The health, social, and financial costs of alcohol and drug use in the United States have reached an all time high. According to the Sixth Special Report to the U.S. Congress on Alcohol and Health (DHHS, 1987), alcohol abuse leads to 100,000 health-related deaths and an additional 100,000 accident-related deaths annually. Moreover, 28 million Americans identify themselves as Adult Children of Alcoholics (ACOA) and believe they have been victimized by being reared by at least one alcoholic parent. Their reported marital and job dysfunction, for which they frequently seek treatment, reflects personal, social, and financial burdens. Moreover, it is estimated that at least 50% of these persons will become problem drinkers; producing a health burden as well. About 30% of our youth experience negative consequences of alcohol and drug use on school performance. Similarly, domestic and other violent acts are commonly associated with alcohol and drug misuse. Treatment costs for alcohol-related health and social problems are estimated at $10 billion annually. Neither prevention nor intervention programs have had the desired impact on abuse. It is estimated that 60% of all persons treated for alcohol abuse relapse (Marlatt & Gordon, 1985). Despite the enormity of the problem, reports show that nursing curricula provide almost no education on the addictive process. Nurse clinicians confirm that they are ill prepared to diagnose and care for addicted persons. This article identifies factors that contribute to the educational gap, discusses some challenges in planning and implementing substance abuse curricula, and offers some specific guidelines for improvement.
Nurses commonly encounter clients with actual or potential substance abuse problems, but report they are illprepared to assess and intervene effectively. A review of the literature reveals a 20-year pattern of findings that support this statement. Johnson (1965) reported a lack of educational preparation on addictive behaviors and their consequences as early as 1965. The findings of two studies published in the 1970s support Johnsons report (Burkhalter, 1975; Holmes, 1975). More recently, Bartek and colleagues (1988) surveyed 83 nurses who practice on general adult medical and surgical nursing units in fifty hospitals in a Midwestern state. Eighty percent of the sample reported having limited classroom and clinical experience with substance-abusing clients, and expressed need for inservice education. The survey results must be interpreted cautiously, however. Although the sample was randomly selected, the return rate was 43%, with only 35% of the questionnaires usable for data analysis.
In a survey of 1,576 psychiatric/mental health nurses conducted in 1983, a majority said they encountered significant numbers of clients who abuse substances. Less than 10% of the respondents believed they were competent to care for these clients. These clinicians stated they received negligible academic and clinical preparation in their educational programs that prepared them to practice with this client population (ANA, 1986).
Only two studies were found that assessed nursing curricula pertaining to substance abuse. Hoffman and Heinemann (1987) contacted 1,035 schools of nursing in the United States regarding undergraduate substance abuse education. Their findings appear to be consistent with data reported by nurse clinicians: undergraduate curricula typically offer one to five hours of required instruction over the four-year enrollment period. Course content offered was reported to consist primarily of definitions and description of phenomena rather than preparation in assessment and intervention skills. Also noteworthy was the finding that substance abuse content appears in psychiatric-mental health nursing courses three times more frequently than in medical-surgical nursing courses, and 10 times more frequently than courses offered by the other two nursing specialties, community and parent-child nursing. The response rate was 36%, so results must be viewed with caution.
Murphy and Hoeffer (1987) surveyed directors of psychiatric mental health nursing programs in the United States regarding their opinions about educational and practice issues and projected changes in specialty curricula at the graduate level. Eighty percent or 102 program directors responded. Forty-four percent of the programs offer subspecialty content in addition to core specialty content. Twenty programs were considering increasing emphasis in subspecialty content within the next three years. However, only two programs were considering adding substance abuse content. Thus, available data suggest an extreme imbalance between academic preparation of nurses in substance abuse content and the competencies expected for them to assume clinical practice and leadership roles. Although past studies reported are descriptive, taken together they support the argument that nursing students receive limited preparation regarding identification and management of clients who abuse potentially addictive substances.
Factors Contributing to the Problem
Four factors are likely to account for the disparity between preparation and expected performance. These are the lack of discernment of the problem by faculty, little interest among nurse scholars, prevailing social attitudes, and the lack of funding. Each factor is discussed briefly.
Decreased Visibility - The lack of discernment (visibility) by faculty may account in part for the preparation/performance gap. Nursing curricula have become less disease (medical-model) oriented; thus content on medical diagnosis and treatment of hospitalized "alcoholics" has been reduced or eliminated. Even though substance abuse content can be included in concept-driven curricula in units, such as alterations in nutrition, sleep, perception and cognition, loss, grief, self-esteem, family violence, and health promotion, nurse educators have not made these linkages. Moreover, the use of some drugs is relatively recent and teaching about the consequences of their use has been overlooked. Bartek et al (1988) reported that although 25%-64% of all clients admitted to acute care facilities have underlying substance abuse problems, a secondary diagnosis is not entered into client records. Similarly, clients admitted to psychiatric care facilities for affective disorders also have substance abuse problems not diagnosed and treated (Hasin, Endicott, & Lewis, 1985). Thus, clinical faculty may miss opportunities to extend nursing assessment and intervention skills to these clients. Finally, in the past decade, specialized substance abuse corporations such as "Care Unit" and "Milam Recovery Centers" have opened, which has shifted the treatment emphasis away from general hospital units where students are typically placed for clinical learning experiences.
Limited Interest Among Nurse Scholars - The rapidly emerging cadre of doctorally prepared nurse researchers has shown less interest in the study of addictive processes as phenomena of concern in comparison with other phenomena. A review of national and international nursing research conference programs held from 1982 through 1987 indicated one out of about every 200 papers was related to substance abuse. The one exception has been research regarding the impaired nurse. Alternatively, nursing leadership organizations such as the American Academy of Nursing (1986) and the American Association of Colleges of Nursing (1987) have urged research and education in the general domains of health promotion, lifestyle behavior change, and preventive intervention.
Acceptance of the Status Quo - Prevailing societal attitudes that condone excess and ignore the consequences of substance abuse may be representative among nurses. Thus, nursing students have few role models among nurse scholars and practitioners who concern themselves specifically with the escalating incidence and consequences of alcohol and drug abuse.
Reduced Federai Funding for Training - Finally, federal and private funding for substance abuse education in nursing at all levels, particularly graduate and continuing education, has been almost nonexistent in recent years. Since higher education has become increasingly expensive, more students tend to enroll in content areas where stipends are available. Faculty who enrolled in substance abuse-related extension courses in the past are now more likely to be enrolled in doctoral study or have twelve-month rather than nine-month employment contracts, making involvement in summer study less feasible.
In summary, substance abuse is a major health and social problem in the United States. Yet nurses, who comprise the largest segment of health-care professionals, appear to be ill prepared to propose innovative prevention and intervention approaches for this growing segment of the population. Changes in curricula, client services, limited scholarship, and the lack of educational funding may have contributed to the problem.
Challenges in Curriculum Planning and Implementation
Four specific challenges that have implications for nursing education are the complexity of client problems already exceed prevailing knowledge forcing the need to "catch up," the need to increase theory development and research devoted to substance abuse among nurse scholars, the conceptual crisis at the multidisciplinary level, and curricular overload.
Complexity of Client Problems - The complicated status of addictions as actual and potential health problems can be shown in the following examples: a) addiction to two or more substances is increasingly more common than addiction to a single substance (Ferri, 1985); b) alcohol and other substances are associated with major affective disorders (Hasin, Endicott, & Lewis, 1985; Mirin, Weiss, Solloguh, & Michael, 1984); c) lifestyle patterns of behavior such as smoking, alcohol, and cocaine use are linked with preventable but leading causes of disability and or death (DHHS, 1987; Istvan & Matarazzo, 1984); and d) the prevalence of AIDS among drug users (Niven, 1987).
There appear to be both common and unique components of use and patterns of abusive substances that affect health status and complicate assessment and diagnosis. For example, some clínica] similarities between alcohol misuse and eating disorders are secrecy surrounding use, hinging, dysphoria, and life-threatening health consequences associated with prolonged misuse. Two recent studies have documented the co-occurence of bulimia and alcohol abuse in young adult women (Lacey & Moureli, 1986; Hatsukami, Ecker, Mitchell, & PyIe, 1986). There is also an alarming incidence of polydrug use among both young adults and the elderly. Interactions among alcohol, prescribed medications, and over-the-counter drugs make older persons especially vulnerable to accidents and depressive episodes. Knowledge needed to care for elderly persons with multiple addictions includes normal adult development and aging, advanced pharmacology, and risk factors such as multiple concurrent losses, psychosocial concerns such as loneliness, and identification of community resources. False assumptions about aging have deterred nursing education, particularly in regard to psychosocial issues, such as the effects of multiple losses and limited coping options (George, 1980).
"Dual diagnosis" is the observance of two major clinical psychiatric phenomena competing for primary treatment. For example, if a client is given a primary diagnosis of affective disorder associated with a substance abuse problem such as alcoholism, the affective disorder is treated, but the client is frequently told to go to AA for his/her alcohol problem. If the diagnosis is the reverse, the client may receive treatment for substance abuse and the affective disorder tends to be neglected. Many treatment facilities refuse to admit clients with dual diagnoses. To provide a rationale for change, longitudinal studies are needed to document both the human and economic costs of dual disorders in which both need primary treatment. Knowledge needed to care for dually diagnosed persons includes neurophysiology, knowledge of current brain physiology, including the roles of neurotransmitters, relationships between depression and the immune system, and individual and family assessment and intervention strategies.
Preliminary clinical findings suggest that cocaine use in pregnant women produces detrimental effects on normal fetal growth and development similar to the known effects of alcohol use during pregnancy, namely, fetal alcohol syndrome. Entirely preventable, fetal alcohol syndrome (FAS) is the leading cause of mental retardation in children (Streissguth & Martin, 1983). Both the pregnant woman (frequently a homeless single teenager) and infant need extended complex care. Knowledge needed to care for these dyads is extensive and includes high-risk pregnancy, neonatal risk, social support, processes of addiction, and relapse prevention. Maternal-child health nurses are becoming well-prepared in the former but need preparation in the latter two content areas.
The Need for Nursing Research and Theory Development - A review of nursing journals that publish research and theory papers conducted by the author indicated that since 1980 only a few nurse-authored research studies pertaining to addiction have been published. The intent here is not to discount the many fine clinical papers published annually in clinical nursing and multidisciplinary journals. Rather, the intent is to suggest that the addictive process is a phenomenon of importance to the discipline, because knowledge of it potentially leads to health promotion and illness prevention strategies.
Research of all types is needed. Interpretive and descriptive studies are important to gain a client perspective seldom captured by researchers in other disciplines. The development of valid and reliable instruments is a pressing need. Since addictive processes involve all body systems, interpersonal systems, the health care, and socio-cultural systems, there is opportunity for cross-specialty as well as multidisciplinary study collaboration.
The Conceptual Crisis in the Multidisciplinary Field of Addictions - Crucial to treating addictive behaviors is the comprehension of underlying models by which a society and its helping professions view excess use of substances. At the present time, the disease model is the prevailing paradigm, even though there is insufficient empirica] evidence to support a singular theoretical model (Alexander, 1987; Fingarette, 1988; Marlatt, 1985; Smith, Milkman, & Sunderwirth, 1985). Moreover, there is little relationship between existing theory and its application in clinical practice. For example, Miller and Hester (1986) showed that inpatient treatment may not be needed for all clients, and that inpatient settings appear to be overused.
The language used by health-care providers in the field also suggests a lack of conceptual clarity and parochialism. Parts of the moral and medical models identified decades ago appear to prevail. For example, persons who drink to excess are considered to have a "disease," whereas persons who use drugs are labeled "addicts." Similarly, the word "aftercare" suggests that the current "one-shot" intensive treatment should be sufficient for all, yet relapse rates do not support this conception. When one makes a significant lifestyle change, ie, remains abstinent from alcohol, one is in "recovery" or in the "sixth month of sobriety." This conceptual crisis impacts nursing because many nurses identify with the medical model and do not hypothesize and test alternative models. In contrast, nurses have an opportunity to develop and test new theoretical frameworks and to change the vocabulary in current use.
Curricular Overload - A final critical challenge may be the lack of support among faculty-controlled curriculum bodies to promote the necessary change. This lack of support is likely based on a serious problem in nursing education today. Students are overloaded with content. Some nurse educators believe curricula should increase focus on the development of reasoning skills and ethical considerations rather than adding clinical content. Others may not be convinced that substance abuse content is of value.
The challenges identified here require changes in conceptualization of the problem, thorough planning that includes preparation of both faculty and students, skillful implementation, and expert program evaluation.
Nursing is ideally suited to engage in the breadth and depth of activities necessary to prevent and/or intervene in addictive conditions. As a practice discipline, nursing knowledge is organized in domains of client, environment, health status, and nursing intervention (Flaskerud & Halloran, 1980; Fawcett, 1984; Kim, 1983). According to Kirn (1983), knowledge for practice within and among all four domains is necessary and there should be balance among the domains even though their emphasis will vary from phenomenon to phenomenon. However, in the case of substance abuse content, 'client' has been consistently emphasized, resulting in inadequate attention to the domains of environment, related health status, and nursing actions that could be designed to prevent and/or alleviate the problem.
Substance abuse is a complex multifaceted phenomenon and must be viewed as such. The client domain includes human responses to the addictive process, such as physiological responses and consequences of use, and psychological responses such as the effects of substances on cognition and affect. The environment domain includes potential for prevention, such as knowledge of social sanctions, product availability, and environmental (job, family) stress. Curriculum content designed around health status could include alterations in health, such as fetal development and poor cognitive performance in school. The reconceptualization strategies suggested here are intended to serve as examples of the range of innovations that can be adopted. The philosophy of education and conceptual framework in each school is expected to guide faculty decision-making.
Preparation of Faculty and Students
Curriculum cannot be planned and implemented effectively without major effort devoted to attitudinal and behavioral change among faculty and students. It is suggested that consultation be sought to initiate faculty development. The lack of current knowledge and negative attitudes among health professionals are serious deterrents to curricular change.
There is ample empirical evidence to suggest that experiential programs for students be developed before didactic and clinical experiences are implemented. Some studies have reported that students who enter the health-care professions have a greater incidence of being reared in alcoholic families than students who enter other fields (Bissell & Haberman, 1984; Sullivan, 1987). The lack of resolution of these issues may deter educational progress. Therefore, students should be offered the opportunity to join professionally led support groups and attend elective courses prior to enrolling in required content.
Generalist (Undergraduate) Education - According to the Social Policy Statement (ANA, 1980), generalists in nursing provide most of the care for the majority of the people served by nursing. The nurse generalist, prepared at the baccalaureate level, needs to be educated with a comprehensive approach to health care. The document. Standards of Addictions Nursing Practice with Selected Diagnoses and Criteria (ANA, 1988), can assist faculty in developing plans to teach clinical decision-making related to the addictive process.
Curricula organized either in clinical departments or integrated designs can accommodate substance abuse con- 1 tent. For example, in maternal-child nursing departments, care of infants with fetal alcohol and cocaine syndrome can be included in perinatal and neonatal instructional units. Model prevention programs conducted in elementary schools can be site visited by students enrolled in Community Health Nursing courses. Strategies for teaching safe drinking can be incorporated into health promotion content. A clinical learning experience based on an objective about prevalence of alcohol use with adults might consist of a chart review of all clients currently on a specific unit to assess the extent to which nursing histories and assessments include data gathering on lifestyle practices, such as substance use, exercise, and leisure. An accompanying clinical experience could include faculty modeling and student opportunities to practice interviewing skills.
Specialist (Graduate) Education - According to the Social Policy Statement (ANA, 1980), specialists in nursing are experts in providing care focused on specific clusters of phenomena drawn from the range of general practice. Specialization involves adding an organized and systemized body of knowledge and competence within a , discrete area of nursing.
Both graduate education and continuing education programs for faculty and clinicians need to be developed. According to the literature cited above, the current cadre of practicing nurses have limited backgrounds in the field and need to be updated by continuing education in both theory and practice. Similarly, improvement in undergraduate * addiction education will lift the current burden graduate programs carry of needing to offer both basic and advanced content.
There should be little concern for duplication in graduate program content. Advanced physiology courses can be taken in University departments outside nursing. Advanced concepts of addiction nursing need to be offered in all specialty courses. Content can be offered in very innovative ways. For example, in schools of nursing that have nationally and internationally recognized centers, ie, perinatal nursing, women's health care, and family nursing, addiction nursing content could focus on those populations where faculty expertise is established.
Programs should offer theories of personal change, realistic expectations in dealing with clients, families, and communities; and include principles of caregiver support. Finally, the nursing practice of specialists includes collaboration and consultation with other nursing specialties and health professionals who focus on addictive behaviors/ conditions; a needed liaison function (ANA, 1987). The document, The Care of Clients with Addictions, (ANA, 1987 ), will assist faculty in selection of content and teaching strategies.
Plans to evaluate the costs and benefits of curricular change should be developed simultaneously with proposed program changes. Ideally, process evaluations would include changes in attitudes as well as knowledge among both student and faculty.
In summary, this article has argued that substance abuse is a neglected component of nursing education, and discussed factors that may have lead to its currently undervalued status. A reconceptualization of content would shift from a medical to a nursing paradigm. Preparatory to curriculum development, attitudinal and behavioral change must occur in both faculty and students. According to Pelletier and Lutz ( 1988 ), in the coming decades, the most important determinants of health and longevity will be personal choices, and nurses have an opportunity to contribute to this important decision-making process.
- Alexander, B. K. (1987). The disease and adaptive models of addiction: A framework evaluation. Journal of Drug Issues, Winter, 47-66.
- American Academy of Nursing (1986). Setting the agenda for the year 2000: Knowledge development in nursing. Kansas City: American Academy of Nursing, 38-39.
- American Association of Colleges of Nursing (1987). Essentials of college and university education for professional nursing. J Prof Nurs, Jan, Feb, 54-69.
- American Nurses' Association (1980). Nursing: A social policy statement. Kansas City: American Nurses' Association.
- American Nurses' Association 11986). Psychiatric mental health clinical nurse specialists. Kansas City: American Nurses' Association.
- American Nurses' Association (1987). The care of clients with addictions: Dimensions of nursing practice. Kansas City: American Nurses' Association.
- American Nurses' Association and the National Nurses' Society on Addictions (1988). Standards of Addictions Nursing practice with selected diagnoses and criteria. Kansas City: American Nurses' Association.
- Bartek, J., Lindeman, M., Newton, M., Fitzgerald, P., & Hawks, J. (1988). Nurse-identified problems in the management of alcoholic patients. J Stud Alcohol, 49, 62-70.
- Bissell, L. & Haberman, PW. (1984). Alcoholism in the professions. New York: Oxford University Press.
- Burkhalter, P. (1975). Alcoholism, drug abuse and addiction. A study of nursing education. J Nurs Educ, 14, 30-35.
- Fawcett, J. (1984). Analysis and evaluation of conceptual models of nursing. Philadelphia: F.A. Davis, 5-6.
- Fingarette, H. (1988). Heavy drinking. The myth of alcoholism as a disease. Berkeley: University of California Press.
- Flaskerud, J.H. & Halloran, E. (1980). Areas of agreement in nursing theory development. Advances in Nursing Science, 3, 1-7.
- George, L.K. (1980). Role transitions in later life. Belmont, CA: Wadsworth. p. 25-35.
- Hasin, D., Endicott, J., alt Lewis, C. (1985). Alcohol and drug abuse in patients with affective syndromes. Compr Psychiatry, 26 ( 3 ), 283-295.
- Hatsukami, D., Eckert, E., Mitchell, J., & PyIe, R. (1986). Affective disorder and substance abuse in women with bulimia. Psychol Med, 14, 701-704.
- Hoffman, A.L., & Heinemann, M.E. (1987). Substance abuse education in schools of nursing: A national survey. J Nurs Educ, 26, 282-287.
- Holmes, PR. (1975). The many faces of alcoholism. Supervisor Nurse, 6, 16-19.
- Istvan, J. & Matarazzo, J. D. (1984). Tobacco, alcohol, caffeine use: A review of their interrelationships. Psychol Bull, 95, 301-326.
- Johnson, M. W (1965). Nurses speak out on alcoholism. Nurs Forum, 4, 16-22.
- Kim, H. S. (1983). The nature of theoretical thinking in nursing. Norwalk, CT: Ap piéton -Century-Crofts.
- Lacey, JH. & Moureli, E. (1986). Bulimic alcoholics: Some features of a clinical sub-group. Br J Addic, 81, 389-393.
- Marlatt, G. A. (1985). Chapter I1 Relapse Prevention: Theoretical rationale and overview of the model. In G.A. Marlatt and JR. GordonlEds. ),Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. New York: The Guilford Press, pp. 3-70.
- Miller, W.R. & Hester, R.K. (1986). Inpatient alcoholism treatment-who benefits? Am Psychol, 41(7), 794-805.
- Mirin, S., Weiss, R., Solloguh, A, & Michael, J. (1984). Affective disorders in substance users. InS. Mirin (Ed.), Substance abuse and psychopathology. Washington, D.C.: American Psychiatric Press, 57-77.
- Murphy, S.A. & Hoeffer, B. (1987). The evolution of subspecialties in psychiatric and mental health nursing. Archives of Psychiatric Nursing, 1, 145-154.
- Niven, R. (1987). The impact of AIDS on the chemical dependency field. Adv Alcohol Subst Abuse, 7, 3-14.
- Pelletier, K.R. & Lutz, R. (1988). Healthy people- healthy business: A critical review of stress management programs in the workplace. American Journal of Health Promotion, Winter 1988, p. 6.
- Perri, M. (1985). Self-change strategies for the control of smoking, obesity, and problem drinking. Coping and substance use. New York: Academic Press, 295-317.
- Smith, D.E., Milkman, H.B., & Sunderwirth, S.G. (1985). Addictive disease: Concept and controversy. In H. Milkman and H. Shaffer (Eds.), The addictions: Multidisciplinary perspectives and treatments. Indianapolis, Ind., Heath Co.
- Streissguth, A. & Martin, JC. (1983). Prenatal effects of alcohol abuse in humans and laboratory animals. In B. Kissin & H. Begleiter (Eds.), The pathogenesis of alcoholism. Vol. 7. New York: Plenum Press, 539-589.
- Sullivan, E.J (1987). Comparison of chemically dependent and nondependent nurses on familial, personal and professional characteristics. J Stud Alcohol, 48, 563-568.
- U.S. Department of Health and Human Services (1987). Sixth special report to the U.S. Congress on alcohol and health. Washington, D.C., DHHS Publication No. (ADM) 87-1519.