Original Article Journal of Addictions Nursing & Volume 25 & Number 1, 28Y34 & Copyright B 2014 International Nurses Society on Addictions
Alcohol and Health Content in Nursing Baccalaureate Degree Curricula Christine Savage, PhD, RN, CARN, FAAN m Janice Dyehouse, PhD, RN m Marianne Marcus, EdD, RN, FAAN
Abstract Globally, a paradigm shift has occurred in the field of alcohol and health from treatment of alcoholism to reducing at-risk drinking. The purpose of this study was to determine if schools of nursing include content reflective of the new paradigm in their Bachelor of Science in Nursing curricula. This was a cross-sectional electronic survey of schools of nursing to determine the mean number of alcohol-related content hours presented, the content offered, and the inclusion of strategies aimed at reduction of at-risk drinking such as screening and brief intervention. The schools (n = 66) reported a mean of 11.3 hours of alcohol-related content, with most of the content related to the treatment of alcohol dependence. Less than 10% required competency in screening and brief intervention. This gap in Bachelor of Science in Nursing curricula carries serious implications in that nurses may not have the knowledge and competencies needed to provide interventions to patients with at-risk alcohol use. Keywords: alcohol, curriculum, nursing
INTRODUCTION A paradigm shift is occurring in the field of alcohol and health; a shift from focusing on treatment of alcohol use disorders (AUDs) to focusing on prevention and early identification of at-risk alcohol use (World Health Organization [WHO], 2011a). This shift is revolutionizing the way health professionals approach the issue of alcohol use and requires an educational foundation that encompasses this wider view of how alcohol use impacts health. This reflects a move from a downstream intervention approach that focuses on acquiring clinical skills to treat those who already have an AUD to foChristine Savage, PhD, RN, CARN, FAAN, Johns Hopkins University School of Nursing, Baltimore, Maryland. Janice Dyehouse, PhD, RN, University of Cincinnati College of Nursing, Ohio. Marianne Marcus, EdD, RN, FAAN, University of Texas at Huston School of Nursing. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Christine Savage, PhD, RN, CARN, FAAN, Johns Hopkins University School of Nursing, 525 N. Wolf St., Baltimore, MD 21205. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000018 28
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cusing on upstream prevention that aims at reducing at-risk drinking and preventing the wider range of negative health consequences related to alcohol use. Because at-risk drinking is the third leading cause of preventable deaths, the WHO and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have shifted their focus to prevention and early intervention (NIAAA, 2005; WHO, 2011b). In the past, nursing curricular content related to alcohol use predominantly focused on providing treatment to persons diagnosed with an AUD. Although these skills are still important, it may be more important, from a public health perspective, to emphasize knowledge and skills related to prevention and early intervention related to at-risk use of alcohol because of the higher prevalence and the burden of disease associated with at-risk alcohol use. At-risk alcohol use puts a person who does not meet the criteria for an AUD at risk for adverse health consequences or harm. A number of terms are used to describe alcohol use that puts a person at risk for alcohol-related harm including atrisk drinking and harmful use of alcohol. At-risk drinking among those without an AUD includes heavy drinking, that is, drinking more than the recommended limits, and episodic heavy (binge) drinking. The recommended limits published by the NIAAA are no more than four drinks for men or three drinks for women and no more than 14 drinks per week for men (seven for women; NIAAA, 2005). Episodic drinking is defined as five or more drinks for men (four or more for women) consumed on a single drinking occasion (Centers for Disease Control and Prevention, 2011; WHO, 2011b). In the United States, in 2010, 23.1% of Americans aged 12 years or older reported episodic heavy alcohol use and 6.8% reported heavy alcohol use (Substance Abuse and Mental Health Services Administration, 2011; U.S. Department of Health and Human Services [USDHHS], 2012a). The global burden of disease associated with at-risk alcohol use is high. According to the WHO, at-risk alcohol use is the third leading risk factor for poor health with approximately 2.5 million deaths each year associated with the harmful use of alcohol. Worldwide heavy episodic drinking is highest in middle-to-high per capita consumption countries and is higher for men than women (WHO, 2011b). The WHO recommends that countries implement comprehensive interventions including individual-, community-, and systems-level strategies to help reduce the burden of disease associated with alcohol use. At the individual level, the WHO recommends a broad base of strategies across the life span January/March 2014
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and the continuum of use. Current efforts to decrease the burden of disease related to alcohol use take into account a broad range of alcohol consumption patterns, not just drinkers who meet the diagnostic criteria for an AUD (WHO, 2011b). On the national level, the Healthy People (HP) 2020 objectives related to alcohol reflect this shift in focus to the continuum of use including total volume, frequency, and patterns of drinking. Only 3 out of the 13 HP 2020 alcohol objectives relate to the end of the continuum of use, alcohol dependence. The other 10 objectives reflect the continuum of alcohol use from abstinence to harmful use with a focus on prevention of at-risk use with adolescents (USDHHS, 2012b). These objectives reflect the new paradigm in the field of alcohol and health that places a greater emphasis on the prevention of at-risk alcohol use and adverse alcoholrelated health consequences across the life span and the continuum of use (see Figure 1). Screening and brief intervention (SBI) is an example of an alcohol-related intervention with clear evidence of effectiveness in reducing at-risk alcohol use (e.g., Aseltine, 2010; Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005). Because of the strong evidence, universal use of SBI with adults and adolescents across healthcare settings is recommended by the National Quality Forum (2007) and NIAAA (2005). In addition, Healthy People 2020 included an objective that SBI be used with all patients with levels 1 and 2 trauma (USDHHS, 2012a). To help guide healthcare providers in the use of SBI, NIAAA developed a clinician’s guide for SBI in adults (NIAAA, 2005) and has a newly released guide for adolescents (NIAAA, 2011). According to the NIAAA guidelines, screen-
Figure 1. Alcohol across the life span and the continuum of use. Journal of Addictions Nursing
ing helps the healthcare provider detect those who may be consuming alcohol at levels that put them at risk as well as detect those who may have an AUD. Those who screen positive for at-risk drinking should be assessed for an AUD and receive a brief intervention. A brief intervention consists of raising the subject of alcohol use, providing feedback, enhancing motivation to change drinking behaviors, and negotiating and advising. Brief interventions are designed to take about 10Y15 minutes and can be delivered in one to four sessions. There are different approaches to brief intervention for those at-risk compared with those with a possible AUD (NIAAA, 2005, 2011). SBI is an example of evidenced-based practice that has emerged over the past 3 decades. SBI is one of the strongest and most widely used evidence-based interventions to reduce at-risk alcohol use across the continuum of use and the life span. SBI can be used during pregnancy, with youth from fourth grade through high school, with the college population, and with adults including older adults. It has shown effectiveness across settings such as the emergency department, acute care, clinics, schools, colleges, community settings, senior citizen centers, and homeless shelters. Alcohol SBI can be used as a universal, selected, or indicated strategy for prevention, early detection, and referral to treatment. To meet the changing recommendations for prevention and early treatment related to at-risk alcohol use, the nursing workforce must be educated with the knowledge and confidence to implement evidence-based interventions such as SBI that have the potential to reduce the harm associated with at-risk alcohol use across the continuum of use and the lifespan. The purpose of this study was to determine the extent to which schools of nursing that offer a baccalaureate of science degree in nursing (BSN) currently include alcoholand health-related content across all life span content areas that reflect this new paradigm shift in the field of alcohol and health.
NURSING CURRICULUM AND PARADIGM SHIFT Even before the global paradigm shift in alcohol and health, the lack of content in nursing curricula related to use of psychoactive substances, including alcohol, has been an issue. In the late 80s, Murphy (1989) declared that there was an urgent need for substance abuse education in schools of nursing. Yet, for the past 3 decades, researchers continue to report that alcohol-related content is not systematically included in nursing curricula. Each study had similar results; alcohol-related content was confined to care of the person with a substance use disorder and was mainly taught in the psychiatric/mental health courses (e.g., Church & Barber, 1995; Hoffman & Heinemann, 1987; Howard, Walker, Walker, & Suchinsky, 1997; Mollica, Hyman, & Mann, 2011; Pillon, Ramos, VillarLuis, & Rassol, 2004; Rassol & Rauaf, 2007). It appears that national faculty development programs aimed at enhancing health professional education related to alcohol and other substance use disorders had limited effect on the inclusion www.journalofaddictionsnursing.com
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of current knowledge in nursing curricula (Brown et al., 2006; Marcus et al., 2005). It is important to know if the content in BSN curricula indicates an integration of recent advances in science related to the prevention and early intervention aimed at decreasing atrisk alcohol use. One difficulty posed by the published studies on alcohol-related content in BSN curricula is the specific alcohol curricular content areas that were measured in these surveys. For example, Mollica et al.’s (2011) recent study followed almost the exact same format used by Hoffman and Heinemann (1987). The curricular content areas included in both of these surveys reflected a more narrow focus on treatment of AUDs rather than a broader approach that includes assessment of content related to genetics, prevention, and reduction of at-risk alcohol use. To help better understand if the full scope of the alcohol-related content is included in nursing curricula, it is important to include content related to prevention that reflects the greatly expanded scientific knowledge that has accumulated since the first survey of schools was conducted in 1989. Thus, the first step before administering a survey was to determine if there was a gold standard that reflected the broader scope of alcohol-related content that should be included in undergraduate BSN curricula. The most recent information on what constitutes essential BSN content related to alcohol and health was established through an NIAAA convened panel of nurse experts in the field of addictions nursing (Murray & Savage, 2010). The nine content areas include the interventions aimed at prevention, early intervention for risky use, treatment of AUD, and the health consequences associated with use. Specifically, the nine content areas are genetics, neurobiology of alcohol addiction, prevention of AUDs, SBI for at-risk alcohol use and AUDs, withdrawal management, treatment for AUDs, alcohol-related health consequences, and legal/ethical issues. These nine content areas were designed for inclusion across the BSN curriculum including adult health/medical surgical, women and children’s health, behavioral health/psychiatric/mental health, and the community/public health nursing courses. These areas reflect the continuum of use across the lifespan and are based on current scientific evidence and best practices. Because no gold standard related to essential curricular content for the full spectrum of substance use, our study focused on alcohol alone rather than substance abuse in general. To determine the extent to which current BSN curricula reflect the new paradigm shift and include the nine essential content areas as established by the NIAAA nurse expert panel, this study included the following research questions: (1) What is the mean number of alcohol-related content hours presented across the lifespan courses in the BSN nursing curriculum? (2) How are those content hours distributed across core the BSN lifespan courses? (3) Which of the nine specific alcohol-related content areas were included in the lifespan courses across the BSN nursing curriculum? (4) Do the schools include specific knowledge and require competency related to SBI using the NIAAA clinician’s guide? 30
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METHODS To answer these questions, a cross-sectional descriptive survey of schools of nursing that offered a baccalaureate degree in nursing was conducted. The institutional review board of our institution confirmed that the study did not meet the definition of human subjects research because the data collected were at the institutional level. The survey was electronically distributed via email to members of the American Association of Colleges of Nursing (AACN) through an AACN’s listserv. The email provided a link to the online survey. The survey was administered using Survey Monkey. Data were then uploaded into IBM SPSS version 19 for analysis. The pool of potential participants is not known. Six hundred seventy schools of nursing are members of AACN, but not all of these schools offer a BSN curriculum, and the number who actively participates in the listserv was not available. The intended respondent was an administrator who was familiar with the BSN curriculum in their school as a whole. To assist in reaching the most appropriate administrator in the school, the survey instructions included the following statement: ‘‘We are conducting a survey of faculty members with primary responsibility for the Bachelor of Science (BS) in nursing curriculumI. If you are not currently responsible for overseeing the Nursing BS/BSN program in your institution please forward the email with the survey request and Web site to that person.’’ The recipient of the listserv was asked to forward the survey to the appropriate person in their school or department who had this organizational-level knowledge. The survey inquired about the number of alcohol-related content hours taught in each of the adult health/medical surgical, women and children’s health, behavioral health/ psychiatric/mental health, and the community/public health nursing courses and which of the nine content areas were covered in these courses. Respondents were also asked if their curriculum included a standalone course or other course with alcohol-related content. They were asked to indicate if their students received content specifically related to SBI for alcohol use using the NIAAA guidelines and if they were required to show competency in SBI. Respondents were then asked to indicate if their students would benefit from more content on alcohol and health and, if so, what content in particular would be beneficial. Finally, we collected information on the title of the person responding to the survey, the number of students in the school, and the state where the school was located. Data were analyzed through the calculation of frequencies, means, and distribution. FINDINGS Sixty-nine schools responded. Of the 69 respondents, three schools were excluded because they did not offer a bachelor’s degree in nursing, leaving 66 schools in the final sample. The total enrollment across the 66 schools was 23,052 for a mean of 355 nursing students per school. There were 25 states represented in the sample with most schools located in the South (n = 29) and the Midwest states (n = 24). Sixty one of the respondents provided information on their position in the January/March 2014
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school. Most of the respondents had an administrative position including dean (19.7%), associate dean (42.4%), or director (25.8%), and three reported that they were members of the faculty. Not all respondents answered the questions related to the specialty-level courses other than psychiatric/mental health nursing. For psychiatric/mental health nursing, 65 of 66 respondents completed the questions, but for the other specialty areas, some respondents stated that they did not know what content was included in the courses. Fourteen respondents indicated that alcohol and health content was included in a course other than the specialty courses, and six indicated that they offered a standalone course on substance abuse.
reporting less than 3 hours of alcohol-related content in the course(s). The courses with the least amount of content hours were women’s and children’s health (mean = 1.8 hours) and community/public health (mean = 1.6 hours). Approximately 80% of the schools reported that they included 2 hours or less alcohol-related content in these courses. When the total content hours was computed for all courses other than the psychiatric course, the mean number of hours dropped to 6 hours with 71% offering 6 hours or less in the lifespan and community health courses. Data on the total hours for the lifespan courses were available for 45 of the respondents. The mean number of hours was 4.5, median was 3, and mode was 2 with a range of 0Y15.
Alcohol-Related Content: Content Hours and Distribution Across Lifespan Courses To answer the first question, ‘‘What is the mean number of alcohol-related content hours presented across the life span courses in the BS Nursing Curriculum,’’ the total number of hours of alcohol content was calculated across the specialty areas. This was done by summing the number of hours reported for each of the specialty areas, not including standalone courses because only one school required that course. The mean hours of alcohol-related content was then calculated across the curriculum. Missing data created a problem in computing total hours, because only 39 schools answered the question on total hours for every specialty area. For the 39 participating schools for which total hours were available, the mean number of hours of alcohol-related content was 11.3 hours (SD = 8.3 hours). The distribution of the hours was then examined and found a median of 8 hours, a mode of 4 with a range of 3Y38 hours. To answer the second question, ‘‘How are those content hours distributed across the BSN life span courses,’’ the mean number of hours included in each specialty area was examined. Most alcohol-related content was presented in the psychiatric/mental health nursing course (see Table 1). As evident in the table, there was a wide range of hours for each content area. The psychiatric/mental health courses had the highest mean (4.9 hours, SD = 5.03 hours), with almost a third (29.3%) of the respondents reporting less than 3 hours of alcohol-related content in the psychiatric/mental health course(s). The next highest mean number of hours was in the adult health/medical surgical nursing courses (2.6, SD = 3 hours), again with two thirds of respondents (66.7%)
ALCOHOL-RELATED CONTENT The extent of inclusion of the nine specific content areas was examined to answer the third research question: ‘‘Which of the nine specific alcohol related content areas were included in the life span courses across the BSN curriculum?’’ Content associated with care of the patient with an AUD (withdrawal and treatment) was included in most of the psychiatric courses (87% and 88%, respectively), in 50% of the adult health courses and three quarters of the standalone courses. This content was covered infrequently in women’s and children’s health and the community health courses. There was less inclusion of prevention and early intervention content. Other than in the standalone courses offered by only six schools, prevention received less attention with 63% of the psychiatric courses including this content area, 35% of community courses, and about 25% of the adult health and women and children’s courses. Health consequences were included in more than half of the adult health, psychiatric, and women and children’s courses. Genetics and neurobiology were more apt to be covered in the psychiatric nursing courses, but only a little over half of the psychiatric courses covered this content. Again, legal/ethical issues were included more frequently in the psychiatric courses than the other courses (see Table 2).
TABLE 1
Schools Including Knowledge and Demonstrated Competencies in SBI The SBI-specific questions were examined to answer the fourth and final question, ‘‘Do schools include specific knowledge and require competency related to SBI using the NIAAA guidelines?’’ Most respondents indicated that screening
Mean Number of Hours per Content Area/Course All Schools Adult Health
Number responding Mean hours
51
Women and Children 54
Mental Health 65
Community 48
Standalone 6
Content in Other Course(s) 14
2.6
1.8
4.9
1.6
1.6
0.4
Range
0Y12
0Y6
0Y35
0Y6
0Y6
0.5Y3
Did not know if alcohol content included
23%
18%
1.5%
27%
0%
0%
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TABLE 2
Alcohol-Related Content by Course: Percent of Respondents Indicating That the Content Was Offered in the Specific Course/Content Area or That Further Content Was Needed
Content Area
Adult Health
Women and Children
Mental Health
Community
Stand Alone
Other
% Indicating Need
Genetics
18.9%
35.8%
52.1%
4.5%
66.4%
28.6%
53.7%
Neurobiology
20.8%
18.9%
54%
4.3%
50%
21.4%
50%
Prevention
24.5%
26.4%
63.3%
34%
71.4%
21.4%
48.8%
Screening
32.1%
50.9%
90.2%
51.1%
83.3%
28.6%
41.5%
Brief intervention
24.5%
18.9%
78.4%
25.5%
66.7% 100%
42.9%
Withdrawal
49.1%
12.1%
87.8%
10.6%
66.7%
7.1%
41.5%
Treatment
50.9%
6.1%
88.2%
27.7%
66.7%
21.4%
39%
Health consequences
66%
56.6%
69.4%
36.2%
83.3%
53.3%
46%
Legal/ethical
24.5%
30.2%
70.8%
29.8%
50%
68.8%
44%
(90.2%) and brief intervention (78.4%) was included in the psychiatric/mental health courses. This content was less apt to be covered in the lifespan or community/public health courses. Only 32.1% of respondents indicated that screening was included in the medical surgical/adult health courses; a little over 50% responded that screening was included in the women’s and children’s health courses and the community/ public health courses. Respondents indicated that brief intervention was covered in only a quarter of the adult health and community/public health courses and in less than 20% of the women’s and children’s health courses (see Table 2). When respondents were asked, ‘‘Do graduates of your bachelor degree nursing programs receive content specifically related to screening and brief intervention for alcohol use using the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines?,’’ close to half reported that their students received this content. However, when asked if students were required to show competency in SBI based on (NIAAA) guidelines, only 9.4% reported that they were. The final section of the survey asked participants to indicate if they believed that additional content on alcohol and health in BSN curriculum would be beneficial to students. More than half responded ‘‘yes,’’ 23% stated ‘‘no’’ to this question, and 15% stated they ‘‘did not know.’’ For those who indicated more alcohol content was needed, there was little variability in the percent indicating specific content areas that needed to be added. Genetics ranked highest with 53.7% of schools indicating that additional content was needed, and treatment ranked lowest with 39% indicating that additional content was needed (see Table 2). DISCUSSION The intent of this study was to determine if current BSN curricula reflect the major paradigm shift related to alcohol and health that has occurred over the past 3 decades. Of particular interest was inclusion of content related to alcohol use across the lifespan courses and use of evidence-based preventive 32
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strategies such as SBI. The mean number of content hours has increased from 1987. However, the wide range in hours of alcohol-related content across the lifespan courses confirmed that no standard approach was used by these schools in relation to the amount of alcohol-related content hours that should be included in these courses. These findings imply that there is a wide range of knowledge among graduating nurses. In addition, only 10% of the schools reported requiring competency in SBI, a well-established evidencebased practice that, if used consistently by nurses, has the potential to not only prevent the development of AUDs but also reduce the global burden of at-risk alcohol use. To better understand if change has occurred in nursing curricula, the findings of this study were compared with the seminal study conducted by Hoffman and Heinemann (1987). Our results indicate that there has been little overall progress in the past 24 years. The range of content hours has not changed from the 1987 study to this more recent study (1Y30 vs. 3Y38 hours). Because of the wide range in hours, further comparisons were conducted. Hoffman and Heinemann found that 67% of schools reported 10 or less content hours offered compared with 69% in this study. Thus, little change has occurred in total content hours. Comparison of distribution of content across the different courses again had similar findings to the 1987 study with the preponderance of content still residing within the psychiatric/mental health courses. This finding raises concerns that students may not be aware that adverse alcohol-related consequences are relevant across healthcare settings, the continuum of use, and the life span. In particular, BSN curricula in the respondent schools do not reflect the fact that nurses need the knowledge and skills necessary for intervening with patients/clients who may be engaged in at-risk drinking or display symptoms of the adverse effect of alcohol on health but do not meet the criteria for an AUD. In contrast to other more recent studies such as Mollica et al. (2011), this study used a gold standard established by experts in the field on what constitutes curricular content January/March 2014
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relevant to alcohol and health that reflects the new paradigm and provided the ability to evaluate BSN curricula based on the new paradigm. The findings reported here are concerning because the lack of alcohol-related content hours in BSN curricula has potentially serious consequences. For example, nurses working in schools need alcohol-related knowledge to actively participate in alcohol prevention with school children especially with the strong evidence that first use of alcohol at ages 11Y14 years increases the risk for the development of an AUD (Centers for Disease Control and Prevention, 2011; DeWit, Adlaf, Offor, & Ogborn, 2000). Practicing nurses may not have adequate knowledge and competencies to provide recommended interventions to patients who consume alcohol. In confirmation of this lack of educational preparation, Owens, Gilmore, and Pirmohamad (2000) found that the nurses they surveyed did not have the skills or knowledge needed to give advice about alcohol consumption. This knowledge gap is particularly concerning because the chance that a nurse will encounter a person whose alcohol use puts them at risk for adverse health consequences is high with close to 25% of Americans reporting alcohol use that puts them at risk for adverse health consequences (Substance Abuse and Mental Health Services Administration, 2011). Focusing education on the treatment of AUDs in adults results in nurses unprepared to intervene with patients across the life span and the continuum of use. Although it is important that nurses recognize symptoms of an AUD, they must also recognize patients without an AUD who are at risk for adverse consequences such as a single episode of at-risk alcohol use that could lead to serious adverse health consequences including motor vehicle crashes, drowning, or alcohol poisoning. This study has several limitations. The first limitation is that information about the number of BSN schools eligible to participate in the study is unknown so it is not possible to calculate an accurate response rate. Second, although recipients of the email were asked to have the survey completed by the person in institution responsible for the BSN curriculum in their school, a further question that confirmed this fact would have help to determine if the respondent was indeed the person with primary responsibility for the BSN curricula. This was particularly concerning because approximately a quarter of respondents indicated that they did not know if alcohol and health content was offered in the adult health and/or community/public health courses. A third limitation is the reliability of the survey instrument. The content validity of the instrument was approached through the input of nurses in the addictions field, but the instrument was not previously tested for its psychometric properties. The instrument would need to be evaluated in larger studies before considering the generalizability of the findings. In addition, not all regions of the country were equally represented, with most of the schools located in the south or the midwest. Thus, the findings may not reflect BSN curricula in other areas of the country. Despite these limitations, the study has important implications. At-risk alcohol use has the potential to harm the Journal of Addictions Nursing
health of every segment of society. Nurses must be prepared to recognize this threat and respond with competence and compassion. The fact that at-risk and harmful alcohol use is the third leading risk factor for premature death worldwide does not appear to be reflected in BSN curriculum. Nurse educators should make a concerted effort to assure that our schools are responsive to this major health issue. Evidencebased content such as SBI should be emphasized, and demonstration of skill competency should be promoted. Consideration must be given to making this content essential in curricular standards and credentialing examinations. NIAAA is in the process of publishing a BSN curriculum that will be available online. This is a critical next step in creating a standard for educating nurses about alcohol and health. Similar work should occur in relation to other substance use. If nursing is truly an evidence-based practice, then it is critical for nurse educators and those involved in BSN curriculum development to actively participate in translating the evidence related to at-risk alcohol use prevention into practice. This can be done by increasing the content on alcohol and health across the curriculum and including evaluation of competency in interventions such as SBI. CONCLUSIONS To close the gap, BSN curricula must now shift from a focus only on educating nurses for a specialty unitVthe specialist nurse who cares for the patient hospitalized on the psychiatric unit with an AUDVto include a broader focus on the skills needed by the generalist nurse who cares for individuals engaging in at-risk alcohol use who would benefit from early identification and intervention. Such a shift would result in all nurses having the basic skills to engage in prevention and early intervention across healthcare settings such as schools, primary care, the emergency department, acute care, and community settings. Because individuals who engage in at-risk drinking can be found in all settings, education of the nursing workforce requires inclusion of alcohol-related content in all the lifespan courses, not just the mental health psychiatric nursing courses. Although standards and guidelines now exist related to evidence-based intervention, these have not been effectively translated into nursing education as the standard of care. The disconnection between current evidence and the traditional content offered in nursing curricula provides impetus for updating nursing curricula (Crabbe, 2002; Enoch & Goldman, 2001; Heilig et al., 2010; Leggio, Kenna, Fenton, Bonenfant, & Swift, 2009; Weiss, 2002). Because nurses are the largest segment of the healthcare workforce and alcohol is one of the top three causes of premature death (WHO, 2011b), nurses must have the knowledge and skills to provide evidence-based interventions across the continuum of use and life span. Nurses in all settings now need to know ways to approach patients/clients about their alcohol use and have tools to screen and refer patients to appropriate resources as well as how to initiate prevention strategies and activities. The best way to accomplish this is to purposefully include alcohol-related content www.journalofaddictionsnursing.com
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in nursing curricula and require of nursing students’ demonstrated competencies in evidence-based interventions that reduce alcohol-related harm. REFERENCES Aseltine, R. H. (2010). The impact of screening, brief intervention and referral for treatment in emergency department patients’ alcohol use: A 3-, 6- and 12-month follow-up. Alcohol and Alcoholism, 45(6), 514Y519. Bertholet, N., Daeppen, J., Wietlisbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care. Archives of Internal Medicine, 165(9):986Y995. Brown, R. L., Marcus, M. T., Straussner, S. L. A., Graham, A. V., Madden, T., Schoener, E., & Henry, R. (2006). Project MAINSTREAMs’s first fellowship cohort: Pilot test of a national dissemination model to enhance substance abuse curriculum at health professions schools. Health Education Journal, 65, 252Y266. Centers for Disease Control and Prevention. (2011). Alcohol and publkc health. Frequently asked questions. Retrieved from http://www .cdc.gov/alcohol/faqs.htm#heavyDrinking Centers for Disease Control and Prevention. (2011). Alcohol and public health: Underage drinking. http://www.cdc.gov/alcohol/factsheets/underage-drinking.htm Church, O. M., & Babor, T. F. (1995). Barriers and breakthroughs: Curriculum in nursing education. Journal of Nursing Education, 34, 278Y281. Crabbe, J. C. (2002). Alcohol and genetics: New models. American Journal of Medical Genetics, 114(8), 969Y974. DeWit, D. J., Adlaf, E. M., Offor, D. R., & Ogborn, A. C. (2000). Age at first use: A risk factor for the development of alcohol use disorders. American Journal of Psychiarty, 157(5), 745Y750. Enoch, M., & Goldman, D. (2001). The genetics of alcoholism and alcohol abuse. Current Psychiatry Reports, 3(2), 144Y151. Heilig, M., Thorsell, A., Sommer, W. H., Hansson, A. C., Ramchandani, V. A., George, D. T., I Barr, C. S. (2010). Translating the neuroscience of alcoholism into clinical treatment: From blocking the buzz to curing the blues. Neuroscience and Behavioral Reviews, 35, 334Y344. Hoffman, A. L., & Heinemann, E. M. (1987). Substance abuse education in schools of nursing: A national survey. Journal of Nursing Education, 26, 282Y287. Howard, M. O., Walker, R. D., Walker, P. S., & Suchinsky, R. T. (1997). Alcohol and drug education in schools of nursing. Journal of Alcohol and Drug Education, 42(3), 54Y80. Leggio, L., Kenna, G. A., Fenton, M., Bonenfant, E., & Swift, R. M. (2009). Typologies of alcohol dependence. From Jellinek to genetics and beyond. Neuropsychology Review, 19(1), 115Y129. Marcus, M. T., Brown, R. L., Straussner, S. L. A., Schoener, E., Henry, R., Graham, A., I Saunders, L. A. (2005). Creating change agents: A national substance abuse education project. Substance Abuse, 26(3Y4), 5Y15.
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Mollica, M. A., Hyman, Z., & Mann, C. M. (2011). Alcohol-related content in undergraduate nursing curricula in the northeastern United States. Journal of Psychosocial Nursing and Mental Health, 49(6), 22Y31. doi:10.3928/02793695-20110503-01 Murphy, S. A. (1989). The urgency of substance abuse education in schools of nursing. Journal of Nursing Education, 28(6), 247Y251. Murray, M., & Savage, C. L. (2010). Guest editorial. Journal of Addictions Nursing, 20(3), 3Y5. National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use conditions: Evidenced-based treatment practices. Washington, DC: National Quality Forum. National Institute on Alcohol Abuse and Alcoholism. (2005). Helping patients who drink too much: A clinican’s guide (2nd ed.). Rockville, MD: U.S. Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism. (2011). Alcohol screening and brief intervention for youth: A practitioner’s guide (2nd ed.). Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://www.niaaa.nih.gov/ Publications/EducationTrainingMaterials/YouthGuide Owens, L., Gilmore, I. T., & Pirmohamed, M. (2000). General practice nurses’ knowledge of alcohol use and misuse: A questionnaire survey. Alcohol and Alcohlism, 35(3), 259Y262. Pillon, S. C., Ramos, L. H., Villar-Luis, M. A., & Rassool, G. H. (2004). Nursing students’ perceptions of the curricula content on drug and alcohol education in Brazil: An exploratory study. Journal of Addictions Nursing, 15(3), 133Y137. Rassol, G. H., & Rawaf, S. (2007). Predictors of educational outcomes of undergraduate nursing students in alcohol and drug education. Nurse Education Today, 28(6), 691Y701. Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. SMA 11-458. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http:// www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf Weiss, F. (2002). Behavioral neurobiology of alcohol addiction: Recent advances and challenges. The Journal of Neuroscience, 22(9), 3332Y3337. World Health Organization. (2011a). Alcohol fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs349/en/index.html World Health Organization. (2011b). Global status report on alcohol and health 2011. Retrieved from http://www.who.int/substance_abuse/ publications/global_alcohol_report/msbgsruprofiles.pdf U.S. Department of Health and Human Services. (2012a). Summary health statistics for US adults: National health interview survey. Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/ sr10_252.pdf U.S. Department of Health and Human Services. (2012b). Healthy People, 2020 substance use objectives. Retrieved from http://healthypeople.gov/ 2020/topicsobjectives2020/overview.aspx?topicid=40
January/March 2014
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Alcohol and Health Content in Nursing Baccalaureate Degree Curricula Christine Savage, PhD, RN, CARN, FAAN m Janice Dyehouse, PhD, RN m Marianne Marcus, EdD, RN, FAAN
Abstract Globally, a paradigm shift has occurred in the field of alcohol and health from treatment of alcoholism to reducing at-risk drinking. The purpose of this study was to determine if schools of nursing include content reflective of the new paradigm in their Bachelor of Science in Nursing curricula. This was a cross-sectional electronic survey of schools of nursing to determine the mean number of alcohol-related content hours presented, the content offered, and the inclusion of strategies aimed at reduction of at-risk drinking such as screening and brief intervention. The schools (n = 66) reported a mean of 11.3 hours of alcohol-related content, with most of the content related to the treatment of alcohol dependence. Less than 10% required competency in screening and brief intervention. This gap in Bachelor of Science in Nursing curricula carries serious implications in that nurses may not have the knowledge and competencies needed to provide interventions to patients with at-risk alcohol use. Keywords: alcohol, curriculum, nursing
INTRODUCTION A paradigm shift is occurring in the field of alcohol and health; a shift from focusing on treatment of alcohol use disorders (AUDs) to focusing on prevention and early identification of at-risk alcohol use (World Health Organization [WHO], 2011a). This shift is revolutionizing the way health professionals approach the issue of alcohol use and requires an educational foundation that encompasses this wider view of how alcohol use impacts health. This reflects a move from a downstream intervention approach that focuses on acquiring clinical skills to treat those who already have an AUD to foChristine Savage, PhD, RN, CARN, FAAN, Johns Hopkins University School of Nursing, Baltimore, Maryland. Janice Dyehouse, PhD, RN, University of Cincinnati College of Nursing, Ohio. Marianne Marcus, EdD, RN, FAAN, University of Texas at Huston School of Nursing. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article. Correspondence related to content to: Christine Savage, PhD, RN, CARN, FAAN, Johns Hopkins University School of Nursing, 525 N. Wolf St., Baltimore, MD 21205. E-mail: [email protected] DOI: 10.1097/JAN.0000000000000018 28
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cusing on upstream prevention that aims at reducing at-risk drinking and preventing the wider range of negative health consequences related to alcohol use. Because at-risk drinking is the third leading cause of preventable deaths, the WHO and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) have shifted their focus to prevention and early intervention (NIAAA, 2005; WHO, 2011b). In the past, nursing curricular content related to alcohol use predominantly focused on providing treatment to persons diagnosed with an AUD. Although these skills are still important, it may be more important, from a public health perspective, to emphasize knowledge and skills related to prevention and early intervention related to at-risk use of alcohol because of the higher prevalence and the burden of disease associated with at-risk alcohol use. At-risk alcohol use puts a person who does not meet the criteria for an AUD at risk for adverse health consequences or harm. A number of terms are used to describe alcohol use that puts a person at risk for alcohol-related harm including atrisk drinking and harmful use of alcohol. At-risk drinking among those without an AUD includes heavy drinking, that is, drinking more than the recommended limits, and episodic heavy (binge) drinking. The recommended limits published by the NIAAA are no more than four drinks for men or three drinks for women and no more than 14 drinks per week for men (seven for women; NIAAA, 2005). Episodic drinking is defined as five or more drinks for men (four or more for women) consumed on a single drinking occasion (Centers for Disease Control and Prevention, 2011; WHO, 2011b). In the United States, in 2010, 23.1% of Americans aged 12 years or older reported episodic heavy alcohol use and 6.8% reported heavy alcohol use (Substance Abuse and Mental Health Services Administration, 2011; U.S. Department of Health and Human Services [USDHHS], 2012a). The global burden of disease associated with at-risk alcohol use is high. According to the WHO, at-risk alcohol use is the third leading risk factor for poor health with approximately 2.5 million deaths each year associated with the harmful use of alcohol. Worldwide heavy episodic drinking is highest in middle-to-high per capita consumption countries and is higher for men than women (WHO, 2011b). The WHO recommends that countries implement comprehensive interventions including individual-, community-, and systems-level strategies to help reduce the burden of disease associated with alcohol use. At the individual level, the WHO recommends a broad base of strategies across the life span January/March 2014
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and the continuum of use. Current efforts to decrease the burden of disease related to alcohol use take into account a broad range of alcohol consumption patterns, not just drinkers who meet the diagnostic criteria for an AUD (WHO, 2011b). On the national level, the Healthy People (HP) 2020 objectives related to alcohol reflect this shift in focus to the continuum of use including total volume, frequency, and patterns of drinking. Only 3 out of the 13 HP 2020 alcohol objectives relate to the end of the continuum of use, alcohol dependence. The other 10 objectives reflect the continuum of alcohol use from abstinence to harmful use with a focus on prevention of at-risk use with adolescents (USDHHS, 2012b). These objectives reflect the new paradigm in the field of alcohol and health that places a greater emphasis on the prevention of at-risk alcohol use and adverse alcoholrelated health consequences across the life span and the continuum of use (see Figure 1). Screening and brief intervention (SBI) is an example of an alcohol-related intervention with clear evidence of effectiveness in reducing at-risk alcohol use (e.g., Aseltine, 2010; Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005). Because of the strong evidence, universal use of SBI with adults and adolescents across healthcare settings is recommended by the National Quality Forum (2007) and NIAAA (2005). In addition, Healthy People 2020 included an objective that SBI be used with all patients with levels 1 and 2 trauma (USDHHS, 2012a). To help guide healthcare providers in the use of SBI, NIAAA developed a clinician’s guide for SBI in adults (NIAAA, 2005) and has a newly released guide for adolescents (NIAAA, 2011). According to the NIAAA guidelines, screen-
Figure 1. Alcohol across the life span and the continuum of use. Journal of Addictions Nursing
ing helps the healthcare provider detect those who may be consuming alcohol at levels that put them at risk as well as detect those who may have an AUD. Those who screen positive for at-risk drinking should be assessed for an AUD and receive a brief intervention. A brief intervention consists of raising the subject of alcohol use, providing feedback, enhancing motivation to change drinking behaviors, and negotiating and advising. Brief interventions are designed to take about 10Y15 minutes and can be delivered in one to four sessions. There are different approaches to brief intervention for those at-risk compared with those with a possible AUD (NIAAA, 2005, 2011). SBI is an example of evidenced-based practice that has emerged over the past 3 decades. SBI is one of the strongest and most widely used evidence-based interventions to reduce at-risk alcohol use across the continuum of use and the life span. SBI can be used during pregnancy, with youth from fourth grade through high school, with the college population, and with adults including older adults. It has shown effectiveness across settings such as the emergency department, acute care, clinics, schools, colleges, community settings, senior citizen centers, and homeless shelters. Alcohol SBI can be used as a universal, selected, or indicated strategy for prevention, early detection, and referral to treatment. To meet the changing recommendations for prevention and early treatment related to at-risk alcohol use, the nursing workforce must be educated with the knowledge and confidence to implement evidence-based interventions such as SBI that have the potential to reduce the harm associated with at-risk alcohol use across the continuum of use and the lifespan. The purpose of this study was to determine the extent to which schools of nursing that offer a baccalaureate of science degree in nursing (BSN) currently include alcoholand health-related content across all life span content areas that reflect this new paradigm shift in the field of alcohol and health.
NURSING CURRICULUM AND PARADIGM SHIFT Even before the global paradigm shift in alcohol and health, the lack of content in nursing curricula related to use of psychoactive substances, including alcohol, has been an issue. In the late 80s, Murphy (1989) declared that there was an urgent need for substance abuse education in schools of nursing. Yet, for the past 3 decades, researchers continue to report that alcohol-related content is not systematically included in nursing curricula. Each study had similar results; alcohol-related content was confined to care of the person with a substance use disorder and was mainly taught in the psychiatric/mental health courses (e.g., Church & Barber, 1995; Hoffman & Heinemann, 1987; Howard, Walker, Walker, & Suchinsky, 1997; Mollica, Hyman, & Mann, 2011; Pillon, Ramos, VillarLuis, & Rassol, 2004; Rassol & Rauaf, 2007). It appears that national faculty development programs aimed at enhancing health professional education related to alcohol and other substance use disorders had limited effect on the inclusion www.journalofaddictionsnursing.com
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of current knowledge in nursing curricula (Brown et al., 2006; Marcus et al., 2005). It is important to know if the content in BSN curricula indicates an integration of recent advances in science related to the prevention and early intervention aimed at decreasing atrisk alcohol use. One difficulty posed by the published studies on alcohol-related content in BSN curricula is the specific alcohol curricular content areas that were measured in these surveys. For example, Mollica et al.’s (2011) recent study followed almost the exact same format used by Hoffman and Heinemann (1987). The curricular content areas included in both of these surveys reflected a more narrow focus on treatment of AUDs rather than a broader approach that includes assessment of content related to genetics, prevention, and reduction of at-risk alcohol use. To help better understand if the full scope of the alcohol-related content is included in nursing curricula, it is important to include content related to prevention that reflects the greatly expanded scientific knowledge that has accumulated since the first survey of schools was conducted in 1989. Thus, the first step before administering a survey was to determine if there was a gold standard that reflected the broader scope of alcohol-related content that should be included in undergraduate BSN curricula. The most recent information on what constitutes essential BSN content related to alcohol and health was established through an NIAAA convened panel of nurse experts in the field of addictions nursing (Murray & Savage, 2010). The nine content areas include the interventions aimed at prevention, early intervention for risky use, treatment of AUD, and the health consequences associated with use. Specifically, the nine content areas are genetics, neurobiology of alcohol addiction, prevention of AUDs, SBI for at-risk alcohol use and AUDs, withdrawal management, treatment for AUDs, alcohol-related health consequences, and legal/ethical issues. These nine content areas were designed for inclusion across the BSN curriculum including adult health/medical surgical, women and children’s health, behavioral health/psychiatric/mental health, and the community/public health nursing courses. These areas reflect the continuum of use across the lifespan and are based on current scientific evidence and best practices. Because no gold standard related to essential curricular content for the full spectrum of substance use, our study focused on alcohol alone rather than substance abuse in general. To determine the extent to which current BSN curricula reflect the new paradigm shift and include the nine essential content areas as established by the NIAAA nurse expert panel, this study included the following research questions: (1) What is the mean number of alcohol-related content hours presented across the lifespan courses in the BSN nursing curriculum? (2) How are those content hours distributed across core the BSN lifespan courses? (3) Which of the nine specific alcohol-related content areas were included in the lifespan courses across the BSN nursing curriculum? (4) Do the schools include specific knowledge and require competency related to SBI using the NIAAA clinician’s guide? 30
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METHODS To answer these questions, a cross-sectional descriptive survey of schools of nursing that offered a baccalaureate degree in nursing was conducted. The institutional review board of our institution confirmed that the study did not meet the definition of human subjects research because the data collected were at the institutional level. The survey was electronically distributed via email to members of the American Association of Colleges of Nursing (AACN) through an AACN’s listserv. The email provided a link to the online survey. The survey was administered using Survey Monkey. Data were then uploaded into IBM SPSS version 19 for analysis. The pool of potential participants is not known. Six hundred seventy schools of nursing are members of AACN, but not all of these schools offer a BSN curriculum, and the number who actively participates in the listserv was not available. The intended respondent was an administrator who was familiar with the BSN curriculum in their school as a whole. To assist in reaching the most appropriate administrator in the school, the survey instructions included the following statement: ‘‘We are conducting a survey of faculty members with primary responsibility for the Bachelor of Science (BS) in nursing curriculumI. If you are not currently responsible for overseeing the Nursing BS/BSN program in your institution please forward the email with the survey request and Web site to that person.’’ The recipient of the listserv was asked to forward the survey to the appropriate person in their school or department who had this organizational-level knowledge. The survey inquired about the number of alcohol-related content hours taught in each of the adult health/medical surgical, women and children’s health, behavioral health/ psychiatric/mental health, and the community/public health nursing courses and which of the nine content areas were covered in these courses. Respondents were also asked if their curriculum included a standalone course or other course with alcohol-related content. They were asked to indicate if their students received content specifically related to SBI for alcohol use using the NIAAA guidelines and if they were required to show competency in SBI. Respondents were then asked to indicate if their students would benefit from more content on alcohol and health and, if so, what content in particular would be beneficial. Finally, we collected information on the title of the person responding to the survey, the number of students in the school, and the state where the school was located. Data were analyzed through the calculation of frequencies, means, and distribution. FINDINGS Sixty-nine schools responded. Of the 69 respondents, three schools were excluded because they did not offer a bachelor’s degree in nursing, leaving 66 schools in the final sample. The total enrollment across the 66 schools was 23,052 for a mean of 355 nursing students per school. There were 25 states represented in the sample with most schools located in the South (n = 29) and the Midwest states (n = 24). Sixty one of the respondents provided information on their position in the January/March 2014
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school. Most of the respondents had an administrative position including dean (19.7%), associate dean (42.4%), or director (25.8%), and three reported that they were members of the faculty. Not all respondents answered the questions related to the specialty-level courses other than psychiatric/mental health nursing. For psychiatric/mental health nursing, 65 of 66 respondents completed the questions, but for the other specialty areas, some respondents stated that they did not know what content was included in the courses. Fourteen respondents indicated that alcohol and health content was included in a course other than the specialty courses, and six indicated that they offered a standalone course on substance abuse.
reporting less than 3 hours of alcohol-related content in the course(s). The courses with the least amount of content hours were women’s and children’s health (mean = 1.8 hours) and community/public health (mean = 1.6 hours). Approximately 80% of the schools reported that they included 2 hours or less alcohol-related content in these courses. When the total content hours was computed for all courses other than the psychiatric course, the mean number of hours dropped to 6 hours with 71% offering 6 hours or less in the lifespan and community health courses. Data on the total hours for the lifespan courses were available for 45 of the respondents. The mean number of hours was 4.5, median was 3, and mode was 2 with a range of 0Y15.
Alcohol-Related Content: Content Hours and Distribution Across Lifespan Courses To answer the first question, ‘‘What is the mean number of alcohol-related content hours presented across the life span courses in the BS Nursing Curriculum,’’ the total number of hours of alcohol content was calculated across the specialty areas. This was done by summing the number of hours reported for each of the specialty areas, not including standalone courses because only one school required that course. The mean hours of alcohol-related content was then calculated across the curriculum. Missing data created a problem in computing total hours, because only 39 schools answered the question on total hours for every specialty area. For the 39 participating schools for which total hours were available, the mean number of hours of alcohol-related content was 11.3 hours (SD = 8.3 hours). The distribution of the hours was then examined and found a median of 8 hours, a mode of 4 with a range of 3Y38 hours. To answer the second question, ‘‘How are those content hours distributed across the BSN life span courses,’’ the mean number of hours included in each specialty area was examined. Most alcohol-related content was presented in the psychiatric/mental health nursing course (see Table 1). As evident in the table, there was a wide range of hours for each content area. The psychiatric/mental health courses had the highest mean (4.9 hours, SD = 5.03 hours), with almost a third (29.3%) of the respondents reporting less than 3 hours of alcohol-related content in the psychiatric/mental health course(s). The next highest mean number of hours was in the adult health/medical surgical nursing courses (2.6, SD = 3 hours), again with two thirds of respondents (66.7%)
ALCOHOL-RELATED CONTENT The extent of inclusion of the nine specific content areas was examined to answer the third research question: ‘‘Which of the nine specific alcohol related content areas were included in the life span courses across the BSN curriculum?’’ Content associated with care of the patient with an AUD (withdrawal and treatment) was included in most of the psychiatric courses (87% and 88%, respectively), in 50% of the adult health courses and three quarters of the standalone courses. This content was covered infrequently in women’s and children’s health and the community health courses. There was less inclusion of prevention and early intervention content. Other than in the standalone courses offered by only six schools, prevention received less attention with 63% of the psychiatric courses including this content area, 35% of community courses, and about 25% of the adult health and women and children’s courses. Health consequences were included in more than half of the adult health, psychiatric, and women and children’s courses. Genetics and neurobiology were more apt to be covered in the psychiatric nursing courses, but only a little over half of the psychiatric courses covered this content. Again, legal/ethical issues were included more frequently in the psychiatric courses than the other courses (see Table 2).
TABLE 1
Schools Including Knowledge and Demonstrated Competencies in SBI The SBI-specific questions were examined to answer the fourth and final question, ‘‘Do schools include specific knowledge and require competency related to SBI using the NIAAA guidelines?’’ Most respondents indicated that screening
Mean Number of Hours per Content Area/Course All Schools Adult Health
Number responding Mean hours
51
Women and Children 54
Mental Health 65
Community 48
Standalone 6
Content in Other Course(s) 14
2.6
1.8
4.9
1.6
1.6
0.4
Range
0Y12
0Y6
0Y35
0Y6
0Y6
0.5Y3
Did not know if alcohol content included
23%
18%
1.5%
27%
0%
0%
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TABLE 2
Alcohol-Related Content by Course: Percent of Respondents Indicating That the Content Was Offered in the Specific Course/Content Area or That Further Content Was Needed
Content Area
Adult Health
Women and Children
Mental Health
Community
Stand Alone
Other
% Indicating Need
Genetics
18.9%
35.8%
52.1%
4.5%
66.4%
28.6%
53.7%
Neurobiology
20.8%
18.9%
54%
4.3%
50%
21.4%
50%
Prevention
24.5%
26.4%
63.3%
34%
71.4%
21.4%
48.8%
Screening
32.1%
50.9%
90.2%
51.1%
83.3%
28.6%
41.5%
Brief intervention
24.5%
18.9%
78.4%
25.5%
66.7% 100%
42.9%
Withdrawal
49.1%
12.1%
87.8%
10.6%
66.7%
7.1%
41.5%
Treatment
50.9%
6.1%
88.2%
27.7%
66.7%
21.4%
39%
Health consequences
66%
56.6%
69.4%
36.2%
83.3%
53.3%
46%
Legal/ethical
24.5%
30.2%
70.8%
29.8%
50%
68.8%
44%
(90.2%) and brief intervention (78.4%) was included in the psychiatric/mental health courses. This content was less apt to be covered in the lifespan or community/public health courses. Only 32.1% of respondents indicated that screening was included in the medical surgical/adult health courses; a little over 50% responded that screening was included in the women’s and children’s health courses and the community/ public health courses. Respondents indicated that brief intervention was covered in only a quarter of the adult health and community/public health courses and in less than 20% of the women’s and children’s health courses (see Table 2). When respondents were asked, ‘‘Do graduates of your bachelor degree nursing programs receive content specifically related to screening and brief intervention for alcohol use using the National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines?,’’ close to half reported that their students received this content. However, when asked if students were required to show competency in SBI based on (NIAAA) guidelines, only 9.4% reported that they were. The final section of the survey asked participants to indicate if they believed that additional content on alcohol and health in BSN curriculum would be beneficial to students. More than half responded ‘‘yes,’’ 23% stated ‘‘no’’ to this question, and 15% stated they ‘‘did not know.’’ For those who indicated more alcohol content was needed, there was little variability in the percent indicating specific content areas that needed to be added. Genetics ranked highest with 53.7% of schools indicating that additional content was needed, and treatment ranked lowest with 39% indicating that additional content was needed (see Table 2). DISCUSSION The intent of this study was to determine if current BSN curricula reflect the major paradigm shift related to alcohol and health that has occurred over the past 3 decades. Of particular interest was inclusion of content related to alcohol use across the lifespan courses and use of evidence-based preventive 32
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strategies such as SBI. The mean number of content hours has increased from 1987. However, the wide range in hours of alcohol-related content across the lifespan courses confirmed that no standard approach was used by these schools in relation to the amount of alcohol-related content hours that should be included in these courses. These findings imply that there is a wide range of knowledge among graduating nurses. In addition, only 10% of the schools reported requiring competency in SBI, a well-established evidencebased practice that, if used consistently by nurses, has the potential to not only prevent the development of AUDs but also reduce the global burden of at-risk alcohol use. To better understand if change has occurred in nursing curricula, the findings of this study were compared with the seminal study conducted by Hoffman and Heinemann (1987). Our results indicate that there has been little overall progress in the past 24 years. The range of content hours has not changed from the 1987 study to this more recent study (1Y30 vs. 3Y38 hours). Because of the wide range in hours, further comparisons were conducted. Hoffman and Heinemann found that 67% of schools reported 10 or less content hours offered compared with 69% in this study. Thus, little change has occurred in total content hours. Comparison of distribution of content across the different courses again had similar findings to the 1987 study with the preponderance of content still residing within the psychiatric/mental health courses. This finding raises concerns that students may not be aware that adverse alcohol-related consequences are relevant across healthcare settings, the continuum of use, and the life span. In particular, BSN curricula in the respondent schools do not reflect the fact that nurses need the knowledge and skills necessary for intervening with patients/clients who may be engaged in at-risk drinking or display symptoms of the adverse effect of alcohol on health but do not meet the criteria for an AUD. In contrast to other more recent studies such as Mollica et al. (2011), this study used a gold standard established by experts in the field on what constitutes curricular content January/March 2014
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relevant to alcohol and health that reflects the new paradigm and provided the ability to evaluate BSN curricula based on the new paradigm. The findings reported here are concerning because the lack of alcohol-related content hours in BSN curricula has potentially serious consequences. For example, nurses working in schools need alcohol-related knowledge to actively participate in alcohol prevention with school children especially with the strong evidence that first use of alcohol at ages 11Y14 years increases the risk for the development of an AUD (Centers for Disease Control and Prevention, 2011; DeWit, Adlaf, Offor, & Ogborn, 2000). Practicing nurses may not have adequate knowledge and competencies to provide recommended interventions to patients who consume alcohol. In confirmation of this lack of educational preparation, Owens, Gilmore, and Pirmohamad (2000) found that the nurses they surveyed did not have the skills or knowledge needed to give advice about alcohol consumption. This knowledge gap is particularly concerning because the chance that a nurse will encounter a person whose alcohol use puts them at risk for adverse health consequences is high with close to 25% of Americans reporting alcohol use that puts them at risk for adverse health consequences (Substance Abuse and Mental Health Services Administration, 2011). Focusing education on the treatment of AUDs in adults results in nurses unprepared to intervene with patients across the life span and the continuum of use. Although it is important that nurses recognize symptoms of an AUD, they must also recognize patients without an AUD who are at risk for adverse consequences such as a single episode of at-risk alcohol use that could lead to serious adverse health consequences including motor vehicle crashes, drowning, or alcohol poisoning. This study has several limitations. The first limitation is that information about the number of BSN schools eligible to participate in the study is unknown so it is not possible to calculate an accurate response rate. Second, although recipients of the email were asked to have the survey completed by the person in institution responsible for the BSN curriculum in their school, a further question that confirmed this fact would have help to determine if the respondent was indeed the person with primary responsibility for the BSN curricula. This was particularly concerning because approximately a quarter of respondents indicated that they did not know if alcohol and health content was offered in the adult health and/or community/public health courses. A third limitation is the reliability of the survey instrument. The content validity of the instrument was approached through the input of nurses in the addictions field, but the instrument was not previously tested for its psychometric properties. The instrument would need to be evaluated in larger studies before considering the generalizability of the findings. In addition, not all regions of the country were equally represented, with most of the schools located in the south or the midwest. Thus, the findings may not reflect BSN curricula in other areas of the country. Despite these limitations, the study has important implications. At-risk alcohol use has the potential to harm the Journal of Addictions Nursing
health of every segment of society. Nurses must be prepared to recognize this threat and respond with competence and compassion. The fact that at-risk and harmful alcohol use is the third leading risk factor for premature death worldwide does not appear to be reflected in BSN curriculum. Nurse educators should make a concerted effort to assure that our schools are responsive to this major health issue. Evidencebased content such as SBI should be emphasized, and demonstration of skill competency should be promoted. Consideration must be given to making this content essential in curricular standards and credentialing examinations. NIAAA is in the process of publishing a BSN curriculum that will be available online. This is a critical next step in creating a standard for educating nurses about alcohol and health. Similar work should occur in relation to other substance use. If nursing is truly an evidence-based practice, then it is critical for nurse educators and those involved in BSN curriculum development to actively participate in translating the evidence related to at-risk alcohol use prevention into practice. This can be done by increasing the content on alcohol and health across the curriculum and including evaluation of competency in interventions such as SBI. CONCLUSIONS To close the gap, BSN curricula must now shift from a focus only on educating nurses for a specialty unitVthe specialist nurse who cares for the patient hospitalized on the psychiatric unit with an AUDVto include a broader focus on the skills needed by the generalist nurse who cares for individuals engaging in at-risk alcohol use who would benefit from early identification and intervention. Such a shift would result in all nurses having the basic skills to engage in prevention and early intervention across healthcare settings such as schools, primary care, the emergency department, acute care, and community settings. Because individuals who engage in at-risk drinking can be found in all settings, education of the nursing workforce requires inclusion of alcohol-related content in all the lifespan courses, not just the mental health psychiatric nursing courses. Although standards and guidelines now exist related to evidence-based intervention, these have not been effectively translated into nursing education as the standard of care. The disconnection between current evidence and the traditional content offered in nursing curricula provides impetus for updating nursing curricula (Crabbe, 2002; Enoch & Goldman, 2001; Heilig et al., 2010; Leggio, Kenna, Fenton, Bonenfant, & Swift, 2009; Weiss, 2002). Because nurses are the largest segment of the healthcare workforce and alcohol is one of the top three causes of premature death (WHO, 2011b), nurses must have the knowledge and skills to provide evidence-based interventions across the continuum of use and life span. Nurses in all settings now need to know ways to approach patients/clients about their alcohol use and have tools to screen and refer patients to appropriate resources as well as how to initiate prevention strategies and activities. The best way to accomplish this is to purposefully include alcohol-related content www.journalofaddictionsnursing.com
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in nursing curricula and require of nursing students’ demonstrated competencies in evidence-based interventions that reduce alcohol-related harm. REFERENCES Aseltine, R. H. (2010). The impact of screening, brief intervention and referral for treatment in emergency department patients’ alcohol use: A 3-, 6- and 12-month follow-up. Alcohol and Alcoholism, 45(6), 514Y519. Bertholet, N., Daeppen, J., Wietlisbach, V., Fleming, M., & Burnand, B. (2005). Reduction of alcohol consumption by brief alcohol intervention in primary care. Archives of Internal Medicine, 165(9):986Y995. Brown, R. L., Marcus, M. T., Straussner, S. L. A., Graham, A. V., Madden, T., Schoener, E., & Henry, R. (2006). Project MAINSTREAMs’s first fellowship cohort: Pilot test of a national dissemination model to enhance substance abuse curriculum at health professions schools. Health Education Journal, 65, 252Y266. Centers for Disease Control and Prevention. (2011). Alcohol and publkc health. Frequently asked questions. Retrieved from http://www .cdc.gov/alcohol/faqs.htm#heavyDrinking Centers for Disease Control and Prevention. (2011). Alcohol and public health: Underage drinking. http://www.cdc.gov/alcohol/factsheets/underage-drinking.htm Church, O. M., & Babor, T. F. (1995). Barriers and breakthroughs: Curriculum in nursing education. Journal of Nursing Education, 34, 278Y281. Crabbe, J. C. (2002). Alcohol and genetics: New models. American Journal of Medical Genetics, 114(8), 969Y974. DeWit, D. J., Adlaf, E. M., Offor, D. R., & Ogborn, A. C. (2000). Age at first use: A risk factor for the development of alcohol use disorders. American Journal of Psychiarty, 157(5), 745Y750. Enoch, M., & Goldman, D. (2001). The genetics of alcoholism and alcohol abuse. Current Psychiatry Reports, 3(2), 144Y151. Heilig, M., Thorsell, A., Sommer, W. H., Hansson, A. C., Ramchandani, V. A., George, D. T., I Barr, C. S. (2010). Translating the neuroscience of alcoholism into clinical treatment: From blocking the buzz to curing the blues. Neuroscience and Behavioral Reviews, 35, 334Y344. Hoffman, A. L., & Heinemann, E. M. (1987). Substance abuse education in schools of nursing: A national survey. Journal of Nursing Education, 26, 282Y287. Howard, M. O., Walker, R. D., Walker, P. S., & Suchinsky, R. T. (1997). Alcohol and drug education in schools of nursing. Journal of Alcohol and Drug Education, 42(3), 54Y80. Leggio, L., Kenna, G. A., Fenton, M., Bonenfant, E., & Swift, R. M. (2009). Typologies of alcohol dependence. From Jellinek to genetics and beyond. Neuropsychology Review, 19(1), 115Y129. Marcus, M. T., Brown, R. L., Straussner, S. L. A., Schoener, E., Henry, R., Graham, A., I Saunders, L. A. (2005). Creating change agents: A national substance abuse education project. Substance Abuse, 26(3Y4), 5Y15.
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Mollica, M. A., Hyman, Z., & Mann, C. M. (2011). Alcohol-related content in undergraduate nursing curricula in the northeastern United States. Journal of Psychosocial Nursing and Mental Health, 49(6), 22Y31. doi:10.3928/02793695-20110503-01 Murphy, S. A. (1989). The urgency of substance abuse education in schools of nursing. Journal of Nursing Education, 28(6), 247Y251. Murray, M., & Savage, C. L. (2010). Guest editorial. Journal of Addictions Nursing, 20(3), 3Y5. National Quality Forum. (2007). National voluntary consensus standards for the treatment of substance use conditions: Evidenced-based treatment practices. Washington, DC: National Quality Forum. National Institute on Alcohol Abuse and Alcoholism. (2005). Helping patients who drink too much: A clinican’s guide (2nd ed.). Rockville, MD: U.S. Department of Health and Human Services. National Institute on Alcohol Abuse and Alcoholism. (2011). Alcohol screening and brief intervention for youth: A practitioner’s guide (2nd ed.). Rockville, MD: U.S. Department of Health and Human Services. Retrieved from http://www.niaaa.nih.gov/ Publications/EducationTrainingMaterials/YouthGuide Owens, L., Gilmore, I. T., & Pirmohamed, M. (2000). General practice nurses’ knowledge of alcohol use and misuse: A questionnaire survey. Alcohol and Alcohlism, 35(3), 259Y262. Pillon, S. C., Ramos, L. H., Villar-Luis, M. A., & Rassool, G. H. (2004). Nursing students’ perceptions of the curricula content on drug and alcohol education in Brazil: An exploratory study. Journal of Addictions Nursing, 15(3), 133Y137. Rassol, G. H., & Rawaf, S. (2007). Predictors of educational outcomes of undergraduate nursing students in alcohol and drug education. Nurse Education Today, 28(6), 691Y701. Substance Abuse and Mental Health Services Administration. (2011). Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. SMA 11-458. Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http:// www.oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.pdf Weiss, F. (2002). Behavioral neurobiology of alcohol addiction: Recent advances and challenges. The Journal of Neuroscience, 22(9), 3332Y3337. World Health Organization. (2011a). Alcohol fact sheet. Retrieved from http://www.who.int/mediacentre/factsheets/fs349/en/index.html World Health Organization. (2011b). Global status report on alcohol and health 2011. Retrieved from http://www.who.int/substance_abuse/ publications/global_alcohol_report/msbgsruprofiles.pdf U.S. Department of Health and Human Services. (2012a). Summary health statistics for US adults: National health interview survey. Retrieved from http://www.cdc.gov/nchs/data/series/sr_10/ sr10_252.pdf U.S. Department of Health and Human Services. (2012b). Healthy People, 2020 substance use objectives. Retrieved from http://healthypeople.gov/ 2020/topicsobjectives2020/overview.aspx?topicid=40
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