Excessive drinking is a global problem, with approximately 2.5 million deaths (4%) worldwide attributable to alcohol (World Health Organization, 2010). In the UK, alcohol-related harm is estimated to cost society £21 billion annually (HM Government, 2012). Health care costs associated with caring for those with alcohol-related problems alone are estimated to be £2.7 billion (Martin et al, 2012). The percentage of patients admitted to hospital for alcohol-related disease, injury or condition, as a primary or secondary reason has increased by 51% from 807 700 to 1 583 725 from 2002/03 to 2011/12 (Lifestyle Statistics and Health and Social Care Information Centre, 2013). The UK falls slightly below the European average with 10.2 litres of alcohol consumed per adult per year (Organisation for Economic Co-operation and Development, 2012). Historically, the UK has been ranked low in death rates from cirrhosis; however, there is now some convergence whereby EU member states with previously high death rates are reducing their drinking habits and therefore their death rates, while the UK gradually increase theirs. (Rehm, 2012)
A large amount of high-quality evidence has accumulated to support the effectiveness of alcohol screening and brief interventions (ASBI) with adults who have an alcohol use disorder (Kaner et al, 2007). Most of this demonstrates effectiveness for non-treatment seeking adults in primary health care (Ballesteros et al, 2004; Whitlock et al, 2004; Kaner et al, 2007; Saitz, 2010). ASBI is a secondary preventive activity targeting individuals whose alcohol consumption level or pattern is likely to be harmful to their health or well-being (Kaner et al, 2009). This generally consists of structured advice or counseling of short duration (as little as five minutes) aimed at reducing alcohol consumption or decreasing the number or severity of problems associated with drinking (Kaner et al, 2007). Both the UK Government and the National Institute for Health and Care Excellence recognise that alcohol misuse is under-identified, leading to missed opportunities to provide effective interventions; therefore, they recommend that NHS professionals routinely carry out ASBI as part of their practice (National Institute for Health and Care Excellence, 2011; HM Government, 2012)
While the health promotion and proactive role of many members of both the in-hospital and community health care team continues to develop, the ambulance services have yet to develop an effective intervention for patients with alcohol-related injury or illness who frequently come under their care, despite the Bradley report promoting advances in urgent care and health promotion in the ambulance services (Department of Health, 2005). Only one Australian study has previously examined the perceptions of ambulance staff and their potential for delivering health promotion interventions to patients with alcohol-related harm (Lynagh et al, 2010). Members of the UK ambulance services could be ideally placed to offer such a service to many patients who may benefit from ASBI but would be missed by primary care pathways.
For paramedics, the incidence of contact with alcohol-related injury or illness is increasing along with a general increase in workload. The total number of emergency calls for the ambulance services of England rose by 7% between 2011 and 2012, from 8.49 million to 9.08 million (Health and Social Care Information Centre, 2013). It is suggested that a third of ambulance costs are alcohol-related, and in the North East alone, the cost of alcohol-related call outs was estimated at £6.98 million in 2011 (Martin et al, 2012).
Aims
Although intervention to reduce excessive drinking might usually be seen as the remit of other health professionals, particularly general practitioners (GPs), the modern paramedic has options for leaving suitable patients at home after assessment, or transporting to the accident and emergency department. Therefore, there are windows of opportunity within the patient's home, and also during transport to the hospital, to perform ASBI. It is important to explore the paramedic role as a valuable means to intervene with patients in need and to consider how their attitudes to working with patients with alcohol-related illness or injury compare with those of other health professionals who might intervene to reduce excessive drinking. Since the publication of The Bradley Report (Bradley, 2009), ambulance services have taken a greater role in the delivery of primary care, and as such a comparison with GPs is of great interest.
While it is understood that alcohol brief interventions from GPs should be an accepted and standard part of primary care services, it is a question of this survey to compare the attitudes of both groups, so that those of a current service provider can be compared with a group of staff who, while not commissioned to currently provide this service, may be able to offer a valuable intervention to patients in the future. Therefore, this present study assessed the attitudes and perceptions of paramedics in the North East of England to working with patients who have alcohol-related illness or injury, comparing these to previously measured attitudes and perceptions among 282 GPs responding to a postal survey in the East Midlands (Wilson et al, 2011).
Methods
Study design
A cross-sectional survey was undertaken across the North East Ambulance Service NHS Foundation Trust (NEAS) between 1 January 1 April 2013. The sample consisted of all current practising paramedics (n=589). Approvals for the study were gained from NEAS prior to the study commencing.
Survey design
The questionnaire was based on a previous survey tool used to ascertain attitudes of English GPs (Wilson et al, 2011). Data gathered included: gender; age; length of service; average number of emergency calls the paramedic attended in a standard three-shift week (36 hours of work); and extent of alcohol-related training received.
The Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ) (Anderson and Clement, 1987) was used to measure positive or negative attitudes of paramedics towards caring for, and offering, health promotion services to patients with alcohol-related injury or illness. As a widely used validated tool (Anderson and Clement, 1987), the SAAPPQ can be analysed to provide insight into five domains corresponding to different aspects of dealing with patients who have alcohol-related needs. Specifically, how adequately trained and prepared a healthcare professional feels (role adequacy); the level of self-esteem they feel when performing tasks and care related to injuries or illnesses caused by alcohol (task-specific self-esteem); how motivated they are to care for these patients (motivation); the extent to which they feel they have a legitimate position and the authority to ask questions and provide ASBI (role legitimacy); and finally the level of their personal satisfaction when providing care (work satisfaction). The SAAPPQ provides a means for joining these scores together to produce a further two domains to describe how secure they are in their role (role security), and their commitment to provide a therapeutic response to patients with alcohol-related injury or illness (therapeutic commitment). Responses to the SAAPPQ questions were scored in accordance with the official scoring matrix (Public Health England, 2010) to provide a mean score in each domain for comparison with scores from the GP survey (Wilson et al, 2011). Role legitimacy, role adequacy, motivation, task-specific self-esteem and work satisfaction are scored out of 14, with 14 representing the highest level of commitment to caring for patients with alcohol-related problems. Role security is scored out of 28 and therapeutic commitment out of 42. Responses were also categorised as positive or negative for all domains of the SAAPPQ to display the level of overall commitment in these same domains. The SAAPPQ was asked twice for each respondent: once in respect of problem drinkers, which the SAAPPQ and our questionnaire identified as referring to people with hazardous or harmful alcohol use, but excluding those dependent on alcohol, and again for dependent drinkers, which the SAAPPQ and our questionnaire identifies as those dependent on alcohol or have a severe problem with alcohol (‘alcoholics’) (National Institute for Health and Care Excellence, 2011). Finally, respondents were asked to write five words that came to mind when being called to care for patients who have dialled 999 for an ambulance for what is perceived as an alcohol-related injury or illness.
Serving paramedics were identified from the personnel records at NEAS. Questionnaires were placed inside an envelope labelled with the paramedic's name and station along with a participant information sheet and pre-addressed reply envelope and were distributed by divisional managers. All paramedics also received an email notifying them of the survey, and information was displayed on the service's intranet home screen. After one month, an online version of the survey was created and emails were sent again to all paramedics with the link to the survey. Social media were also targeted with messages and links posted on Facebook and Twitter. Care was taken during analysis to ensure that duplicate responses (paper and online) were not received by comparing demographic data for duplication. Finally, stations and one local hospital were visited to collect any questionnaires in person from paramedics who were there on the day.
Data from GPs for comparison were abstracted from the results of a previous survey of 282 GPs in the East Midlands (Wilson et al, 2011).
Data analysis
Minitab 16 was used to perform descriptive statistics and the statistical analysis between groups. Means and standard deviations were calculated, along with paired and unpaired t-tests for continuous variables and frequency distributions. Categorical data were analysed using the chi-squared test and means were analysed using the 2 sample t-test. Means were chosen to allow a direct comparison with data from the Wilson et al (2011) survey. A P-value of 0.01 or less was taken to indicate statistical significance to reduce the risk of false positives from multiple tests. Proportions are given of those who answered the individual questions.
Results
Of the 589 paramedics eligible to complete the survey, 24% returned either fully or partially completed forms (n=142). Of those surveys returned, the SAAPPQ was completed fully in 98% of responses (n=139). For the remainder of the questions asked, approximately 10% (n=14) of respondents did not answer each specific question. Seventy three percent (n=103) of the respondents were male. The mean length of time in service was 14.94 (SD 9.10) years. The median age of respondents who answered this question (n=134) was 43 years (range 24–65). When compared with the current demographics of NEAS, this small sample was broadly representative of the larger population, with the current workforce comprising of 61% males and having the largest percentage of staff within the age band of 36–50 years (43%). There are no data available on average length of service within the Trust ( NEAS, 2014).
Work volume
Over the course of three 12-hour shifts, 1.4% (n=2) of paramedics reported that on average they attend between one and 10 jobs; 7% (n=10) between 11 and 20 jobs; 39% (n=56) between 21 and 30 jobs; while 38% (n=54) reported they attend over 30 jobs. Twenty paramedics did not answer this question.
When asked to estimate the percentage of jobs they attended that were related to alcohol, 9% (n=12) reported between 0–10%; 33% (n=47) reported 11–24%; 39% (n=55) reported 35–50%; and 14% (n=20) reported over 50%. Eight people did not answer this question.
Alcohol training
Around one third (37%, n=52) reported having received no alcohol-related training, and a further 40% (n=57) reported having received less than four hours of training. Two people did not answer this question.
Attitudes and perceptions towards those with alcohol-related injury and illness
Fifty seven percent (n=81) assigned working with alcohol-related injury and illness a ‘very high’ or ‘somewhat high’ priority, with only 10% (n=14) assigning ‘very low’ priority. Three people did not answer this question.
Health promotion activities
Paramedics ranked moderating drinking as the fourth most important health promotion activity in benefiting patient health, with 84% (n=118) of paramedics ranking it as very important or important. Not smoking 89% (n=124), not using illicit drugs 87% (n=122) and responsible use of prescription drugs 85% (n=119) were ranked first to third, respectively.
Attitudes to caring for drinkers
Answers to the SAAPPQ were graded as a percentage of positive responses (the number of paramedics who answered positively to both questions for each domain). These scores are relevant for all domains of SAAPPQ other than role security and therapeutic commitment (as those are amalgamations of the other domains).
Paramedics were found to score highest when assigning positive responses to their own role adequacy and legitimacy when caring for both problem and dependent drinkers. However, even with this level of security in their role, they remain poorly motivated and very dissatisfied when caring for those with alcohol-related injury and illness. A significant difference was seen in motivation to care for problem drinkers compared to dependent drinkers, with paramedics feeling far less motivated to work with dependent drinkers (12% versus 35%. p= <0.001).
Male and female paramedic perceptions and attitudes
Motivation and task-specific self-esteem were higher in the female paramedics when caring for both problem and dependent drinkers, as well as having higher levels of therapeutic commitment towards dependent drinkers. However, there was no significant difference by gender in any of the domains of the SAAPPQ.
Length of service
Motivation and therapeutic commitment towards problem drinkers were higher in those with 2.5 to 5 years of service as compared to those with over 20 years of service. However, this was not replicated when asked about dependent drinkers. No significant effect of years of service was found on mean scores in any domain towards either problem or dependent drinkers.
Comparison against GP results
Paramedics scored lower in every domain of the SAAPPQ than GPs (Wilson et al, 2011) and significantly so in all domains apart from self-esteem. Rank order of scores for each domain was similar between paramedics and GPs with role legitimacy and adequacy scoring highest for both paramedics and GPs, and satisfaction scoring lowest (Table 1).
| Domain | Mean score (SD) paramedics | Mean score (SD) GP | P value (2 sample t-test) |
|---|---|---|---|
| With problem drinkers | |||
| Role adequacy | 8.93 (SD 2.35) | 10.06 (SD 1.77) | <0.001 |
| Role legitimacy | 10.06 (SD 2.17) | 11.14 (SD 1.75) | <0.001 |
| Motivation | 7.88 (SD 1.79) | 8.40 (SD 2.06) | 0.007 |
| Self-esteem | 8.85 (SD 2.19) | 9.03 (SD 2.26) | 0.41 |
| Satisfaction | 5.92 (SD 2.40) | 6.90 (SD 2.07) | <0.001 |
| With dependent drinkers | |||
| Role adequacy | 8.59 (SD 2.36) | 9.58 (SD 2.04) | <0.001 |
| Role legitimacy | 10.29 (SD 2.29) | 11.13 (SD 1.75) | <0.001 |
| Motivation | 6.53 (SD 1.91) | 7.94 (SD 2.16) | <0.001 |
| Self-esteem | 9.02 (SD 2.11) | 8.84 (SD 2.37) | 0.47 |
| Satisfaction | 5.81 (SD 2.34) | 6.62 (SD 2.25) | 0.001 |
The percentage of paramedics giving positive responses to each domain was also lower than that for GPs, and significantly so in role adequacy and role legitimacy for both problem and dependent drinkers. Motivation of paramedics to care for dependent drinkers was also significantly lower than that of GPs (Table 2).
| SAAPPQ Domain | % positive response paramedics | % positive response GP | P value |
|---|---|---|---|
| With problem drinkers | |||
| Role adequacy | 50% (n=63) | 78% (n=220) | <0.001 |
| Role legitimacy | 67% (n=83) | 88% (n=248) | <0.001 |
| Motivation | 35% (n=43) | 42% (n=118) | 0.21 |
| Task specific self-esteem | 45% (n=56) | 53% (n=149) | 0.16 |
| Work satisfaction | 7% (n=9) | 15% (n=42) | 0.03 |
| With dependent drinkers | |||
| Role adequacy | 45% (n=56) | 69% (n=195) | <0.001 |
| Role legitimacy | 67% (n=83) | 87% (n=245) | <0.001 |
| Motivation | 12% (n=15) | 35% (n=99) | <0.001 |
| Task specific self-esteem | 43% (n=53) | 49% (n=138) | 0.478 |
| Work satisfaction | 5% (n=6) | 12% (n=34) | 0.023 |
Facilitators and barriers to carrying out ASBI
Paramedics reported that facilitators for carrying out ASBI were: patients requesting help for their drinking (78%, n=109); pathways being available to refer patients to specialist services (75%, n=105); early interventions being proven to be successful (71%, n=100); training programmes available for ASBI (68%, n=95); and screening questionnaires and counseling materials being quick and easy to use (66%, n=92; and 64%, n=89, respectively). Finally, they reported that extra payments for staff who provide ASBI would be a facilitator (62%, n=87).
The barriers to carrying out ASBI included not having suitable counseling materials (77%, n=108); not being trained to recommend reducing alcohol consumption (72%, n=101); not having the facilities or time to deal with prevention issues (69%, n=96); believing that patients would not accept advice and change behaviour (66%, n=93); being too busy dealing with the physical manifestation of alcohol problems (66%, n=92); not having suitable screening tools (61%, n=86) and feeling awkward asking alcohol-related questions (33%, n=46).
Five words
The most common word supplied by paramedics when thinking about working with patients with alcohol problems was ‘frustration’ (54%). On each occasion where frustration was listed, it was the first used. The next four most frequent words were ‘annoyed’ (23%), ‘time wasters’ (22%), ‘sad’ (20%) and ‘sympathy’ (18%).
Discussion
Results of this study show that paramedics estimate that a large proportion of the calls that they attend are in fact related to alcohol, with the majority stating that between 25–50% of calls are such, as is recognised in the literature (Martin et al, 2012). However, the North East of England has the second highest rate of excessive drinking in the UK (Lifestyle Statistics, Health and Social Care Information Centre, 2013); therefore, the proportion of jobs that are alcohol-related may not be directly comparable across the country.
| Facilitator | n | Percentage agree |
|---|---|---|
| Patient requests for help for their drinking | 109 | 78% |
| Pathways were available to refer patients to direct specialist services | 105 | 75% |
| Early intervention was proven to be successful | 100 | 71% |
| Training programmes were available for ASBI | 95 | 68% |
| Quick and easy counseling materials available | 92 | 66% |
| Quick and easy screening questionnaires available | 89 | 64% |
| Extra payments for staff who provide ASBI | 87 | 62% |
| Time was allocated to ASBI by management and seen as a priority | 84 | 60% |
| Barrier | n | Percentage agree |
|---|---|---|
| Do not have suitable counselling materials | 108 | 77% |
| Not trained to recommend reducing alcohol consumption | 101 | 72% |
| Do not have facilities or time to deal with prevention | 96 | 69% |
| Patients would not accept advice and change their behaviour | 93 | 66% |
| Too busy dealing with physical manifestation of alcohol problems | 92 | 66% |
| Do not have time to spend assessing drinking habits | 91 | 65% |
| Do not have suitable screening devices | 86 | 61% |
| Alcohol counselling is too complex and a short discussion would not prove beneficial | 86 | 61% |
| Prevention measures are not part of job role | 64 | 45% |
| Don't have time to perform brief intervention | 62 | 44% |
| Alcohol is not an important issue in ambulance care | 61 | 43% |
| Patients would resent being asked about their consumption | 53 | 38% |
| Feel awkward about asking questions | 46 | 33% |
| Don't know how to identify problem drinkers without obvious symptoms | 45 | 32% |
| Paramedics have a liberal attitude to alcohol | 43 | 31% |
Delivery of brief interventions
The health benefit to heavy drinking patients from the provision of brief interventions has been widely studied and reported (Kaner et al, 2007), along with the benefit to society and the health economy (Bray et al, 2011). The challenge remains to ensure that the patients who need such an intervention are reached, wherever they may present in the health care service. A call for emergency care in connection with an alcohol-related condition represents a valuable opportunity to intervene to reduce risky drinking (French et al, 2008; Lynagh et al, 2010), since the consequences of that behaviour are manifest. Given the rates of alcohol-related calls reported, brief interventions provided by paramedics at the scene of first contact with a suitable patient could offer substantial benefit directly to the patient, as well as to the ambulance service provision as a whole, by reducing numbers of frequent and regular callers known to have alcohol problems, thereby reducing daily demand and pressures on those delivering care.
Training and preparation
It does appear that there is a knowledge and skills gap in the lack of formal training reported in alcohol assessment and health promotion interventions, which has been noted elsewhere (Lynagh et al, 2010). It is essential to gauge the likelihood of success in implementing ASBI by paramedics by identifying factors that may help or hinder such an initiative. This study gives a glimpse of the challenges of integrating ASBI into the ambulance services of the UK. Although most paramedics saw working with patients with alcohol-related injury or illness as a high priority they reported that they had received little relevant training, and their levels of motivation and commitment in this work, measured on the SAAPPQ, were lower in all domains compared to that of GPs currently providing the majority of first contact and referral services for alcohol services.
The lack of training is significant in the respect of the top perceived barriers recorded being ‘not having suitable counseling materials’ and ‘not being trained to recommend reducing alcohol consumption’. This, along with the majority of paramedics stating that they ‘do not have suitable screening devices’, and that ‘alcohol counseling is too complex and a short discussion would not prove beneficial’ suggest the benefits that could be achieved with the introduction of training. This finding has been found in other primary care settings (Johnson et al, 2011). However, the majority of paramedics see health promotion to reduce excessive drinking as important, and see working with these patients as a high priority in their day-to-day duties. Main facilitators of change were identified as more training around tools and evidence of interventions. A recent study by Cund (2013) showed that when alcohol education features strongly in nurse training, those nurses exhibit positive attitudes and beliefs about working with patients who have an alcohol misuse problem (Cund, 2013). This could be easily transferable to paramedic training. The responding paramedics also made it very clear that a functioning referral pathway from the ambulance service to alcohol specialist services would encourage them to perform assessments and appropriately refer onward.
Moving forward
The challenge remains to improve attitudes and perceptions of paramedics towards those with alcohol-related injury and illness. As we have shown, there is a desire to be able to do more for these patients and their evident frustration needs to be replaced with the capacity to have a positive impact and in turn reduce demand on the ambulance services. A pilot study of a practical alcohol BI for delivery by paramedics represents an important first step towards an evidence base supporting the inclusion of early and integrated training in the basic paramedic curriculum. As seen in both the mean scores and the percentage of positive responses to the SAAPPQ, there is no difference in perceptions by paramedics when caring for either problem drinkers or dependent drinkers; however, there was a reduction in the level of motivation when caring for dependent drinkers. This difference was not seen in the GP survey (Wilson et al, 2011). This could be due to the fact that dependent drinkers are usually easier to identify by their outward appearances and actions. Further, as seen by the use of the words ‘annoyed’ and ‘timewasters’ it appears that paramedics often view drinkers as abusers of the system who are there by their own choices.
This study showed that paramedics have a more negative outlook on patients with alcohol-related injury and illness than GPS. As more ambulance services are moving into the urgent, pre-hospital care realm, then paramedics will have to take on greater primary care roles. If ways cannot be found to increase levels of paramedic motivation to care for these patients, then opportunities will be missed to provide best evidence-based care. Nehlin et al (2012) have shown that just three hours of tailored training can improve psychiatric staff motivation, knowledge and attitudes when caring for patients with alcohol-related needs. Simple steps such as this could provide significant improvements and the possibility of a behavioural change for paramedics could also prove beneficial in the overall approach.
Strengths and limitations
While response rate was low for this study (24%), and is obviously a limitation that has been found elsewhere in this group (Boyle et al, 2007; Hargreaves et al, 2014), this is still an important first view of the perceptions of paramedics to caring for patients with alcohol-related injury or illness. Possible reasons for the low response rate could be the increasing workload demand on the ambulance service, non interest in the research topic or research overload. At the time that this survey was being distributed, two further research surveys were also being circulated. Furthermore, it could be that those paramedics who took the time to complete and return the survey were those who had some element of strong views (either positive or negative) towards the subject area. It should also be noted that this study is based on the subjective views of serving paramedics and not on measurable clinical data. Due to the low response rate, it cannot be assumed that this is a fully representative sample of the front-line paramedics of the North East Ambulance Service NHS Foundation Trust.
Despite these limitations, this study clearly shows the challenges related to paramedics working with patients with alcohol issues. Levels of commitment, motivation, and satisfaction, are low in front-line paramedics; however, role adequacy and legitimacy remain high, which suggests that paramedics do see working with patients with alcohol-related injury or illness as a legitimate part of the job. This survey provides a first step in exploring how this can happen more effectively. The next step might be to carry out an electronic national survey of paramedics as well as to carry out some qualitative work with paramedics to explore individual perceptions underlying these challenges.
This survey also highlights practical barriers to the implementation of paramedic-delivered brief interventions for alcohol. Lower levels of training, commitment and motivation suggest that substantial resources would be required to develop and implement such a programme, and this initiative would depend on the willingness of ambulance service Trusts to invest appropriate staff time. Nevertheless, it is reassuring to note that in the case of NEAS, one of the local community alcohol nursing services has already expressed interest in completing a pilot study of such a co-ordinated care approach. A further issue is the limited options available to paramedics for onward referrals to, and direct support from, specialist alcohol agencies. Modern paramedics have a wide range of onward referral pathways for other conditions to ensure the right care gets to the right patient at the right time. The provision of an alcohol pathway would extend their capacity to ensure that the best care reaches patients in need. Furthermore, a pilot feasibility study of BI for alcohol delivered by paramedics in response to alcohol-related calls, either in the patient's home or in the back of an ambulance, would provide a strong indicator of the potential for a full trial to demonstrate patient or economic benefit from such an intervention.
Conclusions
Paramedics are in a position that gives an opportunity to reach those patients who may not present themselves at a local GP surgery and who may be lost to regular contact with the wider NHS. This provides a previously unutilised chance to intervene and provide brief interventions at the point of contact.
At this present time, levels of commitment, motivation, satisfaction, legitimacy and adequacy are low in front-line paramedics; however, if they are adequately trained and have appropriate referral pathways open to them, ASBI may be a future possibility. A further larger scale survey of the ambulance service is required to gain a true representation of the whole organisation and along with a wider audit of service use, and specifically those patients with ARII who are not transported to the emergency department to receive further interventions. This audit data, along with repeat caller data from the same group will provide both an insight into the number of missed opportunities for intervention and also the cost-benefit ration for such an intervention pathway.