1

Excessive and irresponsible alcohol consumption has rapidly become a major issue affecting

society and is estimated to cost Britain £20 billion per year (Health Development Agency

(HDA) 2005). So serious is the issue, for the first time the Government has developed a

cross departmental ‘Alcohol Harm Reduction Strategy’ that sets out ways to change attitudes

and behaviour (Cabinet Strategy Office 2004). Choosing Health: Making healthy choices

easier (Department of Health (DoH) 2004) suggests that the National Health Service (NHS)

promote health by building upon the recommendations of the Alcohol Harm Reduction

Strategy by using ‘brief intervention’ approaches in primary care and hospitals.

The HDA and DoH acknowledge the role of nurses as providers of brief intervention advice in

the documents previously stated. Despite this, in practice, the involvement of nurses is

unclear as most brief intervention programmes in primary care focus upon outcomes

delivered in general practice and not specifically just by nurses. In order to develop

appropriate public health focused evidence based nursing services in the community, there

to be clarification which nurses working in primary care could utilise brief alcohol

interventions. A descriptive, systematic search strategy and literature review will be

completed to seek out and explore factors surrounding nurse led activities in the community.

From this initial review one of each of the most appropriate qualitative and quantitative

articles will be critically appraised. Finally, evidence from these articles will critically analysed

and its implications in clinical practice discussed.

2

MSc Evidence Based Practice in Health & Social Care:

What influences change in thedelivery of alcohol related

brief interventions bynurses in primary care?

Oct 2008

In the UK, primary care encompasses health services in the community such as family

doctors (GP’s), pharmacists, dentists, health visitors, midwives, district and practice nurses to

mention a few. The following definition acknowledges evidence based practice as a core

principle:

“Primary care is essential health care based on practical, scientifically sound, culturally appropriate and socially acceptable methods. It is universally accessible to people in their communities, involves community participation, is integral to, and a central function of, the country’s health system, and is the first level of contact with the health system” (Canterbury District Health Board 2003)

Brief interventions as their name suggest are short, opportunistic advisory sessions. These

are undertaken by non-specialist staff towards patients who drink excessively but are not

seeking help or receiving treatment regarding their issue. (Moyer et al 2002). One of the

difficulties of consistently appraising brief intervention evidence is the lack of a clear

definition. Heather (1995) suggests that in order to understand such evidence it is vital to first

understand the methodological differences and to be able to distinguish between the style,

length and content of interventions. It appears the source of confusion surrounding brief

intervention occurs in two areas (National Treatment Agency for Substance Misuse (NTASM)

2006). Firstly, in relation an individual’s intent there must be clarity in the following

categories:

1. Those who are seeking help from specialists / services

2. Those people who are not seeking help from specialists / services

These definitions focus upon the persons stage of intent to change behaviour. Those who

are active and seeking to change their behaviour should not be classified as receiving brief

intervention. Once classified as a brief intervention it can then be sub-divided into:

1. Simple/Minimal Brief Intervention: A few minutes of structured advice

2. Extended Brief Intervention: 20-30 minutes of structured therapy

(usually involving more than one session)

Once clear definitions of both primary care and brief intervention have been established, the

search process commences by converting the clinical issue into a simple answerable

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question (Colyer & Kamath 1999). To aid the development of this, a widely acceptable 4

stage systematic process was utilised (Sackett et al 1997 cited Craig & Smith 2006). The

process known by the acronym PICO and it relates to:

Patient or population

Intervention

Comparison or control

Outcomes

Step one of the process seeks to define the patient or population. The initial response was

that this would be a patient group who required intervention. After some consideration it was

decided that the focus of the evidenced based review would actually be on the nurses

themselves because, despite acknowledgement of their role, little is known about the impact

of their work and their attitude towards it. In reality the nurses who complete the majority of

brief interventions are practice nurses who are employed by, and work in, GP surgeries.

Despite this, most studies focus upon the delivery of interventions by GP’s. To ensure a

comprehensive search of all nurses despite their job title, ‘primary care nurse’ was chosen

over community or practice nurse. Use of this term ensures a distinction between GP

practice and practice nurse without excluding the primary care services that are delivered by

both disciplines in the same surgery / clinic.

When considering the population group the inclusion criteria of only United Kingdom (UK)

based studies was deemed appropriate. This was due to the limits to generalisability of Non

UK research findings. Many brief intervention alcohol studies are European or American.

Inclusion of data from nurses and their patients from these countries would be incomparable

due to diverse sociological factors such as licensing, legislation and consumption (Scottish

Executive 2004).

Step two, ‘intervention’ relates to brief intervention. Step three is a comparison or control. In

terms of brief interventions by nurses, a control either occurs or it doesn’t depending on the

research design. Although this appears to be simple positive or negative outcome, care will

be taken to ensure that any interventions actually meet the defining criteria afore mentioned

by the nationally recognised NTASM Group (2006).

Finally, step four seeks to establish the effectiveness of nurses upon patient’s alcohol

consumption. Outcomes should be measurable (Sackett et al 2005) but it became apparent

4

that the word ‘effectiveness’ was too vague and thus immeasurable. Therefore the

measurable outcome was adapted to focus upon the end result of the nurse’s activity, i.e.

changes in practice and patient alcohol intake. In relation to intake, the term ‘reduction’ was

purposefully avoided, as it is important to acknowledge all interventions whether they’re

positive, neutral or detrimental. By comprehensively reviewing all types of studies and

results, future service development can avoid making the same mistakes and be ethically

more viable (Arnd-Caddigan & Pozzuto 2006) and financially feasible (Friedman 2002). From

this process the following question was derived: What influences change in the delivery of

alcohol related brief interventions by nurses in primary care?

To enable this question to be of practical use in searching for appropriate literature a

computer based search strategy was used to ensure high recall (the proportion of relevant

studies retrieved) and high precision (specificity) (Eysenbach et al 2001). A Boolean search

method was used. This logical method allows the researcher to search and to specify how

terms will be used and also influences how databases interpret such terms (Craig & Smyth

2002). Boolean logic uses an algebraic method of looking at the terms ‘and’, ‘or’ and ‘not’. It

then seeks to include, exclude or overlap these terms depending on the phrasing of the term

question. In this example, the terms primary care nurse, brief alcohol intervention and

effectiveness-were used. One of the main benefits of Boolean search techniques to a

researcher is that they can be used to perform accurate searches and reduce the risk of

producing many irrelevant documents (Jansen & Spink 2006). It is important to understand

that Boolean search principles as they run many modern day search engines that include

Google.

As Boolean search methods rely strongly on key words it was vital to ensure the defined

terms nurse, brief alcohol intervention and effectiveness were appropriate and not open to

misinterpretation or had no other meaning. Medical Sub Headings (MeSH) are a

standardised list of terms devised by the National Library of Medicine in America. The use of

MeSH increases the likelihood of a successful search (Lambrou 2004), however difficulty in

locating appropriate subject headings and inexperience in use can affect search returns

(Conn et al 2003). An example of a practical difficulty experienced was the Americanised

spelling and scope of MeSH terms. Acknowledgement of the issue, use of controlled

vocabularies or thesauri helped reduce the significance of issues. For example ‘primary care’

is not a common term in America. Subject searches look for a match on the entire subject

(MeSH) term, as an exact term was not known, truncation was used to broaden the search.

5

The starting point for searching was the Cochrane Library and its Central Registry of

Controlled Trials & Database of Abstracts and Reviews of Effects (DARE). This was done for

2 reasons, firstly to ascertain if any previous studies had been done. Secondly, because it is

considered the ‘gold standard’ database for evidence (Greenhalgh 2006). This gold standard

is however based upon good quality quantitative studies. One of the criticisms of Cochrane

relates to the bias (Bachmann et al 2002). By ignoring qualitative studies a great deal of

contributory factors that may enhance health care knowledge and practice are being lost

(Booth 2001). In addition to the fundamental issue of qualitative versus quantitative bias,

there are problems with ‘time lag’ from the start of a review to it’s to publication, which can be

up to 2 years (Burr & Johansen 2004). As well as the fact that even when evidence is clear

on the effectiveness of an intervention, the review does not often reveal how to replicate or

pursue the recommendations (Keirse 1998).

Despite the criticism of Cochrane, it was felt the positive regard for quality, minimal bias due

to high quality in depth reviews outweighed the negative points. With these arguments in

mind, search bias was minimised by exploring other pertinent sources and timely

qualitative/quantitative research were explored in utilising other databases and guidance

(e.g. DoH/HDA). The academically contentious source, Google was also reviewed. The

search engine reportedly now has an estimated 20 billion pages and is the most search tool

in the world (Notess 2006). The search engine uses an automatic ‘Boolean AND’ between

terms and, is increasingly comprehensive and is useful in finding ‘grey’

(incomplete/unpublished) literature (Conn et al 2003). Results are listed by relevance,

number of hits and sponsorship. Goggle’s strengths (size and scope) are also its weakness.

It searches for spelling and grammatical variants without making clear it has done so (Notess

2006). When searching Google scholar for brief intervention alcohol, primary care and nurse

over 16,600 results were returned in 0.35 seconds. In terms of searching for evidence,

Google is the fastest, most accessible method to gain health related research information.

This trend needs to be acknowledged, but importantly researchers need to understand it and

utilise it with caution.

Following preliminary and less conventional Google searching a thorough review of more

formally recognised health databases was made. Using the electronic library services from

the University all 37 health and social care databases were initially selected. However only

MEDLINE, British Nursing Index (BNI) and CINAHL (Cumulative Index to Nursing & Allied

Health Literature) were chosen for extensive searching.

6

MEDLINE is acknowledged as the premier source for bibliographic and abstract coverage of

biomedical literature (Haynes et al 1994). It encompasses medical and nursing as well as

allied health research. Retrieval of data from empirical search strategies (i.e. one that is

based on experience) has almost perfect sensitivity or specificity and high precision (Montori

et al 2005). MEDLINE is very medically focused, and sole use runs the risk of omitting

nursing research (Brazier & Begle 1996). To ensure the nursing perspective was not

forgotten CINAHL was also reviewed, as it is a prominent source of professional nursing,

allied health, biomedicine, and healthcare research (Craig & Smyth 2002). As both Medline

and CINAHL are U.S based databases the BNI was also included to reduce the risk of

omitting U.K based studies. By searching beyond MEDLINE at a diverse range of databases,

recall and precision are increased (Conn et al 2003 and Eysenbach et al 2001) this ensures

a more systematic comprehensive search takes place.

From the search a number of pieces of research were ‘short listed’. The exclusion criteria

stopped at research undertaken over 10 years ago (as its relevance to today’s alcohol

related issues differ to greatly) and non-U.K based studies reduced this shortlist further.

Once studies jointly delivered by G.P’s and not solely nurse related studies were removed

this a handful to be read for suitability to undergo a more in depth critical appraisal. From

these 2 papers were chosen; Interestingly, both studies were in the Google Scholar top 7

‘hits’ that took less than half a second to complete.

To aid a review of the quantitative research ‘effectiveness of nurse-led brief alcohol

interventions: a cluster randomised controlled trial’ (Lock et al 2002) a critical appraisal tool

was utilised. Critical appraisal is ‘the assessment of evidence by systematically reviewing its

relevance, validity and results to specific situations’ (Chambers et al 2004). The tool, a

checklist based ‘script’ provides guidance and a systematic method to aid analysis of design

and data analysis (Critical Appraisal Skills Programme (CASP) Public Health Resource Unit

(PHRU) 2006a). Critics of such tools argue that using these tools encourages researchers to

use " technical fixes " to understand design elements such as sampling, grounded theory,

coding, validation and triangulation, without necessarily understanding deeper issues and the

reasoning behind qualitative research theory (Barbour 2001).

The study aimed to evaluate the clinical and cost effectiveness of nurse led screening and

brief interventions in reducing alcohol consumption in primary care. The population studied

were patients served by 369 GP practice catchments areas in the North East of England.

After initial screening regarding alcohol consumption using a well known DoH approved

7

alcohol use disorders identification test (AUDIT) (Babor et al 2001) those with a ‘positive’ test

were offered either a 5 -10 minute ‘Drink less’ protocol based session (Centre for Drug and

Alcohol Studies 1993) or standard treatment which involved discussion about drinking and

receipt of a ‘Think about Drink’ leaflet produced by the Health Education Authority. Outcomes

were considered within the design. These were reduction in alcohol consumption and cost

benefits analysis for the service and patients.

The study was a randomised controlled trial (RCT), which is the highest level within the

hierarchy of evidence (Greenhalgh 1997). This design method of a cluster RCT was used to

avoid contamination of patients in one setting influencing the other trial groups. Geographical

segmentation was used to ensure control (standard treatment) and intervention settings

(drink less brief intervention) remained separate. Participating GP practices (which employed

the nurses delivering the interventions) were allocated by a randomised computer

programme and were informed by a non-participatory researcher. The number of practices

was balanced to as near to 50/50 as possible, and the clusters were ‘stratified’ or grouped

according to common characteristics. All of these actions ensured effective randomisation,

which is necessary to allow conclusions from the evidence to be unambiguous and

defensible (Bland 2000)

Once practices were identified the individual nurses working in each setting were recruited

and trained to provide standard or enhanced alcohol advice. Intervention conditions were

masked by informing all nurses the impact of alcohol advice was being assessed. This was

slightly subversive but ethically, morally and clinically had no effect upon the outcomes and

was necessary to reduce bias (Torgeson & Roberts 1999) as a direct result of this method all

patients receiving any intervention were not influenced by staff. After patients had been

selected to participate in the study, they were scheduled to be followed up to see the impact

of the interventions after 12 months. Very quickly, the designers of the study added a contact

at 6 months to ‘enrich’ their data and provide more precise evidence (if any) about behaviour

change over time and cost implications of reduced alcohol related issues (accidents, illness

and occupational health etc).

In order to recruit enough patients sufficient GP practices needed to be signed up to

undertake the study. A ‘power’ calculation was undertaken to establish how large a sample of

GP practices were needed to be sure of accurate and reliable results whilst ensuring effects

of intervention are detected. Power analysis and sample size estimation are vitally important

in experimental design. If sample size is too low, an experiment lacks precision and thus

8

reliable answers to the questions it is investigating. And conversely if sample is too large,

resources will be wasted on fruitless investigations (Bland 2000). The study used a computer

generated power calculator that estimated 76 of the 369 GP practices were required; each

was to recruit 5 patients to the study thus providing 380 participants.

Unfortunately for the researchers there was a significant drop out rate of practices (only 40

completed the trial). The reasons for the drop outs were recorded and explained. This lead to

a type II error that the earlier power calculation aimed to avoid. Too few practice participants

led to a chance that the effect of intervention would be missed (i.e. there is no significant

effect) when in reality, the beneficial effect WAS present in the population as overall alcohol

intake was reduced, but the sample drawn didn’t show it. Poor recruitment of practices had a

knock on effect upon individual patient recruitment. The erroneous conclusions from the 78

patients (a mere 20% of the target of 380) were even greater (Greenhaugh 2006). The

researches did express their concerns at these figures; however, due to financial constraints

of the study they were unable to continue to attain the required number of participants. This

did not chance the fact that subsequent results, data analysis and conclusions based on this

foundation were thus considered statistically flawed and of little use in clinical practice (Egger

et al 2001) .

In order to review the statistical significance of the control and intervention groups the

common t-test was not used, as it is only able to look at error between only two means

(Bland 2000). ‘Two tailed’ methods called ANOVA (ANalysis Of VAriance between groups)

and ANCOVA (ANalysis Of COVAriance) between groups were used to test the hypotheses

of two or more means in this study the effectiveness of intervention and cost effectiveness).

Both revealed p-values (probability) from AUDIT, units per week, and lifestyle data were

‘smaller’ than the 0.05 significance level set by the researchers prior to undertaking the

research. A null hypothesis, in this instance is rejected if the p-value is smaller than or equal

to the significance level (Sackett et al 2005). Critics of the t-value method feel that the

commonly used level of 0.05 is an inappropriate criteria for deciding ‘significance’. A number

of resreacher now favour ‘p-rep’, this stands for the probability that an effect can be

replicated (Killeen 2005).

In terms of this study, p-rep would have been a more suitable design and would have

generated more positve outcomes if this was the measure. This is due to the fact that design

was rigorous and effective in it randomisation (demographic and geographically) and is

therefore applicable throughout the U.K. This is supported with a reported confidence interval

9

(CI) of 95%, which means that if samples of the same size are drawn repeatedly from the GP

population, a confidence interval can be calculated (Smithson 2003). In this instance 95% of

these intervals should contain the population mean or average patient. Interestingly, the p-

value of the DPI (drink problem index) measurement was the only sample intervention that

showed a positively converse result. This is a positive from so many statistical negatives as it

demonstrates that irrespective of the type of intervention actually doing something reduces

alcohol intake, a factor which has been previously proven and was not the actual basis of the

research (NTASM 2006)

The researchers stated “we could find no evidence that brief alcohol intervention was

superior to standard advice on alcohol plus a health education leaflet in a primary care

setting” (Lock et al 2006 p434 ). Their primary conclusion for this was the lack of time to

obtain participants and thus inadequate control conditions. Following the critical review and

advice from Barbour (2001) to look at the deeper issues and reasoning it has been possible

to uncover a fundamental flaw in the research design. The researchers failed to define and

show knowledge of a correct definition of brief intervention. In reality their study had no

control as both the standard and protocol led interventions were actually a brief intervention

(NTASM 2006). This meant that in reality even if the number of participants were adequate

the results would have most likely been the same. The failure to correctly understand the

concept and correct definition of a brief alcohol intervention has considerable implications

upon future practice.

The second research paper ‘A qualitative study of nurses’ attitude and practices regarding

brief alcohol intervention in primary health care’ (Lock et al 2002). Both articles were

completed by Lock and Kaner plus various ‘others’ in the two studies. Since 1999 Lock and

associates have had 11 publications, 8 of which were research studies carried out between

1999 and 2004. The consideration of researcher bias was made, to examine any possibility

of this and a CASP tool (PHRU 2006b) was utilised. The tool acknowledges it is a simplified

review tool and suggests researchers look beyond its set of prompts to explore a wider

range of dimensions of qualitative research. Dixon-Woods et al (2004) agree with this and

suggest that additional criteria are needed that recognise the diversity of study designs and

theoretical perspectives are needed to distinguish between minor errors and fatal flaws in

design.

The study aimed to explore why the use of brief alcohol interventions are under exploited by

nurses. This is at odds with other research that suggests nurses are effective and

10

enthusiastic health educators in many other areas of health promotion (Le Touze and Calhan

1996 & Glasgow et al 2002 ). As alcohol has become a major socio-economic and health

related issue exploration of barriers is justifiable. A grounded theory approach was used to

underpin the methodology of data collection and analysis. This approach looks at systematic

organisation of seemingly unlinked and complex qualitative data such as interview transcripts

or observational studies. (Glazer & Strauss 1997 cited Greenhalgh 2006). As with many

research studies, there was a common failure to state in the design the specific aspects of

grounded theory and how they were used. This leads to confusion and difficulty in analysing

study design (Dixon-Woods et al 2004).

Data was obtained from 24 nurses from GP surgeries in the Nort-east of England. The study

recruited one nurse from each GP practice who had expressed an interest in alcohol related

research. 10 of the 24 nurses from this samlple were ‘convienient’ as the these staff had

already assited with previous research with the same researchers (Lock et al 1999). The

additional nurse recruits were ‘purposively’ included as this sample provided a new

perspcetive as well as a balanced range of nurse age, experience and involvement in alcohol

brief intervention. This combination of convenience and purposive sampling was used until

the grounded theory based approach found no new issues emerging from the interview data.

At this point of ‘data saturation’ the recruitment of additional new participants ceased and in

depth analysis ensued.

The researcher used a simple, methodological ‘FRAMEWORK’ system to comprehensively

order, code and categorise the large volumes of data from the taped transcripts (Richie &

Spencer 1994). This allowed comparative analysis between the nurses results. This form of

data analysis is felt to be adequate in providing basic information but there was an

opportunity missed to gain further insight into the sociological impact of alcohol in primary

care. As grounded theory seeks to move on from simply collating information to attaining a

‘substantive (i.e. grounded) theory or model’: research questions need to be open and

general, not preformed or specificly related to a hypothesis (Charmaz 2006).A more complex

tool other than CASP would have encouraged exploration of other theoretical research

perspectives (Dixon-Woods et al 2004). Use of a critical qualitative research (critical

ethnography) approach (Carspecken 1995) would have allowed the researchers to explore

and understand current sociological issues and put them in a broader historical and social

context. This involves looking at ideology, hidden assumptions and power. It is believed this

is of great benefit to nursing as it aids its the ‘redefinition’ of the discipline to to meet the

needs of patients (Hardcastle 2006).

11

The study provided a comprehensive summary of findings and broke down conclusions into

logical sections such as - issues that generate confusion, staff perceptions of alcohol intake

and personal behaviour. A diagram that summarised all of the results was included, this was

felt to be complicated and confusing and appeared attempt to give the study more kudos by

providing a quantifiable element (Greenhalgh 2006). The conclusions demonstrated that

despite opportunity primary are nurses fail to engage in interventions due to the lack of

training and preparation to deal with such issues. Analysis of factors influencing nurses in

alcohol intervention highlighted requirements for clearer health messages about intervention

and facilitation skills to increase confidence in delivering brief alcohol interventions.

Evidence based practice and ‘effective’ use of research to enhance nursing practice has

been a key policy driver within the NHS over the past few years (DoH, Making a difference

1999). In order to enhance brief alcohol interventions in local primary care, based on the

evidence from the research reviewed, a number of recommendations can be made. Barriers

that may effect implementation will also be discussed and ways to minimise their impact

suggested. Delivery of such services can be challenging and costly. Liberating the talents

(DoH 2002) encourages the NHS to utilise existing resources (i.e. staff) to meet the demands

of the service through professional development and modernisation (Howkins & Thornton

2003).

Education regarding brief intervention amongst nurses was consistently raised as a key issue

to enable effective interventions. Lock (2002) suggests that more should be done to provide

nurses with better preparation, education and support to carry out such work. Ensuring

education and training are appropriate and adequate requires a great deal of planning and

collaboration within an NHS trust and appropriate stakeholders. An effective NHS

organisational infrastructure should incorporate training, professional development and

clinical governance in order to create a quality education action plan (Babor 2000, Foxcroft

and Cole 2000). The 2 key elements that form the plan that will effect nurses are the training

strategy (and the consequential action plans and training sessions) and clinical practice

guidelines. Both these elements need to encourage changes to health services at both a

micro and macro level (NICE 2005).

A recent review of a brief intervention training strategy demonstrated a 60% increase in staff

confidence in delivery (Burrell et al 2006). However, brief intervention training sessions alone

are not an effective sustainable action. Evidence regarding the most appropriate education

12

methods suggests that interactive multifaceted (a combination that includes two or more of:

audit, feedback, reminders and local processes and delivery of care analysis) will have the

greatest long term impact. Conversely lectures and materials (such as guidelines and written

materials alone) have little effect upon practice (Bero et al 1998). Utilisation of this research

about educational delivery method will be of great use in planning actual sessions to staff

and will reduce the risk of poor information uptake and under use in practice.

Clinical practice guidelines are designed to support staff in making decisions about patient

care (Woolf 1999). They are based upon systematic reviews of clinical evidence based

practice and therefore are the main method for communicating evidence-based practice to

staff (NICE 2005). The problems of getting staff to act upon and use guidelines are widely

recognised (Wollersheim et al 2005). Anecdotally files are unread and under utilised unless a

problem occurs. There are 3 areas where implementation of guidelines fail, understanding

these can aid in reducing future barriers to their introduction. The first of these guidelines,

relate to micro individual views regarding knowledge, attitudes, beliefs. Change occurs here

though persuasion, education and training. The second focuses upon service level issues

and includes perceived relevance, validity and practical implementation. Finally there are

more global macro issues relating to an organisation which may have established traditions,

procedures and processes (Foy et al 2001). As a result increased usage of guidelines could

be made by making them more pertinent to individuals, services and the organisation by

providing practical solutions in plain English (Michie & Johnson 2004). This should coincide

with a marketing strategy to ‘sell’ the benefits of guidelines at all levels of the organisation

(David et al 2004).

In the current socio-economic health climate additional funding to address these issues is

unlikely (Thomas et al 2006). Solutions must be generated within existing resources such as

the clinical governance, training and development and professional development teams.

Support from these would, at strategic, level increase the priority of evidence-based practice

amongst GP’s, commissioners and managers and improve dissemination of information and

communication issues amongst seemingly disparate services. At practitioner level, greater

implementation and acknowledgement of the importance of evidence based practice would

increased motivation by reducing uncertainty of roles and practices and by providing visible

improvements in patient outcomes (Newman 1998). This lateral cost neutral approach to

moving research into practice could be provided by constructing a network of practitioners

who will lead an effective learning organisation by contributing to guidelines and leading

example (Rosenheck 2001). In practical terms, this would involve harnessing the energies

13

and academic output of all staff who have undertaken or plan to complete first degrees or

post graduate studies. A formal contract between the funding body (the NHS trust) and

individual would set out the terms of this mutually beneficial relationship. The trust will benefit

by having ‘free’ academic led input and staff will be able to deliver better quality patient care

based upon practical, clear guidelines that they have developed.

Word Count 4982

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