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Can you please summarize this Article? Nurses' guide to alcohol and promoting healthy lifestyle changes Anne Harrington-Dobinson, William Blows Abstract In this the third and final part, the focus is on the support and care of patients who are working towards a solution for their drink problem. While a number of treatment regimens exist for the management of alcohol abuse and there are well established groups to assist patients and their families, this article concentrates on three critical themes. The first concerns the promotion of insight. Only when the drink problem is understood by patients, carers and professionals alike, and shared in common terms, can rehabilitation begin to work. The second concerns communication channels. The propensity of some patients to deny their problem, or to lapse from therapy, makes communication especially challenging. While some patients are helped to overcome the risk of lapsing by being segregated fi-om their usual community for some time (the clinic approach), many less wellresourced patients must tackle this problem fi-om home and with the help of community-based practitioners. Finally, the interplay of treatment (detoxification) and psychological support is discussed, arguing that the nurse has an important part to play in motivating patients and helping them to solve problems as they arise. The Department of Health (DH) document Alcohol Misuse Interventions: Guidance on Developing a Local Programme of Improvement (DH, 2005) and two previous articles in this series have shown that alcohol misuse can seriously harm an individual's physical and psychosocial wellbeing. Frequently, nurses and doctors come in contact with patients who have an alcohol-related disease and there is an opportunity to educate the patient to adopt a healthier outlook towards alcohol consumption. Those individuals who are affluent can be removed from the 'drinking community' for a period until they are rehabilitated. However, the majority of clients whose health has been damaged by alcohol are often seen in an acute general hospital. It is for those individuals that the authors aim to promote a strategy for support and guidance to reduce alcohol consumption with an objective to empower them to amehorate their health. Promotion of insight and patient education Patient education is seen as a major dimension of caring for the patient or client. Benner (1984) indicated that nurses should see themselves as advocates who stand alongside and empower patients and their families to have a voice when they are weak and vulnerable. Furthermore, Peplau (1952) believed that the nurse-patient relationship was characterized by four interlocking phases: orientation, identification, exploitation and resolution. Peplau also saw the role of the nurse as a resource person, teacher, leader in local situations, surrogate parent, and counsellor. By considering these two nurse theorists' views on caring, it can be seen that the nurse has a key role to play in the promotion of insight for clients who misuse alcohol. Often these clients may be reluctant to share that they have a drink problem. Heather and Robertson (2000) stated that people drink alcohol for different reasons; they take alcohol because it can either act as a positive 'reinforcement'— a stimulant or'a pick me up' which is sometimes called 'Dutch Courage'. When more alcohol is taken in excess then the reverse happens, the chent may become depressed or has reduced self-awareness. They may deny that they are dependent on alcohol. In response to a situation where someone is dependent on alcohol the nurse can adopt a health education/promotion approach known as 'case management' which necessitates the nurse to take a leadership role and to work with an interdisciphnary team (Rankin and Stallings, 2001). The nurse develops a therapeutic rapport with the patient/client and helps him gain an insight into the extent ofhis alcohol problem. The nurse takes the lead in decision-making related to health promotion and coordinates the teaching process once the client understands personal meaning and the cause and effect of alcohol misuse. Health promotion, as defmed by the World Health Organization (WHO, 1986 pi) is:'the process of enabling people to increase control over, and improve, their health'. Prior to developing health promotion teaching strategies, the nurse should explore his or her perceptions and reactions towards clients who misuse alcohol to avoid any prejudice that may negatively influence the assessment process of the client. The nurse's ability to be self-aware will ensure objectivity when dealing with the client's perception and awareness of the physical and psychosocial impact of alcohol on their health. A nurse who had personal experience of being in a household and had witnessed domestic abuse caused by an alcoholic member of the family would be advised to avoid getting into a 'case management' approach with the client (Jefferson, 1995). It might prove difficult when they revisit certain painful memories and it would interfere with the nurse—patient interaction. They may choose to tactfully disclose to the client that they had witnessed the social harms that alcohol misuse can cause. Kunyk and Olson (2001) state that one person's lived experience is unique and arguably it cannot be understood by another. The nurse should employ empathy in understanding the client's needs. What is required is sufficient projection of'self into the private world of the other, and to be able to at least understand effectively what the experience means to the client. It is the transpersonal care that will make the client feel that a nurse is willing to advise, guide, help and offer support. Egan (1990 p24) states that 'helping is a two-way street, understanding client is not enough. It is essential to understand your own assumptions, beliefs, values, standards, skills, strengths, weaknesses, idiosyncrasies, style of doing things, foibles and temptations.. .helpers who do not know how to understand themselves can inflict a deal of harm on their clients.' Readiness to learn It is necessary to gauge the client's readiness to learn, which is based on motivation, interest, maturation and the willingness to consider a change in lifestyle. The client should be sober, that is they should be at a certain 'level of wellness' and they should be commended and acknowledged for having considered that there is a need to make serious lifestyle adjustments. An assessment of the client's needs is the necessary starting point when considering health promotion or education (La-wton, 1999). If a client does not know that his over-indulgence has been detrimental to his health he may not realize that he can seek support to reduce his alcohol consumption. This would be noted as 'felt need'; the client perceives a need that may lead him to express a request for educational support. Lawton (1999) said that not all felt needs will become an expressed need as there may be barriers to expressing needs, such as a lack of motivation or a lack of assertiveness skills. While the client is in hospital, the nursing assessment can obtain valuable data into how healthy the client perceives himself to be. This would be an important 'opening line' for the nurse—patient interaction and the development of trust. Prevention of disease In the case of a client who has an alcohol problem, health promotion relates to the prevention of disease by reducing consumption. Planned health education should be implemented following an assessment - the purpose being to assist, rather than to force or demand, the individual's lifestyle change. Rankin and Stallings (2001) propose a 'self-regulation model' which advocates that a person's understanding of their illness will be a critical factor in the decision about treatment. They argued that people do not operate solely on a cognitive basis but also process information emotionally. Thus, the nurse should use cognition and emotion to 'drive health-promoting behaviour that is consonant with his or her desired selfactuahsation' (Rankin and Stallings, 2001 p56). Prochaska and DiClemente (1984) introduced a 'Stages of Change Model' that identifies four phases in an individual's motivation to adopt a healthier lifestyle: the pre-contemplation, contemplation, action and maintenance phases. Pre-contemplators may demonstrate change once the pressure is on, but they return to their problematic behaviour once the pressure has eased. Therefore, it is important to ascertain the client's intention and motivation to remove or reduce alcohol consumption. It will then lead to the contemplation phase, where the client is aware that his health will deteriorate if a change in drinking habit is not made. Readiness to change is required from the client which will then lead to preparation for change; the implementation of an action plan and maintaining ‘the healthier lifestyle'. The client’s insight and nurse's support Cognition by the individual is important, that is, can he identify concrete symptoms of alcohol dependence, what causes him to misuse alcohol, how long has he depended on alcohol and what have been the consequences so far? Dependence is a state in which a person requires a steady amount of alcohol to avoid experiencing the symptoms of withdrawal (i.e. negative reinforcement). Cameron (1985 p390) suggests that alcohol dependence is a, '...state, psychic and usually also physical, resulting from taking alcohol, characterised by behavioural and other responses that always includes a compulsion to take alcohol on a continuous or periodic basis'.The nurse obtains data to plan an educational strategy by establishing a rapport, using attentive hstening skills to explore the client's motivation towards adopting a healthier lifestyle, and to provide support to develop self-regulatory skills to reduce their problem. Assessment of alcohol dependency An assessment of an individual's alcohol dependency can be undertaken using the CACE (Cut-out, Annoyed, Guilty, Eye-opener) methodology (Elvin, 1984).The assessed level of dependency will then act as a basehne against which an individual can measure his progress. The four questions in the CAGE questionnaire are: Educational models Health promotion and health education models, such as the 'Theory of Reason Action' (Ajen and Fishbein, 1980) and 'Health Behef Model' (Becker, 1974) explain relative behaviour by an individual in qualitative terms. These models can provide nurses with an insight into how an individual's behaviour, i.e. drinking alcohol, and the influence of the social environment, can both act as predictors of their behavioural intention. The nurse's cognition can influence the patient's health outcomes. Therefore, a cooperation and mutual participation model of health education can be adopted when educating patients about lifestyle changes. It embraces the notion of friendship and imparting of expert advice (Coates, 1999). Communication style The nurse must convey information to the clients in a persuasive manner. The nurse-patient relationship is based on at least three different forms of'social power' (Rankin and Stalhngs, 2001): • Legitimate power - the nurse has educational knowledge about the subject matter and her role obligation as a health promoter • Expert power - the nurse has 'superior' knowledge and the ability to understand the physiological and social damage caused by alcohol misuse • Persuasiveness and informational expert power - the manner by which the nurse imparts life skills and educates patients. The client requires emotional, feedback, informational and instrumental support. Emotional support requires the nurse not to stigmatize or label the client as 'an alcoholic'; the nurse shows acceptance and demonstrates a commitment to assist the individual to consider the harm that alcohol is causing and shows care and concern for the wellbeing of the client. The nurse could also involve the family in supporting the client. Feedback support is achieved by active listening while assessing how and when alcohol is consumed. The nurse allows the client to vocalize his concerns and gain insight into his problem. Informational support is the development of coping strategies that the chent could adopt by providing him with supportive interaction. Finally, instrumental support is to direct the client to available resources to assist him, e.g. seeking GP referral to attend an NHS drug and alcohol rehabilitation centre. It is necessary not to overload the client with too much information.The extent to which a patient may take advice will depend on many factors, including how much advice is remembered and understood, and how satisfied the patient is with the nurse's style of communication. Rankin and Stalhngs (2001) state that health professionals often try to teach too much in a short time causing a 'learning overload'. The patient will feel powerless, frustrated and defeated in tackling their drink problem. Case management approach and the promotion of self-regulation The on-going assessment of the client's needs is done without passing any value judgements during the interaction, otherwise it will not motivate the client to change 'unhealthy' behaviours. The development of a 'client-helper' relationship will evolve over time with the continuity of consultation and support provided by the same nurse. This supportive relationship must be maintained to promote 'insightful' learning in the client. Egan's (1990) writing on 'The Skilled Helper' suggested that carers need to humanize the helping process by adopting a pragmatic approach. He named a 'No Formula Approach to Goal Setting' whereby the nurse guides the client to set his own agenda and goals to accomplish a realistic drinking pattern. Furthermore, a skilled nurse who possesses confldence, competence, communication and caring (Rankin and Stallings, 2001) would be more successful in promoting the client's selfefBcacy (Bandura, 1998), meaning that he will think about his actions and will learn how to self-regulate his drinking habits. The nurse should demonstrate that she has expertise, credibility, knowledge, skills, attitude and understanding. She must show warmth, genuine interest in the client's welfare, empathetic understanding and must demonstrate active listening. This will promote the client's self-esteem. It will convey to the client that his is worthy of the nurse's time and commitment. The client learns to trust the nurse, and in return, the nurse gains the patient's confldence. Skilled questioning by using closed- and open-ended questions is essential because it serves to encourage conversation, promote information gathering and clarifies the issues involved. It can also inform the nurse about the client's feehngs and beliefs, identify problems, check whether the client is listening and focus the discussions on the maintenance of healthy lifestyles. A person-centred care approach helps to develop a professional relationship. It is essential that the nurse recognizes the importance of respecting her client while making a conscious effort to engage her client in the decision-making process. Heather and Robertson (2000) reported that problem drinkers drink to reduce their self-awareness of the social or domestic problems that they may be facing, and they try to escape from many of their stresses, worries and anxieties by consuming alcohol. It becomes a vicious circle, and they try to reduce their awareness of the problems which have arisen from drinking by drinking more. The 'dulled' mind of the drinker (see Part 1) externalizes the problem and they may blame others as contributors to the problem, and thereby sabotage their own attempts to resolve the problem. There are cases when individuals have gone into 'spontaneous remission', meaning that the person gives up problem drinking of his own accord, and this may be due to a change in his social life. Once the factor(s) that led the client to drink is identifled, the nurse could guide the 108 British Journal of Nursing, 2007. Vol 16, No 2 individual to plan and craft his strategy to adopt a healthier lifestyle where he is not dependent on alcohol. Crafting a strategy and goal setting Nurses should identify the clues that her client is drinking (see Part 2) (Paton, 1994). However, the chent should not be made to feel bad that he misuses alcohol. Ask the client to keep a drink diary and record the amount of alcohol consumed each time, what time of the day, when is the urge to take a drink, how do you feel before and after the drink? In this way the client takes the responsibility to set his own target to identify how he can reduce the intake of alcohol and find alternative solutions. Specialist referral and help resources The client may be referred to counsellors and self-help groups, including Alcoholics Anonymous and the Council on Alcohol, which give advice about alcohol problems, counselling, psychotherapy, social skills training as well as family and marital therapy. The nurse can help the client identify the role models that the client can look up to as an example. Medical treatment Detoxification-tmay be useful if the patient is physically dependent on alcohol. Chlorniethiazole may be prescribed, but patients will need to take time off from work and have a supportive family while taking the medication. Alcohol sensitization drugs such as disulfiram (Antabuse®) 200 mg daily can also be prescribed but family supervision is needed because if the patient drinks and takes the medication then he or she can experience severe headaches, heart palpitations, nausea and dizziness (Paton, 1994). Maintain contact and continuity of care It should be the client's choice to adopt a healthy lifestyle. He or she cannot be coerced to give up alcohol. It is important to maintain some form of therapeutic communication with the client so that he or she does not feel like a parcel being passed on to other agencies (Paton, 1994). Conciusion Nurses are well placed to contribute to the cUent's rehabilitation, and they can add to the wider debate about what is problematic with alcohol use. Irrespective of whether or not we are helping to treat patients or simply discussing drinking habits with teenagers, insight is an important concept. Nurses need insight into the reasons why alcohol is discussed in terms of a 'problem'. Communication is central to the understanding of alcohol abuse coupled with the careful coordination of psychological support with the treatment options chosen. Because alcohol affects perception, mood and physiological functions it is entirely appropriate that the nursing response is integrative, ensuring that patients understand what is on offer and why. HH