1st International Alcohol, Tobacco and Other Drugs Nursing

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1st International Alcohol, Tobacco
and Other Drugs Nursing Midwifery
ConferenceFlinders UniversityAdelaide,
Australia April 16, 2003ISSUES IN NURSING
EDUCATION

• Dana Murphy-Parker, RN, MS, CNS
• Professor of Nursing
• Arizona Western College
• Yuma, Arizona

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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.

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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?

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Todays 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

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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

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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

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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"!
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All that was needed was.

• Will Power and Restraint

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1935 Alcoholics Anonymous

• Founded by Bill Wilson and Dr. Bob
• Both the medical and psychiatric communities
  rejected it

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1940- Yale Center for Alcoholic Studies

• First academic program to seriously study
  alcoholism

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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

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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

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Confrontation Model (cont)

• 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 Modeltactic of
  attacking defenses to break denial.

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Nursing and Professional Organizations
Specialty of Substance AbuseEfforts 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)

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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 Professions
  Response to the Problem

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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.

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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.

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PUBLICATIONS (USA) Supporting a Lack of
Addictions Education in Nursing School Curricula

• Survey found 82-98 of baccalaureate, masters
  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 masters
  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

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In The USAEducational 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..

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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.
  Georges 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.

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Why NOT????What are the reasons that we are not
educating nursing students and nurses in this
area?
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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.

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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

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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)

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International Council of Nurses (ICN) 1st TINN
MeetingLondon, 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.

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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?

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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.

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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
• PretestgtgtgtgtTreatmentgtgtgtgtPosttestgtgt 3 month
• Group 2
• PretestgtgtTreatment Recovered Guest
  SpeakergtgtgtgtPosttest gtgtgt3 month F/U test

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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
• Stimulant
• Hallucinogen
• Depressant
• Phenothiazine (correct answer, C)
• 2. Nursing assessment of the alcoholic during
  detoxification would include data related to
• Ability to tolerate job-release stress
• Ability to express emotion
• Response to major tranquilizers given
• Seizure potential (correct answer, D)

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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.

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

1. Emotional difficulties as causes of alcoholism
2. Loss of control
3. Prognosis for recovery
4. The alcoholic as a steady drinker
5. Alcoholism as a character defect
6. Social status as a cause of alcoholism
7. Alcoholism as an illness
8. Harmless voluntary indulgence
9. Alcohol is a highly addictive substance

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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).
• Findings
• Group 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/psychologica
  l problems contributes to a greater risk for
  alcoholism

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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

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Significant Findingsfrom 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.

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Significant findings Between Group 1 Group 2

• Factor 4
• The 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

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Significant findings Between Group 1 Group 2,
(2)

• Factor 5
• 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

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Significant findings Between Group 1 Group 2,
(3)

• Factor 6
• Social status of a person with 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

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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 1s mean increased from pre-test to
  post-test indicating that Group 1 was more likely
  to think that alcoholism is not a disease
• Group 2s 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.

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Factor 8Voluntary 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

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Significant Findingsfrom 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 1s 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.

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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)

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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?

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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.

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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)
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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