Inc. J. Nun. Swf.
Vol. 16, pp. 41.50.
- Pergamon
Press Ltd.. 1979. Printed inGreat
Britain
0020.4878/79/0301-0041802.00’0
Student learning following an educational experience at an alcohol Rehabilitation Cen tre in Saskatoon, Saskatchewan, Canada LOISM.
SORGEN,
R.N., B.Sc.N.,
M.C.Ed. Box2648,
St. Paul, Alberta, Canada 7OA 3A0 Introduction
Ever since man began recording history there is written evidence that the tragedy resulting from excessive drinking has been recognized. It has only been within the past 25 yr. however, that alcoholism has come to be defined as a public health problem and not as a moral issue (Pursch, 1974). Today, alcoholism is probably the largest medico-social problem of our time (Macdonald and Patel, 1975). In Canada, LeDain (1973) identified alcohol as the most serious non-medical drug use problem. In the United States, Jaffe (1965) and Bourne and Fox (1973) consider alcohol a more significant problem than that of all other forms of drug abuse combined. Laman (1974) suggests alcoholism is today the number one public health problem and Strachan (197 1) writes: The incidence, range, extent alcohol, and more particularly
and costs, both humanitarian and economic, stemming from the problems alcoholism, equal or rank above all other health and social concerns.
of
In Canada, it is estimated that at least 70% of the population over age 15 uses alcohol and over one million Canadians are alcoholics. Less than 5% of these alcoholics are on ‘Skid Row’*; the majority are men and women of all ages, from all socio-economic and cultural groups (Reid, 1977). For every one of the individuals there are five or six other persons related by family or business who are affected (Hecht, 1973). In the province of Saskatchewan, the rate of alcoholism in the general population rose by one-third between 1960 and 1970 (Kim, 1970) and from 1961 to 1975 the per capita consumption of gallons of absolute alcohol increased by 64% (Reid, 1977). Accordingly, the number of deaths attributed to alcoholism has risen, as have other alcohol related problems such as convictions for impaired driving, alcohol induced aggression, teenage *U.S. Slang. An urban section inhabited by vagrants and derelicts houses, etc. (Funk and WagnaIls, Standard College Dictionary).
and consisting
mainly
of cheap
bars,
flop-
LOIS M. SORGEN
42
drinking, alcohol in the work environment and physical and mental health problems associated with the use of alcohol. Considering what far reaching effects these factors have on all levels of society, it becomes clear that the health and well being of a great number of Canadians are either directly or indirectly affected by alcoholism. With the growing recognition and awareness of this problem, increasing numbers of health care workers are being urged to examine their roles and responsibilities in relation to the treatment and prevention of alcoholism. The research problem
There is no question that all nurses, regardless of what field they are practising in, will encounter individuals with alcoholism or alcohol-related problems, and more and more attention is being drawn to nurses’ responsibility in relation to the care of these individuals. Mislap (1972) points out that as nurses continue to move out from traditional hospital settings they will often be the first person patients affected by alcohol will encounter. This extension of the nurse’s role will give her/him more responsibility in preventative care and rehabilitation. The nurse must not only be able to recognize the early signs of problem drinking in order to act as a case finder but also include education on alcoholism as a part of nursing practise with individuals, families and communities (Burton, 1964; Heinemann, 1974; Laman, 1974; Wilkins, 1973; Thoreson, 1976). Because the nurse’s attitude toward his/her patient is one of the major factors determining the quality and quantity of care given (Travelbee, 1973; Boorer, 1971) the nurse needs an opportunity not only to gain knowledge and skills but to examine his/her own feelings and attitudes. In relation to alcoholism, Childress (1970), Strachan (1971) and Mueller and Schwerdtfeger (1974) stress that nurses must resolve their judgmental attitudes before they can intervene therapeutically. From a review of the literature it is clear that not only a great many nurses, graduate and student alike, but other health care workers such as physicians, medical students, psychologists and social workers hold negative or unaccepting attitudes toward the alcoholic and his/her treatment and that educational input does seem to result in some modification of these attitudes. It would seem, then, that for those individuals studying nursing some educational experience aimed at increasing knowledge and reducing negative stereotypes of alcoholism and the alcoholic must be provided. A Rehabilitation Centre in Saskatoon, Saskatchewan, has since 1975 provided baccalaureate nursing students with such an experience. Students attend the Centre for 10 days of the 20 day educational program which focuses on the physiological, psychological and sociological aspects of alcoholism. In May and June, 1977, 16 baccalaureate nursing students from the University of Saskatchewan attended the Centre, and at that time empirical research was conducted to evaluate knowledge gain and attitude change related to this educational experience. The research problem was to determine if a lo-day educational experience at an alcohol rehabilitation centre is significantly effective in increasing knowledge and reducing negative attitudes of alcoholism and alcoholic persons. Definition of terms
Alcoholics:
“those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an inter-
STUDENTLEARNINGFOLLOWINGANEDUCAT~ONALEXPER~ENCE
Alcoholism:
Attitude:
Educational experience:
43
ference with their bodily and mental health, their interpersonal relations, and their smooth social and economic functioning; or who show the prodromal signs of such developments. They therefore require treatment.” (World Health Organization, 1952.) “A chronic disease manifested by repeated implicative drinking so as to cause injury to the drinker’s health or to his social and economic functioning.” (Keller, 1958.) “. . . an underlying disposition which enters, along with other influences, into the determination of a variety of behaviours toward an object or class of objects, including statements of beliefs and feelings about the object and approach-avoidance action with respect to it.” (Cook and Selltiz, 1967.) A planned activity, the goal of which is a change in thinking, feeling and acting. (Tyler, 1968.) The agency setting and description
The Rehabilitation Centre is an inpatient treatment facility which offers a 28-day program for the rehabilitation of persons suffering from alcoholism. The Centre was opened in 1972 and is funded by the Provincial Department of Health. There are a total of 40 beds, 25 of which are for the alcoholics and 15 for the spouses of the alcoholics undergoing treatment. The aim of the program at the Rehabilitation Centre is to assist the alcoholic to attain and maintain sobriety through total abstinence. Underlying this aim is the belief that alcoholism is an illness, of which there is no single identifiable cause. Rather, the interdependence of physiological, psychological, sociological and spiritual factors are believed to lead to the physiological tolerance of, and dependence on alcohol. The approaches utilized in the treatment program are based on these causative variables and are therefore multi-dimensional. Similarly, staffing is multi-disciplinary. Services provided by these personnel include an educational program on the illness of alcoholism, individual counselling, group therapy, recreation and an introduction to the fellowship of Alcoholics Anonymous. The Centre also encourages the spouse of the alcoholic to become involved. The rehabilitation program can thus be summarized as a process through which an alcoholic can learn to live without alcohol while achieving greater physical and emotional health.
Description of the study population
The University College of Nursing offers a four-year baccalaureate program leading to a Bachelor of Science in Nursing. The 63 students who completed the third year of this program in 1977 comprised the study population of this research. Sixteen students attended the Rehabilitation Centre in May and June, 1977 to complete the requirements of a half class in the practise of psychiatric nursing. Those students who did not attend the Centre were in clinical practice on the psychiatric ward in University Hospital. Students were given the opportunity to request the experience at the Centre. They were asked to submit their reasons in writing, and requests were met as much as possible. For
LOIS
44
M. SORGEN
some, the reason was an alcoholic family member. Four groups of four students each participated in 10 days or 80 hr of the rehabilitation program. The students interacted with residents and staff in a variety of situations such as lectures, films, group therapy sessions, recreation and an Alcoholics Anonymous meeting. The researcher, who as a faculty member was also responsible to the College of Nursing for the educational experience of these students, met with the students for approx 6 hr during the 2 weeks. At these times, issues and concerns related to the experience were discussed. The research method and design
The nature of this study was experimental and is described by Campbell and Stanley (1963) as a Nonequivalent Control Group Design No. 10. The study population was made up of the 63 students completing the third year of the 4 yr baccalaureate nursing program at the University of Saskatchewan. The experimental group consisted of those 16 students who attended the Rehabilitation Centre and the control group was the 47 students who did not. Fourteen of the 16 students in the experimental group were self selected and since the Centre was able to accommodate 16 students, two additional students were selected by a process of randomization. No statistically significant difference was found between the two groups on the pretests which limits the self selecting bias. A comparison
of the results between the experimental
Test
Group
Control
and control
groups on the pretests
Group
(x)
(N)
WI
S.E.,,
/-test
I
ATDP-0
16
60
47
63.9
3.59
4.
Facts
16
31.6
47
31.5
2.82
0.04
0.6
Marcus Emotional
difficulties
I6
21.6
47
21.0
0.94
Loss of control
16
18.8
47
17.6
I .09
1.1
Prognosis
for recovery
16
20.3
47
18.7
0.96
0.1
Alcoholic drinker
as a steady I6
8.5
47
8.6
0.58
0.9
Alcoholism character
and defect
lb
12.6
47
12.4
I .60
0.1
Social status of alcoholic
16
10.9
47
II.1
I.14
-0.2
Alcoholism illness
16
10.8
47
11.4
2.41
-0.3
as an
Harmless boluntar) indulgence
16
9.5
47
8.8
0.68
1.0
Addiction
16
19.0
47
19.1
1.19
0. I
liability
X = mean. ATDP-0 = Attitudes towards disabled persons form 0. S.E.,,,, = Standard error of differences between means
The treatment of independent
variable was the educational
experience at the Centre.
Sl‘Ci’DENTLEARNlNGFOLLOWING
ANEDUCATIONAL
EXPERIENCE
45
This experience was comprised of the program content and the interpersonal interaction of students with the clients and staff. Students participated in the program in much the same manner as did the clients undergoing rehabilitation. That is, they attended the same lectures, viewed the same films, attended an Alcoholics Anonymous meeting, participated in recreational activities and group therapy sessions. The students also met with various individual staff members to discuss theoretical assumptions underlying the approaches utilized. The dependent variable was the cognitive and affective change related to alcoholism as measured by the pre- and post-tests. The hypotheses
1. There was a significant difference in knowledge gain related to alcoholism between those baccalaureate nursing students who attended an alcoholic Rehabilitation Centre and those nursing students who did not. 2. There was a significant difference in attitude change related to alcoholic persons between those baccalaureate nursing students who attended an alcoholic Rehabilitation Centre and those who did not. The sources and collection of data
The same pre- and post-tests were administered to the treatment and control groups. The tests were three questionnaires: two were standardized tests designed to measure attitudes, and one was designed to measure knowledge of facts related to alcohol and alcoholism. The Questionnaire on Attitudes Toward Alcoholic Persons was adapted from the Attitudes Toward Disabled Persons-Form 0 (ATDP-0), developed by Yuker, Block and Young (1966). The word ‘alcoholic’, was substituted for the word, ‘disabled’, throughout the form, and the word ‘people’, was substituted for the word, ‘children’, in items one and six. The Alcoholism Questionnaire was developed by Marcus (1963) and consists of 40 items which measure the following nine factors: emotional difficulties, loss of control, prognosis for recovery, steady drinking, character defect, social status, illness conception, harmless indulgence and addiction liability. The Questionnaire on Facts Related to Alcohol and Alcoholism was compiled by researchers within the Alcoholism Commission of Saskatchewan. In addition to the data collected from the pre- and post-tests, individual interviews were conducted with the 16 students in the treatment group. The interview schedule was developed by the researcher and was used as a guide only. Interview schedule
1. How have you found your experience here at the Centre? 2. What were your expectations of this experience? Were they met? 3. If anything impressed you about this experience, can you describe it? 4. Have you learned anything new or different about alcoholism? 5. What, if anything, stands out in your mind about the various contacts you have had with the alcoholic men and women here?
LOIS M. SORGEN
46
6. Have your feelings about alcoholic men and women changed in any way? 7. Do you feel that this experience has any value in terms of your future practise? 8. In your opinion, what has been the most positive aspect of this experience? The most negative? The pre-tests were administered to the total study population on 31 March, 1977. The post-test was administered to the treatment group on the last day of the Centre experience at which time the interviews were recorded. The control group was given the post-test on 30 May, 1977. The results of the questionnaires
Fifty-nine students completed the pre-tests in March, 1977. Sixteen students in the experimental group and 36 students in the control group completed the post-tests. Pre- and post-test scores for each student in the two groups were compared, and the standard error of the means was calculated by the formula: s = E(X, - x,y
N,-1
+ E(X,
-x2)*
N,-2
-
E = Sum X = Mean (Garrett, 1956).
The standard error of the differences between the two means (S.E.,,) using the formula: S.F.,,
was then drawn
= dz
(Garrett, 1956). A one tailed t-test at the 0.05 level of significance was then applied, using 50 degrees of freedom. A t-test was calculated by the formula: t=
D S.E.,,
D = degrees of freedom (Garrett, 1956). With 50 degrees of freedom, a t value of 1.6777 is required for 0.05 level of significance. Since one of the three questionnaires isolates a total of 9 factors, the statistical calculations were computed on a total of 11 factors. The data from the Questionnaire on Facts Related to Alcohol and Alcoholism were used to test the first hypothesis. The results did support the hypothesis that there was a significant difference in knowledge gain by the students who attended the Centre as compared with those who did not. The data from the Questionnaire on Attitudes Toward Disabled Persons-Form 0 and the Alcoholism Questionnaire were used to test the second hypothesis. The results from the ATDP-0 did not support the hypothesis. On this test there was no significant
STUDENTLEARNING
FOLLO WING AN EDUCATIONAL
EXPERIENCE
47
Table 1. A comparison of mean change scores (post score - pre score) between experimental and control groups in the questionnaire on facts related to alcohol and alcoholism Test
Control
Exp. group (N)
(XDM)
16
2.9
WI
group
l-test
=.DM
(XDM)
._~~._
Facts *Significant
36
0.4
2.63*
0.95
at the 0.05 level of significance.
difference in attitude change between those students who attended the Centre and those who did not. Table 2. A comparison of mean change scores (post score - prescore) between experimental and control groups in the questionnaire on attitudes toward disabled persons-Form 0 Test
Control
Exp. group
ATDP-0
(N)
(XDM)
16
3.8
09
group
S.E
f-test
.DM
VDM)
36
-1.1
3.28
1.41
The Alcoholism Questionnaire isolates 9 factors which are considered to represent the major dimensions of popular opinion about alcoholism and alcoholic persons. The results from the Alcoholism Questionnaire indicate support of the second hypothesis on 4 of the 9 factors. These 4 factors are the belief that the alcoholic is not a weak-willed person, that the alcoholic is not a harmless drinker whose drinking is motivated only by his fondness for alcohol and that alcohol is a highly addicting substance. The data from the Alcoholism Questionnaire do not support the hypothesis on the remaining five factors: that emotional difficulties of psychological problems are an important contributing factor in the development of alcoholism; that most alcoholics do not, and cannot be helped to, recover from alcoholism; that periodic excessive drinkers can be alcoholics; that alcoholics come from the lower socio-economic strata of society; and that alcoholism is not an illness. Table 3. A comparison
of mean change scores (post score - pre score) between experimental in the alcoholism questionnaire Exp. group
Factor
(N) Emotional difficulties Loss of control Prognosis for recovery Alcoholic as a steady drinker Alcoholism and character defect Social status of alcoholic Alcoholism as an illness Harmless voluntary indulgence Addiction liability *Significant
at 0.05 level of significance.
Control
group
S.E.,,
and control
groups
I-test
(XDM)
(XDM)
16 16 16 16 16
ml.9 4.0 a.6 2.3 4.5
36 36 36 36 36
1.1 0.1 a.9 0.7 a.3
1.09 0.99 0.79 1.19 I.21
a.82 3.89’ 0.48 1.29 -3.46;
I6 16 16 16
-2.3 -2.0 -3.4 2.9
36 36 36 36
0.9 il.5 -0.6 0.7
1.09 0.99 0.96 0.94
-1.28 ml.52 -2.(15* 2.41*
LOIS
48
M. SORGEN
A discussion of the interviews
All students elaborate All
in the experimental
on statements
16 students
described
enthusiasm
in relation
During
the interviews, prior
related feelings while
the students
describing
openly
also identified,
they
had
people.
were admitted
to a hospital
where
she had ‘treated
have felt when encountering
after
stated
Their
difference
in scores on factors
Nine of the students
change
factor,
Neither
One student’s
Anger
them
in
belief
his/her
own
is unable by
noting
summer. student
a dirty
described
how
practise.
choice
had felt that the
to drink.
to control the
It was of
his/her
statistically
drinking significant
Questionnaire.
difference
significant
alcoholics
“Just
they had believed
significant
a statistically
inconsistencies
were
alcoholics
when
the alcoholic
was found
difference
had heard it and I knew it, but 1 didn’t
“I
comment,
the apparent
row’,
No statistically
was there
fear
laugh or ridicule
the previous
is supported
‘skid
an
used the
and
like children’
two, five and eight on the Alcoholism
this stereotype.
they had about
Several of the students previously.
in her nursing
the alcoholic
used the term,
person was within factor.
and made
a point,
behavior.
may well explain
to
the most
of these were directly
to the fact that all of these students
weak-willed
to them that,
however.
expressed
which
Many
was how another
an alcoholic
seem to be related
was basically
surprise
one and it is of interest
experience
no longer
she had worked
who I’d let go and be glad he was gone”
These feelings
and
stated that they had chosen not to think
One person stated she would that
alcoholic
felt
and some of the students
acknowledged
she would
to expand
of the experience.
shared the feelings
Questionnaire.
how
another
drunk
the Centre
the 2 weeks at the Centre.
on the Alcoholism
when
about alcoholic
as a very positive
who did not request
to completing
‘disgust’,
and encouraged
understanding
to their learning.
to the 9 factors
term,
were interviewed
to gain further
the experience
note that the two students
alcoholic
group
in an attempt
on this
on the illness really
feel it”,
between
responses
on the questionnaires
on how
they
saw the alcoholics
and those in the interviews. In different people
with
ways,
become an alcoholic! supports
the magnitude
relating
The significant future
they would to him/her.
wouldn’t
all students
with
able and willing have avoided
its impact to identify
the alcoholic,
difference
now
(including
themselves)
on the addiction
as
could
liability
factor
felt that because they were now aware on the family difficulties
and community,
and make
referrals.
they now saw themselves
Being able to do this was seen as a direct
actions which they had experienced student summarized it in this way: them-it
statistical
practise,
of the problem,
much’more
before
commented
as they have and how anyone
this.
In terms of their now
all students
the same feelings
of
they were Whereas
as comfortable
result of the personal
in inter-
with the alcoholic men and women at the Centre. One “It was being able to meet them and actually talk with
be the same if we only had the films and classroom
lectures.”
Conclusion
If one assumes that the questionnaires and that the weaknesses
clusions can be drawn. 1. The majority of nursing 2. An experience
were valid,
of the study were negligible students
in a treatment
the students on the results,
hold stereotyped
setting
where students
honest in their interviews then the following
con-
views of the alcoholic. interact
with alcoholics
appears
STUDENT
LEARNING
FOLLOWING
AN EDUCA
TIONAL
EXPERIENCE
49
to reduce these stereotyped views. 3. ‘The stated belief that alcoholism was an illness did not necessarily represent the real views of the respondents. 4. All of the students who attended the Centre believed the experience was an extremely valuable one in terms of their future practise. 5. All of the students who attended the Centre thought that every nursing student should be afforded this learning experience.
Summary
As was hypothesized, the nursing students who participated in the two week educational experience at a Rehabilitation Centre for alcoholics did increase their knowledge of alcoholism and did experience a change in some of their attitudes about alcoholic people. The importance of nurses examining their own feelings and attitudes toward alcoholism has been stressed by many authors: Nicolle (1963), Glud (1961), Burton (1964), Childress (1970), Holmes (1963) and Lewis (1956). Without a nonjudgmental and nonprejudiced attitude, it is felt that knowledge alone will be of very little value in terms of providing care to alcoholics and their families. Yuker (1956) states a prejudicial attitude is: “the tendency to group people into categories and to tend to perceive people in terms of their group membership, not as individuals. The prejudicial person will tend to prejudge others and react to them in a stereotyped fashion, judging them in terms of their group membership.”
According to this statement, a person who has a prejudicial attitude toward alcoholics will believe that all alcoholics are alike. Statements made by the students who attended the center did, in fact, support this. They saw all alcoholics within the ‘skid row’ stereotype, and only after the experience did they remark on their individuality. Yuker goes on to add that the two most important factors in changing prejudicial attitudes are an awareness of the attitude and “close personal contact and meaningful interaction between the prejudicial person and members of groups toward which he is prejudiced” (1965). Both of these factors were a very major part of the learning experience provided for the students. With the students knowledge gain and evidence of a more accepting attitude toward the alcoholic, certain implications arise. 1. That nursing educators examine curriculum content related to alcoholism. 2. That, in view of the point which Yuker (1965) makes regarding the importance of an awareness of one’s prejudicial attitudes, some mechanism be utilized whereby all nursing students can examine and become aware of the attitudes which they hold toward alcoholism and the alcoholic person. 3. That as a participatory learning experience of the type and by the 16 students in the treatment group results in a reduction of negative stereotypes and prejudicial attitudes (Yuker, 1965), the possibility of similar learning experiences should be investigated and made available for as many students as possible. By providing such experiences for nursing students it is hoped that, in their future practise, they will be able to make a significant contribution to the prevention, treatment and rehabilitation of this major social problem.
50
LOIS
M. SORGEN
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- Pergamon
Press Ltd.. 1979. Printed inGreat
Britain
0020.4878/79/0301-0041802.00’0
Student learning following an educational experience at an alcohol Rehabilitation Cen tre in Saskatoon, Saskatchewan, Canada LOISM.
SORGEN,
R.N., B.Sc.N.,
M.C.Ed. Box2648,
St. Paul, Alberta, Canada 7OA 3A0 Introduction
Ever since man began recording history there is written evidence that the tragedy resulting from excessive drinking has been recognized. It has only been within the past 25 yr. however, that alcoholism has come to be defined as a public health problem and not as a moral issue (Pursch, 1974). Today, alcoholism is probably the largest medico-social problem of our time (Macdonald and Patel, 1975). In Canada, LeDain (1973) identified alcohol as the most serious non-medical drug use problem. In the United States, Jaffe (1965) and Bourne and Fox (1973) consider alcohol a more significant problem than that of all other forms of drug abuse combined. Laman (1974) suggests alcoholism is today the number one public health problem and Strachan (197 1) writes: The incidence, range, extent alcohol, and more particularly
and costs, both humanitarian and economic, stemming from the problems alcoholism, equal or rank above all other health and social concerns.
of
In Canada, it is estimated that at least 70% of the population over age 15 uses alcohol and over one million Canadians are alcoholics. Less than 5% of these alcoholics are on ‘Skid Row’*; the majority are men and women of all ages, from all socio-economic and cultural groups (Reid, 1977). For every one of the individuals there are five or six other persons related by family or business who are affected (Hecht, 1973). In the province of Saskatchewan, the rate of alcoholism in the general population rose by one-third between 1960 and 1970 (Kim, 1970) and from 1961 to 1975 the per capita consumption of gallons of absolute alcohol increased by 64% (Reid, 1977). Accordingly, the number of deaths attributed to alcoholism has risen, as have other alcohol related problems such as convictions for impaired driving, alcohol induced aggression, teenage *U.S. Slang. An urban section inhabited by vagrants and derelicts houses, etc. (Funk and WagnaIls, Standard College Dictionary).
and consisting
mainly
of cheap
bars,
flop-
LOIS M. SORGEN
42
drinking, alcohol in the work environment and physical and mental health problems associated with the use of alcohol. Considering what far reaching effects these factors have on all levels of society, it becomes clear that the health and well being of a great number of Canadians are either directly or indirectly affected by alcoholism. With the growing recognition and awareness of this problem, increasing numbers of health care workers are being urged to examine their roles and responsibilities in relation to the treatment and prevention of alcoholism. The research problem
There is no question that all nurses, regardless of what field they are practising in, will encounter individuals with alcoholism or alcohol-related problems, and more and more attention is being drawn to nurses’ responsibility in relation to the care of these individuals. Mislap (1972) points out that as nurses continue to move out from traditional hospital settings they will often be the first person patients affected by alcohol will encounter. This extension of the nurse’s role will give her/him more responsibility in preventative care and rehabilitation. The nurse must not only be able to recognize the early signs of problem drinking in order to act as a case finder but also include education on alcoholism as a part of nursing practise with individuals, families and communities (Burton, 1964; Heinemann, 1974; Laman, 1974; Wilkins, 1973; Thoreson, 1976). Because the nurse’s attitude toward his/her patient is one of the major factors determining the quality and quantity of care given (Travelbee, 1973; Boorer, 1971) the nurse needs an opportunity not only to gain knowledge and skills but to examine his/her own feelings and attitudes. In relation to alcoholism, Childress (1970), Strachan (1971) and Mueller and Schwerdtfeger (1974) stress that nurses must resolve their judgmental attitudes before they can intervene therapeutically. From a review of the literature it is clear that not only a great many nurses, graduate and student alike, but other health care workers such as physicians, medical students, psychologists and social workers hold negative or unaccepting attitudes toward the alcoholic and his/her treatment and that educational input does seem to result in some modification of these attitudes. It would seem, then, that for those individuals studying nursing some educational experience aimed at increasing knowledge and reducing negative stereotypes of alcoholism and the alcoholic must be provided. A Rehabilitation Centre in Saskatoon, Saskatchewan, has since 1975 provided baccalaureate nursing students with such an experience. Students attend the Centre for 10 days of the 20 day educational program which focuses on the physiological, psychological and sociological aspects of alcoholism. In May and June, 1977, 16 baccalaureate nursing students from the University of Saskatchewan attended the Centre, and at that time empirical research was conducted to evaluate knowledge gain and attitude change related to this educational experience. The research problem was to determine if a lo-day educational experience at an alcohol rehabilitation centre is significantly effective in increasing knowledge and reducing negative attitudes of alcoholism and alcoholic persons. Definition of terms
Alcoholics:
“those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows a noticeable mental disturbance or an inter-
STUDENTLEARNINGFOLLOWINGANEDUCAT~ONALEXPER~ENCE
Alcoholism:
Attitude:
Educational experience:
43
ference with their bodily and mental health, their interpersonal relations, and their smooth social and economic functioning; or who show the prodromal signs of such developments. They therefore require treatment.” (World Health Organization, 1952.) “A chronic disease manifested by repeated implicative drinking so as to cause injury to the drinker’s health or to his social and economic functioning.” (Keller, 1958.) “. . . an underlying disposition which enters, along with other influences, into the determination of a variety of behaviours toward an object or class of objects, including statements of beliefs and feelings about the object and approach-avoidance action with respect to it.” (Cook and Selltiz, 1967.) A planned activity, the goal of which is a change in thinking, feeling and acting. (Tyler, 1968.) The agency setting and description
The Rehabilitation Centre is an inpatient treatment facility which offers a 28-day program for the rehabilitation of persons suffering from alcoholism. The Centre was opened in 1972 and is funded by the Provincial Department of Health. There are a total of 40 beds, 25 of which are for the alcoholics and 15 for the spouses of the alcoholics undergoing treatment. The aim of the program at the Rehabilitation Centre is to assist the alcoholic to attain and maintain sobriety through total abstinence. Underlying this aim is the belief that alcoholism is an illness, of which there is no single identifiable cause. Rather, the interdependence of physiological, psychological, sociological and spiritual factors are believed to lead to the physiological tolerance of, and dependence on alcohol. The approaches utilized in the treatment program are based on these causative variables and are therefore multi-dimensional. Similarly, staffing is multi-disciplinary. Services provided by these personnel include an educational program on the illness of alcoholism, individual counselling, group therapy, recreation and an introduction to the fellowship of Alcoholics Anonymous. The Centre also encourages the spouse of the alcoholic to become involved. The rehabilitation program can thus be summarized as a process through which an alcoholic can learn to live without alcohol while achieving greater physical and emotional health.
Description of the study population
The University College of Nursing offers a four-year baccalaureate program leading to a Bachelor of Science in Nursing. The 63 students who completed the third year of this program in 1977 comprised the study population of this research. Sixteen students attended the Rehabilitation Centre in May and June, 1977 to complete the requirements of a half class in the practise of psychiatric nursing. Those students who did not attend the Centre were in clinical practice on the psychiatric ward in University Hospital. Students were given the opportunity to request the experience at the Centre. They were asked to submit their reasons in writing, and requests were met as much as possible. For
LOIS
44
M. SORGEN
some, the reason was an alcoholic family member. Four groups of four students each participated in 10 days or 80 hr of the rehabilitation program. The students interacted with residents and staff in a variety of situations such as lectures, films, group therapy sessions, recreation and an Alcoholics Anonymous meeting. The researcher, who as a faculty member was also responsible to the College of Nursing for the educational experience of these students, met with the students for approx 6 hr during the 2 weeks. At these times, issues and concerns related to the experience were discussed. The research method and design
The nature of this study was experimental and is described by Campbell and Stanley (1963) as a Nonequivalent Control Group Design No. 10. The study population was made up of the 63 students completing the third year of the 4 yr baccalaureate nursing program at the University of Saskatchewan. The experimental group consisted of those 16 students who attended the Rehabilitation Centre and the control group was the 47 students who did not. Fourteen of the 16 students in the experimental group were self selected and since the Centre was able to accommodate 16 students, two additional students were selected by a process of randomization. No statistically significant difference was found between the two groups on the pretests which limits the self selecting bias. A comparison
of the results between the experimental
Test
Group
Control
and control
groups on the pretests
Group
(x)
(N)
WI
S.E.,,
/-test
I
ATDP-0
16
60
47
63.9
3.59
4.
Facts
16
31.6
47
31.5
2.82
0.04
0.6
Marcus Emotional
difficulties
I6
21.6
47
21.0
0.94
Loss of control
16
18.8
47
17.6
I .09
1.1
Prognosis
for recovery
16
20.3
47
18.7
0.96
0.1
Alcoholic drinker
as a steady I6
8.5
47
8.6
0.58
0.9
Alcoholism character
and defect
lb
12.6
47
12.4
I .60
0.1
Social status of alcoholic
16
10.9
47
II.1
I.14
-0.2
Alcoholism illness
16
10.8
47
11.4
2.41
-0.3
as an
Harmless boluntar) indulgence
16
9.5
47
8.8
0.68
1.0
Addiction
16
19.0
47
19.1
1.19
0. I
liability
X = mean. ATDP-0 = Attitudes towards disabled persons form 0. S.E.,,,, = Standard error of differences between means
The treatment of independent
variable was the educational
experience at the Centre.
Sl‘Ci’DENTLEARNlNGFOLLOWING
ANEDUCATIONAL
EXPERIENCE
45
This experience was comprised of the program content and the interpersonal interaction of students with the clients and staff. Students participated in the program in much the same manner as did the clients undergoing rehabilitation. That is, they attended the same lectures, viewed the same films, attended an Alcoholics Anonymous meeting, participated in recreational activities and group therapy sessions. The students also met with various individual staff members to discuss theoretical assumptions underlying the approaches utilized. The dependent variable was the cognitive and affective change related to alcoholism as measured by the pre- and post-tests. The hypotheses
1. There was a significant difference in knowledge gain related to alcoholism between those baccalaureate nursing students who attended an alcoholic Rehabilitation Centre and those nursing students who did not. 2. There was a significant difference in attitude change related to alcoholic persons between those baccalaureate nursing students who attended an alcoholic Rehabilitation Centre and those who did not. The sources and collection of data
The same pre- and post-tests were administered to the treatment and control groups. The tests were three questionnaires: two were standardized tests designed to measure attitudes, and one was designed to measure knowledge of facts related to alcohol and alcoholism. The Questionnaire on Attitudes Toward Alcoholic Persons was adapted from the Attitudes Toward Disabled Persons-Form 0 (ATDP-0), developed by Yuker, Block and Young (1966). The word ‘alcoholic’, was substituted for the word, ‘disabled’, throughout the form, and the word ‘people’, was substituted for the word, ‘children’, in items one and six. The Alcoholism Questionnaire was developed by Marcus (1963) and consists of 40 items which measure the following nine factors: emotional difficulties, loss of control, prognosis for recovery, steady drinking, character defect, social status, illness conception, harmless indulgence and addiction liability. The Questionnaire on Facts Related to Alcohol and Alcoholism was compiled by researchers within the Alcoholism Commission of Saskatchewan. In addition to the data collected from the pre- and post-tests, individual interviews were conducted with the 16 students in the treatment group. The interview schedule was developed by the researcher and was used as a guide only. Interview schedule
1. How have you found your experience here at the Centre? 2. What were your expectations of this experience? Were they met? 3. If anything impressed you about this experience, can you describe it? 4. Have you learned anything new or different about alcoholism? 5. What, if anything, stands out in your mind about the various contacts you have had with the alcoholic men and women here?
LOIS M. SORGEN
46
6. Have your feelings about alcoholic men and women changed in any way? 7. Do you feel that this experience has any value in terms of your future practise? 8. In your opinion, what has been the most positive aspect of this experience? The most negative? The pre-tests were administered to the total study population on 31 March, 1977. The post-test was administered to the treatment group on the last day of the Centre experience at which time the interviews were recorded. The control group was given the post-test on 30 May, 1977. The results of the questionnaires
Fifty-nine students completed the pre-tests in March, 1977. Sixteen students in the experimental group and 36 students in the control group completed the post-tests. Pre- and post-test scores for each student in the two groups were compared, and the standard error of the means was calculated by the formula: s = E(X, - x,y
N,-1
+ E(X,
-x2)*
N,-2
-
E = Sum X = Mean (Garrett, 1956).
The standard error of the differences between the two means (S.E.,,) using the formula: S.F.,,
was then drawn
= dz
(Garrett, 1956). A one tailed t-test at the 0.05 level of significance was then applied, using 50 degrees of freedom. A t-test was calculated by the formula: t=
D S.E.,,
D = degrees of freedom (Garrett, 1956). With 50 degrees of freedom, a t value of 1.6777 is required for 0.05 level of significance. Since one of the three questionnaires isolates a total of 9 factors, the statistical calculations were computed on a total of 11 factors. The data from the Questionnaire on Facts Related to Alcohol and Alcoholism were used to test the first hypothesis. The results did support the hypothesis that there was a significant difference in knowledge gain by the students who attended the Centre as compared with those who did not. The data from the Questionnaire on Attitudes Toward Disabled Persons-Form 0 and the Alcoholism Questionnaire were used to test the second hypothesis. The results from the ATDP-0 did not support the hypothesis. On this test there was no significant
STUDENTLEARNING
FOLLO WING AN EDUCATIONAL
EXPERIENCE
47
Table 1. A comparison of mean change scores (post score - pre score) between experimental and control groups in the questionnaire on facts related to alcohol and alcoholism Test
Control
Exp. group (N)
(XDM)
16
2.9
WI
group
l-test
=.DM
(XDM)
._~~._
Facts *Significant
36
0.4
2.63*
0.95
at the 0.05 level of significance.
difference in attitude change between those students who attended the Centre and those who did not. Table 2. A comparison of mean change scores (post score - prescore) between experimental and control groups in the questionnaire on attitudes toward disabled persons-Form 0 Test
Control
Exp. group
ATDP-0
(N)
(XDM)
16
3.8
09
group
S.E
f-test
.DM
VDM)
36
-1.1
3.28
1.41
The Alcoholism Questionnaire isolates 9 factors which are considered to represent the major dimensions of popular opinion about alcoholism and alcoholic persons. The results from the Alcoholism Questionnaire indicate support of the second hypothesis on 4 of the 9 factors. These 4 factors are the belief that the alcoholic is not a weak-willed person, that the alcoholic is not a harmless drinker whose drinking is motivated only by his fondness for alcohol and that alcohol is a highly addicting substance. The data from the Alcoholism Questionnaire do not support the hypothesis on the remaining five factors: that emotional difficulties of psychological problems are an important contributing factor in the development of alcoholism; that most alcoholics do not, and cannot be helped to, recover from alcoholism; that periodic excessive drinkers can be alcoholics; that alcoholics come from the lower socio-economic strata of society; and that alcoholism is not an illness. Table 3. A comparison
of mean change scores (post score - pre score) between experimental in the alcoholism questionnaire Exp. group
Factor
(N) Emotional difficulties Loss of control Prognosis for recovery Alcoholic as a steady drinker Alcoholism and character defect Social status of alcoholic Alcoholism as an illness Harmless voluntary indulgence Addiction liability *Significant
at 0.05 level of significance.
Control
group
S.E.,,
and control
groups
I-test
(XDM)
(XDM)
16 16 16 16 16
ml.9 4.0 a.6 2.3 4.5
36 36 36 36 36
1.1 0.1 a.9 0.7 a.3
1.09 0.99 0.79 1.19 I.21
a.82 3.89’ 0.48 1.29 -3.46;
I6 16 16 16
-2.3 -2.0 -3.4 2.9
36 36 36 36
0.9 il.5 -0.6 0.7
1.09 0.99 0.96 0.94
-1.28 ml.52 -2.(15* 2.41*
LOIS
48
M. SORGEN
A discussion of the interviews
All students elaborate All
in the experimental
on statements
16 students
described
enthusiasm
in relation
During
the interviews, prior
related feelings while
the students
describing
openly
also identified,
they
had
people.
were admitted
to a hospital
where
she had ‘treated
have felt when encountering
after
stated
Their
difference
in scores on factors
Nine of the students
change
factor,
Neither
One student’s
Anger
them
in
belief
his/her
own
is unable by
noting
summer. student
a dirty
described
how
practise.
choice
had felt that the
to drink.
to control the
It was of
his/her
statistically
drinking significant
Questionnaire.
difference
significant
alcoholics
“Just
they had believed
significant
a statistically
inconsistencies
were
alcoholics
when
the alcoholic
was found
difference
had heard it and I knew it, but 1 didn’t
“I
comment,
the apparent
row’,
No statistically
was there
fear
laugh or ridicule
the previous
is supported
‘skid
an
used the
and
like children’
two, five and eight on the Alcoholism
this stereotype.
they had about
Several of the students previously.
in her nursing
the alcoholic
used the term,
person was within factor.
and made
a point,
behavior.
may well explain
to
the most
of these were directly
to the fact that all of these students
weak-willed
to them that,
however.
expressed
which
Many
was how another
an alcoholic
seem to be related
was basically
surprise
one and it is of interest
experience
no longer
she had worked
who I’d let go and be glad he was gone”
These feelings
and
stated that they had chosen not to think
One person stated she would that
alcoholic
felt
and some of the students
acknowledged
she would
to expand
of the experience.
shared the feelings
Questionnaire.
how
another
drunk
the Centre
the 2 weeks at the Centre.
on the Alcoholism
when
about alcoholic
as a very positive
who did not request
to completing
‘disgust’,
and encouraged
understanding
to their learning.
to the 9 factors
term,
were interviewed
to gain further
the experience
note that the two students
alcoholic
group
in an attempt
on this
on the illness really
feel it”,
between
responses
on the questionnaires
on how
they
saw the alcoholics
and those in the interviews. In different people
with
ways,
become an alcoholic! supports
the magnitude
relating
The significant future
they would to him/her.
wouldn’t
all students
with
able and willing have avoided
its impact to identify
the alcoholic,
difference
now
(including
themselves)
on the addiction
as
could
liability
factor
felt that because they were now aware on the family difficulties
and community,
and make
referrals.
they now saw themselves
Being able to do this was seen as a direct
actions which they had experienced student summarized it in this way: them-it
statistical
practise,
of the problem,
much’more
before
commented
as they have and how anyone
this.
In terms of their now
all students
the same feelings
of
they were Whereas
as comfortable
result of the personal
in inter-
with the alcoholic men and women at the Centre. One “It was being able to meet them and actually talk with
be the same if we only had the films and classroom
lectures.”
Conclusion
If one assumes that the questionnaires and that the weaknesses
clusions can be drawn. 1. The majority of nursing 2. An experience
were valid,
of the study were negligible students
in a treatment
the students on the results,
hold stereotyped
setting
where students
honest in their interviews then the following
con-
views of the alcoholic. interact
with alcoholics
appears
STUDENT
LEARNING
FOLLOWING
AN EDUCA
TIONAL
EXPERIENCE
49
to reduce these stereotyped views. 3. ‘The stated belief that alcoholism was an illness did not necessarily represent the real views of the respondents. 4. All of the students who attended the Centre believed the experience was an extremely valuable one in terms of their future practise. 5. All of the students who attended the Centre thought that every nursing student should be afforded this learning experience.
Summary
As was hypothesized, the nursing students who participated in the two week educational experience at a Rehabilitation Centre for alcoholics did increase their knowledge of alcoholism and did experience a change in some of their attitudes about alcoholic people. The importance of nurses examining their own feelings and attitudes toward alcoholism has been stressed by many authors: Nicolle (1963), Glud (1961), Burton (1964), Childress (1970), Holmes (1963) and Lewis (1956). Without a nonjudgmental and nonprejudiced attitude, it is felt that knowledge alone will be of very little value in terms of providing care to alcoholics and their families. Yuker (1956) states a prejudicial attitude is: “the tendency to group people into categories and to tend to perceive people in terms of their group membership, not as individuals. The prejudicial person will tend to prejudge others and react to them in a stereotyped fashion, judging them in terms of their group membership.”
According to this statement, a person who has a prejudicial attitude toward alcoholics will believe that all alcoholics are alike. Statements made by the students who attended the center did, in fact, support this. They saw all alcoholics within the ‘skid row’ stereotype, and only after the experience did they remark on their individuality. Yuker goes on to add that the two most important factors in changing prejudicial attitudes are an awareness of the attitude and “close personal contact and meaningful interaction between the prejudicial person and members of groups toward which he is prejudiced” (1965). Both of these factors were a very major part of the learning experience provided for the students. With the students knowledge gain and evidence of a more accepting attitude toward the alcoholic, certain implications arise. 1. That nursing educators examine curriculum content related to alcoholism. 2. That, in view of the point which Yuker (1965) makes regarding the importance of an awareness of one’s prejudicial attitudes, some mechanism be utilized whereby all nursing students can examine and become aware of the attitudes which they hold toward alcoholism and the alcoholic person. 3. That as a participatory learning experience of the type and by the 16 students in the treatment group results in a reduction of negative stereotypes and prejudicial attitudes (Yuker, 1965), the possibility of similar learning experiences should be investigated and made available for as many students as possible. By providing such experiences for nursing students it is hoped that, in their future practise, they will be able to make a significant contribution to the prevention, treatment and rehabilitation of this major social problem.
50
LOIS
M. SORGEN
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