Journal of Nursing Education

Letter to the Editor Free

Adapting Team Awareness and Replication (With Response)

Joel Bennett, PhD


Click here to read the article 


Click here to read the article 

To the Editor:

In the July issue of the Journal of Nursing Education, Cadiz et al. (2012) published the article “Quasi-Experimental Evaluation of a Substance Use Awareness Educational Intervention for Nursing Students.” As an original developer of the Team Awareness training, I was quite excited to see this article about its application and extension to student training. Indeed, the positive experimental results on knowledge and self-efficacy are promising, and hopefully they will lead others to consider adopting this brief program for nurse training. We have much to gain by helping nurses early in their careers to be equipped to address substance abuse issues, not only in their colleagues but potentially in their patients as well. Dr. Cadiz et al. (2012) should be applauded for their effort.

At the same time, there are some issues with both the approach taken by Cadiz et al. (2012), as well as with the results, that I believe warrant notification of the Journal’s readers. Essentially, there are some dangers associated with the way the intervention was adopted and, from the perspective of the original evidence-based program, there are concerns (listed below) about “program drift,” or unintended modifications to the curriculum that could corrupt its fidelity and intent. I will be brief, and readers can review original articles on Team Awareness and the original curriculum on the Organizational Wellness & Learning Systems’ Web site (

I wish to note that Team Awareness was originally designed as a prevention intervention for the workplace culture; that is, to promote a culture of health and healthy choices among workplace social groups. It was not designed as a set of separate tools that participants could use in different ways for different purposes. The overall goals are holistic—bring workers together to experience the social aspects of the program and learn skills (for well-being, stress management, communication, peer referral) in the context of the social group.

Concern 1. The nursing intervention separated out the peer referral elements (nudge) from the original curriculum. Hence, the social context of the work group (team, social cohesion, and coworker relationships) in which peer referral (nudging) occurs may have been absent from the educational setting.

Explanation. The original Team Awareness program uses several interactive exercises for team building and positive communication before the peer referral element is introduced. These exercises may be essential for first establishing a relational connection among participants before they conduct the role-play in which they practice the nudge skill. Simply adding more time to role-play is not a substitute for building familiarity among participants; they should share their opinions and ideas about mental health and substance abuse prior to role-play. As an analogy, consider the nurse who has great technical skills for patient care but lacks emotional intelligence for perspective taking and empathy. He or she may know exactly what to do or say but may fail to consider the social context and empathic connection necessary to optimize use of the tool.

Concern 2. Failure to show changes in stigma reduction may be due to the lack of these social context elements in the training setting. In addition, without a reduction in stigma, it is possible that the nudge skill could be misused by participants.

Explanation. In previous studies with Team Awareness, we were able to obtain decreases in stigma associated with help seeking. The failure to replicate this finding suggests (a) possible problems in translating the material into the nursing education setting, (b) decrements in program fidelity, or (c) method problems associated with the measurement of stigma. When we train trainers to conduct Team Awareness, we always emphasize that the nudge training should never be conducted by itself, and we indicate that nudge could be misused by those who lack sensitivity or otherwise judge, label, or stigmatize those they are seeking to encourage. In the adaptation by Cadiz et al. (2012), it seems that nudge was not offered alone; therefore, no fault should be placed on the trainers, as care was taken to make the adaptation. It would be helpful to know in more detail (a) what efforts were taken to reduce stigma, (b) how stigma was measured, and (c) the authors’ thoughts on why no stigma effect was obtained.

Concern 3. Failure to either describe or include efforts made to create a psychologically safe and confidential training atmosphere.

Explanation. When we train trainers to conduct Team Awareness, we always emphasize that the training begins with a full description of confidentiality guidelines and that participants need to agree to abide by these guidelines (e.g., “What is said here, stays here.”). Without going into depth herein, the materials in the training may coincide with real and relevant mental health and substance use issues for participants. Hence, a student may be learning the material to “help others,” but it actually may pertain to his or her own health and well-being. In fact, the first several modules from Team Awareness (prior to nudge) cover well-being, ethics, stress management, and tolerance of problems. Although these modules may not have been used by Cadiz et al. (2012), readers should know that the program is designed to be, first, a “healer heal thyself” program and—only secondarily—a peer referral program. Either way, failure to describe the confidentiality guidelines is also potentially a human participants issue. The article by Cadiz et al. states that the school of nursing institutional review board approved the study, but it would be important to know the confidentiality guidelines used, as well as the associated caveats for replication.

Joel Bennett, PhD

Organizational Wellness & Learning



  • Cadiz, D.M., O’Neill, C., Butell, S.S., Epeneter, B.J. & Basin, B. (2012). Quasi-experimental evaluation of a substance use awareness educational intervention for nursing students. Journal of Nursing Education, 51, 411–415. doi:10.3928/01484834-20120515-02 [CrossRef]


Dr. Bennett is one of the developers of the Team Awareness training and is a consultant for its adaptation.

Thank you for the opportunity to address Dr. Bennett’s concerns about our article, “A Quasi-Experimental Evaluation of a Substance Use Awareness Educational Intervention for Nursing Students” (2012). We will respond to each of Dr. Bennett’s three concerns: (a) social context in an educational setting, (b) non-significant results for stigma reduction, and (c) creation of a psychologically safe and confidential training setting.

Concern 1. The social context of the work group in which peer referral (nudging) occurs may have been absent from the educational setting.

Response. Dr. Bennett’s concern highlights a major difference between the 8-hour Team Awareness (TA) training program and our 2-hour seminar. Whereas TA focuses on the social context of the work group, our seminar focuses on the ethical context within which a nurse must resolve challenges encountered in the practice setting. In addition, our seminar does not attempt to conduct a full TA intervention. Rather, it increases students’ awareness of their ethical and legal responsibility when a colleague demonstrates substandard behavior, and we use only two modules of TA to provide a skill set that aids in sharing a message of concern with that colleague.

Concern 2. Nonsignificant results for stigma reduction.

Response. Dr. Bennett noted that we did not obtain significant results for reduced stigma and provided his own theory as to why and asked for more explanation. To address stigma in our training, we discussed alcohol and other drug (AOD) prevalence statistics in the profession, nurse attitudes toward colleagues with AOD issues, and the risks that could lead to AOD issues, and we showed a video of a nurse in successful recovery. In the Measures section of our article, we described the stigma scale. We are happy to share that measure with Dr. Bennett and any interested party. Also, we stated that the nonsignificant reduction of stigma could be attributed to the seminar as being a single, 2-hour event and that future research should examine multiple events over time. Regardless of the stigma result, we did observe significant positive effects on knowledge, training utility, and self-efficacy to intervene. We maintain that the seminar is a worthy effort with positive results that fits the timeframe available in the nursing curriculum.

Concern 3. Failure to make a psychologically safe and confidential training setting.

Response. We disagree with Dr. Bennett’s assertion that the training environment is not safe. In addition to approval by the institutional review board, we incorporated the following safety features into the seminar: (a) nursing faculty were present during the training, (b) a standard case study from the nursing ethics literature for skill practice was used rather than participant personal stories, and (c) information was provided about campus and local resources students can access for assistance with personal problems. In addition, the training facilitators, the nurse faculty, and the students were all trained in the privacy clauses outlined in the Health Insurance Portability and Accountability Act (1996).

Once again, we appreciate the opportunity to respond to Dr. Bennett’s concerns, and we believe we have provided sufficient explanation to address them. We invite anyone who may be interested in the seminar or our evaluation to contact Dr. Cadiz.

David Cadiz, PhD

Chris O’Neill, DMin, RN

Oregon Nurses Foundation


  • Cadiz, D.M., O’Neill, C., Butell, S.S., Epeneter, B.J. & Basin, B. (2012). Quasi-experimental evaluation of a substance use awareness educational intervention for nursing students. Journal of Nursing Education, 51, 411–415.
  • Health Insurance Portability and Accountability Act of 1996. Public Law No. 104-191. Retrieved from


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