Journal of Nursing Education

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Clinical Knowledge and Skill Priorities in Substance Abuse Education: A Nursing Faculty Longitudinal Survey

Shirley A Murphy, PhD, RN, FAAN; Craig S Scott, PhD; Lynn P Mandel, PhD

Abstract

ABSTRACT

The aims of this study were to: 1) determine which of 16 substance abuse content areas nursing faculty fellows considered important for their professional growth; 2) determine content areas in which faculty fellows planned to obtain knowledge and skill development during the coming year; and 3) to identify content areas faculty fellows thought undergraduate and/or graduate students should be taught. Questionnaires were mailed to the 43 nursing faculty fellows who were recipients of substance abuse federal training during the 1989-1994 academic years. The response rate was 81%. One and a half years later, 66% responded to the same items on a follow-up survey. The results showed that faculty ratings of knowledge and skill development needs for themselves and their students in nursing were stable over time. Findings can be used to guide faculty and curriculum development in alcohol and other substance abuse.

Abstract

ABSTRACT

The aims of this study were to: 1) determine which of 16 substance abuse content areas nursing faculty fellows considered important for their professional growth; 2) determine content areas in which faculty fellows planned to obtain knowledge and skill development during the coming year; and 3) to identify content areas faculty fellows thought undergraduate and/or graduate students should be taught. Questionnaires were mailed to the 43 nursing faculty fellows who were recipients of substance abuse federal training during the 1989-1994 academic years. The response rate was 81%. One and a half years later, 66% responded to the same items on a follow-up survey. The results showed that faculty ratings of knowledge and skill development needs for themselves and their students in nursing were stable over time. Findings can be used to guide faculty and curriculum development in alcohol and other substance abuse.

At both the undergraduate and graduate levels, a global assumption of nursing education is the provision of the necessary foundation for clinical practice. The knowledge, skills and attitudes that students learn should closely reflect those that will later be required of them as generalist and specialist nurse clinicians. One content area of nursing education, substance abuse, is addressed in this article.

The health, social, and financial costs of alcohol and drug (AOD) use in the United States reached $98.6 billion in 1990- up 40% since 1985, and were expected to reach $136.4 billion by 1993 (Rice, 1993). Alcohol abuse contributes to more than 100,000 health-related deaths annually, 30% of our youth experience its negative effects on school performance, and violent acts are commonly associated with alcohol and drug misuse (United States DHHS, 1990). It is estimated that at least 60% of all persons treated for alcohol and drug abuse relapse (Marlatt & Gordon, 1985).

Despite the enormity of the problem, reports show that nursing curricula provide limited education on the addictive process. Hoffman and Heinemann (1987) contacted 1,035 schools of nursing in the United States regarding coverage of substance abuse in undergraduate nursing education. Their findings were 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 was reported to consist primarily of definitions and description of phenomena rather than preparation in assessment and intervention skills.

Bartek, Lindeman, Newton, Fitzgerald, and Hawks (1988) surveyed 83 nurses who practiced on general adult medical and surgical nursing units in 50 hospitals in a Midwestern state. Eighty percent of the sample reported having limited classroom and clinical experience with clients who had substance abuse/dependence diagnoses. These survey results must be interpreted cautiously, however, because 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 cUents who abuse substances (ANA, 1988). Less than 10% of the respondents believed they were competent to care for these clients and stated they received negligible academic and clinical preparation in their educational programs that prepared them to practice with this client population.

Thus, available data suggest an extreme imhnlnnfA between academic preparation of nurses in substance abuse content and the competencies expected for them to assume clinical practice and leadership roles. The literature supports the argument that nursing students receive insufficient preparation regarding identification and management of thente who abuse potentially addictive substances.

In 1989, in an effort to reduce educational deficits in the area of alcohol and other drug abuse, the National Institutes for Alcohol Abuse and Alcoholism, and Drug Abuse (NIAAA and NTDA) called for proposals and began funding selected schools of nursing and medicine to enhance development of faculty and health care curricula in substance abuse. Three schools of nursing in the United States were funded in 1989, an additional six were funded in 1990. Each school in the Faculty Development Program selected three to five faculty "fellows" for training. Their salaries were supplemented by grant funds for up to 20% of their time. The first grant year was devoted entirely to faculty fellow individualized knowledge and skill development. The second and third years were devoted to increasing substance abuse content in curriculum, with less emphasis on faculty training. The fourth and fifth years were targeted for evaluation.

Role shifts within one's career best conceptualize our view of transition applicable to the faculty development award in alcohol and drug abuse. These within-career role shifts are influenced by two major factors. The first is the extremely rapid growth of nursing as a discipLLne and demands on nursing faculty to obtain expertise in several areas of nursing science. The second is both the challenge and dilemma on individual faculty to meet professional demands while choosing areas of interest to them. Mezirow (1978) calls the process "perspective transformation.'' Some faculty may discover an educational leave is not feasible, funds for concentrated study are not available, or other factors prevent changing their course of action. Solutions to this problem are found in such programs as the Faculty Development Program addressed here. Opportunities are provided for nursing faculty members to devote part-time study in an area of perceived need.

The study reported here was undertaken because faculty fellows are an important source of information for setting priorities for substance abuse curriculum development. The specific aims were to: 1) determine which of 16 substance abuse content areas nursing faculty fellows considered personally important to their professional development; 2) determine content areas faculty fellows planned to obtain knowledge and skill development during the next academic year; and 3) identify content areas the faculty fellows thought undergraduate and graduate students should be taught.

Methods

Design

A survey design guided sampling and data collection. The original 43-member cohort was surveyed twice (Time 1 and Time 2).

Sample

The ten schools of nursing funded in 1989 and 1990 for faculty development in substance abuse represented all geographic sections of the United States. The population consisted of all 43 faculty fellows from the 10 NlAAA/NlDA-funded nursing sites. Names of potential subjects and their university addresses were obtained from a project directory distributed by NIAAA. The survey was distributed by mail to all faculty fellows in these sites.

Surveys at Time 1 were completed and returned by 35 faculty fellows (response rate of 81%). One and a half years later (Time 2), 23 of the 35 faculty fellows responded to a follow-up survey (response rate of 66%). Sample characteristics are reported for the 35 nursing faculty fellows who completed the first survey. AU major nursing specialties were represented in the sample: Psychiatric Mental Health, 11(26%); MaternalChild/Women's/Family Health, 10(23%); Community Health, 5 (12%); Adult/Gerontological Health, 9 (21%). The majority of respondents were Assistant Professors, 17(49%), 15(43%) were Associate Professors, 2(5%) were Professors; and one (3%) was an Instructor. Years of teaching experience ranged from three to 20 years. The majority were PhD-prepared (JV=29, 83%). All except one respondent were female.

Instrument

The Substance Abuse Priorities Questionnaire (SAPQ) is a 32-item survey developed by the first and second authors. Two documents provided the basis for the inclusion of specific content areas: 1) the NIAAA/NIDA position paper developed by nurse educators and clinicians recognized for their work in addictions (Felton, 1989), and 2) the Core Curriculum of Addictions Nursing (Jack, 1990), published by the National Nurses Society on Addictions. The topics these two groups considered essential included: pathophysiological and psychosocial consequences of alcohol and drug abuse; diagnostic criteria for abuse and dependence; prevention; indices of effectiveness of appropriate treatments and procedures; patient and family education; consequences for infants exposed to substances in utero; family issues; public policy-making referrals; HIV, and impaired nurses. Screening, assessment, referral, and intervention were recommended skills to be attained in each of these areas.

The SAPQ was pilot-tested with faculty fellows at two schools prior to study administration. Respondents rated 16 different substance abuse content areas on four dimensions: 1) importance to their professional growth; 2) acquisition of knowledge/skills planned for the coming year; 3) whether all undergraduate students should receive instruction on each content topic; 4) whether all or only some graduate students in fellows' specialties should receive instruction on each content topic. Importance to professional growth and undergraduate instruction were rated as "yes" or "no" while planned knowledge and skills acquisition and graduate student instruction were rated on a 4-point Likert scale (growth: l=none, 2=a little growth, 3=8ome growth, 4=considerable growth, graduate student instruction: l=none, 2=a few, 3=some, 4=all). The 16 broad substance abuse content areas provided for response were: acute alcohol intoxication/withdrawal; drug overdose/withdrawal; alcohol dependency/addiction; cocaine dependency/addiction, opiate dependency/addiction; misuse of prescription drugs; drug interactions; multiple addictive behaviors; fetal alcohol syndrome; teratogenic effects of cocaine; implications for HJV exposure; family patterns; age-related changes in drug tolerance; genetic vulnerability for substance abuse; chemically impaired health care providers; community programs. The rationale for selecting these content areas was that they addressed the major concerns that students in health professions need to have knowledge of and skills for screening, assessment, referral, and intervention, including client and family education.

Content validity of the SAPQ was assessed by having four faculty fellows and two school of nursing program directors review the instrument. Reliability was assessed by Cronbach's alpha (ot=.93).

Results

Faculty Fellow Ratings of Importance and Planned Acquisition of Knowledge and Skills

Results showed that almost all content areas were rated as important to at least 70% of the faculty fellows with the exception of fetal alcohol syndrome (FAS), teratogenic effects of cocaine, and chemically impaired health providers. More than 95% of the faculty fellows planned knowledge and skill acquisition pertaining to family patterns associated with substance dependency. In each area, a slightly smaller percentage indicated that they planned at least some professional development in content they identified as important to them. For example, content areas with the highest number who planned "some" or "considerable" professional growth were acute alcohol intoxication/withdrawal, alcohol dependency/addiction, and drug overdose/withdrawal. In contrast, only about 50% of the faculty fellows planned to learn more about FAS and teratogenic effects of cocaine on fetal development.

There were differences in planned professional growth, depending upon nursing specialty. At least 70% of adult/gerontology and psychiatric/mental health nursing fellows reported professional interest in areas such as alcohol intoxication, dependency, or addiction, opiate dependency, misuse of prescription drugs, drug interactions, age-related changes in drug tolerance, chemically impaired health care providers, and community programs. At least 80% of maternal/women's health nursing fellows expressed interest in FAS, teratogenic effects, and multiple addictive behaviors. The fellows also reported that they planned at least some professional growth in most of same areas in which they expressed an interest (Table 1).

Nursing Faculty Fellows' Recommended Instruction for Students

More than 80% of the faculty fellows responded that undergraduate and graduate students should receive some instruction in all 16 content areas. All content areas were considered important for graduate students. More than 70% responded that all graduate students should receive instruction in 12 of the 16 content areas. More than 50% responded that all graduate students should be educated in the other four areas: FAS, teratogenic effects, genetic vulnerability, and community programs.

There were no significant differences by specialty in the percentage of faculty fellows who responded that undergraduates should receive instruction in the 16 areas. Adult/gerontology and psychiatric/mental health nursing faculty fellows were more likely than maternalchild/women's health faculty fellows to report that all graduate students should receive instruction in drug overdose, opiate dependency, misuse of prescription drugs, drug interactions, and age-related changes. Maternal-child/women's health nursing fellows were more likely to indicate that all students should have instruction in PAS and teratogenic effects.

Problem recognition was rated more important than assessment for undergraduate students. Both problem recognition and assessment were rated of almost equal importance for graduate students. Skills related to patient education and prevention were considered important by more than 80% of the fellows for both undergraduate and graduate students in all content areas except FAS. Intervention skills were considered more important for graduate than for undergraduate students.

Follow-up Administration of the SAPQ

One and a half years later (Time 2), the follow-up survey was conducted to determine whether the faculty fellow cohort's knowledge and skill development priorities had changed as the faculty fellow training decreased and the curriculum modification activities were increasing.

Initial ratings (Time 1) were compared with the followup responses (Time 2) for the 23 fellows (66% of the original sample) who completed both surveys. There was no significant change in the number of areas considered important, content areas for anticipated knowledge and skills development, the content areas undergraduates should be taught, and content areas graduate students in faculty fellows' specialties should be taught. However, statistically significant decreases were identified in the number of faculty fellows who planned extensive growth in areas such as alcohol withdrawal (t=2.71, />=£.013), drug withdrawal (t=3.76, ? «.001), multiple addictive behaviors (t=4.39, p=£.001), implications for HIV (t=2.50, p=s.021), and family issues (t=3.63, p=s.002). Fewer respondents planned professional growth in most other areas although the differences were not statistically significant. By contrast, there were no significant changes in the number that thought that all or almost all gradu-\ ate students in their specialties should receive instruction in each content area.

Table

TABLE 1Percentage of Nursing Faculty Fellow by Specialty for 16 Substance Abuse Content Topics: Importance vs. Planned Professional Development/Growth

TABLE 1

Percentage of Nursing Faculty Fellow by Specialty for 16 Substance Abuse Content Topics: Importance vs. Planned Professional Development/Growth

Discussion

Overall, considerable consensus was noted for most substance abuse content areas with the exception of FAS and teratogenic effects of cocaine on fetal development, and to a lesser extent, genetic vulnerability toward alcohol abuse/dependence, and community programs. The nursing faculty fellows rated selected substance abuse content areas as important, planned some professional growth, and recommended that both undergraduate and graduate students receive instruction in most areas related to substance abuse.

The lack of planned skill development in the area of FAS and teratogenic effects of cocaine on fetal development was probably due to the small number of maternal and child specialists surveyed. Some may have become knowledgeable about FAS prior to becoming faculty fellows. It is also likely that fellows in other specialties, given limited time and resources, had set other priorities in their own specialty areas.

The results suggest several implications for nursing education. First, if nursing faculty fellows' views about substance abuse knowledge and skill development become institutionalized, students are likely to receive a much more comprehensive substance abuse education, which is needed. Second, because NIAAA/NIDA guidelines required that all specialty areas be represented, the placement of substance abuse content in curriculum is Likely to be integrated into more courses, which would be a positive change. Finally, if faculty fellow plans for substance abuse knowledge and skills development have been realized as a result of the current NIAAA/NTDA initiative, fellows can be viewed as resources for other faculty and nurse clinicians.

An important next step would be to survey schools of nursing again, as Hoffman and Heinemann (1987) did in the mid-1980s. However, it is suggested that inquiry be conducted to determine whether students are learning and applying substance abuse knowledge. Performancebased assessments are recommended. For example, the use of standardized patient examinations with graduating seniors is one way to evaluate whether curricula are preparing students to provide services included in the survey data reported here.

Conclusion

This study surveyed faculty fellows in 10 schools of nursing that were awarded federal funds to increase faculty AOD knowledge and skills, and to improve AOD curricula. Respondents identified a broad range of topical areas as important for both faculty and student knowledge and skill development. The results demonstrate increased understanding of the complexity of AOD problems and their impact on individuals, families, and communities. Moreover, faculty involved in the Faculty Development Programs differentiated content areas to be offered to all undergraduate students versus content needed for graduate subspecialty preparation. The results further suggest that faculty development programs show potential for identifying and meeting the educational needs of students that should make an impact on prevention and intervention with substance abuse in the United States.

Table

TABLE 2Percentage of Nursing Faculty Fellows Recommending Instruction for Undergraduate and Graduate Students in the 16 Substance Abuse Content Topics

TABLE 2

Percentage of Nursing Faculty Fellows Recommending Instruction for Undergraduate and Graduate Students in the 16 Substance Abuse Content Topics

References

  • American Nurses Association. (1988). Standards of addictions nursing practice with selected diagnoses and criteria. Kansas City, MO: Author.
  • Bartek, J., Lindeman, M., Newton, M. Fitzgerald, P, & Hawks, J. (1988). Nurse-identified problems in the management of alcoholic patients. Journal of Studies on Alcohol, 49, 62-70.
  • Felton, G. (1989). Minimum knowledge and skills for aAcohol and other drug abuse teaching: A draft consensus statement. Report of the Nursing Education Workshop: Alcohol and Other Drugs in Undergraduate Curricula. Co-sponsored by The National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse.
  • Hoffman, A.L., & Heinemann, M.E. (1987). Substance abuse education in schools of nursing: A national survey. Journal of Nursing Education, 26, 282-287.
  • Jack, L. (Ed.). (1990). The core curriculum of addictions nursing. Skokie, IL: National Nurses Society on Addictions.
  • Marlatt, G.A., & Gordon, S, (1985). Relapse prevention: Maintenance strategies in the addictive behaviors. New York, NY: Guilford Press.
  • Mezirow, J. (1978). Perspective transformations. Adult Education, 28, 100-110.
  • Rice, D.P. (1993). The economic cost of alcohol abuse and alcohol dependence: 1990. Alcohol Health and Research World, 17(1), 10-11.
  • U.S. Department of Health and Human Services (1990). Seventh special report to the U.S. Congress on alcohol and health. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.

TABLE 1

Percentage of Nursing Faculty Fellow by Specialty for 16 Substance Abuse Content Topics: Importance vs. Planned Professional Development/Growth

TABLE 2

Percentage of Nursing Faculty Fellows Recommending Instruction for Undergraduate and Graduate Students in the 16 Substance Abuse Content Topics

10.3928/0148-4834-19961101-06

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