In 1988 the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA) funded three nursing education programs to support curriculum development projects related to alcohol- and other drug-related problems. These demonstration projects were charged with developing a model program for integrating educational modules in alcohol and other drug abuse (AODA) at the undergraduate, graduate and faculty levels. One of these programs, Nursing Education in Alcohol and other Drug Abuse (Project NEADA), was established at the University of Connecticut. The purpose of this article is to discuss the issues of implementation and effectiveness that are critical to the success of curriculum change in substance abuse education.
Given the challenges inherent in such a project, a multifaceted motivational orientation seemed appropriate and provided the most inclusive approach to our work. Drawing from organizational theory and faculty development models (Bennis, Benne, Chinn, & Corey, 1976; Findlay, 1988; Gagne, 1988; Schmahl, 1966; Woods & Shaver, 1992), the following organizational change processes were identified and initiatives were developed to promote them: (1) consciousness raising - developing activities to generate interest and involvement; (2) ownership - encouraging faculty to share responsibility for improving the curriculum in relation to substance abuse issues; (3) feedback - structured opportunities for evaluating progress within the curriculum development process; and (4) communications - information dissemination strategies for external visibility and internal feedback.
One basic assumption held by the program leaders was that for this to be a successful curriculum project, there must be a feeling of "ownership" by the faculty. If something was to be taught, it would have to come from the unilateral support of the faculty who would teach it.
Firmly believing that the participation of all faculty members was crucial to the goal of faculty ownership, the leaders concluded that the process, not the product, was the uppermost consideration in the initial development of the project. In addition, it was acknowledged from the beginning that we were not in the business of preparing a specialist in Addictions Nursing. Integration was emphasized and all nursing courses ultimately were seen as potential candidates for module development in the model curriculum.
From the beginning of Project NEADA two approaches to the implementation of curriculum changes were considered. The first can be described as a "top down" approach in which senior administrators recommend to faculty the circumstances and conditions of integrating substance abuse curriculum changes into their ongoing instructional and clinical programs. The second approach to implementation is a "bottom up" procedure in which faculty are asked to participate in the process of planning new curricula and devising ways to integrate substance abuse instruction into the curriculum. Although Project NEADA initially attempted to test the bottom up approach to curriculum change, a third approach emerged that combines the best elements of each. This can be characterized as a "catalytic" approach in which key faculty take responsibility for serving as role models, facilitators, and implementors while at the same time remain sensitive to the concerns and needs of those faculty who are less interested or involved.
Faculty Development Activities
The NEADA faculty development model viewed curriculum innovation as a dynamic process of attitude change, skills training, and consensus building, all leading to the promotion of substance abuse education for nursing students. The mechanisms for conducting the faculty development process included establishing a working group of interested faculty; conducting faculty and student surveys of attitudes, knowledge and skills; organizing faculty workshops to provide exposure to new concepts and scientific findings; using the workshop and other forums (e.g., faculty meetings) to feed back to faculty the results of the surveys; involving faculty in skills training workshops; and working with individual faculty and administrators to overcome barriers to the implementation of curriculum change.
The heart of the Project was an interdisciplinary Working Committee, composed of both academic and clinical faculty from the School of Nursing, the University and from the larger community. The committee's 25 members included a pharmacologist, a nutritional expert, a psychologist, media specialists, representatives from the Academic Advisory Center, and graduate students. Members participated in subcommittee activities devoted to specific tasks in the development of the various learning modules.
It is important to note that the Working Committee represented an interdisciplinary, grass roots effort. Working from the "bottom up," most participants contributed their time voluntarily out of concern and interest. They were given a great deal of freedom to create and develop their ideas. In addition to attending monthly meetings of the Working Committee, many joined smaller task groups that met between meetings.
The committee was organized early in the project as a mechanism for planning the curriculum modules, catalyzing faculty acceptance, overcoming resistance to change, and providing support, encouragement, skills and resources to faculty who wished to become active in substance abuse education. Guided by the core project staff the Working Committee met on a regular schedule throughout the 2-year development process. It consisted of both nursing school faculty and outside consultants who often served as resources for facultyinspired curriculum initiatives. Although there was considerable turnover in the membership of the committee, faculty participation was uniformly high throughout the project despite a number of obstacles. Problems included no release time for interested faculty to participate, lack of interest on the part of some key faculty, perceived competition for scarce curriculum time, lack of expertise in substance abuse, and outright resistance by some faculty who chose not to engage in an open discussion of substance use.
These problems were overcome by developing an esprit de corps within the committee through informal working meetings, the organization of two successful faculty workshops, sponsorship of monthly colloquia, the generation of interest through the faculty surveys, and the frequent dissemination of useful information in monthly mailings. Faculty workshops were a key element in maintaining involvement in the curriculum change process.
Early in the project an "Addictions Update" workshop was organized to provide an opportunity for School of Nursing Faculty and other interested professionals to learn more about addictive disorders and to consider the role of substance abuse education in the nursing curriculum. The three keynote speakers focused on coming to terms with substance abuse, definitional issues, and nursing's response to the challenge of addiction. Roundtable discussions were devoted to faculty development, continuing education, and curriculum needs in the areas of undergraduate nursing education, nursing administration, primary community care, perioperative nursing, critical care nursing, and neonatal/ maternal child health. The first workshop was attended by 50 participants, including 25 faculty.
Given the success of the first Addictions Update workshop, a second conference was held and attended by 45 people, approximately half of them involved in nursing education.
A major objective of the project was to develop a curriculum module to teach new techniques for screening, diagnosis and early intervention. In order to prepare faculty to teach these techniques, a 3-hour workshop was held at the University's Counseling Center. The workshop was conducted by a psychologist, a nurse, and a substance abuse specialist, all members of the Working Committee. The workshop consisted of preparatory readings, a didactic presentation, a simulated patient interview, role playing exercises, small group discussions, and a written evaluation by participants. The workshop was designed to introduce important concepts, and to evaluate the ways in which screening and brief intervention can best be taught to undergraduate nursing students. Faculty were particularly interested in the feedback obtained from participants regarding the effectiveness of the teaching procedures (e.g., lecture, role play exercise, simulated interview, etc.), and how these might be improved for classroom application.
Following this exercise members of the Working Committee developed a script for an instructional video that was filmed at the end of the project. The experience gained during this phase was used to develop an Instructor's Guide for the training video that can be used along with the curriculum materials (McRee, Babor, & Church, 1991) with a minimum of training and supervision.
A faculty survey of knowledge, attitudes and beliefs was conducted early in the project. The results were reported to the onsite nursing faculty as part of the faculty development process. The survey provided useful information to guide additional faculty development efforts, and also served as a means of building consensus in favor of curriculum change.
The modules developed out of this process (Church, Fisk, & Neafsey, 1991) were piloted, evaluated, and revised with the expectation that the end-products would be as flexible and adaptable as possible. The modules are freestanding yet integratable, and include instructor's guides and suggested teaching aids. In addition, video "trigger tapes" were developed for teaching about addiction to drugs other than alcohol, as well as a videotape on screening and early intervention.
The premise that the mission of undergraduate education in nursing is to prepare generalist practitioners was basic to our considerations in developing the three undergraduate modules. The modules can be used separately in individual courses, or together as a package in a single course. They address the essential knowledge and skills for primary, secondary and tertiary care levels for clients in a variety of healthcare settings, including identifying and supporting impaired colleagues.
At the graduate level, the modules focus on the recognition and management of issues related to AODA, in particular, specialty areas within nursing education (i.e., Primary Community Care Nursing, emergency/critical care, nursing administration).
The Post Baccalaureate Core Module was designed for all graduate students regardless of their specialty. It is a synthesis of the three undergraduate modules and is intended to provide a foundation for each of the graduate level specialty modules. This module also serves as a foundation for continuing education. The two faculty development modules were developed as a direct result of the experience gained and information collected from the faculty development activities described above.
Barriers and Breakthroughs
Project NEADA was guided from its inception by both a formative and summative evaluation process. Formative evaluation produces information that is fed back during the curriculum development process to help improve it. Summative evaluation was done after the curriculum modules were completed to provide information about effectiveness to those who would consider using them. The following procedures were employed: (1) workshop evaluations; (2) surveys of attitudes, knowledge and skills among nursing faculty and students; (3) student evaluations of specific curriculum modules; (4) process analysis of curriculum implementation.
The survey data collected early in the project from an anonymous self report questionnaire, indicated that faculty saw an active role for nurses in the management of substance-abusing patients. They believed that nurses can be effective, and had positive attitudes about the patients themselves. Nevertheless, they perceive some obstacles to nurses' effectiveness, such as patients feeling ill at ease about providing information and talking about their problems. Finally, the faculty seemed to be genuinely interested in developing a better knowledge base about substance use disorders, were interested in faculty development in these areas, and saw a clear need for curriculum changes regarding the teaching of topics related to substance use.
The results of a related student survey suggested that student nurses prefer alcohol- and drug-dependent patients significantly less than other kinds of patients. They also had a somewhat ambivalent concept of the substance-using patient in terms of such critical features as motivation, maturity and prognosis. Nevertheless, like the faculty, students saw an active role for nurses in the management of substance-abusing patients, felt that nurses can be effective, and had positive attitudes about the patients themselves. They too perceived obstacles to nurses' effectiveness, such as patients feeling reluctant to talk about their problems.
In addition to the surveys, students were asked to evaluate several of the new modules to measure how the curricula affected attitudes, knowledge, skills and perceived self efficacy. The results suggest that the curriculum modules are associated with significant changes in competence (self-efficacy), and they were generally perceived as useful to the students' needs.
Another component of the evaluation was designed to study the faculty change process that leads to the successful implementation of a model substance abuse curriculum. Process analysis was used to identify the obstacles to successful curriculum change, and the techniques that could be employed to overcome resistance and to involve faculty in alcohol and drug abuse education. A combination of quantitative and qualitative procedures was used to produce the faculty development modules. These modules were designed not only to show how to use the model curriculum, but also how to improve its chances of acceptance by faculty.
In the course of the first year of Project NEADA, a number of obstacles were identified as potential threats to successful curriculum change in any educational institution. These include competition for scarce resources, limits on faculty time, sensitivity to substance abuse issues, and denial of substance abuse problems among faculty and students. These obstacles must be overcome if nursing faculty are to incorporate substance abuse content into their courses. The main processes found to be effective were the consensus-building activities such as the Faculty Survey, professional development activities designed to familiarize faculty with substance abuse issues, and workshops devoted to skills development. These procedures were incorporated into the Faculty Development modules.
The evaluation of Project NEADA indicates that considerable progress was made toward the implementation of this model substance abuse curriculum. Both quantitative and qualitative data were collected to inform the decision-making process and to identify obstacles that would affect faculty change.
Although we were not able to compare the top down and bottom up approaches directly, it appears from the initial resistance to Project NEADA that curriculum change can be very difficult in the area of substance abuse. It is clear that the mere availability of curriculum materials may not suffice to persuade faculty to incorporate substance abuse issues into the ongoing evaluation of nurses. The evaluation results indicate that while students and faculty have an appreciation of the importance of substance use disorders in their work, they will be reluctant to allocate time to the curriculum unless they are actively involved in the planning process.
Key faculty members were active in the planning process and communicated their enthusiasm to other faculty through formal and informal channels. As a result, there was a remarkable change in the general faculty's acceptance of the project, and in their willingness to cooperate with the evaluation of the curriculum modules. In the second year of Project NEADA there was considerably less resistance by faculty and much greater interest in substance abuse issues by both faculty and students.
Project NEADA identified a number of activities that may be useful in the facilitation of change. These include the student and faculty surveys, faculty development workshops and the Working Committee process. Perhaps the most important leasons learned is that faculty development needs to receive as much attention as the curriculum plan itself
The results suggest that at least two areas of nursing education need to be considered in relation to the application of substance abuse knowledge to routine health care practice. The first is a mastery of skills and knowledge pertaining to the identification and management of substance use disorders. The second is the inculcation of a different set of attitudes and values that help to define the role of the caregiver.
In the area of facts and competencies, it is important to emphasize that the education of nurses in recognition and management of substance abuse should take the form of both didactic and experiential learning. In addition to concepts, screening procedures, and counseling skills, it is extremely important for students to practice these skills using techniques like role play exercises and interviews with simulated patients. Particular attention should be devoted to modeling the various elements of effective counseling, such as personalized feedback, empathie communication, motivational interviewing, and mutual participation in the intervention plan.
The second component of nursing education necessary for the advancement of care for substance abuse patients is the socialization of nurses in a way that makes them more effective behavior change agents. There is probably no one course or practicum that can socialize nursing students into the role of patient-oriented nurses. Faculty role models are needed here. As the findings from Project NEADA suggest, such role models can be created through faculty development exercises distributed over several academic years.
In a recent article based on a survey of 298 nurses, Long and Gelfund (1992) concluded that both the basic nursing curriculum and continuing education programs should provide more time and attention to the problems of addiction. The educational deficits of teachers and students alike must be addressed if the gaps in such knowledge are to be effectively filled. Further, the authors believe that the responsibility for integrating information related to substances of abuse and their impact on the nation's health should be shared by all educators everywhere.
Perhaps the most significant finding from Project NEADA is the importance of consensus building and the need to allow time to move toward a collective approach to substance abuse education. It has been said that: "... ideally, the change-agent should combine in some measure the wisdom and sense of perspective of the historian and the penetrating acumen of the scientific observer, while putting into practice the skills and arts of appropriate and resolute action" (Bennis, Benne, Chinn, & Corey, 1976). As change-agents, participants in Project NEADA attempted to transform their awareness into action In the process, they developed a collégial approach to relevant curriculum integration that could serve as a model for other professional faculty.
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