Journal of Addictive Behaviors and Therapy Open Access

Keywords

Alcohol; Alcohol overuse; Binge brinking; Young people; Adolescents; Nursing; Paul Ricoeur; Qualitative data analysis; Patient involvement; Pierre Bourdieu; Habitus; Social capital

Introduction

Young Danish people have higher alcohol consumption and an earlier onset of alcohol than young people in other European countries [1,2]. Some of them will meet the health care system; either because they have been drinking too much or because they are injured. This article describes the results from a study focusing on the way in which the nurses focus on the alcohol overuse, and on how the nurses act when they meet the young people in the emergency admission/emergency ward.

Background

For many centuries, alcohol has been a recognized stimulant, just like it has been used recreationally [1]. Alcohol is an organic solvent that can damage the body [1]. In addition to the health consequences heavy drinkers are associated with psychological and social problems [1]. The above-mentioned effects place alcohol as one of the most significant public health problems in Denmark [1-3] and the consequences of heavy drinking goes far beyond the individual drinker [4].

The socioeconomic consequences of alcohol overuse in denmark is calculated to be approximately 13 million DKK annually, which is considered as seriously underestimation since the costs for nursing homes, industrial accidents and rehabilitation are not included [4]. While there were 8.859 admissions with alcohol related primary diagnosis in 1977, the number has increased to 17.109 admissions in 2003 [5]. In 2013, there were a total of 13.264 alcohol related contacts to the hospital. Far more men than women had contact with the hospital because of alcohol-related disorder. Among 27.416 people there were 18.533 men (68%) and 8.883 women (32%) [6].

In the 1960’s, the Danish alcohol culture changed radically and the alcohol consumption increased steadily until the mid-1980’s [3]. The consumption peaked in 1983 with 12.8 L of pure alcohol per Danish citizen per year, and at present Danish citizens is drinking about 12 L of pure alcohol per year [6].

Among men and women aged 16-24 years, there is a tendency to binge drinking. 8,2% of the men in this population consume 30 or more drinks during one week [7], and many of these so-called heavy drinkers do not apprehend their alcohol consumption as a problem [1]. A report shows that 79% do not think they are personally exposed to any the risks by drinking alcohol [8].

Several studies have pointed out Danish adolescents to have high alcohol consumption, as also in the most resent ESPADreport [2]. Here Denmark is placed in a first place, where 37% of young people aged 15-16 years, have been drunk in the past month [2]. The Danish alcohol culture and alcohol policy is very liberal, both compared to the other Nordic countries and internationally [3]. Young people consume alcohol mainly in social contexts [8], even though it is well known that if you drink alcohol early (before 14 years of age) it increases the risk of alcohol dependence and thus alcohol-related illness later in life [8]. One can therefore assume that the liberal attitude to alcohol in Denmark can lead to a large consumption of alcohol and thereby contribute to the development of alcohol problems later.

Aim

Patient involvement is standing out distinctly in the Danish health care system as one of the methods to help patients gain control in relation to their health. Patient involvement was therefore on of the main issues in this study. The aim of this study was to examine how nurses act when they meet these young people in the Emergency admission/emergency ward and to gain insight into how they deal with this group of patients. The focus was to get insight into if patient involment is used as a method to help these young patients admitted to the hospitals with an alcohol related primary diagnose so that they gain competences to act upon their drinking habits.

Method

Systematic literature search

Systematic literature retrieval was conducted between February-May 2016 using the online databases CINAHL, PubMed and PsycINFO. Search terms used were: “alcohol abuse”, prevention, nurse*, health promotion and competence. A total of 114 articles were found. Exclusion criteria’s such as:

• Ages: 0-15 years and 25+ years

• Other cultures than Danish

• Basically, the target group dealing with abusers

• These exclusion criteria reduced the amount of references to six relevant articles.

Review of selected literature

The review of the literature showed that nurses have a lack of knowledge, training and education to carry out alcohol screening in relation to brief interventions [9-12]. This emerged two themes:

• Nurses have a lack of knowledge and training regarding consequences of alcohol overuse and a lack of performance regarding alcohol screening in relation to brief intervention.

• Alcohol screening in relation to brief intervention can prevent alcohol overuse.

Brief interventions are defined as an action that can motivate a person to change a problem [13] by processes of motivation and training [12].

The themes emerged from the review was used to design the study.

Interviews and informants

Five nurses working in an emergency admission or/and an emergency ward in three different hospitals in Copenhagen (Hvidovre, Bispebjerg and Nordsjællands Hospital) participated in this study. The interviews followed a semi structured qualitative approach. The approach was inspired by the literature review, and were structured using a semi-structured interview guide, which focuses on the following [14]:

1. The department/ward

2. Attitude and action

3. Patient involvement

4. Personal questions

Recordings were transcribed as soon as possible after each interview.

Theoretical frame and analysis method

The study employs a phenomenological-hermeneutic approach, inspired by Poul Ricoeur. Phenomenology focuses on a pure description of a phenomenon [15,16], which in this case are the nurses’ experiences and their focus regarding the young people’s alcohol overuse. As this study also aims to identify what kind of impact the phenomenon has on the nurses’ actions it requires an interpretation. Ricoeur describes the process of interpretation as involving three phases, i.e. a naive reading, structural analysis and a critical interpretation and discussion [17,18].

The transcribed interviews were read several times and the initial naive reading and understanding provided direction regarding the structural analysis. The aim of structural analysis was to explain parts of the text and validate/invalidate the understanding gained from the naive understanding. The process is here characterized by oscillation between entirety and section and there is thus an ongoing dialectic process between intimacy and distance in relation to the text.

The critical interpretation and discussion was based on the preunderstanding of the author, the naive reading, the structural analysis and the literature.

Ethical considerations

Permission was given from the assistant or head nurse in Emergency admission / emergency ward where the interviews and the survey took place. Furthermore, the informants were well informed about their rights regarding voluntary participation, and their rights to withdrawal from the study as well as the right not to answer the questions [14,19].

Results

The nurses state that the overuse of alcohol seems to be a normal part of the youth culture where young people are seeking limits and must learn to manage their consumption. To questions concerning who the nurses believed had the responsibility for the alcohol overuse amongst the young people, it was agreed among them that the parents, the friends and the educational institutions should hold the responsibility. Thus, it appears that the overuse of alcohol among young people among the nurses was connected with the Danish culture, as the informants did not understand or grasp the alcohol overuse as a problem related to the health care system. However, the nurses expressed their concern about the overuse of alcohol by the young people, which was verbalized and described as being “scary that they drink so much”, “they are often heavily intoxicated” and “they drink very, very, very much”. Despite this concern, the nurses did not focus on patient involvement aspect or on preventing the overuse of alcohol.

The nurses did not perceive the overuse of alcohol by young peoples as a problem related to the health care system, but understood or grasped these young people as a completely different category of patients as other alcohol abusers. The informants seem to divide the alcohol overusers and the alcohol abusers into two categories, even though they stated that the young alcohol overusers are submitted to the ward Thursdays, Fridays, and Saturdays every week. Despite that this categorisation were essential for their interventions. Thus, they acted instrumentally focusing on the current alcohol overuse instead of focusing on prevention and involvement to give the young patients competences to act preventive. Finally, the informants stated, that they have a lack of focus and training on patient involvement and on prevention regarding the alcohol overuse in relation to this group of young people.

The findings of the study appear in the form of four themes and subthemes:

1. The Danish alcohol culture

• It is normal to consume alcohol in Denmark

• As a part of the culture the nurses themselves drink alcohol

• The nurses showed concern for the alcohol overuse, but they did not take any steps regarding prevention measures and actions, despite this concern

2. Two different categories: “overuse” versus “abuse”

3. Acute medical and treatment-oriented perspective

• The focus area was on the instrumental nursing

• The focus area was not on the dialogue-oriented approach

4. Lack of knowledge and education

In the following this article will only discuss the first two themes and subthemes.

The Danish alcohol culture

The informants experience the Danish culture as an alcohol culture where large alcohol consumption is normal. The alcohol overuse in the group of young people is part of a culture where young people seek limits and must learn to manage their consumption. The normalization of the alcohol overuse causes the lack of focus on any prevention. This finding is not yet described in other studies and is therefore in the following unfolded and analysed in relation to Bourdieu’s habitus-term.

According to Bourdieu, the human consciousness is socially constructed and embedded in special mental matrices and these are the result of the person’s upbringing, experience and education [20]. The nurses also grew up in a culture where a large alcohol intake is normal. This means that a large alcohol intake also is a part of the nurses’ human habitus, which affects their efforts and strategies regarding prevention of the alcohol overuse by the young people. They find the alcohol overuse normal and they verbalize it as part of the Danish culture. According to Bourdieu it is seldom an informed choice when people act and behave in life [21]. The concept of habitus can in a way be understood as habits or unconscious behaviour patterns. The nurses in this study must be aware of this, to be able to act outside their habitus. Thus, the nurses’ cultural habitus obstructs or interfere with their ability to act focusing on patient involvement and thereby prevention of the alcohol overuse of the young people.

Two different categories: “overuse” versus “abuse”

The other main theme derived from the structural analysis divided informants’ in two categories: overuse and abuse. Bourdieu’s theoretical concepts of symbolic and social capital were used for analysing and discussing these concepts. Alcohol plays a significant role in the Danish youth community and is culturally embedded. According to the socialists Peter Gundelach and Margarita Järvinen [22] the social community is the main reason that the Danish youth are drinking. Adolescence engages in social communities, and Gundelach and Järvinen believe that alcohol and drunkenness is essential for integration in the community with peers or persons on the same age [22]. This supports the figures for 2011 showing that 76% of the 15-16 year old Danish young people have been drinking at least once during the last month [2]. In the present study, it also appears that the nurses are reluctant in relation to preventing a problem with widespread social acceptance.

The individual does not have a social capital, but the social capital is embedded in the community [23], and thus the social community is an important factor in relation to the alcohol culture of young people. In the current study, it appears that the nurses find the alcohol overuse normal. The nurses stated that young people are part of a youth culture where alcohol consumption and alcohol overuse is part of being young. The nurses in this study seem to accept this culture and they see it as a normal way of acting. The nurses were laughing when they told stories about the young people and their alcohol overuse. In addition, the nurses stated that it is part of the Danish youth culture where young people are seeking limits and must learn to manage their consumption.

With Bourdieus concepts of habitus one can state that the youth in Denmark is characterized by a habitus and social capital that allows them to and makes it normal to consume large amounts of alcohol. Alcohol is a normal part of the Danish culture, and therefore the nurses and the health system in Denmark does not prevent the overuse or involve these young people in order to give them competences to prevent it themselves. The two different categories: “overuse” versus “abuse” is a new finding and no similar findings about patients’ division into two categories emerged from the literature searches.

The “overuser” is by the nurses defined as the overuse of young people, which they experience normal and therefore do not focus on acting towards in terms of prevention or involvement. The “abuser” in the contrary means an alcohol abuser, typically an elderly patient hospitalized in order to get treatment. Abusers make an impression on the nurses and thus they focus on this patient group. An abuse is not experienced as normal, and other literature points out that stigma takes place in relation to this patient group.

Conclusion

Nurses perceive the Danish culture as an alcohol culture where we find it normal to consume large amounts of alcohol. Adolescent’s alcohol overuse is therefore a part of a culture where young people are seeking limits and must learn to manage their consumption. The normalization of the alcohol overuse causes the nurses to not focus on or make any prevention or involvement interventions.

With Bourdieu one can say, that nurses live in and are part of a culturally specific habitus that hinder the prevention of adolescents’ alcohol overuse. If interventions for adolescents’ overuse shall be implemented in practice, it is therefore necessary to focus on the culturally habitus. This could be done for example through education.

According to Bourdieu, the “overuser” is given a symbolic capital because alcohol overuse is perceived normal. Conversely “the abuser” is not given symbolic capital, since this category is not perceived as normal. Thus, it can be concluded that the acceptance of and normalization of adolescents’ alcohol overuse implies that they are not stigmatized. Furthermore, the nurses are helping to maintain this acceptance by not involving them and preventing their overuse.

Perspective

Implementation for clinical practice

The study contributes with new knowledge regarding prevention in relation to the alcohol overuse by adolescents. The fact that the nurses in this group grew up in a culture where a large alcohol intake is normal, and where alcohol is a part of their cultural habitus, hinders them from taking any action towards involvement and prevention initiatives in relation to this group of patients.

By using a Ricoeur inspired method to analyse the interviews a deeper understanding of the phenomenon of the alcohol overuse by young people was achieved. These findings not only states something specific, but also derived something universal about this group of patients. Thus, nurses can draw on this new knowledge and find new practices in their treatment and care for the young patients hospitalized with an alcohol overuse.

The literature suggests that brief interventions including motivational interviewing can be done in 5-15 min and thereby motivate the patient to change behaviour and uncover ambivalence. Interventions can reduce the frequency and quantity of alcohol-related problems. Thus, in practice, we should emphasize and introduce these brief interventions in Danish Hospitals to be able to prevent the alcohol overuse by young peoples. This could prevent that an overuse leads to an abuse resulting in alcohol-related complications [1,6,8].

The literature also suggests that prevention must also turn to the young people’s parents, as they are role models and have great influence on adolescents drinking habits [24-26]. Nurse’s involvement and prevention interventions focused on young people therefore cannot stand-alone. The literature also suggests that banning alcohol sales in retail cannot stand alone, if adolescent’s alcohol overuse shall be reduced [3]. Youth age limit for buying alcohol must therefore be raised combined with prevention initiatives that seek to influence other factors – for example, by focusing on parents and other adults influence on adolescents drinking patterns [3].

Future Research

Involvement and prevention focus and action initiatives in relation to the alcohol overuse by young patients are a dimly lit subject, as research seem to be aimed at alcohol abusers and people with alcohol problems. Therefore, further research in this area is needed. Quantitative studies targeting patient perspectives and subjective experiences seem to be important in this unexplored area.

Acknowledgements

This is a chapter in a thesis on the Master of Science in nursing. The author acknowledges and thanks the nurses who participated in this study as well as the clinical departments.