There is a critical need for nurses and nursing faculty to be competent and to recognize and care for clients with substance abuse disorders, one of today's major health care problems, Until recently few schools of nursing offered comprehensive content on the topic with the result that many nurses lack preparation to meet this significant challenge in their practice settings. Developing faculty expertise and enhancing nursing curricula are important strategies for improving future practice but are only a partial solution to overcoming the educational deficit in current practice and to enhancing nursing's overall contribution in the area of substance abuse. Carefully planned collaborative links between education and practice settings are needed to create a learning environment that fosters confident, responsible practice. The intent of this article is to outline progress toward improving nursing competence in substance abuse practice and to suggest reality-based learning strategies as a future direction for this important goal for nursing education. Two successful models of collaboration between education and practice, designed to augment basic curriculum and improve nursing knowledge, skills and attitudes related to alcohol, tobacco and other drug (ATOD) abuse are described. The first, a project at the University of Illinois at Chicago, encourages nurses in hospital and clinic settings to recognize ATOD abuse in the general acute and primary care client population. The second, a nurse-managed clinic established by the University of Texas Houston Health Science Center School of Nursing, provides an opportunity for students and faculty to do primary care with a population of recovering addicts.
Need for Nursing Education in Substance Abuse
Alcohol, tobacco and other drug abuse continue to threaten the health and socioeconomic welfare of the American people despite major legislative, law enforcement, therapeutic, and educational efforts to prevent and treat these problems. There are more deaths and disabilities from substance abuse than from any other preventable cause. One in four of the two million deaths in this country each year is attributable to alcohol, illicit drug or tobacco use (Substance Abuse, 1993). An estimated 20% to 50% of all hospital admissions are alcohol-related and alcoholism and drug addiction, taken together, are now the third leading cause of death in the United States (Bowen & Sammon, 1988; Bush, Shaw, Cleary, Delbanco, & Aronson, 1987; Moore et al., 1989; Tweed, 1989). Cigarette smoking, the major manifestation of nicotine addiction, causes one in six deaths in this country (U.S. Department of Health and Human Services, 1989). Morbidity and mortality rates are frequently only estimates. The full impact of addictive disorders on health is virtually incalculable. Addictive disorders are often undetected, underreported, or overshadowed by accompanying illnesses. In addition, the deleterious effects of substance abuse extend beyond the individual and contribute to an ever widening circle of family dysfunction and destructive social consequences.
Substance abuse, undeniably one of the nation's most significant public health problems, is encountered by nurses in all practice arenas. Despite the extent of the problem within nursing's purview, nurses indicate that they are not adequately prepared to prevent, recognize, or treat these disorders. A national survey by Hoffman and Heinemann (1987) documents the limited number of hours of instruction in substance abuse in schools of nursing. One to five hours of ATOD use/abuse content was typical for the 336 schools in the sample (36% response rate). The content is usually presented in psychiatric-mental health nursing courses. Murphy (1989) stated that nurses consistently report a lack of preparation to care for clients with addictive disorders. She urged reconceptualization of the problem and curricular revision.
Progress Toward Increasing Nursing Competence in Substance Abuse Practice
Progress is being made. Mechanisms are now in place to alter the imbalance between academic preparation and society's need for nursing competence in this area. The American Nurses Association (ANA), the Drug and Alcohol Nursing Association (DANA) and the National Nurses' Society on Addictions (NNSA) published a definitive monograph entitled The Care of Clients with Addictions: Dimensiona of Nursing (ANA, DANA; NNSA, 1987). This document set forth the standards and criteria for safe, competent practice with addicted clients throughout the health'illness continuum. The NNSA published Nursing Care Planning with the Addicted Client (Jack, 1989, 1990a) and The Core Curriculum of Addictions Nursing (Jack, 1990b). Guidelines in these pubUcations prescribe nursing actions for caring for addicted clients and their families. Recognition of addiction nursing as a specialty was enhanced by administration of the first Certified Addictions Registered Nurse (CARN) examination in December 1989. The examination, developed with expertise from the National League for Nursing, is offered by NNSA. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NTDA) sponsored the development of disciplinespecific model curricula for medicine and nursing and are currently sponsoring faculty development initiatives for schools of medicine, nursing, social work, and psychology. Eleven schools of nursing, including the University of Illinois at Chicago and the University of Texas Houston Health Science Center, have received grants from NIAAA/NTDA and the Center for Substance Abuse Prevention (CSAP) to provide a national cadre of faculty with ATOD abuse expertise and enhance nursing curricula in this area (Gerace, Sullivan, Murphy, & Cotter, 1992). Clearly, with the development of practice standards, model curricula, and a certification process, and through faculty development initiatives, the foundation for nursing competence in substance abuse is now in place. The next critical step is to establish collaborative links with practice settings, links that assure that requisite learning is reality-based and in step with the future of health care.
Suggested Future Directions
In making the case for a new paradigm for nursing education, one that accepts the concept of health as more than the absence of disease and as a personal responsibility, Lindeman (1992) notes that learning experiences for nurses should be based in the larger social context and include community-driven health care which may not always be led by health care providers. She states that nurses must have skills in working with families of all ages and configurations and with communities "because attitudes and behaviors regarding health practices are learned and reinforced" within those contexts (Lindeman, 1992, p. 294). Health promotion and disease prevention, features of a reformed health care system, require that nurses have skills in primary care, skills that can best be acquired if learning experiences are located in social reality. Bevis (1989), Reilly and Oermann (1992), and deTornyay (1992) stress the importance of reality-based learning for nursing education. Reilly and Oermann (1992) state that "the emphasis of the reality dimension on the clinical problem rather than the setting is significant" (Reilly & Oermann, 1992, p. 5). When the clinical problem is substance abuse, given the prevalence of that problem, reality-based learning can occur in virtually all practice settings. If the outcome is to assure that nurses in all settings will recognize substance abuse, this learning can and should be fostered in any social context. If the goal is to assure that nurses develop confidence in caring for recovering addicts then some learning experiences should be situated within an ATOD treatment context. Both outcomes are needed to assure the level of competence required to address this practice challenge.
A Humanistic-Behavioristic Paradigm
Munhall (1992) notes that nursing is both a practice discipline, based on pragmatism, and a human science, rooted in existentialism. She suggests that nursing curriculum, in reality, requires an overarching paradigm that includes behaviorism and humanism rather than one that represents a shift from one to the other. Such a paradigm is realistic and highly desirable for clinical practice with substance abusing clients. Addressing this problem in nursing settings requires knowledge, skills and attitudes that permit a nonjudgmental approach to clients in any health care context. Nursing curriculum for this sensitive area must be, at once, grounded in behaviorism, which sets forth prescribed responses to predictable symptoms, and humanistic to allow for exploration of the meaning of the experience to individuals. Nurses must develop competence in designing and carrying out care plans related to addiction and, at the same time, acknowledge the individualistic and unpredictable nature of the human condition.
A Curriculum Model
Holding that nursing education for ATOD abuse competence requires a humamstic-behavioristic curriculum, situated in social reality, the authors acknowledge the critical importance of collaborative links or partnerships with health care agencies and the community. A curriculum model is suggested that builds on a foundation of humanism, behaviorism, and relevant knowledge in the substance abuse field, is shaped through collaborative linke to practice realities, and results in competent nursing responses to alcohol and other drug abuse in society. The Figure illustrates the curriculum model. Concepts and content related to substance abuse, addressed both from the pragmatic and existential viewpoints, form the foundation for learning. Recognizing signs and symptoms of the various classifications of substances of abuse, managing detoxification, making referrals, and supporting clients in recovery constitute appropriate behavioral responses to addictive disorders. Analyzing the stigmas, denial, and shame that accompany the psychosocial aspects of addiction contribute to understanding of the meaning of the experience for addicted individuals. Nurses and student nurses are introduced to this complex clinical problem, and the expected responses, through didactic experience, lectures, seminars and role playing. Collaborative links to client populations then become processes for assuring that learning is based in reality. Learners experience the clinical problem in a variety of settings. It is through the context of social reality that the two components of the overarching paradigm can come together to achieve the outcome and to define professional practice with addictive disorders, "...a deliberately planned sequence of action carried out by highly skilled individuals in response to particularized needs of clients" (Reilly Sc Oermann, 1992, p. 3). Two models for establishing the collaborative link« for reality-based learning that are crucial to curricular success and competent practice are described below. The first example, The Partnership Model, emphasizes recognition of ATOD abuse potential in all hospitalized clients. The second example. The Nurse-Managed Clinic Model, addresses the importance of developing confidence in caring for individuals in recovery.
Figure. Curriculum model for reality-based learning in alcohol, tobacco and other drug abuse (ATOD).
The Partnership Model
In collaboration with the ongoing faculty development program at the College of Nursing, the purpose of the hospital project, or Partnership Model, at the University of Illinois at Chicago is to expand the level of clinical nurses' knowledge and skills in ATOD abuse. Specifically, the program is aimed at improving recognition and screening skills, as well as developing skills in brief intervention, giving clients feedback and education about substance use and referring them to appropriate resources. An additional aim is to develop hospital policies and protocols related to the care of clients who have ATOD abuse problems.
Initially an mterdisciplinary hospital steering committee was formed in the targeted hospital. Membership includes key individuals who can facilitate change within the hospital, including nurses in leadership positions in the institution, two nurse faculty members from the College of Nursing, a physician with ATOD abuse expertise, a social worker, and a doctoral student with ATOD abuse expertise. The steering committee advises, facilitates and monitors the program.
Next, a core group of nurses, one from each hospital unit and clinic, was enrolled to participate in a three-year ATOD abuse educational program. Nurses recruited were 35 clinical specialists and educators, nurses in advanced clinical tracks in the system. One-third of the nurse participants have advanced degrees and over half have more than 10 years of nursing experience. This core group participated in pre-testing as part of a longitudinal evaluation plan. Baseline data included measures of the nurses' substance abuse knowledge and attitudes and a description of prior clinical experiences with substance abusing clients. In addition each in-depth training session is evaluated by participants and monitored by individuals from the steering committee.
The actual educational experience consists of two fullday workshops each year for three years. The workshops provide didactic and experiential learning as well as clinical skills practice. They are learner-centered in that they are developed in response to identified educational needs of the nurses. For example, when initial observations and other data suggested that negative and stereotypical attitudes constituted a major barrier to identification of and interventions with substance abusing cuente, recovering cuente from various walks of life were invited to participate in the workshops. Given an opportunity to question cliente about their recovery and how health care professionals influenced that process, the nurses reported feeling less angry, overwhelmed, and helpless to intervene.
Outcomes of the Partnership Model, evident among the nurses as well as the faculty participants, are practical and varied. The nurses report that sessions with recovering individuals lead to a more realistic notion about their rolee related to ATOD abuse in general practice settings. They began to recognize that they could not realistically solve every substance abuse problem and "cure" every client. However, nurses can and should screen clients for ATOD abuse and "plant seeds" by providing cuente with concerned feedback about their substance use and education about helpful resources when indicated. Another outcome of the model is that two nurses at the hospital contacted Alcoholics and Narcotics Anonymous and requested that they start chapters at the institution. The nurses are now educating staff and medical residente to refer clients to these self-help groups. Moreover, several nursing units have incorporated ATOD use/abuse screening questions into the nursing admission assessment on their units. Nurses have also developed prevention bulletin boards and placed educational materials in clinics. Preliminary data indicate that an increasing number of nurses are indeed counseling clients about substance use, providing brief interventions and referral as appropriate. Scores on post-tests of knowledge, skills and attitudes also reflect the significant gains.
As a result of the collaborative link with clinical nurses, College of Nursing faculty involved in the Partnership Model, now have a reality-based notion of what substance abuse screening and intervention content should be part of the nursing curriculum. They know that it is crucial to address the complexity of substance abuse by teaching specific content, developing clinical skills and fostering constructive attitudes necessary to approach clients in a nonjudgmental manner. Reality-based learning has enabled both college faculty and hospital nurses to move toward confident, competent practice related to ATOD abuse encounters in clients in the general hospital setting.
The Nurse-Managed Clinic Model
In 1983, the University of Texas Houston Health Science Center School of Nursing established a nursemanaged clinic at Cenikor Foundation, a residential therapeutic community for adults who are recovering from substance abuse. Cenikor is a well-established treatment program which has been in existence for 25 years. The initial purposes of School of Nursing intervention at Cenikor were: 1) to provide selected health services such as screening, referral, health maintenance, and education to Cenikor residents, and 2) to provide faculty with an outpatient site for increasing skills in interviewing, physical assessment, and client education. Nursing faculty formed a unique partnership with Cenikor staff to enhance health surveillance, health promotion and education for recovering addicts and to create a practice site in primary care for faculty.
Once the program was established, contact with Cenikor was expanded to include undergraduate and graduate students. Each semester eight to ten undergraduate students in the clinical practicum in community health nursing meet some of their course objectives in this setting. They carry out an "aggregate process," or community nursing process, which requires comprehensive assessment, planning, intervention and evaluation in a defined community. In this context, Cenikor is the community, a community of approximately 165 individuals who are in a two-year recovery program. Interventions include implementation of a health education curriculum for this at-risk population, the design of a specific women's program to meet the unique needs of recovering women, immunization programs, and mock disaster drills. Undergraduate students also participate in primary care activities in the clinic either as a part of community health nursing or, on occasion, as a part of the health assessment course.
Graduate students use the setting for practical experience in the nurse practitioner courses and for thesis research in ATOD abuse. Cenikor residents regularly participate in the substance abuse elective course by describing their experience as part of a panel of recovering individuals.
The overall educational benefits of these interactions are significant. Students learn first-hand to assess the physical and psychosocial manifestations of ATOD use/abuse. They develop ease in communicating with and understanding this population and they learn to recognize the signs and symptoms in other populations. Perhaps of greatest benefit is the fact that they gain an overall understanding of the real and immediate impact of ATOD abuse on health care and on society as a whole.
Faculty involvement at Cenikor was initially a voluntary, community service endeavor. It soon became clear that more comprehensive health care was needed and that the services of a nurse practitioner would be ideal. Cenikor clients were regularly referred to the county hospital, thus interrupting their treatment and that of a "buddy" who was required to accompany the ill or injured resident. There is often a long wait at the hospital as many non-emergent illnesses are seen there. A study of illnesses and injuries among Cenikor residents over a two-month period revealed that 50% could have been managed by a nurse practitioner. In the spring of 1988, a proposal was written to provide a part-time nurse practitioner for the Cenikor facility. Cenikor staff were unfamiliar with the scope of practice for nurse practitioners so a job description was outlined as follows:
1. Provide comprehensive intake histories and physicals with referral to the physician as needed.
2. Establish and maintain health/illness records on all residents.
3. Perform risk analyses based on past health histories.
4. Provide general health surveillance and consultation.
5. Participate in multidisciplinary decisions on health issues.
6. Refer residents to appropriate health care agencies when required; schedule appointments with doctors, dentists, and clinics.
7. Evaluate the effects of prescribed medication and treatment.
8. Provide individual and group health education to promote healthy Lifestyles.
9. Design and participate in research protocols to investigate the physical effects of substance abuse.
The proposal for a School of Nursing faculty practice at Cenikor was initially funded by an outside corporation. By the time that funding ended, the value of the nurse practitioner was fully realized and the position became a permanent one in the Cenikor budget. Since 1988 four nurse practitioner faculty have practiced at Cenikor, each further refining the services. Chente no longer endure long waits to be seen for minor illnesses, immunizations or physicals. A recent overall evaluation of Cenikor as a treatment facility revealed that residents were particularly satisfied with the health services provided. What was originally a makeshift area with donated equipment and volunteer nurses tucked away on the fourth floor, is now a modern clinic with three examination rooms, an office, a waiting room with educational video equipment, and a small laboratory located in very visible space on the first floor. Each of the nurse practitioners, and their students, have acquired skills in ATOD use/abuse. They have also learned the unique features of therapeutic community as a model for substance abuse treatment. Three faculty members are conducting research at Cenikor and Cenikor staff point with pride to this model arrangement for health care.
Even if the problem of substance abuse were to be immediately eradicated from our society, the residual health care deficits would remain. Nurses and student nurses will continué to face the challenge of this clinical problem in virtually every practice setting. A comprehensive curriculum to assure nursing competence in this area should be based on a foundation of ATOD use/abuse information, much of which is now available in learning modules, videotapes and textbooks (Burns, Thompson, & Cicone, 1993; Church, Fisk, & Neafsey, 1990; Naegle, 1991, 1992; Sullivan, 1995). Learning must also include access to the social reality of practice settings and experiential learning opportunities. In addition to the two examples Mghlighted above, there are many creative and innovative ways in which health care settings and communities can become learning environments for addressing the clinical challenge of substance abuse. Because the problem is so prevalent, collaborative links with prisons, shelters for the homeless, schools, neighborhood clinics, and senior centers are only a few of the possibilities that afford opportunities to consider actual and/or potential ATOD abuse and to design population-specific prevention, assessment, intervention, and referral strategies. These learning opportunities are the necessary contextual links between acquisition of basic knowledge and skills and the desired outcome, a hiunanistic-behavioristic nursing response to substance abuse in society.
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