Keywords

Alcohol or Drug-related Problems, Attitudes, Curriculum, Nurse, Nursing Education, Stigma

 

Authors

  1. Nash, Angela J. PhD, CPNP-PC, PMHS
  2. Marcus, Marianne T. EdD, RN, FAAN
  3. Cron, Stanley MSPH
  4. Scamp, Nadine LMSW
  5. Truitt, Morgan BSN
  6. McKenna, Zara BSN

Abstract

Abstract: Stigma and insufficient training for addressing alcohol or drug problems in clinical settings are two significant barriers to earlier identification and access to care for patients with alcohol or drug (AOD)-related problems. Nurses are crucial players in this strategy, yet nurses often report poor motivation and insufficient training for working with AOD-affected patients. This article describes and reports preliminary evaluation results of an educational experience that integrated AOD curriculum into a community/public health nursing clinical practicum. The purpose of the intervention was to meet the required objectives for our university's community/public health nursing clinical course, improve students' attitudes and therapeutic commitment for working with AOD-affected patients, and prepare students for providing high-quality nursing care for individuals with AOD-related problems.

 

Article Content

MAIN TEXT

The Institute of Medicine (IOM) reported in 2013 that, compared with the residents of 16 other wealthy nations, Americans' lives are shorter and for 3 decades, general health indicators in nine areas have steadily declined (IOM, 2013). Five of the nine identified health deficiencies can be linked to alcohol, drug, or tobacco abuse (IOM, 2013). If identified, alcohol or drug (AOD) problems can be treated, and affected people can recover (IOM, 2006). Nurses in acute and primary care settings are crucial players in the IOM strategy for earlier identification and access to care for patients with AOD-related problems (IOM, 2013). Two significant barriers to early identification of AOD problems and access to care for affected individuals are stigma and discrimination by health care professionals (HCPs) and insufficient training on addressing AOD use in clinical settings (Ahern, Stuber, & Galea, 2007; McFarling, D'Angelo, Drain, Gibbs, & Olmsted, 2011; Vadlamudi, Adams, Hogan, Wu, & Wahid, 2008; van Boekel, Brouwers, van Weeghel, & Garretsen, 2013).

 

Stigma and Discrimination

Stigma has been shown to negatively impact physical and mental health of affected individuals (Link & Phelan, 2006). Stigmatizing attitudes of HCPs toward people with AOD-related problems negatively affect access and delivery of health care for affected individuals (van Boekel et al., 2013). Health-related stigma occurs when HCPs make adverse social judgments of patients with certain health issues based on perceptions that individuals should be able to control their behavior and thus are to blame for the presenting health problem (Link & Phelan, 2006; van Boekel et al., 2013). This perception leads HCPs to voice less expressions of concern and to offer help less frequently. Stigma or the fear of being stigmatized is a source of shame and chronic stress for people with AOD-related problems, which can worsen the course of their presenting illness and leave them at an increased risk for other stress-related illness (Link & Phelan, 2006). People who present with AOD-related problems in health care settings report experiencing blame, judgment, and discrimination from HCPs (McFarling et al., 2011; Storti, 2002). Studies have shown that the perception of negative attitudes or discrimination by HCPs can lead to mistrust and avoidance of health care, delays in access to health care services, and decreased likelihood of completing treatment (Brener, Hippel, Kippax, & Preacher, 2010; Pauly, McCall, Browne, Parker, & Mollison, 2015; van Boekel, Brouwers, van Weeghel, & Garretsen, 2014).

 

Nursing's Role

Nursing is the most trusted profession, and therapeutic relationship is a hallmark of professional nursing care. Nurses often report being attracted to nursing because of their compassion and desire to make a difference in people's lives. However, the complexities and realities of caring for patients affected by AOD often result in tensions between the kind of care they want to provide and the care they actually deliver (Neville & Roan, 2014; Vadlamudi et al., 2008). Some nurses perceive AOD-affected patients as being manipulative and report poor regard for these patients, along with feelings of frustration, anger, fear, and intolerance (Henderson, Stacey, & Dohan, 2008; Neville & Roan, 2014; Vadlamudi et al., 2008). A study comparing providers with varying degrees of familiarity and skills in working with AOD-affected patients found that providers' training, experience, and confidence levels were directly related to their regard for AOD-affected patients (van Boekel et al., 2014). In another study, students who received education specifically designed to enhance their skills in empathy, relationship building, and advocacy showed increased self-efficacy for provision of compassionate care (Adam & Taylor, 2014). Educating nursing students about the science and experience of addiction and giving them opportunity to work directly with affected patients may lead to the attitudinal changes needed to enhance their professional relationship skills, thereby eliminating the formidable barrier of stigma for patients with AOD-related problems.

 

AOD Educational Gap

The second most common barrier to caring for patients with AOD-related problems nurses report is a lack of skill and self-efficacy for addressing AOD issues (Vadlamudi et al., 2008). Scant education prepares nurses or other HCPs to provide care for patients affected by AOD in general clinical settings (Crothers & Dorrian, 2011; Savage, Dyehouse, & Marcus, 2014; van Boekel et al., 2013). A cross-sectional survey of nursing schools revealed that baccalaureate nursing (BSN) students received an average of only 11.3 hours of AOD-related content hours, with 90% of this content focused singularly on the treatment of addictive disorders (Savage et al., 2014). Addressing the gap between current nursing education and skills needed to care for AOD patients could provide the groundwork for successful implementation of the IOM's strategy to increase early identification and intervention for AOD patients. This could potentially improve the health outcomes for 60.1 million Americans with risky levels of alcohol use and 24.6 million who use illicit drugs (Substance Abuse and Mental Health Services Administration, 2014).

 

The aim of this article is to describe and report preliminary evaluation results of an educational experience that integrated AOD curriculum into a community/public health nursing (CPHN) clinical practicum. The purpose of the intervention was to meet the required objectives for our university's CPHN clinical course, improve students' attitudes and therapeutic commitment for working with AOD-affected patients, and prepare students for providing high-quality nursing care for individuals with AOD-related problems.

 

THE EDUCATIONAL EXPERIENCE

The Institution

This integrated AOD community/public health clinical practicum is one of several CPHN clinical rotations at the University of Texas Health Science Center at Houston School of Nursing. Participants were senior-level BSN students in their CPHN rotation (August 2013 to May 2016) who self-selected a women's residential substance use disorder (SUD) treatment center for their clinical rotation site. The clinical instructor selected this location because her research focuses on recovery from SUDs and stigma is a known barrier to recovery (IOM, 2006; van Boekel et al., 2013).

 

Curriculum and Clinical Practicum

The UTHealth CPHN course and clinical practicum is required for all senior-level BSN students, and approximately 120 students enroll each semester. The focus of the CPHN course is to integrate professional nursing and public health principles and methods to apply the nursing process to individuals, groups, and populations. CPHN skills provide the groundwork for the clinical practicum (community assessment, diagnosis, intervention, and evaluation). Instructors select a community setting and design unique clinical experiences to help students meet the course objectives with the population served by the selected agency. Supervising 10 students at each clinical site, instructors facilitate students' completion of 135 clinical hours each semester (1 full day per week). Students self-select their clinical practicum from a list of community agencies that serve a variety of populations, basing their selections on their preference of agency location, clinical instructor, or interest in the population served.

 

Setting

The described CPHN practicum was held at Santa Maria Hostel (SMH), one of Texas' largest nonprofit SUD treatment centers for women. SMH serves low-income pregnant or parenting women and is one of the only treatment centers in Texas where children may stay in residence with their mother while she is receiving treatment. SMH provides a continuum of services and levels of care, including residential detoxification, residential intensive and supportive treatment, intensive outpatient services, and supportive living services. Two programs housed at the SMH provide residential treatment for women involved with the criminal justice system.

 

Integrated AOD Curriculum and CPHN Clinical Experience

The clinical experience was designed to help students meet the required objectives for CPHN clinical course. In CPHN, a population is the unit of care. Professional nursing and public health principles and methods are emphasized in applying the nursing process to populations. The focus is on identifying and prioritizing population-level health problems, recognizing and addressing determinants of health, preventing health problems, and advocating for health equity and access for all (Pullis, 2014). The population was women and their children affected by SUD (see Appendix for a table that shows the integration of AOD objectives into CPHN clinical objectives).

 

To prepare students to apply their CPHN skills working directly with a population affected by SUD, the instructor integrated into the practicum up to 30 hours of educational experiences (e.g., agency visits, media, expert speakers, skills workshops, observational experiences, and reflective activities). Topics were related to AOD clinical skills and the health determinants or health issues faced by women and their children who are affected by AOD such as the following:

 

* The neuroscience and experience of addiction

 

* Recovery and the role of peer recovery support models

 

* The physical and mental health effects of adverse childhood events and trauma

 

* Motivational interviewing

 

* Screening, brief intervention, and referral to treatment

 

* Fetal alcohol spectrum disorders

 

* The impaired health professional and peer assistance programs

 

* Social-political issues related to substance abuse (e.g., human trafficking, criminal justice issues, domestic violence, child abuse, etc.)

 

 

Direct Work With Clients

Students spent most of their clinical day shadowing and experiencing SMH clients' daily schedule of classes and group therapy. They practiced their CPHN skills by leading their respective group of clients in a health education intervention each clinical day. The students assessed the community needs, provided a planned educational activity tailored to the specific needs of their group, and integrated activities to evaluate the efficacy of their teaching. The topics of the educational interventions varied by semester and from group to group, depending on the needs of the community. Examples of topics include sexually transmitted infections, the impact of prenatal AOD exposure on children and adults, relational parenting skills, stress management, healthy meal planning, job interview techniques, prerequisites for nursing education, and exercise. In addition, the students collaborated with professionals from SMH and other community agencies, including licensed professional counselors, health educators, licensed chemical dependency counselors, case managers, and nutritionists in multidisciplinary interventions.

 

Skills Building

In postclinical conferences, students practiced CPHN skills such as assessing communities, researching demographics and epidemiology, deriving community diagnoses, and composing behavioral objectives with evaluation in mind. They also learned and practiced skills that would help them with early identification and referral of patients with AOD-related problems such as motivational interviewing and screening, brief intervention, and referral to treatment. At the end of the semester, students formally present their community work to community agencies and/or the entire class of CPHN students and their faculty.

 

Community Observations

To enrich and broaden the clinical experience beyond a single group of clients (indigent women), students selected from a variety of related community observational experiences (8-10 hours) in which they individually observed various advocacy or outreach activities and peer recovery support programs that serve people from all socioeconomic strata. This helps students to recognize how ubiquitous AOD issues are in our culture (IOM, 2006).

 

Reflective Activities

Students wrote essays reflecting on their reactions to the observational experiences and discussed their plans to implement (or not) the new knowledge in their professional nursing practice. Students also participated in weekly group reflections on topics such as issues that arose in counseling, the educational sessions, community crises faced by clients, or topics learned in outside activities. The purpose of these reflective activities was to develop intercultural competence by prompting students to explore their personal attitudes and beliefs, promote their skills in written communication and critical thinking, and develop their personal philosophy of care for patients with AOD-related problems (Koh, Nowinski, & Piotrowski, 2011; see Table 1 for breakdown of educational activities)

  
Table 1 - Click to enlarge in new windowTABLE 1 Breakdown of Educational Activities

EVALUATION

Quantitative

To measure change in students' attitudes toward working with patients with AOD-related problems, two confidential Web-based surveys, the Short Alcohol and Alcohol Problems Perception Questionnaire (S-AAPPQ) and the Drug and Drug-Related Problems Perception Questionnaire (DDPPQ), were administered on the first and last days of the clinical rotation. The surveys included questions about basic demographics and prior experiences with people who struggle with AOD.

 

The S-AAPPQ is a 10-item shorter version of the original AAPPQ. Respondents rate their level of agreement on a 7-point Likert scale, from 1 = strongly agree to 7 = strongly disagree. Higher scores reflect attitudes that are more positive. The original AAPPQ and the S-AAPPQ have shown acceptable validity and reliability in several studies (Gorman & Cartwright, 1991; Terhorst et al., 2013).

 

The DDPPQ is a 22-item survey, derived from the original AAPPQ with similar questions and subscales. Respondents rank their level of agreement on a 7-point Likert scale, from 1 = strongly agree to 7 = strongly disagree. Lower scores reflect attitudes that are more positive. The DDPPQ has shown acceptable validity and reliability but has not been used as extensively as the S-AAPPQ (Watson, Maclaran, Shaw, & Nolan, 2003; Watson, Maclaren, & Kerr, 2007).

 

Both surveys assess attitudes and therapeutic commitment with the constructs of role adequacy, role legitimacy, motivation, task-specific self-esteem, and work satisfaction. Two composite scores related to caring for AOD-affected individuals are calculated: role security (the sense that I am able and have the right) and therapeutic commitment (my motivation, work satisfaction, and self-esteem) (Cartwright, 1980, 1993, 1996; Watson et al., 2007). The surveys are based on Cartwright's work positing that education and self-esteem help to improve positive therapeutic attitudes, but these factors are secondary to support and experience with affected patients. Cartwright posited that training, support, and experience lead to a sense of role security (role legitimacy and role adequacy), which leads to improved therapeutic commitment (motivation, task-specific self-esteem, and work satisfaction; Cartwright, 1980, 1993).

 

Statistical Analysis

Data were examined for patterns of distribution and outliers. Descriptive statistics were then calculated for S-AAPPQ and DDPPQ total and subscale scores on the pretest and posttest. Because of concerns that the data may not follow a normal distribution, the Wilcoxon signed rank test for paired samples was used to evaluate the impact of the clinical practicum on S-AAPPQ and DDPPQ scores.

 

Qualitative Evaluation

The qualitative evaluation included analysis of responses to the following questions:

 

1. What has changed in you (personally or professionally) because of this clinical experience?

 

2. Please describe a few things you learned in this clinical experience that you did not learn elsewhere in your nursing education and state how the content will influence your future work as a professional nurse.

 

3. What elements of the clinical practicum are solid and should be continued? In addition, which elements do you believe should be changed or dropped?

 

 

Qualitative Analysis

Employing thematic content analysis, qualitative data were examined to discover patterns and themes in the data across semesters.

 

RESULTS

Demographics

As of August 2016, 99 BSN students had completed the described practicum, and 62 completed preclinical and postclinical surveys. Only students completing both surveys were included in the analysis. Of the students who completed the practicum, 93% were female, and 81% were 18-29 years old. Most (70%) of the students reported having had some experience in their personal life with someone who had AOD problems, and more than 70% reported having seen AOD-affected people in clinical settings.

 

Quantitative Results

S-AAPPQ scores improved after the CPHN practicum. Significant improvement was noted in total scores (p < .001) and in the scores on all the subscales except motivation (p = .72). Improvements were noted in the composite scores of role security (role adequacy + role legitimacy) (p < .001) and therapeutic commitment (motivation + task-specific self-esteem + work satisfaction; p < .001; Table 2).

  
Table 2 - Click to enlarge in new windowTABLE 2 Results: Short Alcohol and Alcohol Problems Perception Questionnaire (S-AAPPQ)

Similarly, DDPPQ scores improved after the practicum. Significant improvement was noted in total DDPPQ scores (p < .001) and in the scores on all the subscales. Significant improvement was noted in the composite score of role security (p < .001) and therapeutic commitment (p < .001; Table 3).

  
Table 3 - Click to enlarge in new windowTABLE 3 Drug and Drug-Related Problems Perception Questionnaire (DDPPQ)

A possible explanation for the lack of change in scores on the S-AAPPQ motivation subscale is that the preclinical scores were not low: 37.5% were neutral and 31% "somewhat agreed" with the statement "I want to work with drinkers." Postclinical scores remained neutral or somewhat positive but did not significantly change. This is possibly because students self-select an SUD treatment center as their clinical site, implying their motivation for caring for this population.

 

Qualitative Results

Most students' responses to the three open-ended questions were positive. The only responses that might be considered negative were suggestions for improvement given in response to Question 3b, "Which program elements do you believe should be changed or dropped?" The suggestions focused on clinical details like time spent in the clinical setting. Themes that emerged from students' responses to the open-ended survey question (with exemplars) included the following:

 

* Growth in professional role (examples included therapeutic communication, self-efficacy for asking the "difficult" questions, and confidence in the ability to effect change in patients through health education)

 

[white circle] "I know as nurses we're supposed to ask the difficult questions, but I realize in taking this clinical that sometimes we bypass those questions so we don't feel uncomfortable or like we're prying into their personal lives. The reality is that we as nurses have to ask some of these very personal and private questions. It may save someone's life one day."

 

[white circle] "I have acquired a wealth of knowledge that I will carry over into my nursing practice. I feel that I will be able to identify the needs of patents who may suffer from a substance abuse condition, as well as provide therapeutic interventions for them."

 

* A new understanding of the complex health determinants of addiction (such as trauma, prenatal alcohol exposure, use of substances in adolescence, and generational patterns)

 

[white circle] "I learned about the long-term manifestations of fetal alcohol spectrum disorders and its effect on managing finances, time, and everyday tasks. I learned about trauma and how it unfortunately recurs in a cyclical manner throughout generations."

 

[white circle] "Prior to this course, we had only touched on substance abuse. This course taught me about the roots of substance abuse and addiction and gave me tons of knowledge on the myriad of options out there for those in recovery. I'm sorry my other classmates did not have the opportunity to really learn about those struggling with substance abuse and the best practices to help them."

 

* Growth in empathy and respect for patients affected by substance use disorders

 

[white circle] "I learned what it was like day to day for people with addiction to drugs and alcohol. I learned that no single addict is like another and more than anything, they need support, not criticism."

 

[white circle] "It was an honor to work with people with substance use disorders and seeing the positive spectrum of recovery. I have a hopeful attitude towards people who suffer with this disorder. This was truly a rewarding experience."

 

 

DISCUSSION

Nurses are crucial players in the IOM strategy for earlier identification and access to care for patients with AOD-related problems (IOM, 2006). Although AOD abuse is a highly prevalent health issue, few BSN students get the opportunity to work in the community with this population (Savage et al., 2014). The described CPHN practicum addresses two significant barriers to early identification of AOD and access to care for affected individuals: stigma and insufficient preparation for addressing AOD use in clinical settings (Crothers & Dorrian, 2011; Link & Phelan, 2006; Vadlamudi et al., 2008; van Boekel et al., 2013). One of the unique aspects of this practicum is that students can meet the objectives of a required course in a setting that provides them with AOD knowledge, thereby enriching their overall curriculum in this area. This may serve as an example for integration of AOD skills into clinical educational experiences across disciplines.

 

Cartwright theorized that factors such as education, experience, and support in their role lead HCPs working with AOD-affected patients to experience role security (which reflects the belief that their role is legitimate and one they have the ability to fulfill). Role security then leads to therapeutic commitment (which reflects motivation, task-specific self-esteem, and work satisfaction; Cartwright, 1993). Nurses with increased therapeutic commitment are more likely to develop good therapeutic relationships with affected patients, which is central to nursing practice (Peplau, 1997). Students in this CPHN practicum consistently showed changes in attitudes toward patients with AOD problems. Nurses who can provide and maintain an atmosphere of support marked by understanding and acceptance are more likely to develop strong therapeutic relationships with AOD-affected patients. Skills in addressing AOD issues are most likely to be effective in the context of these relationships (Peplau, 1997).

 

Future Directions

We plan to strengthen the study in future semesters by surveying students in other CPHN groups who did not receive AOD-related educational experiences to determine if the positive changes occurred because of the AOD-related experiences rather than because of growth in CPHN skills. We also plan to contact graduates who participated in the practicum to determine their employment setting and ask them to complete the S-AAPPQ and DDPPQ. This will help determine if participants are more likely to be working with AOD-affected clients and if attitudes and therapeutic commitment have changed over time in practice.

 

Preparing nurses to develop strong therapeutic relationships with AOD-affected patients by integrating AOD skills and experiences across clinical settings is one strategy that holds potential to improve access to care and recovery for AOD-affected patients (IOM, 2013).

 

Acknowledgments

The authors wish to express their gratitude to the clients of Santa Maria Hostel for their welcome and acceptance of the nursing students. Sharing their courageous journeys to recovery made a profound difference in the kind of nursing care the students will provide for others who struggle with alcohol or drug-related problems.

 

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