Nurses are ideally placed to spot the signs of alcohol abuse and should be prepared to open a conversation about the issue with family members, writes Linda Latham
Starting a conversation about alcohol misuse, whether it be with a spouse, a family or with friends, is a culturally awkward endeavour in Ireland. Despite the fact that Irish society tolerates a high level of alcohol consumption, it is a conversation that should be encouraged well before children start experimenting with alcohol.
This conversation should be initiated tentatively by nurses, whether at work, in the community or in their own homes. Some estimates suggest that nurses misuse drugs and alcohol at nearly the same rate (10-15%) as the rest of the population. The American Nurses Association estimates that 6-8% of nurses use alcohol or drugs to an extent that is sufficient to impair professional performance. 1 It may be very uncomfortable for us to consider that a nurse can be high functioning and high achieving though suffering from a substance-use disorder such as alcoholism. Therefore, it makes sense that the conversation starts with us.
Often the best placed person to facilitate the discussion surrounding the misuse of alcohol is the nurse who is caring for the patient whose illness is related to that misuse – in hospital or in the community. Too often, however, the opportunity is lost as the ‘tyranny of the urgent’, most often the physical care needs associated with alcohol misuse, is attended to. Providing appropriate care, the clinician focuses on the patient.
Once out of the hospital environment it is imperative that the nurse also takes into consideration the impact that the patient’s hazardous and dependent drinking has on other individuals – especially dependent children, families and the wider community. The impact of alcohol abuse is not only felt in the spouse or partner relationship but can have a devastating effect on the children in such families.2 Problem alcohol use can undermine the wellbeing of entire families.3
There are no national clinical guidelines in Ireland regarding the care of children with a substance abusing parent. However, UK guidelines assert that effective treatment of the parent with substance abuse can have major benefits for the child, and that services and clinicians need to work together to protect and improve the health and wellbeing of affected children.
Parents have the opportunity to positively influence their children in many ways but the reality is that they also influence and reinforce future drinking behaviour from a very early age, through their own attitudes and drinking patterns. A Drink Wise TV campaign in Australia called ‘Kids absorb your drinking’ identifies the traits that are passed on from generation to generation. Often the child absorbs the nuances of behaviour surrounding drinking habits from a very young age or even while in utero. There is a current data shortage in Ireland regarding children and families affected by parental alcohol problems.4
|Vignette on intervention opportunity|
It was a busy Monday morning in the surgery. As well as booked in appointments there was a long list of ‘walk in’ patients
Patient: I won’t keep you – it’s just that I don’t know what to do with my young one. She won’t go to school for me and I can’t get her to come over to the surgery?
Nurse: Oh, what is wrong? Is she sick?
Patient: Oh no. It’s not that, it’s just she has now had 25 days off school and they want a doctor’s note.
Nurse: Well, we can’t give you a note you know as we haven’t seen your child and therefore can’t state she is sick. What is the real problem?
Patient: Ah well I can’t seem to get her to do anything I want her to do… going to school is the final straw
Nurse: And what do you say to her? How do you manage it?
And so ensued a long conversation about how the situation had escalated to shouting angry interchanges and finally the realisation that she was a child raised by an alcoholic mother who had behaved in a similar way and her partner was regularly hiding alcohol in the home.
Brief intervention in this situation was to watch the three-minute ‘Kids absorb your drinking’ video. The patient left saying “I understand where I am going wrong now. We are all going to watch that advert together this evening.”
Further follow up with continuing care management
There is also an international knowledge gap about life-span developmental conceptualisations, although there are long-term prospective studies which have been slowly adopted.5
Generational predictors and outcomes have been studied in the UK. The National Child Development Study (NCDS) is a continuing, multidisciplinary longitudinal study that follows the lives of about 17,000 people born in the UK in a certain week in 1958. A longitudinal study on data from childhood to mid-life from the NCDS was conducted and predictors were collected at ages seven, 11 and 16 years, and alcohol outcomes collected at ages 16, 23, 33 and 42 years. Findings identified that alcohol use and problems in adulthood can be predicted by indicators of social background, adjustment and behaviour in childhood and adolescence, and that the early roots of adolescent and adult alcohol use behaviours appear to begin in childhood.6 In light of these facts, we must ask: how, as a profession, can we encourage recovery and safeguard children and affected families?
Encouraging pathways to recovery
Nurses based in the community, such as mental health nurses, public health nurses and practice nurses, are often the first professionals who notice dysfunction in the lives of families. Indeed, the GP’s role can to help those with chaotic and difficult lives.7
The range of health and social problems for families is expansive and providing a listening ear to a family member, who is suffering, is the first port of call. The pathway to recovery can be obstructed unless a nurse is prepared to actively listen to the initial, often guarded and hidden, plea for help from family members. Not all nurses are familiar with the questions to ask but many can, with experience, become alert for hidden cues.
The type of treatment recommended for any individual is dependent on an adequate and thorough assessment by a competent professional. Nurses should know the basics of how to assess the situation. The AUDIT or CAGE assessment tools are useful for assessing the extent of the problem and for those who are wondering if alcohol is affecting their family member adversely. For the individual family member who is suffering under the cloud of alcohol addiction, the assessment is not as straight forward. Often the patient presents in primary care with stress- -related illness, such as anxiety, depression, anger or an inability to cope with any kind of extra pressure in their own lives or those of their children. Often the desire to provide a secure and alcohol-free environment in their own home leads them to over-control their environment and become angry and aggressive.
There is an urgent need for appropriate services for those who are dealing with alcohol-related harm in their family on a daily basis. Knowing the therapeutic environment and local ancillary services is key to being able to provide care and appropriate referral. Treatment for the alcohol misuser will usually move from the least intensive model to the most intensive model depending on the history and past effectiveness of treatment. Ongoing treatment for the families affected can be delivered through agencies such as Al-anon, which campaigns for the burden of alcohol-related harm to be lifted from the individual, community and state.
Other local services should be contacted to provide phone numbers and meeting times of groups that are willing to engage with families in crisis. Al-anon offers peer-to-peer understanding and non-professional support for families and friends of problem drinkers in an anonymous environment, whether the alcoholic is still drinking or not (www.al-anon-ireland.org).
Collaboration across health and social care is a key feature of effective treatment.8 Families have complex needs and are a resource-intensive group, which provide the greatest challenge for service provision. Many have a myriad of health and social problems that require interventions from a range of providers.
Appropriate referral to local HSE social work departments should be timely, and a duty of safeguarding children should be paramount. Barnardos provides guidance and support through various means. Childline can also be contacted for information and support (www.childline.ie). Teen Counselling is a professional counselling service provided through Crosscare for 12-18 year olds and their parents (www.teencounselling.ie).
Typical issues dealt with include:
Another example of service provision is the HSE counselling in primary care (CIPC) service. Although this service will not engage with anyone who has a history of addiction, it does provide help for related disorders such as:
These services are available on a time-limited basis to those over 18 years, and holders of current medical cards. Local services in the community may be available, however these need to be accessed through community services.
Recovery from the shadow of alcoholism for any family members affected can only be possible if the conversation about alcohol misuse has been started. Nurses should encourage reasonable expectations among family members about recovery from a chronic relapsing illness. Recovery is a life-long effort and may require multiple episodes of intervention and treatment and long-term consistent care management. The changes that must occur in order to create a transformed identity for the family members of those who are addicted to alcohol are significant and the reconstruction of a new and transformed identity needs to be encouraged.9
Linda Latham is a registered advanced nurse practitioner and registered nurse prescriber at the Thomas Court Primary Care Centre in Dublin
|Continuing education - Brain disease - Alcohol misuse and the family|