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British Journal of Oral and Maxillofacial Surgery 46 (2008) 102–106

Delivery of a brief motivational intervention to patients with

alcohol-related facial injuries: Role for a specialist nurse
F. Oakey a, A.F. Ayoub b,∗, C.A. Goodall b, A. Crawford c, I. Smith d, A. Russell d, I.S. Holland e

a Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK

b Department of Oral and Maxillofacial Surgery, University of Glasgow Dental Hospital and School, Glasgow, UK
c RCA Trust, Paisley, UK
d Gartnavel Royal Hospital, Glasgow, UK
e Glasgow, Regional Maxillofacial Unit, Southern General Hospital, Glasgow, UK

Accepted 21 November 2007

Available online 21 December 2007

Abstract

In this paper we focus on providing an alcohol screening and intervention service within maxillofacial surgery. Two trained nurses screened
patients with alcohol-related facial injuries who attended maxillofacial outpatient clinics, and gave brief motivational interventions to those
who had been drinking to a hazardous level. Patients were followed up at 3 and 12 months after the intervention. 195/249 patients (78%)
drank to a hazardous level. One hundred and ninety-five patients received an intervention. Duration of intervention was between 5 and 65
minutes. Reasons for refusal to participate included lack of interest or time, and the main reason for exclusion was length of time since injury.
The follow up rate was 103 (53%) at 3 months and 134 (69%) at 12 months.
Conclusions: The high level of hazardous drinking among people with facial trauma suggests a clear need for alcohol screening and intervention.
It is feasible for nursing staff to deliver brief interventions in a busy maxillofacial trauma clinic.
© 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Facial injuries; Alcohol abuse; Brief intervention

Introduction
The maxillofacial area is one of the most frequently injured
in assaults on adults1 so oral and maxillofacial surgeons are
one of the main specialities involved in treating victims of
violent crime. Alcohol excess and interpersonal violence are
two of the major aetiological factors associated with facial
trauma in the UK.2,3 Most victims of crime state that their
assailant was under the influence of alcohol4 and many vic-
tims of assault have consumed alcohol before their injury.5
Alcohol misuse is a growing problem in Scotland and in
∗ Corresponding author. Tel.: +44 0 141 211 9604;
fax: +44 0 141 211 9601.
E-mail address: a.ayoub@dental.gla.ac.uk (A.F. Ayoub).
recent years has become a high priority for the Scottish
Executive.6
Many maxillofacial injuries require complex surgical
intervention, which has an appreciable demand in terms of
manpower for a relatively small specialty, as well as finan-
cial implications for the NHS. In addition, the long lasting
effects on patients both physically and psychologically are
well documented.7,8
Despite successful surgical management of facial trauma,
the underlying aetiological factors, often alcohol misuse, are
not adequately addressed. Screening and brief intervention
for hazardous drinking are one way to tackle this problem,
but they do not currently form part of routine practice in oral
and maxillofacial trauma units. Brief motivational interven-
tions for alcohol are opportunistic interventions based on a

0266-4356/$ – see front matter © 2007 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2007.11.013
 F. Oakey et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 102–106
style of counselling designed to change behaviour9,10 and
focus on an individual’s “readiness to change”.11 Interven-
tions as short as five minutes can be effective in reducing
hazardous drinking.12 Although there are limited maxillo-
facial studies, this type of intervention has previously been
used successfully. Smith et al,13 reported a reduction in alco-
hol consumption in a population of young male patients with
facial trauma a year after injury when they were given a brief
intervention by a nurse and compared with a group of similar
patients who were given no such intervention. They con-
cluded that the intervention was effective and that it takes
some time for change to occur as effect had been negligible
3 months after the intervention.. The brevity of these inter-
ventions means that they are cost effective in hospital.14,15
Barriers to provision of such interventions include lack of
time, confidentiality,16 and lack of training and support.17
The aims of this study were, firstly, to assess the degree
of hazardous drinking among trauma patients in the West of
Scotland and secondly, to assess the feasibility of delivery of
a brief intervention for alcohol in a busy outpatient clinic by
a trained nurse. We focus on the logistics associated with the
provision of this service and the potential role of a specialist
trauma nurse.
Methods
This study was conducted at three hospital sites in the West of
Scotland, UK, between February 2003 and June 2005. Ethics
committee approval and patients’ written informed consent
were obtained.
Two registered nurses, working within the surgical spe-
cialty, recruited patients over 16 years of age with facial
trauma that had been sustained during the preceding two
weeks from outpatient clinics. Patients were screened using
the Alcohol Use Disorders Identification Test (AUDIT).18,19
A score of 8 or above indicates hazardous drinking. Non-
hazardous drinkers (those who scored less than 8) were
discharged from the study.
Patients were asked how many drinking days they had had
in the past 30 days, the number of standard drinks on a drink-
ing day, and the number of heavy drinking days in the past 30
days (days on which they had drunk 6 or more units for men
or 4 or more for women). Standard characteristics includ-
ing details of the injury and any previous alcohol-related
facial injuries were also noted. Nurses then delivered one of
two alcohol interventions to which patients were randomly
Table 1
AUDIT scores of participants in the trial
AUDIT score AUDIT category
8–15 Hazardous drinkers-(at risk of alcohol-related problems)
16–19 Harmful drinkers-(alcohol-related problems are present)
>20 Dependent drinkers-(have features of alcohol dependence)
103
assigned. Randomisation was carried out using a sealed enve-
lope system and patients were randomised in blocks of four
to ensure balance.
The alcohol interventions were either a brief motivational
intervention or a standard alcohol information leaflet (Greater
Glasgow NHS Board: Alcohol: Questions and Answers).
The brief motivational intervention was based on a book-
let adapted with the permission of the Addiction Research
Foundation; the target duration was 20 minutes. Nurses’
training included a part-time certificate course in counselling
(COSCA) and two days training in motivational interview-
ing and the project protocols (AC). Neither nurse had any
previous specialist training in treatment of alcohol-related
problems.
Patients were reviewed 3 and 12 months after interven-
tion, largely for the purpose of assessing the efficacy of the
intervention. Patients supplied further data about their drink-
ing since they were last seen. Three attempts were made to
contact the patient if they failed to respond they were also
offered the option of follow-up by telephone or postal ques-
tionnaire. Variables influencing return for follow up were
analysed using a chi-square test.
Results
Subjects
Two hundred and forty nine (217 male and 32 female) patients
were eligible to participate in the study and were screened
with AUDIT. A total of 195 patients (78%) were defined as
hazardous drinkers by scoring 8 or more in AUDIT (Table 1).
The median score was 15 (range 8–40) with 87 (45%)
patients scoring 16 or over, indicating harmful or dependent
drinking.
Refusals and Exclusions
Fifty-eight patients (11%) (46 male, 12 female) refused to
participate (Table 2).
A total of 222 patients (42%) were excluded from the
study before consent (Table 3), the major reason being that
their injury was more than two weeks’ old. This limita-
tion was placed because another limb of the study looked
at post traumatic stress disorder and patients had to be seen
within two weeks so that any acute stress reaction could be
detected.
Number (%) of patients (n = 195)
108 (55)
35 (18)
52 (27)
104 F. Oakey et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 102–106

Table 2 A total of 134 patients (69%) patients were reassessed

Reasons given for refusal to participate in the study (n = 58) at 12 months, 64 of whom returned in person. Eight were
Reason Number of patients excluded at 12 months; of these, one had died, one had been
Not interested 13 murdered, and six had moved without noting the change of
No time 13 address.
Waiting time at clinic was too long 7 The key factor influencing return in person at 3 months
Patient too distressed 5
“Don’t drink so doesn’t apply to me” 4
was distance from the base hospital (p < 0.05), which was
Industrial or sports injury 3 probably related to the cost of travel. This was true for both
In pain 3 groups. Patients were paid additional travelling expenses to
Not able to come for follow-up 2 attend again at 12 months, and this influenced the return rate,
Peer pressure not to take part 1 primarily in the younger patient group (p < 0.05).
“Don’t like hospitals or doctors” 1
Patient about to be discharged 1
Psychiatric problems 1 Outcome of interventions
Patient in fear of life 1
Patient considered to be too old 1 Changes in drinking behaviour are discussed in detail else-
Patient offended 1 where, but both control and intervention groups showed a
Patient embarrassed 1
reduction in a number of aspects of drinking behaviour at 3
months (drinking days, heavy drinking days and number of
Intervention times standard drinks on a drinking day). There were no significant
differences between the two intervention groups at 3 months,
The median duration of intervention for the brief motivational but, significant differences emerged 12 months after interven-
intervention group was 25 minutes, (range 5–65 minutes), tion, with the brief motivational intervention provided by the
and median 5 minutes (range 5–50 minutes) for the leaflet nurse producing the greatest reduction in drinking variables.
group; this did not affect the running of the clinic. There was
no significant difference in the median time of intervention
between the two nurses. Appointment length had no effect Discussion
on clinic times at the review visit, as patients who attended
did so for the specific purpose of participating in the study. The degree of hazardous drinking clearly shows a need for
alcohol screening and intervention among people with facial
Drop out rates trauma. The number of refusals was small (11%), suggesting
that patients would welcome this service.
A total of 103 patients (53%) patients were reassessed at 3 Patients who refuse to take part in intervention studies may
months. Forty-six attended in person and a further 57 returned not have reached the “contemplation stage” of the “readiness
postal questionnaires. Reasons for requesting postal ques- to change” model for dealing with their problematic drinking,
tionnaires rather than attending the follow up interview in and this may have affected their decision to participate.20
person were: work commitments, travelling distances, family It was clear, however, that some patients who refused to
obligations, and Armed Forces’ tours of duty. Four patients participate were unwilling to spend further time at the clinic.
were excluded from the study at 3 months because of failure A possible solution would be early liaison between the nurse
to inform the research nurse of: change of address, request to and the surgeons to ensure review of patients throughout
withdraw, or imprisonment. the clinic, instead of appointing several trauma patients to
the same time; this may have avoided the exclusion of 41
Table 3
patients because either the nurse or an interview room was
Reasons for exclusion of patients from the study (n = 222) not available.
Reason for exclusion Number of patients
An AUDIT cut-off point of equal to or over eight was
chosen for all patients. In retrospect, this may have underes-
Injury more than 2 weeks old 165
Nurse busy with another patient 38
timated the level of hazardous drinking among women in the
Patient demented 3 study, as AUDIT is known to be less sensitive in women.21
Patient with young children 3 However, the total number of eligible female patients was
No interview room available 3 small.
Patient fainted 2 Some of the patients with AUDIT scores of less than eight
Language problem 2
Patients hard of hearing 1
(n = 13) had been drinking to excess at the time of injury, and
Eye too swollen to read 1 these patients may have been infrequent binge drinkers. This
Patient confused 1 is not adequately addressed by AUDIT and this should be
Patient sedated 1 taken into consideration if brief intervention becomes part of
Patient aggressive 1 standard clinical practice. Excessive alcohol excess increases
Patient intoxicated 1
the likelihood of trauma, and it may be more appropriate to
 F. Oakey et al. / British Journal of Oral and Maxillofacial Surgery 46 (2008) 102–106
use the amount of alcohol consumed at the time of injury as
an entry point to intervention. It is also known that people
who binge drink infrequently are more likely to be injured
than those with a chronically high alcohol intake.22
Trained nurses from a surgical background can suc-
cessfully provide brief motivational interventions to injured
patients and can encourage patients to reduce their alco-
hol consumption. This reinforces previous findings by other
authors.13 Better outcomes were achieved with one to one
contact than the use of leaflets. This study shows that an
alcohol-related background is not essential for provision of
an intervention, and staff nurses working within the specialty
can be trained to provide this in addition to their other duties.
The research nurses occasionally had problems with aggres-
sive patients and it is therefore sensible that clinics should
not be carried out in isolation. Nurses attended trauma clin-
ics and saw patients alongside the surgeons. It is, however,
important to provide the nurse with the space and time during
the clinic to provide the intervention undisturbed. Each one
should have a designated room and should not be expected
to carry out routine clinical duties such as removal of sutures
during the trauma clinic.
The duration of interventions varied; there are no clear
guidelines for the optimum length of a brief motivational
intervention23 and those as short as five minutes have been
shown to be effective.12 However, it would have been sensible
in a trial to control this more closely. Clinically the length of
the intervention is less critical and is largely dictated by the
patient.
One hundred and three patients (53%) were followed up
at 3 months, and 134 (69%) at 12 months. These follow up
rates are somewhat lower than those in the only other compa-
rable study that we know of in patients with facial injuries.13
However, it is not unusual in studies dealing with injured
patients to lose a significant number to follow up.24 We note
that the key factors influencing this seemed to be financial
incentives, age, and distance of travel to the hospital, which
were probably related to the cost of travelling to the base
hospital. Smith et al,13 achieved good response rates of 92%
(of 151) at 3 months and 81% (of 151) at 12 months after
the intervention, with patients using telephone follow up as
their main method of review. In their study, the use of tele-
phone interviewing may have increased the response rate at
follow up and provided a more accurate picture of patient’s
alcohol intake than the face-to-face interview. While follow
up is essential to monitor the outcome of research studies, it
would not be required after an intervention if this was part of
a clinical service. We suggest, however, that if this service is
implemented by other units, a proportion of patients should
be followed up initially for quality control purposes, and to
ensure efficacy, as the results may be different in other hands
depending on the precise content of the intervention.
Attention should be directed towards providing nurses
with training and support to provide brief motivational inter-
ventions in trauma clinics. This would allow interventions
to be provided as and when required. The role of the spe-
105
cialist trauma nurse could extend beyond this to training,
facilitation, and support of the oral and maxillofacial ward
staff in implementing screening and other programmes for
alcohol. This in turn would help to increase the identifica-
tion of hazardous drinkers and potentially reduce alcohol
consumption and NHS costs incurred in the treatment of
recurrent alcohol-related injury (which occurred in about one
quarter of patients). Trauma nurses could play an important
part in; screening for alcohol and drug problems and their
commonly encountered consequences such as post traumatic
stress disorder; provision of interventions; and liaison with
other specialties, such as alcohol and drug services and psy-
chiatry. They could provide a point of contact and support
for patients after injury, provide basic information about the
injury and treatment and act in a liaison role between the
patient and the surgeon. It is conceivable that such a role
could also be extended to other surgical specialties deal-
ing with alcohol-related trauma such as plastic surgery and
orthopaedics.
Acknowledgements
This project was supported by Grant No. R 02-2 from the
Alcohol Education and Research Council to A. Ayoub, A.
Crawford, G. Gilchrist, I. Smith and A. Bowman. We thank G.
Gilchrist, A. Bowman, D. Koppel, M. Docherty, D. Campbell,
K. Green, C. Bennie and Noel Thomson for assistance and
all the patients who gave up their time to take part.
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N.S.S. Jayasuriya
S.A.K.J. Kumara
T. Sabesan
OMF Unit, Dental Institute,
Colombo, Sri Lanka