Emerg Med 2013; 20(4): 263–267.

17.

Fleming

Olsen

Stathes

, et al. Virtual reality skills training for health care professionals in alcohol screening and brief intervention. J Am Board Fam Med 2009; 22(4): 387–398.

18.

Jeong

Song

Kim

, et al. The association between acute alcohol consumption and discharge against medical advice of injured patients in the ED. Am J Emerg Med 2016; 34(3): 464–468.

19.

Broderick

Kaplan

Martini

, et al. Emergency physician utilization of alcohol/substance screening, brief advice and discharge: a 10-year comparison. J Emerg Med 2015; 49(4): 400–407.

20.

Mellor

McCabe

Ricciardelli

, et al. Evaluation of an alcohol intervention training program for nurses in rural Australia. J Res Nurs 2012; 18(6): 561–575.

21.

Jones

. Systematic review of alcohol screening tools for use in the emergency department. Emerg Med J 2011; 28(3): 182–191.

22.

Forsythe

Lee

. The evidence for implementing alcohol screening and intervention in the emergency department – time to act. Int Emerg Nurs 2012; 20(3): 167–172.

23.

Babor T, Higgins-Biddle J, Saunders J, et al. AUDIT. The alcohol use disorders identification test. Guidelines for use in primary care. 2nd ed. World Health Organization, Department of Mental Health and Substance Dependence, https://apps.who.int/iris/bitstream/handle/10665/67205/WHO_MSD_MSB_01.6a.pdf;jsessionid=E2E965BF61F923F216C3F6CDA944F780?sequence=1 (2001, accessed 26 May 2019).

24.

Koivunen

Harju

Kauko

, et al. Alcohol risk drinking, quality of life and health state among patients treated at the sobering unit in the emergency department: one year follow-up study. Int Emerg Nurs 2017; 31: 22–29.

25.

Speroni

Fotch

Dawson

, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs 2014; 40(3): 218–228.

26.

Luck

Jackson

Usher

. Innocent or culpable? Meanings that ED nurses ascribe to individual acts of violence. J Clin Nurs 2008; 17(8): 1071–1078.

27.

Cheshin

Anat

Eiseman

. Encountering anger in the emergency department: identification, evaluations and responses of staff members to anger displays. Emerg Med Int 2012, pp. 2012Article ID 603215.

28.

Trinks

Festin

Bendtsen

, et al. What makes emergency department patients reduce their alcohol consumption? A computer-based intervention study in Sweden. Int Emerg Nurs 2013; 21(1): 3–9.

29.

Benger

Carter

. Could inter-agency working reduce emergency department attendances due to alcohol consumption?. Emerg Med J 2008; 25(6): 331–334.

30.

Whitty

Nagel

Jayaraj

, et al. Development and evaluation of training in culturally specific screening and brief intervention for hospital patients with alcohol-related injuries. Aust J Rural Health 2016; 24(1): 9–15.

31.

Rattray

Jones

. Essential elements of questionnaire design and development. J Clin Nurs 2007; 16(2): 234–243.

32.

Bryman A and Cramer D. Quantitative Data Analysis with SPSS 12 and 13. A guide for social scientists. Hove: Routledge, 2005, pp.3–126.

33.

Hakala

Koivunen

Åstedt-Kurki

. Staff's attitudes and knowledge in the care of intoxicated patients in the emergency department: integrative literature review. Nurs Evidence [Tutkiva Hoitotyö] 2017; 15(2): 30–40.

34.

Cipher

Introduction to statistical analysis. In: Gray

Grove

Sutherland

(eds). Burns and Grove's The practice of nursing research, 8th ed. St Louis, MO: Elsevier, 2017, pp. 519–534.

35.

World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects, https://www.wma.net/wp-content/uploads/2016/11/DoH-Oct2013-JAMA.pdf (2008, accessed 23 March 2019).

36.

Finnish Advisory Board of Research Integrity. Responsible conduct of research and procedures for handling allegations of misconduct in Finland, http://www.tenk.fi/sites/tenk.fi/files/HTK_ohje_2012.pdf (2012, accessed 23 March 2019).

37.

O'Brien

Leonard

Deering

. Could an advance practice nurse improve detection of alcohol misuse in the emergency department?. Int J Ment Health Nurs 2012; 21(4): 340–348.

38.

Vadlamudi

Adams

Hogan

, et al. Nurses' attitudes, beliefs and confidence levels regarding care for those who abuse alcohol: impact of educational intervention. Nurse Educ Pract 2008; 8(4): 290–298.

39.

Bakke

Bogstrand

Normann

, et al. Influence of alcohol and other substances of abuse at the time of injury among patients in a Norwegian emergency department. BMC Emerg Med 2016; 16: 20.

40.

Blow

Walton

Barry

, et al. Alcohol and drug use among patients presenting to an inner-city emergency department: a latent class analysis. Addict Behav 2011; 36(8): 793–800.

41.

Parkman

Neale

Day

, et al. Qualitative exploration of why people repeatedly attend emergency departments for alcohol-related reasons. BMC Health Serv Res 2017; 17: 140.

42.

Verelst

Moonen

Desruelles

, et al. Emergency department visits due to alcohol intoxication: characteristics of patients and impact on the emergency room. Alcohol Alcohol 2012; 47(4): 433–438.

Nursing staff's self-assessed skills concerning the care of acutely ill alcohol-intoxicated patients in emergency departments