1st International Alcohol, Tobacco and Other Drugs Nursing &

Midwifery ConferenceFlinders UniversityAdelaide, Australia

April 16, 2003

ISSUES IN NURSING EDUCATION

Dana Murphy-Parker, RN, MS, CNSProfessor of Nursing

Arizona Western CollegeYuma, Arizona

Getting from There to Here

Chair of International Committee, National Nurses Society on Addictions: looking for UK connections professionally

Association of Nurses in Substance Abuse, Annual Conference, April, 1998

Clinical placement in January, 1999 for graduate work exchange, University of Colorado,Denver.

Experiental philosophical differences in the way drug and alcohol problems and treatment approaches were viewed.

Questions?

How has the treatment of substance misuse/addictions evolved in the USA?

Why is drug and alcohol problems not viewed as a healthcare issue

How has the “Abstinence Philosophy”, the “War on Drugs”, the “Just Say No”, program, “Zero

Tolerance” & “Mandatory Minimum Sentencing” impacted on treatment

programs in the United States? What can the US learn from Britain (and

now Australia) in regard to treatment of persons with substance

misuse?

Today’s Objectives Give a brief history of substance abuse

philosophies and concepts in the USA. Discuss the development of nurses’

involvement in raising awareness of the need for substance abuse education within the nursing profession in the USA.

Discuss a research study which examined the relationship of addiction education and attitudes/beliefs of nursing students towards persons with alcohol problems

Acknowledgment: • Ruby Martinez, PhD, RN, CS University of Colorado Health Sciences Center Alpha Kappa Chapter-at Large, Sigma Theta Tau, International

Historical Events Affecting Substance Misuse in the USA

1870 - American Association for the Cure of Inebriates (AACI).

1876 - Quarterly Journal of Inebriety 1884 – Sister society formed in England and

co-conference between US and England in 1887.

1888 - AACI changed name to American Association for the Study & Cure of Inebriety.

1891 - Over 2,000 physicians , numerous libraries and asylums subscribed to the associations’ journal.

1914 - Harrison Anti-Narcotic Act

Historical Events Affecting Substance Misuse in the USA, (2).

1914 - Harrison Anti-Narcotic Act “A physician could prescribe narcotics in the course of his professional practice only” ***** It was simply “feeding a bad habit, not only

immoral, but now illegal (Gray, 1998, p. 45).” 1920 - American Association for the

Study & Cure of Inebriety becomes non-existent.

1920 – The Volstead Act: Prohibition of alcohol in the USA

The most important consequence of the Harrison Anti-Narcotic Act was attaching

criminal consequences to drug addiction. The emphasis was placed on interdiction and

prohibition, rather than on assistance and treatment (Sullivan, 1995).

The interpretation and enforcement of this law cast a long and chilling shadow over the development of progressive treatment

programs for substance misuse in the USA.

The Harrison Anti-Narcotic Act was initiated with an appropriation of $150,000 for enforcement of its provisions. Over eighty years later, we are spending that much every three minutes with the "War on Drugs"!

1935 Alcoholics Anonymous Founded by Bill Wilson and Dr. Bob

Both the medical and psychiatric communities rejected it

1940- Yale Center for Alcoholic Studies

First academic program to seriously study alcoholism

1950s American Medical Association

Declared “Alcoholism” a disease in 1954

By the end of this decade, there were 200 small independent treatment programs in the USA

Confrontation Model Ruth Fox, MD - Founder of the American

Society o f Addiction Medicine (ASAM) in 1955.

She summarized her clinical experience and views in psychodynamic terms. -

“Most patients refuse to face their alcoholism for many years, using the defense mechanisms of denial, rationalization, regression & projection..the

Confrontation Model (con’t) The person builds up an elaborate

defense system in which he DENIES that he is an alcoholic (drug addict)…rationalizes that he drinks for all of his problems in life and projects the blame for the trouble he is in on others (1967)

Assumption of these inherent defenses were accepted Confrontation Model…tactic of attacking defenses to break denial.

Nursing and Professional Organizations: Specialty of Substance Abuse

Efforts within the Profession

National Nurses Society on Addictions (1975)

Drug and Alcohol Nurses Association Consortium of Association of Nurses in Substance Abuse

All 3 have merged into The International Nurses Society on Addictions – 1996 – 1998; name change in 2000.

National Consortium of Chemical Dependency Nurses (NCCDN)

Need for Educational Content on Substance Abuse Disorders 1984 – America Nurses

Association, Drug and Alcohol Nurses Association & National Nurses Society on Addictions “Addictions and Psychological Dysfunctions: The Profession’s Response to the Problem

A Response from the Nursing Profession 1992: American Association of Colleges

of Nurses (AACN) formed Substance Abuse Task Force to develop policy statement to address problems of substance use in the nursing community.

1993: AACN developed a position statement of the need for addictions content to be included in all nursing education.

FEDERAL INITIATIVES: FACULTY DEVELOPMENT (1991) :NIAAA, NIDA & OFFICE FOR SUBSTANCE ABUSE PREVENTION (NOW CENTER FOR SUBSTANCE ABUSE PREVENTION)

• PROJECT SAEN: Dr. Madeline Naegle of New York University.

NLN (1991) AN ADDICTIONS CURRICULUM &

Other Helping Professions: Dr. Elizabeth M. Burns, Ohio State University

SON. (1993) PROJECT NEADA (1990):

Dr. Olga M. Church, University of Connecticut SON.

PUBLICATIONS (USA) Supporting a Lack of Addictions Education in Nursing School Curricula Survey found 82%-98% of baccalaureate,

master’s & nurse practitioner programs offered the subject of alcohol & drug abuse on an average of 3-5 hours during the entire training program. (Carter. 1983)

Sullivan & Handley (1993) consistently found that there were less than 5 hours of substance abuse content given in both baccalaureate & master’s level nursing.

Hoffman and Heinemann (1987) found that undergraduate curricula offered an average of 1 – 5 hours of substance abuse instruction over a course of 2 – 4 years in diploma, associate and BSN program

In The USA:Educational Preparation For Addictions Nursing Practice Has Lagged Behind Education For Other Nursing Specialties. Murphy, Shirley (1989). Journal of Nursing

Education). “The Urgency of Substance Abuse Education in Schools of Nursing”. “Nurses….report their educational experiences offer little to prepare them to develop substance abuse prevention & intervention program”

Naegle, Madeline A. (1989) (Alcohol Health & Research “World) “Targets for Change in Alcohol & Drug Education for Nursing Roles”. “(Nursing) education has not kept pace with these (abuse of alcohol & drugs) issues, and most nurses daily confront deficits in their understanding of alcohol & drug abuse..

Educational Preparation For Addictions Nursing Practice Has Lagged Behind Education For Other Nursing Specialties(2)

Rassool, G.H. & Oyefeso, N. (1993). The Need for Substance Misuse Education in Health Studies Curriculum: A Case for Nursing Education. Nurse Education Today, 13, 107-110. Both at St. George’s Hospital in London

A systemic review of nursing curricula conducted in 1997 (Howard, Walker & Walker) concluded that:

little attention was devoted to either theoretical or clinical education in the substance area and that the proportion of alcohol and drug education received by student nurses was substantially lower than that of medical students and other healthcare professionals.

Why NOT????

What are the reasons that

we are not educating

nursing students and

nurses in this area?

Nurses Attitudes Towards Persons With Addictions

Literature Review on Attitudes Naegle (1989) states a negative

attitude and pessimism persists within the nursing community that doubts alcoholics can have successful treatment outcomes

Studies (Starkey, 1980; Smith, 1992) show nurses to be moralistic, pessimistic, authoritarian & perceive this population to be weak rather than ill.

Client Response as a Determinant of Attitude

Research demonstrates that the quality of care provided is correlated to attitudes of providers (Hanna, 1991).

Eleanor J. Sullivan (1995) states that nurses attitudes towards persons with addiction problems correlate with their amount of knowledge about addictions

G. Hussein Rassool (1998) suggests the development of a non-judgmental and positive attitude towards alcoholics and other substance abusers may be partly related to training and education

The Relationship Between Attitudes and Knowledge

A lack of knowledge about alcohol & drug abuse issues is a primary reason for nurses’ negative attitudes towards working with persons with addictions (Happell & Taylor, 1999)

International Council of Nurses (ICN); 1st TINN Meeting

London, 1999

THE NUMBER 1 theme which emerged:

“Education on substance misuse and addictions in nursing is

missing or insufficient in nursing school curricula and a resolution

for improvement must go the ICN, WHO & UN”.

“Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes/Beliefs of Nursing Students Towards Alcoholics”

Is the lack of teaching of addictions in nursing schools across the country related to a negative attitude on the part of the nurse when working with a person experiencing a problem with alcohol?

Would deliberate addictions education given to nursing students make a difference in their attitudes towards a person with an alcohol problem?

Would exposing nursing students to a person who has successful recovered/overcome alcoholism further make a difference in the nursing students attitudes?

HypothesisBasic Premise: Students knowledge about addiction would increase by offering a lecture on substance abuse 1. Beliefs of nursing students toward

people with alcohol problems will be more favorable after a program of classroom instruction about alcohol problems.

2. A group of nursing students given both classroom instruction and exposure to a person recovering from alcoholic disease will express more favorable attitudes towards persons with the disease after teaching and discussion.

3. A group of nursing students given both classroom instruction and exposure to a person recovering from problems with alcohol will express more favorable attitudes towards persons with the disease than students exposed to classroom teaching only.

“Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics”:

A Quasi-Experimental Repeated Measure Design

Group 1 Pretest>>>>Treatment>>>>Posttes

t>> 3 month Group 2

Pretest>>Treatment & Recovered Guest Speaker>>>>Posttest >>>3 month F/U test

Knowledge of Alcoholism was measured by a questionnaire devised by authors using the CARN (Certified Addictions Registered Nurse) Review Resource Manual. (permission granted by Lynette Jack, PhD, RN, CARN

Examples of questions:1. The nurses bases her assessment of the

alcoholic client on the knowledge that pharmacologically, alcohol is a

A. StimulantB. HallucinogenC. DepressantD. Phenothiazine (correct answer, C)

2. Nursing assessment of the alcoholic during detoxification would include data related to:

A. Ability to tolerate job-release stressB. Ability to express emotionC. Response to major tranquilizers givenD. Seizure potential (correct answer, D)

Results of Knowledge Tests There were no significant knowledge

differences between the 2 Groups for the pre-test.

Both Groups had an increase in knowledge level from the pre-test to the post-test.

Group 2 who had the discussion with the recovering person, demonstrated significantly higher knowledge scores from Group 1 from the pre-test to the post-test.

Marcus Alcoholism Questionnaire Marcus Alcoholism Questionnaire (1963)(1963)9 Factors On Which The Instrument Attitudes About Alcoholism

1. Emotional difficulties as causes of alcoholism

2. Loss of control3. Prognosis for recovery4. The alcoholic as a steady drinker5. Alcoholism as a character defect6. Social status as a cause of alcoholism7. Alcoholism as an illness8. Harmless voluntary indulgence

9. Alcohol is a highly addictive substance

No further significant differences between the Group 1 and Group 2

Factor 1: Emotional difficulties as causes of alcoholism

A high score indicates that emotional difficulties contribute to alcoholism (True).

FindingsGroup 1 & Group 2 both had increased means

from pre-test to post-test indicating that students increased their understanding/belief that a person who has a history of emotional/psychological problems contributes to a greater risk for alcoholism

Significant Findings:Significant Findings: from Pre-tests to Post-tests Factor 2: Loss of control

A high score indicates the belief that the alcoholic is unable to control his drinking behavior (True)

Findings Group 1 & Group 2 showed a significant

difference from pre-test to post-test. This meant that students were more likely to believe and understand that a person who has problems with alcohol are unable to control the amount they drink.Group 2 subscales improved over Group 1 indicating Group 2 had greater recognition of loss of control

Significant Findings:Significant Findings:from Pre-tests to Post-tests (2)

Factor 3: Prognosis for recovery: A high score indicates the belief that one

can not and does not recover from alcoholism. (False)

Findings:Group 1 & Group 2 showed improved scores

from pre-test to post-test which supported that the nursing students did increase their beliefs that a person could recover from alcoholism.

Significant findings:Significant findings: Between Group 1 & Group 2

Factor 4: The Alcoholic as a Steady DrinkerThe Alcoholic as a Steady Drinker. A

high score indicates that a person who periodically drinks (“binge drinking”) excessive amounts of alcohol can have problems with alcohol (True)

Findings : Group 2 had a significantly higher mean than Group 1

Significant findingsSignificant findings Between Group 1 & Group 2, (2)

Factor 5:

Alcoholism and Character Defect: Alcoholism and Character Defect: A high score indicates the belief that the alcoholic is a weak-willed person (False)

Findings: Group 2 had a significantly lower mean than Group 1.

***** In addition, both Group 1 and Group 2 had significantly lower means from the pre-test to the post-test

Significant findings:Significant findings: Between Group 1 & Group 2, (3)

Factor 6:

Social status of a person with Social status of a person with alcoholism: alcoholism:

A high score indicates the belief that alcoholics come from the lower socioeconomic strata of society (False)

Findings: The pre-test to post-test means

increased slightly for both groups, indicating a poor understanding regarding social status of person with alcohol problems

Between Group Differences (Not Significant) Factor 7: Alcoholism as a disease. A high score indicates the belief that

alcoholism is not an illness (False)Findings Group 1’s mean increased from pre-test to

post-test indicating that Group 1 was more likely to think that alcoholism is not a disease

Group 2’s mean slightly decreased from pre-test to post-test indicating that Group 2 students were more likely to believe that alcoholism is a healthcare disorder.

Factor 8:Voluntary heavy indulgence of alcohol is harmless

A high score indicates the belief that the alcoholic is a harmless heavy drinker whose drinking is motivated only by his fondness for alcohol (False)

Findings Group 1 & Group 2 had lower means

from pre-test to post-test indicating that both groups of students believed that heavy drinking was harmful and that a person who drinks heavily has a problem with alcohol rather than simply liking to drink

Significant Findings:Significant Findings:from Pre-tests to Post-tests (4)

Factor 9: Alcohol is a highly addicting substance

A high score indicates the belief that alcohol is a highly addicting substance (True)

Findings Group 1’s mean scores showed that these

students were less likely to believe that alcohol was a highly addicting substance

Group 2 did have a higher mean from Group 1 however there was no change in their mean from pre-test to post-test.

“Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics”

1. Have you had any personal experience with anyone having an alcohol problem that you feel effects your attitude towards alcoholics?” (include yourself(asked on pre-test only) Yes ____ No ____.

If your answer is YES, please briefly explain 2. "Do you believe that a person who has an addiction to alcohol

can recover?" Yes _______ No ______. Please briefly explain your

answer.**(asked on pre & Post test)__ 3. "If the School of Nursing were to offer a course in The Role

of the Nurse in Addiction Issues, would you be interested in taking this course?" _______Yes ______NO **(asked on post test)

“Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics”

The qualitative questions revealed the high prevalence of alcohol abuse within American families

Recovery is possible if the person wants to and is willing to accept help

Most interesting was that whether a participant indicated a “yes” or “no” on their thoughts about the possibility of recovery, their written explanations about recovery were similal

indicates that the concept of recovery is not clear, What does recovery mean??

How do we measure SUCCESS?

“Examining the Relationship of Addictions Education in Nursing School Curricula to Attitudes of Nursing Students Towards Alcoholics”

Main Themes The person must be willing to stop drinking Once the drinking stops they will forever

struggle with how alcohol fits into their life Alcoholism is a chronic condition that

involves relapse Some participates viewed recovery as

inconsistent with the chronic nature of alcoholism. Even with abstinence, the person is still not “recovered” because the underlying condition of alcoholism is still present for that person.

“To Treat the hemorrhage or the pancreatitis and not the alcoholisms is poor health care, akin to treating anemia without treating the colon cancer that causes it (Sullivan, 1995)”

“Changing the Conversation” in the USAA National Treatment Initiative(CSAT/SAMHSA)

“We envision a society where people who are addicted to alcohol or other drugs, people in recovery from addiction, and people at-risk for addiction are valued and treated with dignity; and where stigma, accompanying attitudes, discrimination and other barriers to recovery are eliminated. We envision a society where addiction is recognized as a public health issue, a treatable disease for which individuals should seek and receive treatment; and where treatment is recognized as a specialized field of expertise” ”