Journal of Nursing Education

The Effects of the Problem-Based Alcohol Early-Intervention Education Package on the Knowledge and Attitudes of Students of Nursing

David Arthur, PhD

Abstract

ABSTRACT

The profession of nursing is seeking to establish its unique professional identity by developing disciplinefocused research and clinical practice supported by university education. However, according to refereed literature, educating undergraduate nurses in alcohol-related problems is lacking. The literature reveals that nurses in general lack the necessary knowledge, attitudes, and skills to work with problem drinkers. Alcohol early intervention is advocated as a strategy compatible with contemporary nursing practice. This paper reports a study that commenced with the development of a problembased, five-week Alcohol Early Intervention Education Package (AEIEP). This package became an intervention around which the knowledge and attitudes of a sample of 212 students of nursing were evaluated. A comprehensive instrument was developed to measure the respondent's knowledge and attitude regarding alcohol-related problems in general and specifically in early intervention. The effects of the education intervention on the different strata of students, were examined in a quasi-experimental, pre-post test design. The findings demonstrated it had a significant effect on the knowledge and attitudes of students enrolled in an integrated bachelor of nursing curriculum.

Abstract

ABSTRACT

The profession of nursing is seeking to establish its unique professional identity by developing disciplinefocused research and clinical practice supported by university education. However, according to refereed literature, educating undergraduate nurses in alcohol-related problems is lacking. The literature reveals that nurses in general lack the necessary knowledge, attitudes, and skills to work with problem drinkers. Alcohol early intervention is advocated as a strategy compatible with contemporary nursing practice. This paper reports a study that commenced with the development of a problembased, five-week Alcohol Early Intervention Education Package (AEIEP). This package became an intervention around which the knowledge and attitudes of a sample of 212 students of nursing were evaluated. A comprehensive instrument was developed to measure the respondent's knowledge and attitude regarding alcohol-related problems in general and specifically in early intervention. The effects of the education intervention on the different strata of students, were examined in a quasi-experimental, pre-post test design. The findings demonstrated it had a significant effect on the knowledge and attitudes of students enrolled in an integrated bachelor of nursing curriculum.

While much has been written about alcohol early intervention in general, little has been published on methods of teaching such material to students of nursing in the context of attempting to improve knowledge and attitudes. In NSW Australia, the Department of Health (1991) released a strategic plan that provided a mandate to proceed with nurse-initiated alcohol early intervention. There is evidence that this is happening at a clinical level (Novak & Burns, 1994) and various authors have continued to promote the ideas and practice of alcohol early intervention by nurses (Goodin, 1992; Kemp & Sayers, 1993; Novak & Burns, 1994; Rollnick, Heather and Bell, 1992; Watson, 1994). Despite these moves the international literature reports that nurses tend to have negative attitudes toward people with alcohol-related problems, yet are confronted with patients with alcohol-related problems and lack the professional expertise to provide intervention.

This study demonstrates that an educational intervention can influence the knowledge and attitudes of students of nursing. It was based on a belief that alcohol early intervention has proven successful and nurses are capable of implementing early-intervention strategies because of their position in the health care system as well as developing autonomy as practitioners.

LITERATURE REVIEW

This paper emerged from a larger study (Arthur, 1996) that synthesized the literature on alcohol problem treatment and nursing education trends into a method for teaching alcohol early intervention to nurses (Arthur, 1997 & 1996; Babor, Ritson & Hodgson, 1986; Bien, Miller & Tonigan, 1993; Saunders, 1988a & 1988b). The language used in this field can become confusing because there is a tendency to mix traditional terms with those more recently developed to reflect a current clinical approach. The traditional-term alcoholic is generally bypassed for the term-dependent drinker; a drinking continuum extending from safe to hazardous to harmful to dependent, is generally preferred to a deliniation between the dependent drinker and the rest. The notion of controlled drinking for hazardous and harmful drinkers is as acceptable as abstinence (while accepting that for many dependent drinkers abstinence is the preferred option); the number of problem drinkers (in the hazardous and harmful categories) is approximately four times that of dependent drinkers.

Nurses' Knowledge and Attitudes

Sullivan & Hale's (1987) summary of the nursing literature from the 1970s suggested that nurses' beliefs about alcoholics were significantly more negative than toward nonalcoholics and they claimed that studies conducted prior to 1980 were limited by sample size or limited locale. In the 1980s and 90s there was general agreement, with the exception of Allen (1993), that nurses generally hold negative attitudes toward alcoholics.

The following studies were critically reviewed elsewhere (Arthur, 1996) but highlight a belief in traditional disease concepts of alcoholism (Allen, 1993; Cannon & Brown, 1988; Sullivan & Hale, 1987). Another (Reieman & Schrader, 1984) found subscription to the disease model generally and that a positive attitude was correlated to referral patterns. One study (Goodin, 1992) found that supervized clinical experience in alcohol treatment settings increased role adequacy and subscription to the drinking continuum model. Gerace et al. (1995) used a measure to study the effects of education showing that there was an increase in knowledge and treatment optimism while Goodin et al. (1994) supported the importance of education in influencing therapeutic attitudes.

Arthur (1996) summarized the findings of recent nursing studies into three categories evident in the literature and explained nurses' negative attitudes of: the flawed character of the drinker (Sullivan & Hale, 1987; Romney & Bynner, 1985; Reisman & Schrader, 1984; Wechsler & Rohman, 1982); the biological basis of the problem (Reisman & Shrader, 1984; Cannon & Brown, 1987; Sullivan & Hale, 1987; Engs, 1982; Wechsler & Rohman, 1982); and nurses' personal views of their own alcohol use and experiences with drinkers (Parette et al. 1990; Goodin, 1992; Naegle, 1991).

These research papers referred to: 1) high percentage of people in the health care system with alcohol-related problems; 2) prevalence of problem drinking; 3) cost to society; 4) negative attitudes influence or block effective treatment; 5) professions' concern of insufficient response; and 6) nurses in a prominent position to impact the problem with appropriate skills (Arthur, 1996).

A recent movement in Australia (Goodin, 1992) and a study in the UK (Watson, 1994) has supported a movement toward adoption of early-intervention strategies, although the discipline of nursing has yet to clarify the best way to teach and measure the variables related to early intervention, as opposed to traditional approaches to the management of alcoholism. Only one survey (Novak & Burns, 1994) attempted to establish nurses' activities in alcohol early intervention, and not in the context of the effects of education on the student or registered nurse. This is despite the burgeoning literature from other health disciplines that advocate adopting alcohol early intervention (Babor, Ritson, & Hodgson, 1986; Bien, Miller, & Tonigan, 1993; Saunders, 1988a & 1998b).

The methodological criticisms of the nursing studies reviewed included sampling problems (either poor response rate or small or convenience samples), lack of carefully developed conceptual frameworks providing direction, and the use of instruments that could be viewed as dated. Despite these shortcomings the messages conveyed were clear. Nurses like all health care professionals tend to adopt negative approaches toward working with people with alcohol-related problems and this may impact on the management of such people. There was also evidence of a tendency to subscribe to the disease model. Recommendations included the importance of strengthening education programs for professionals to help influence the attitudinal and knowledge problems that were evident.

A course on alcohol early intervention was developed as part of a bachelor of nursing program, and the purpose of this study was to evaluate the effects of the course on the participant's knowledge and attitudes toward various aspects of working with clients who consume alcohol. The study aimed to examine: participant's attitudes toward problem drinkers contrasted with attitudes toward dependent drinkers; degree of preparation for working with people with alcohol-related problems; ability to provide brief counseling for hazardous and harmful drinkers; and their knowledge about alcohol-related problems.

METHOD

A quasi-experimental design with nonequivalent control groups was employed where the experimental and control groups were not equated by randomization. A longitudinal approach measured student changes before, during, and after they were given the alcohol early-intervention package.

Each consenting student completed a measurement instrument, the Alcohol Early Intervention Education Package Questionniare (AEIPQ), before and after the five-week learning package and at one other time (Figure). For group one this was 8 academic weeks after the completion of the package while for group two it was completed 8 academic weeks before the package, then before and after the package. In groups 3 and 4, the gap was six weeks. Group three completed the package before group four. The cross over design of the study allowed for some control of the practice eñect (groups two and four) and an opportunity to examine retention (groups one and three).

Intervention

The AEIEP (Arthur, 1996) was a problem-based learning intervention based on the assumption that interactive, situation-specific learning is a suitable method of teaching nursing. The problem-based learning method is student centered and is widely reported in the health science literature, where students are provided real-life triggers about which individual learning needs and available sources of knowledge are identified in small tutorials (Alavi, 1995). Students then explore the problems at their own pace and prepare to share their findings in subsequent tutorials. For example, five weeks after the commencement of the intervention, the students were given the task of interviewing a simulated client who had been admitted to the hospital for routine surgery and was identified as a hazardous drinker by a routine screening tool. In sequential steps, they were encouraged to identify their own learning needs, build up a case history, and prepare for an interview.

Figure. Time frame for the administration of AEIPQ and AEIEP.

Figure. Time frame for the administration of AEIPQ and AEIEP.

The first tutorial hour each week was designed to present problem scenarios to help students identify their learning needs and directions while the second tutorial each week was designed to explore issues, present findings, and clarify direction. Each week students were also given objectives. Regular meetings were held with tutors to address consistency issues. The material was presented in the form of triggers that the students should see as coming from the real practice world. In this case, the students were presented with typical work situations where they would be required to screen patients for their alcohol consumption. They were given case studies and patient data that focused their studies. In addition, tutorials, discussions and reflection, helped develop compatible attitudes for working with problem drinkers. Students were provided with an additional motivator in the form of a simulated client whom they interviewed, thus learning and demonstrating necessary intervention skills gained from these experiences.

Measurement Instrument

Since the AEIPQ's six sections were in line with the stated research aims, we developed and explored: 1) demographic variables; 2) attitudes toward problem drinkers contrasted with; 3) attitudes toward dependent drinkers; 4) degree of preparation for working with people with alcohol-related problems; 5) ability to provide brief counseling for hazardous and harmful drinkers; and 6) knowledge about alcohol-related problems.

Following questions in section one, relating to age, gender, and experience in nursing, section two of the AEIPQ examined attitudes of the sample toward problem drinkers. These were measured by the Short Alcohol and Alcohol Perceptions and Problem Questionnaire (SAAPPQ) that was developed by Cartwright (1980) and replicated by others (Anderson & Clement, 1986, Gorman et al, 1990; Goodin, 1992) because it has demonstrated construct validity and reliability on measuring attitudes toward the continuum of drinkers. The 10 items ask for a response on a 7-point Likert scale with a high score, indicative of a more favorable attitude. Since no previous studies had examined the subscale structure of the instrument in a nursing sample, a principal components factor analysis was conducted for all respondents including all items of the SAAPPQ. A 5-factor solution (SPSS-X, 1988) was requested to confirm or otherwise the five dimensions described in the instrument. This was performed at entry level because the sample size was more appropriate with the total group of respondents (n = 212) than with smaller groups- for the type of analyses performed. The five-factor solution hypothesised was not confirmed, with the factor structure suggesting that only four clear factors existed, and that item 'a': pessimism is the most realistic attitude to take with drinkers, did not correlate as predicted with other items, particularly item *b.' The results also suggested that with item 'a* removed the reliability of the SAAPPQ would improve. Item 'a' was removed and a four-factor solution sought for all respondents at entry level.

The results revealed four factors with Eigen values greater than 1, accounting for 73% of the variance (Tabie 1). These results suggested that the SAAPPQ measured four subscales. Further, with item 'a' removed the motivation subscale collapsed and item 'b' I want to work with drinkers, logically loaded into the work satisfaction subscale. Factor analysis at final testing supported the notion of four factors adding strength to the SAAPPQ as a reliable measure with construct validity for four subscales or dimensions: work satisfaction, role adequacy, role legitimacy, and task-specific self-esteem.

The Cronbach alpha reliability supported the internal consistency of these subscales. For the total sample, the overall reliability of the SAAPPQ improved from entry level (0.59) to 0.75 at final testing. The subscales work satisfaction, role adequacy, and role legitimacy demonstrated acceptable levels (>0.70) of reliability. A further reinforcement to internal consistency was added by Pearson, item-with-item total, correlation coefficients that ranged from 0.45 to 0.67, using the total sample at final testing.

Section three of the AEIPQ was designed to provide a contrast between attitudes toward problem drinking and dependence. In line with a previous study that advocated the direction (Goodin, 1992), it was decided to use some items that reflected attitudes toward dependent drinkers. This scale consisted of 9 items on a 7-point Likert scale that came from a 28-item instrument developed by Caswell & McPherson (1983). It was developed from statements derived from traditional and emerging concepts of alcohol dependence with New Zealand General Practitioners. Use of the instrument was replicated in a sample of Australian GPs (Jurd & Lee, 1989) and aspects of the instrument were used in a study of nurses (Goodin, 1992). The items chosen represented the traditional disease-abstinence approach, moralism, the modified-disease conception, and the drinking continuum. An examination of the scale reliability (Cronbach's alpha < 0.6) for all respondents was disappointing. The two subscales iraditional disease-abstinence and modified disease concept had alpha coefficients greater than 0.6, yet no significant differences between pre- and post-test were noted. Four factors were isolated using confirmatory factor analysis (SPSS, 1986) accounting for 65.5% of the variance. WhUe the rotated factor matrix did support the hypothesized factor structure because of the poor internal consistency and the skewed nature of some items, caution is to be exercised with inferential statistics. Therefore, item statistics rather than subscale statistics were reported. Nevertheless, the scale was used to compare differences between groups. The disappointing structure of this instrument became one of its main limitations.

Table

TABLE 1Nine-Item SAAPPQ: Rotated Factor Matrix for a Four-Factor Solution1

TABLE 1

Nine-Item SAAPPQ: Rotated Factor Matrix for a Four-Factor Solution1

Section four of the questionnaire contained one Likert item on a 7-point scale that was included to examine the respondent's degree of preparation for working with drinkers, while section five also contained one item and examined their ability to provide brief counseling for a person identified as drinking at a hazardous or harmful level.

Section six examined knowledge about alcohol-related problems using a knowledge test constructed for the study and consisted of 23 questions. The first 10 required a yes or no response; the remaining questions were multiple choice. The knowledge level was measured by a mean score. A range of ability was tested, from recall of facts, through applications of concepts and principles, to higher-order problem solving and questions related to safe drinking; early intervention principles; controlled drinking versus abstinence; and early intervention techniques. To base inferential statistics on a reliable test, some investigations were made into the test characteristics. Minor adjustments were made to the instrument for comparative purposes. The initial test was developed in consultation with experts in the area and a sample of experts completed the test, commenting where appropriate. In this sense, the content validity was a function of expert knowledge. The post-test reliability as measured by Chronbach's cooefficient was 0.91, suggesting that the instrument was reliable for measuring knowledge.

Sample

The focus of this study was on students enrolled in year 2 of a bachelor of nursing program who were to study the Alcohol Early Intervention Education Package (AEIEP). There were two primary groups of students: second year undergraduates studying a degree that leads to registration as a nurse and registered nurses (RNs) completing either a diploma-to-degree conversion or certificate-to- degree-conversion. The undergraduate students had limited clinical experience compared to the RN group. This was interesting since it also contained a significant number of students from other cultures. Comparisons could then be made between undergraduate students with little clinical experience and RNs with experience, and local RNs and international RNs from other cultures (mainly Asian) who had come to the university from their home countries to convert their certificates to degrees.

Of the 212 students who consented to participate, 144 were preregistration students (UGs) and 68 were RNs. Since the students were a convenience sample and the group allocation was based on educational reasons rather than random allocation, this became a limitation of the study of generalizability and representativeness of the results. However, given the high degree of participation and being a compulsory course, it was unlikely that selfselection was an issue. Therefore, the degree of equivalence between the groups was maintained.

RESULTS

Demographic Characteristics

There were 174 (87%) females among the sample: 80 (40%) were less than 21 years of age with 40 (20%) greater than 30 years of age. Of the 2 12 respondents, 38% had previously completed a course in nursing. Of the 77 respondents who had previously completed a course in nursing, 21 (27%) had completed a diploma, 41 (53%) had obtained a hospital certificate, while 11 (14%) had previously worked as enrolled nurses (ENs). Of the RNs, 26 (34%) completed their nursing education in Australia; 17 in Hong Kong; and 13 in Taiwan. These courses were conducted in English in 47 (62%) of these cases; 18 (24%) Chinese (Mandarin or Cantonese); and 8 (11%) Korean.

Table

TABLE 2Mean (and SD) for all Respondents for Kerns Comprising the SAAPPQ (items reversed*)

TABLE 2

Mean (and SD) for all Respondents for Kerns Comprising the SAAPPQ (items reversed*)

Attitudes Toward Problem Drinkers

An attitude score was calculated using the SAAPPQ for each respondent before and after the education intervention. A mean score was calculated for the total sample and for each of the four groups of students. There was a significant improvement in attitude towards working with drinkers as a result of the AEIEP. A mean score was calculated for all groups at pre-test (4.06, SD = 0.77) and post-test (4.63, SD = 0.84). A f-test revealed a significant difference between the means (i = 9.01, p < 0.001).

At an item level, descriptive statistics for the total group (n = 212) at entry level (each respondent's first test) and final testing (each respondents last test), were calculated for each of the items in the four subscales of the SAAPPQ. With the item scores reversed, a response toward agreement (7) was indicative of a favorable attitude.

Three items comprised the work satisfaction (WS) subscale of the SAAPPQ Table 2). The total response at entry level for these items indicated a tendency toward not liking or wanting to work with drinkers. At final testing, there was an increase in the mean scores for work satisfaction as measured by the three items, although the scores remained below the midpoint on the continuum. The increase in mean score for the subscale work satisfaction was found to be statistically (i = 6.23, p < 0.001) significant (Table 3), yet the mean score at post-test was below the midpoint (4) of the continuum and the lowest of all of the four subscales.

Two items comprised the subscale role adequacy (RA)

(Table 2). At entry level, for the total sample, both the means for these items were toward the midpoint on the continuum. There was a significant increase (i = 10.46, ? < 0.001) in role adequacy, as measured by these items, for the final test (Table 3).

Another two items measured role legitimacy (RL) and solicited a response along the agreement-disagreement continuum to the right to assess and question clients (Table 2). At entry level, the mean response for both these items was at the midpoint of the continuum or greater, increasing at final testing, and a statistically significant increase (i = 2.43, ? < 0.05) in the subscale mean was noted (Table 3)

Task-specific self-esteem (SE) sought a response to the degree of pride and inclination to work with drinkers. The increase in mean scores for this subscale was statistically significant (t = 2.22, p < 0.05).

The intervention aimed at improving attitudes toward working with problem drinkers (as opposed to dependent drinkers), the improvement in attitudes as measured by the SAAPPQ, and its reliable subscales was encouraging. Given that most of these people will not work specifically with dependent drinkers but will work with problem drinkers in the course of their work, this is a desirable result.

All groups showed an improvement in mean score for the SAAPPQ between pre- and post-testing as a result of the AEIP. There was a significant difference between preand post-test for the total group mean. The difference between control and pre-test and post-test to retention test was found to be not significant (Table 4).

Attitudes Toward Dependent Drinkers

One aim of the intervention was to help students move from a disease model approach to a more contemporary view of problem drinking- Nine items were included to provide a contrast to the respondents' attitudes toward dependent drinkers and problem drinkers, and consisted of statements derived from the literature (Goodin, 1992, p. 56; Caswell & McPherson, 1983) that were used in previous studies of medical officers' and nurses* attitudes toward dependent drinkers and alcoholics (people beyond the problem-drinking stage).

Table

TABLE 3Pre- and Post-test Differences for SAAPPO and Subscales

TABLE 3

Pre- and Post-test Differences for SAAPPO and Subscales

Items 'a' to 'd' in this section were designed to reflect respondents' attitudes toward the traditional diseaseabstinence approach related to dependent drinkers (those drinkers beyond the problem-drinking stage). These reflect dominant biological model ideas. Students were asked to respond along a continuum from strongly agree (7) to strongly disagree (1), so that responses toward 7 were indicative of a more favorable attitude towards the contemporary view, than responses toward 1.

Items 'a' to 'c* demonstrated a similar pattern of response with increases from entry testing to final testing. The difference between the means for 'a' and 'c' were significant (Table 5) with the final test higher. The difference in mean for item 'd' was not significant and the mean score at final testing remained below the midpoint of the continuum. At entry level, 34% strongly agreed with the statement that alcoholism is a disease (item 'd') (median = 2) while at final testing, this changed to 32% (median = 3). This item was found to be significantly skewed; hence the median is a more appropriate indication of results.

There was a tendency to disagreement with item V that was designed to reflect moralism, with a significant increase at final testing (Table 5). Items T/ 'g,1 and Ti/ drew responses toward the agree end of the continuum. These items were designed to examine the modified disease concept. All solicited responses greater than 5 at initial testing and with the exception of item 'g* reflected an increase at final testing.

Item T approached the idea of a continuum, of drinking and solicited responses slightly below the midpoint of the continuum at entry, and slightly above at final testing. A sum of the scores, once negative items were reversed, produced an overall attitude score toward different aspects of dependent drinkers with a response toward 7 generally reflecting a positive attitude toward people who drink beyond the problem stage.

Table 6 shows the difference between groups and their mean scores on the 9 items in question 20, at control, pre, post, and retention testing. The groups UG 1, UG 2, and RN 1 demonstrated an improvement in attitude following the intervention while the RN 2 group showed an improvement from control testing to pré-test but a slight decrease in mean after the intervention. The RN 1 group, with mainly Australian students, showed the highest mean following the intervention. The difference between the means for all respondents at pre- and post-testing revealed a significant increase (mean difference of 0.29, i = 5.19, p< 0.001).

Following the AEIEP intervention, there was an increase in the mean score for the items for the groups UG 1, UG 2, and RN 1 between pre- and post-testing (Table 6). There was no significant difference between the means from control to pre-test, and between post-test to retention test.

The data reflecting attitudes toward dependent drinkers were not as significantly altered when compared to the improvement in attitude as measured by the SAAPPQ. The AEIEP was designed to emphasize problem drinking rather than dependent drinking and this may be a contributing factor to the responses. While there were problems detected with the items measuring the attitudes toward dependent drinkers, they are often considered more entrenched and probably harder to influence with a learning package of this kind. As the subscale structure proved difficult to support, subscale means were not reported. Thus, the use of multiple ¿-tests was acknowledged as a limitation. While caution is expressed with these findings, there was a significant difference between the pre- and post-test scores for the combined groups.

Table

TABLE 4Mean (and SD) for SAAPPQ (9 items) by Group

TABLE 4

Mean (and SD) for SAAPPQ (9 items) by Group

Table

TABLE 5Mean (and SD) for all Respondents for Attitude Towards Dependent Drinkers' Hems (negative Items* reversed)

TABLE 5

Mean (and SD) for all Respondents for Attitude Towards Dependent Drinkers' Hems (negative Items* reversed)

Degree of Preparation

This question asked for response on a 7-point continuum, from 7 strongly agree, to 1 strongly disagree to the statement: "Tu date I believe that I have received sufficient education and training in the nursing care for persons with alcohol-related problems." The mean response (and standard deviation) for the total group at entry level was 2.25 (1.55) with 70% responding 1 or 2 reflecting a feeling of poor preparation. At final testing this improved to a mean of 4.85 (1.43) following the AEIEP with only 6% responding 1 or 2. Clearly, the intervention had a positive effect on respondents' beliefs about their preparation, which was found to be statistically significant (/ = 17.67, p < 0.001).

Ability to Provide Brief Counseling

There was a significant improvement in the sample's belief in their ability to provide brief counseling (t = 19.19, p < 0,001) as a consequence of the education program. This item solicited respondent's agreement, on a continuum of 1 to 7, to the item: "I think I could provide brief counseling for a person identified as drinking at a hazardous or harmful level." The total group mean response was 2.85 (1.63) at entry level improving to 5.5 (1.36) at final testing.

Knowledge

For the 21 items in the knowledge test for which there was a maximum score of 21, there was a significant improvement in the mean knowledge score (£ = 27.26, p < 0.0001} for all groups (total sample) from pre-test to posttest.

The greatest improvement was noted in the RN groups whose means were both lower than the UG groups at pretest level. RN 1 obtained the highest mean followed by UG 2 at post-test. UG 1 obtained the lowest mean score at post- test.

A clear improvement in knowledge was observed as a result of the intervention. The RN 2 group (mainly from overseas origin) showed the greatest improvement in means following the intervention, from a mean of 9.66 at pre-test to 17.40 at post-test.

DISCUSSION

Attitudes

Since the education intervention was designed to contrast drinking problems along a continuum, two attitude measures were included to examine the differences between problem drinkers and the traditionally more difficult group, dependent drinkers.

Table

TABLE 6Mean (and SD) for Attitudes Toward Dependent Drinkers' Items by Group

TABLE 6

Mean (and SD) for Attitudes Toward Dependent Drinkers' Items by Group

Table

TABLE 7Comparison of Group Mean and Standard Deviation for Knowledge Items

TABLE 7

Comparison of Group Mean and Standard Deviation for Knowledge Items

There was a significant improvement in the attitude of the respondents in the area of working with problem drinkers. This attitude was divided into work satisfaction, role adequacy, role legitimacy, and self-esteem. The improvement in attitude was most significant in the subscale role adequacy, followed by work satisfaction, role legitimacy, and to a lesser degree task-specific selfesteem. The relative increase in role adequacy was similar to the findings of Gorman (1990) in a study of mixed professionals. The RN 2 group showed a lower degree of work satisfaction at the entry level compared to other groups, which improved at final testing but remained lower than the others. This is indicative of a positive effect of the AEIEP in this group of people wanting to work with and liking drinkers. This could be a function of their cultural background or their use of English as a second language with scores improving as students became more familiar with the material and teaching methods. In role adequacy, both preregistration groups demonstrated less confidence in working with people with alcohol-related problems.

An interesting improvement in the local registered nurse group attitude towards role legitimacy was noted with an improvement continuing after the intervention to the retention test. Comparatively the international RN group showed a decrease of legitimacy when asking clients about their drinking. This again may be related to their Asian cultural background. There was a curious reduction to the midpoint of the continuum of the UG 1 group at retention test and may be explained by group dynamics or the characteristics of the teacher involved.

The instrument proved sufficiently sensitive to act as a measure of attitude, overall and in subscales. There were subtle differences between groups but general improvement in attitude following the AEIEP.

Since most of the students will work in conventional areas of nursing where problem drinkers are more likely to be found, this general improvement in attitude and role-related activities was an encouraging result. The attitudes, as measured by the complete instrument, of the groups were similar indicating that all students, irrespective of background in nursing, age, and cultural background have similar attitudes. At a subscale level a difference was noted between the international RN group and the UG 1 group from pre-test to post-testing.

The students' attitude toward dependent drinkers was favorably and significantly improved as a result of the educational intervention. There was a concerning belief that alcoholism is a disease that was not significantly changed by the education intervention. However, this was counterbalanced by an item that suggested abstinence is the only option for recovery, to which a significant change was noted away from this statement, after the intervention. The intervention had a favorable and significant influence on each of the groups with the exception of the international RN group whose mean score was not significantly improved and remained lower than all other groups.

This rinding was contrasted to the local group that demonstrated a significantly higher score than the other groups. This suggested that the group of local registered nurses, who may have negative entrenched attitudes toward dependent drinkers, had been favorably influenced by such a learning intervention. It is likely on the other hand that nurses from other cultures where drinking is less socially accepted and viewed in a different conceptual light, may have more entrenched attitudes toward dependent drinkers. The mixed nature and size of the sample inhibit adequate conclusions, but this is an area worthy of further exploration

Improved confidence from learning a tangible technique for working with drinkers may be one of the influencing variables in attitude change. Empowering students to take some initiative can engender a feeling of competence and improved perception of self.

To add strength to the respondents' overall feeling of preparation as a result of the intervention, two questions explored their belief about their preparation for the nursing care of people with alcohol-related problems and ability to provide brief counseling.

The respondents' perceived degree of educational preparation for providing nursing care for people with alcohol-related problems improved markedly from the negative to the positive following exposure to the intervention. The same result was noted for confidence in providing brief counseling to hazardous or harmful drinkers. This was an encouraging result that reflected the degree of empowerment and confidence that emerged.

Knowledge

The knowledge test was designed and written for the purpose of assessing this component of the course. The instrument was useful and sensitive to individual group performance. Although the results at post-test suggested that more teaching emphasis needed to be given in certain areas, this is a strength of the instrument in one way, suggesting it is sensitive to certain areas and for certain groups.

There was a significant improvement in the students' knowledge about alcohol early intervention aa a result of the AEIEP. Interestingly, both registered nurse groups had lower pre-test scores than the preregistration groups, which may have been because of the mature-age students' lack of familiarity with the university system, terminology, or confidence in such assessment procedures. However, at post-test the local RN group demonstrated the highest score with international RNs demonstrating the greatest mean improvement. The UG 1 group again were the poorest performers relatively, with a significantly poorer score than UG 2 at post-testing. While there was a significant degree of retention loss, this was balanced by the gap between pre- and post-testing scores and the fact that the mean scores between pre-test and retention test remained significant. Areas of greater retention loss could be studied further.

This data analysis supported in part, the notion that the preparation of the group of RNs, prior to studying the AEIEP, was inadequate in their knowledge of alcohol, particularly early-intervention. Further, the mean scores for the different groups suggested that there was little difference between undergraduate students with little nursing experience and RNs with much experience in their attitudes and knowledge toward alcohol and intervention strategies. There was improvement of both groups' knowledge and attitudes as a result of the AEIEP suggesting that the program had been a success in affecting attitudes and gaining knowledge.

The significant reduction in means was a concern although the broader view of the AEIEP within a larger curriculum indicated that the material should be reinforced the following year in a subsequent course that addresses more severe alcohol problems and related management strategies.

It was demonstrated by examining control and retention group performance that the AEIEP intervention had an independent effect on the groups studying the course. Although extraneous variables and threats to validity can be a problem in such a study, the intervention was shown to be effective for influencing change in knowledge and attitudes.

This study represents an attempt to introduce material designed to better equip students of nursing to work in a notoriously underdeveloped area. The study is clearly limited by the convenience sample and generalization beyond this sample is not intended. The attitude and knowledge measures, although statistically reliable and demonstrating face and construct validity, were limited by the nature of such measures being quantitative and objective and subject to the flaws of scale measurements, including social desirability response and responses based on haste rather than careful thought. Nevertheless, the easily replicated design and the results do encourage future research incorporating qualitative methods and clinically focused studies to investigate the impact of nursing intervention in this area.

CONCLUSION

This paper has presented an overview of a study that was designed to bring alcohol early intervention into focus in a bachelor of nursing course. The five-week intervention was designed in a problem-based interactive format to stimulate student inquiry and present learning material in a meaningful way. To evaluate the effects on the student's knowledge and attitudes in a notoriously complex area, a quasi-experimental design was chosen with the education intervention providing the intervention, and a composite questionnaire the measure.

The results showed that there was a positive and significant improvement in students' attitudes toward working with drinkers, and a significant improvement in knowledge, while both areas showed a tendency towards retention. There is a place for an education package that provides students of nursing with an introduction to early intervention to help develop attributes for working in a new era where a broader role is needed for clients often ignored in traditional health care settings.

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TABLE 1

Nine-Item SAAPPQ: Rotated Factor Matrix for a Four-Factor Solution1

TABLE 2

Mean (and SD) for all Respondents for Kerns Comprising the SAAPPQ (items reversed*)

TABLE 3

Pre- and Post-test Differences for SAAPPO and Subscales

TABLE 4

Mean (and SD) for SAAPPQ (9 items) by Group

TABLE 5

Mean (and SD) for all Respondents for Attitude Towards Dependent Drinkers' Hems (negative Items* reversed)

TABLE 6

Mean (and SD) for Attitudes Toward Dependent Drinkers' Items by Group

TABLE 7

Comparison of Group Mean and Standard Deviation for Knowledge Items

10.3928/0148-4834-20010201-05

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