In recent years, books on the assessment, treatment, and relapse prevention in the abuse of alcohol, drugs, and other addictions have been published (Donovan & Marlatt, 1988; Hester & Miller, 1989; Marlatt & Gordon, 1985). These volumes have filled an important gap for both students and clinicians by providing empirically based directions for specialized aspects of clinical practice. However, no texts or compilations of readings offer a comprehensive graduate level foundation in addictive behaviors from either a multidisciplinary or nursing perspective. This article describes the development of a theory- and research-based collection of readings and a course designed to meet this need.
Although the course book of readings was developed for master's and PhD degree students in nursing, it could be easily adapted to graduate students in other health and behavioral science disciplines. In this article, "substance abuse* is defined as the misuse of alcohol, tobacco, and prescribed drugs, and the use of illegal drugs. "Addictive behavior" is defined as the repeated cognitions and actions used to obtain substances that induce mind-altered states of being despite the fact that negative effects experienced outweigh positive effects experienced (Hatterer, 1982).
A review of the literature including current textbooks indicated that course development pertaining to addictive behaviors has not kept pace with the scope of the problem. For example, nurses commonly encounter clients with actual or potential substance abuse problems, but are ill-prepared to assess clients and intervene effectively (Bartek, Lindeman, Newton, Fitzgerald, & Hawks, 1988). Students in nursing receive little or no academic or clinical preparation regarding addictive substances in their basic educational programs. Hoffinan and Heinemann (1987) contacted 1,035 schools of nursing in the United States regarding undergraduate curricula in substance abuse. Their findings are consistent with data reported by nurse clinicians: Undergraduate curricula typically offer 1 to 5 hours of required instruction over a 3- or 4-year enrollment period. Content is primarily definition/description of phenomena. Thus, students enrolling in graduate programs have minimal knowledge and clinical experience pertaining to addictive behaviors.
Reports pertaining to graduate education are even more abysmal. Currently, few graduate programs offer courses pertaining to drug and alcohol abuse and the consequences of use (Murphy & Hoeffer, 1987). Thus, available data suggest an extreme imbalance between academic preparation of nurses in substance abuse content and the competencies expected of them to assume clinical practice and leadership roles, particularly at the graduate level. Advanced learners are preparing for roles in education and administration as well as clinical practice. Therefore, courses designed to meet career goals of advanced learners need to include content based on individual, familial, and societal consequences of the use of addictive substances; principles of prevention and early case-finding; current treatment issues, such as matching patients to treatment options; and regulation and control of substances. These issues can be addressed theoretically by the biopsychosocial approach, which is well accepted in nursing education.
Theoretical and Empirical Rationale for the Course Content
The learning experiences described in this article are based on the integration of two research-based models of addictive behavior. The first is a multi-dimensional causal model published by Huba, Wingard, and Bentler (1980). The second is a process model published by Prochaska and DiClemente (1984) (Figure).
Huba et al. (1980) identified four constellations of intraand extra-individual interactive causal factors that affect drug-taking behaviors. These four constellations or domains are: biological, intrapersonal, interpersonal, and sociocultural. Within each domain, several factors have been identified as positive or negative influences of drug-taking behavior. For example, in the sociocultural domain, environmental stress and product availability may interact with genetic factors in the biological domain and with cognitive and perceptual factors in the intrapersonal domain. Educational implications of the model as suggested by Huba et al. (1980) are that: (1) initiation of drug use does not involve recognition of a singular path; (2) the phenomenon of drug-taking is complex and crosses knowledge development and utilization which involves many disciplines; and (3) linkages among factors may suggest how treatment works.
Prochaska and DiClemente (1984) studied both addicted and nonaddicted persons. From empirically derived findings, a process of behavior change was identified that consisted of four phases: precontemplation, contemplation, action, and maintenance. The precontemplation phase is characterized by denial or unawareness in the substance user. However, family members and others see the problem and begin to lose patience with the abusive substance use in this phase and may even organize an intervention to get the person into formal treatment. The second phase, contemplation of change, is characterized by awareness of the problem, but with resistance to making change (stopping use). Addicted persons may stay in this phase indefinitely, i.e., "I'll quit tomorrow." The third phase, decision and action for change, is the most brief and is characterized by planning and initiating change. The final phase, maintenance, is the most difficult. Relapse rates range from 60% to 90% in persons who have had formal treatment (Marlatt & Gordon, 1985). Taken together, the Huba et al. causal model and the Prochaska and DiClemente process model provide direction for course development pertaining to addictive behaviors.
Advantages for the Teaching/Learning Process
Causal and process models of addiction have several advantages over disease and moral models of substance use described in the literature (Brickman et al., 1982). First, clinical data suggest that clients who seek substance abuse treatment are likely to be addicted to more than one substance simultaneously. Since the process leading to treatment, maintaining abstinence, and experiencing relapse are similar regardless of substance, these frameworks provide an opportunity to discuss many addictive substances, rather than a single one, which is commonly alcohol abuse or dependence. Second, the disease model can be a potentially confusing framework for students new to the study of substance abuse because of the paradox it creates around control issues. Nursing generally takes the position that the client has control over decision/choices pertaining to health care. However, to be addicted is to be out of control. The same paradox arises again when treatment options are taught and discussed. Psychotherapy promotes client attributions of internal control whereas 12-step models such as Alcoholics Anonymous, Narcotics Anonymous, and Overeaters Anonymous, suggest one must "give up control to a higher power." A course organized around causal and process models can debate all these issues without conflicting conceptual approaches.
The course and course reader, developed and implemented in 1988 by the author, replace a prior offering. The 3-credit-hour course prepares enrollees for two distinct options: (1) students can enroll in the course as a prerequisite for two clinical courses that follow, providing depth in addictions nursing knowledge and clinical practice; or, (2) students can enroll in the course to obtain background for their studies in other departments, providing breadth of knowledge. For example, students gain understanding of consequences of alcohol and drug abuse in pregnancy in the substance abuse course, which better prepares them in perinatal nursing, part of the degree requirements in another specialty.
Pattern of organization
The 10-week graduate course consists of four units of study: Overview of the Addictive Process, Transition from Use to Abuse, Cessation of Substance Use, and Maintenance of Cessation. Each unit has objectives to be achieved. Assigned readings consist of current research, conceptual issue papers, and documented reports. A variety of in-class learning experiences are offered and include guest lectures, media presentations, and various methods of discussion. A revised set of readings is created each year, which provides discussion of both classic and contemporary issues. Two basic textbooks are recommended for students enrolled without prior study of substance abuse.
Unit I, Overview of the Addictive Process, presents a life-cycle approach to the initiation of substance use. Objectives for Unit I are to compare and contrast various conceptual models of addictive behavior, to identify prevalence of substance use across age and ethnic groups, and to analyze relationships between early and later exposure to and use of addictive substances. The life span approach provides an opportunity for students to become cognizant of the extent and array of addictive behavior and the consequences of single or poly drug use.
Students are introduced to the intergenerational transmission of alcoholism through examples of research such as adoptive and twin studies (Goodwin, 1974) and behavioral trait studies (Tarter, 1988). Ethical issues are also introduced; for example, students read a paper by Becker and Burke (1988) entitled "Neonatal drug addiction: An analysis from two moral orientations."
In Unit II, Transition from Use to Abuse, the goals are to analyze risk factors associated with substance abuse; to differentiate among factors contributing to use including genetic, biophysiological, psychological, and environmental factors; to examine multiple approaches to assessment of addictive behaviors; to describe physiological, neurochemical, immunologie, and psychological human responses to singular or polydrug use; to describe health and social consequences of substance abuse at three levels of analysis, i.e., individual, family, and societal; and to list specific nursing actions aimed to prevent or reduce negative consequences of use. In this unit, students read sections of the latest special report to the United States Congress on alcohol and health, research reports on expectancy and craving, identify diagnoses, review and critique assessment tools and techniques, and delineate adverse consequences of substance abuse as they affect the family, community, and society.
In Unit III, Cessation of Substance Use, the objectives are to describe major theoretical approaches of interventions, to analyze conceptual issues related to recovery from addiction, to compare and contrast various treatment strategies for addictive behaviors, to propose ways to individualize treatment, to analyze professional attitudes toward addiction, to describe characteristics of impaired nurses and alcoholism counselors, to analyze the concept of caregiving in addictive populations, to identify support mechanisms for addiction nurses, to examine multidimensional models of treatment evaluation, and to describe methodological strengths and weaknesses of past program evaluation efforts. In this unit, students are exposed to controversial topics including spontaneous remission, i.e., "self-quitters," (Stall & Biernaki, 1986), controlled drinking (Hester & Miller, 1989), the value of inpatient versus other treatment settings (Miller & Hester, 1986), research regarding the cost-effectiveness of various types of treatment (Emrick, 1987), codependency, and alcohol and drug problems among nurses.
In Unit IV, Maintenance of Cessation, the goals are to describe the maintenance phase of cessation; compare definitions of "relapse" proposed by disease, moral and behavioral models of addictive behavior; to discuss factors likely to lead to relapse; and to analyze assessment and skill training strategies used in relapse prevention protocols. In this unit, students critique research and clinical programs of skill development to prevent relapse. For example, students have an opportunity to examine questionnaires designed to assess the degree of confidence clients have in refusing alcohol in high-risk situations, such as meeting a drinking friend unexpectedly and being asked to go to a familiar bar.
The course has been evaluated by both students and peer faculty each time it is offered. Both formative and summative evaluation procedures are used. The goals of the course units appear in writing and are reviewed at the beginning of the course as well as at the beginning of each unit. A verbal evaluation by the professor is conducted at mid-term. On completion of the course, students submit anonymous written evaluations to the University Academic Assessment Center for analysis. Results are reported to the professor in both closed-ended and openended format. Peer evaluation has been conducted in two ways: with a peer expert professor attending classes and with a peer review of all course materials. Feedback is given verbally and in writing using forms approved by department faculty. The course has been evaluated very favorably by graduate students in all departments in the school of nursing as well as by graduate students in other schools in the university.
Implications for the Preparation of Specialists in Addictions Nursing
In a general way, the course meets criteria for the development of scholars in nursing. The course combines various types of inquiry, i.e., ethical, personal, empirical, and esthetic (Carper, 1978); encourages critical thinking and active participant learning; and requires a synthesis of complex content. A limitation is that the course emphasizes deductive rather than inductive reasoning. However, when students enroll in the course, they do not have a grasp of either the theory or research in the field. Concurrent clinical experience may encourage more inductive thinking.
More specifically, students are exposed to several perspectives, i.e., causal and process models of addiction, and disease, moral, and cognitive frameworks. Such an approach serves some important needs. First, it is thought that children of alcoholics (COA) are overrepresented in nursing. That is, COA may gravitate toward the health professions because of dysfunctional family backgrounds and the need to try to understand these family dynamics and themselves. The variety of perspectives offered in this course allows students to choose explanations they can accept, depending on personal circumstances. Second, many treatment facilities where students go for clinical experience are based on traditional medical models of care.
The course described in this article provides a common language for multidieciplinary effectiveness, yet challenges nursing students to become innovators and leaders through knowledge and skill development.
Substance abuse education for graduate students in nursing is in the beginning phase. No current textbooks exist that consider multidisciplinary as well as nursing perspectives. This article described the development of a course based on a biopsychosocial model of addiction that draws primarily from current research findings to substantiate knowledge needed for addictions nursing practice.
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