Nurse Education in Practice xxx (2013) 1e7

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Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disordersq Roger J. Zoorob a, Kristy M. Durkin b, c, Sandra J. Gonzalez d, *, Susie Adams e a

Department of Family and Community Medicine, Meharry Medical College, Nashville, TN, USA Department of Social Work, University of West Florida, Pensacola, FL, USA c University of Alabama, Tuscaloosa, USA d Department of Family and Community Medicine, Meharry Medical College, Nashville, 37208-3599 TN, USA e PMHNP Program, Vanderbilt University School of Nursing, Nashville, TN, USA b

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 29 November 2013

Alcohol consumption during pregnancy can result in birth defects known as fetal alcohol spectrum disorders. This study examined whether 1-h training sessions on alcohol screening, brief intervention, diagnoses, and treatment of fetal alcohol spectrum disorders could increase practical knowledge and confidence in nurses and student nurses. Data were collected from 420 nurses (n ¼ 95) and student nurses (n ¼ 325) in the southeastern United States, from 2009 to 2011. Pre- and post-test data were analyzed using chi-square tests and t-tests. The post-training response rate was 84%. Nurses were more likely to know what constitutes binge drinking, facial abnormalities associated with fetal alcohol syndrome, and criteria for diagnosis. Nurses were also more confident in educating about effects of prenatal alcohol use, identifying fetal alcohol spectrum disorders and utilizing resources. Training materials may need to be improved and/or longer training programs developed for student nurses, and nursing school programs should place more emphasis on educating and preparing student nurses regarding this topic area. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: Nursing education Training Fetal alcohol spectrum disorders Alcohol Prevention

Introduction In the United States of America (U.S.A.) approximately 49.6% of childbearing age (18e44) women report consuming alcohol (Behavioral Risk Factor Surveillance System (BRFSS), 2010). Many of these women are also sexually active and often do not use effective forms of contraception (Brimacombe et al., 2009). Moreover, 50% of pregnancies in the U.S.A. are unplanned (Finer and Henshaw, 2006; Tsai and Floyd, 2004) and approximately 40% of women are unaware they are pregnant until 4e7 weeks into the pregnancy (Denny et al., 2009), indicating that many may be consuming alcohol during the early stages of embryonic development (O’Connor et al., 2009). As a result, these women may be at high risk

q The study was supported by the Southeastern Fetal Alcohol Spectrum Disorders Regional Training Center cooperative agreement 1U84DD000443-03 awarded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. The CDC had no involvement in the study design; collection, analysis, and interpretation of data; writing the report; and decision to submit the report for publication. * Corresponding author. Tel.: þ1 615 327 6572; fax: þ1 615 327 5634. E-mail address: [email protected] (S.J. Gonzalez).

for an alcohol exposed pregnancy as they may unknowingly continue to consume alcohol during pregnancy (Floyd et al., 2007; Tsai and Floyd, 2004). Although many women quit or reduce alcohol consumption after learning they are pregnant (Harrison and Sidebottom, 2009), 7.1% of pregnant women report alcohol use within the past 30 days and 1.2% of pregnant women report binge drinking (defined as 4 or more drinks on one occasion) (BRFSS, 2010). Fetal alcohol spectrum disorders (FASD) was identified in 2004 and the term accounts for the wide range of physical features, behavioral problems, and cognitive conditions caused by drinking alcohol while pregnant (Brimacombe et al., 2009; Olson et al., 2007). Historically, only individuals with FASD symptoms on the severe end of the spectrum were diagnosed with fetal alcohol syndrome (FAS) (Jones and Smith, 1973; Jones et al., 1973). FAS is generally discovered at birth or during early childhood when the serious facial abnormalities are immediately apparent (i.e. small palpebral fissures, smooth philtrum and thin upper lip) (Astley, 2004). The mild to moderate symptoms of FASD, however, present as subsequent developmental delays or mild facial abnormalities and often go undetected and undiagnosed (Andrew, 2011). The prevalence of FASDs in the United States is estimated to be as high as 10 per 1000 births (May et al., 2009). As FAS is on the severe

1471-5953/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nepr.2013.11.009

Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

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R.J. Zoorob et al. / Nurse Education in Practice xxx (2013) 1e7

end of the FASD spectrum, those who exhibit the full range of these effects are not as common; however, prevalence rates are comparable to other common developmental disabilities such as Down’s syndrome or spina bifida (May and Gossage, 2001). In fact, FAS is the largest known cause of birth defects in the U.S.A. with as many as 6000 cases per year (Barry et al., 2009) and has been estimated in the U.S.A. to be as high as 2 per 1000 live births (May and Gossage, 2001). Nurses make up the largest number of health care professionals in the U.S.A. (Spratley et al., 2000) and are thus in an excellent position to have an impact on the problem of birth defects (Coakley, 2007). Therefore, programs educating nurses and student nurses about the risk of prenatal alcohol consumption and FASD are critical for harm reduction and potentially reducing incidence and prevalence (Caley, 2006). One study on public health nurses found that only 42% had received prior training on the subject of FASD and only 1 in 5 believed the training was effective (Logan et al., 2003). In a study of school nurses, 72% reported needing more information on screening women for risky or hazardous drinking; educating pregnant women about the effects of alcohol on their babies; and conducting alcohol cessation brief interventions (Caley, 2006). Alcohol screening and brief intervention (SBI) offers an evidencebased, cost-effective approach to identifying and managing risky alcohol drinking (Fleming et al., 2002). Screening involves a series of questions which assess alcohol use followed by a brief counseling session aimed at increasing the individual’s awareness of their alcohol use and possible consequences. According to the Centers for Disease Control and Prevention (CDC), women of childbearing age and those who are pregnant are advised to abstain from alcohol during pregnancy (CDC, 2009). Nurses and student nurses in the U.S.A. encounter women during their childbearing years in every area of professional practice and in multiple settings: prenatal clinics, labor and delivery, well-child care settings, hospitals, schools, rehabilitation centers, and home visits (Caley, 2006; Coakley, 2007). However, a study on nurses and midwives found that the knowledge base on pregnancy and substance abuse was very low (Raeside, 2003). Another study found that 52% of school nurses report they rarely or never provide advice and education on the consequences of alcohol use during pregnancy to adolescent female patients (Caley, 2006). Further, nurses encounter children and families across the lifespan who are at risk for or who have FASD, and nursing interventions are key to the prevention and treatment of this problem (Caley et al., 2006). Recommendations for nurses in preventing secondary disabilities in FASD include screening, case-finding, health teaching, case management, referral and follow-up (Caley et al., 2006). School nurses have been found to feel “somewhat” to “very” unprepared to identify, diagnose, and manage or coordinate treatment for children with FASDs and approximately 36% did not know, or were unsure what facial features were associated with FAS (Caley, 2006). Further, few could correctly identify the facial features associated with FAS: short palpebral fissures (20%), smooth philtrum (32%), and thin upper lip (48%) (Caley, 2006). Recent studies have found that by simply presenting materials and/or providing training to nurses about FASD, an increase in knowledge, improved assessment skills, and greater use of practice skills related to FASDs will occur in both prevention and treatment areas (Caley et al., 2010; Payne et al., 2011). Nurses surveyed on their knowledge, attitudes and practices concerning FAS and alcohol consumption in pregnancy, and then given educational resources on the prevention and diagnoses of FASDs were found to have an increase in the proportion of those who knew all the essential features of FAS from 11.9% to 17%, at six months post training. Similarly those had suspected FAS based on prior knowledge of the essential features, increased from 38.2% to 48.8%; those

who identified FAS, from 3.9% to 11.4%; those who diagnosed FAS, from 3.2% to 4.7%; and those who referred to confirm a diagnosis of FAS, from 14.3% to 21.2% (Payne et al., 2011). In a study where nurses participated in a workshop on increasing implementation of prevention interventions for FASD, 35% of the nurses increased providing information on FASD, 21% conducted alcohol screenings, 4% increased brief interventions and 8% made referrals (Caley et al., 2010). In order to help educate nurses, student nurses and other medical professionals about the significance of FASD, alcohol screening and brief intervention to prevent FASD, the CDC established a set of educational guidelines based on seven core competencies that may be used in training. For each area of competency, it is expected that the curriculum will increase knowledge, change attitudes and improve skills in evaluating and intervening with prenatal alcohol use (CDC, 2009). Based on a review of the current literature, no study was located that focused on assessing student nurses’ knowledge regarding FASD prevention, diagnosis and treatment. Further, no studies were located comparing student nurses to nurses prior to and following training using the CDC’s core competency training guidelines. Survey data were collected from nursing students and nurses at baseline and at follow-up. The following factors were examined: knowledge about alcohol use prevalence and risky drinking patterns in women of reproductive age, FASD diagnosis and treatment knowledge, practices regarding alcohol use screening tools, confidence in providing alcohol screening and brief intervention, confidence in FASD diagnosis and treatment, and barriers that hinder alcohol screening, brief intervention, and FASD diagnosis. It is intended that the proposed tool will identify gaps in the curricula of existing nursing school programs. Such deficiencies could then be corrected through adapting trainings to better fit the learning needs of student nurses as well nurses on this topic. Methods Participants Data were collected from 420 nurses (n ¼ 95) and student nurses (n ¼ 325) in the southeastern U.S.A. between 2009 and 2011 by the Southeast FASD Regional Training Center. The center contacted nursing school programs and other agencies that employ nurses to schedule FASD competency-based trainings. Convenience sampling was used and data were reported for all participants who received the training. Institutional review board approval for the study was obtained prior to participant enrollment. Materials A survey, using a questionnaire, was conducted. The questionnaire was developed in collaboration with the CDC and the FASD Regional Training Centers and was adapted from surveys developed by previous researchers to assess provider knowledge and awareness of FASD (Gahagan et al., 2006; Nanson et al., 1995). The survey contained various response options, including multiple-choice, Likert-type scales, and free-text entries. Questions included knowledge about risky drinking patterns in women of childbearing age; identification of FASD/FAS; frequency of alcohol screening and brief intervention (SBI); confidence in providing SBI, utilizing resources to refer persons who may need formal diagnosis or treatment and in coordinating services; and barriers to providing SBI to pregnant and childbearing age women or diagnoses of FASD/FAS. The survey was piloted to a select group of medical students and residents before administration, in order to assess completion time, appropriateness of wording, and readability.

Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

R.J. Zoorob et al. / Nurse Education in Practice xxx (2013) 1e7

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Table 1 FASD prevention knowledge. Pre-test

Which of the following represents a true statement regarding alcohol use in US? An episode of binge drinking for women of childbearing age is defined as: Which one of these is NOT considered a standard drink: Total

Post-test

Students (n ¼ 325) %C

Nurses (n ¼ 95) %C

P-value

Students (n ¼ 266) %C

Nurses (n ¼ 86) %C

P-value

199 (61.2%)

45 (57.7%)

ns

159 (60%)

58 (69.9%)

ns

106 (32.8%)

33 (41.8%)

ns

166 (61.9%)

65 (76.5%)

.05

170 (52.3%)

34 (47.9%)

ns

179 (67.3%

57 (68.7%)

ns

49%

49.1%

63.1%

71.7%

*p < .01, **p < .05, ns ¼ not significant.

Currently there are five FASD Regional Training Centers (RTCs), each assisting the CDC in carrying out a 2002 Congressional mandate to develop, implement, and evaluate educational curricula for medical and allied health practitioners and students for FASD prevention, identification, and care (CDC, 2002). The training curricula used was based on the Fetal Alcohol Spectrum Disorders Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice (CDC, 2009). The seven competencies include: 1) historical, biomedical, and clinical knowledge about FASDs; 2) screening and brief interventions for pregnant and reproductive age women; 3) models of addiction; (e.g., characteristics of alcohol use, states of alcohol use, dependence, addiction in women, and stages of change in alcohol use); 4) effects of alcohol on the embryo and fetus; 5) screening, diagnosis, and assessment of individuals with FASDs; 6) long-term case management for individuals with FASDs; and 7) legal and ethical issues related to FASDs. The Southeast FASD Regional Training Center’s trainings were conducted by a team that included physicians, psychologists, nurses and social workers. Procedure All data analyses were conducted with SPSS statistical software (SPSS, Version 19). To facilitate intergroup comparisons, all respondents were divided into two groups: nurses (n ¼ 95) and nursing students (n ¼ 325). Pre-test and post-test analyses based on group responses were conducted using chi-square tests and independent-sample t-tests for comparisons of continuous measures. Descriptive statistics were computed and used to summarize the knowledge, clinical practices, and educational needs of respondents. Missing or invalid responses for a particular question were excluded from analysis. For some analyses, multiple-choice and four-point Likert scale responses were collapsed to yield two categories. For the purposes of this study the sample was derived from six universities/colleges, 3 state departments of health, 2

regional conferences, and 2 hospital/clinics located in the southeastern part of the US, for a total sample size 420. The response rate post-training was 84%. The participants represented the states of Georgia, Kentucky, Mississippi, South Carolina, Tennessee, Texas and U.S. Virgin Islands. Results Knowledge Prior to receiving core-competency training, participants were asked several survey questions to assess their knowledge of populations needing screening, the definition of at-risk drinking, highrisk female drinkers, quantity/frequency of a binge, and risk factor demographics. Post training, the nurses were significantly more likely to be able to accurately define how many drinks defined a binge episode for women compared to student nurses (76.5% vs. 61.9%) (X2 ¼ 6.024; p < .05). (See Table 1) Participants were also asked about the prevalence of the more severe form of prenatal alcohol effects, fetal alcohol syndrome (FAS) and other dynamics associated with the diagnosis of FASDs and treatment. Prior to training the nurses were significantly more likely than the students to know the prevalence of FAS (30.5% vs. 8.3%) (X2 ¼ 31.405; p < .01) and this difference remained at post-training (75.6% vs. 26.2%) (X2 ¼ 67.115; p < .01). At post-training, nurses were significantly more likely than students to know what three facial abnormalities were associated with FAS (96.3% vs. 84.7%) (X2 ¼ 7.740; p < .01); and what is not required to confirm a diagnosis of FAS (78.3% vs. 61.9%) (X2 ¼ 7.551; p < .01) (See Table 2). Alcohol screening tools There are a number of widely used screening instruments. Among these are the CAGE, the T-ACE, the TWEAK and the AUDIT (see Box 1). With regard to using standardized instruments for

Table 2 FASD diagnoses and treatment knowledge. Pre-test

Based on CDC studies, the prevalence of FAS in the US is estimated to be: Which of the following problems are associated with FASDs? Which of the following include all three facial abnormalities associated with FAS? Which of the following is NOT required to confirm a diagnosis of FAS? Which of the following can be used to treat individuals with FASDs? Total

Post-test

Students (n ¼ 325) %C

Nurses (n ¼ 95) %C

P-value

Students (n ¼ 266) %C

Nurses (n ¼ 86) %C

P-value

27 (8.3%)

29 (30.5%)

.01

70 (26.2%)

65 (75.6%)

.01

312 (96%)

88 (96.7%)

ns

264 (98.9%)

84 (100%)

ns

132 (40.7%)

39 (43.8%)

ns

227 (84.7%)

79 (96.3%)

.01

122 (37.5%)

35 (42.2%)

ns

166(61.9%)

65 (78.3%)

.01

296 (93.4%)

47 (100%)

ns

249 (95%)

47 (100%)

ns

55.2%

63%

73.3%

90%

*p < .01, **p < .05, ns ¼ not significant.

Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

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R.J. Zoorob et al. / Nurse Education in Practice xxx (2013) 1e7

Box 1 Alcohol use screening tools

CAGE: A four item instrument used to screen for excessive drinking and alcoholism. The acronym stands for Cut Down, Annoyed, Guilty, Eye-Opener. AUDIT: The Alcohol Use Disorders Identification Test. A 10item questionnaire developed by the World Health Organization (WHO) to screen for harmful alcohol consumption. T-ACE: A four ı´tem questionnaire used to identify at risk drinking. The acronym stands for Tolerance, Annoyance, Cut Down, Eye Opener. TWEAK: A five ı´tem scale initially developed to screen for at risk drinking during pregnancy. The acronym stands for Tolerance, Worried, Eye-Opener, Amnesia, K/Cut Down.

alcohol use assessment, nurses were significantly more likely than students to report not using a validated alcohol risk screening tool to assess use in childbearing age women (11.5% vs. 3.1%) (X2 ¼ 4.425; p < .05). With regard to which group uses the most appropriate tools (TWEAK and T-ACE) for assessing alcohol use in childbearing age women more frequently, nurses (38.5%) were more likely to use an appropriate tool than students (28.5%). Most nursing students reported using the CAGE to screen for alcohol use. In fact, students were significantly more likely than nurses to report using the CAGE to screen childbearing age women for alcohol use (49.1% vs. 15.4%) (X2 ¼ 10.707; p < .01). Of those who reported using some other tool, nurses were significantly more likely to use another less common tool to assess alcohol use than the students (7.7% vs. 0%) (X2 ¼ 17.678; p < .01) (Table 3). Confidence Prior to and after training, participants were asked to rate themselves on a scale from 0 to 10 (where 0 ¼ not confident in my skills and 10 ¼ totally confident in my skills) with regard to their confidence in providing alcohol screening and brief intervention to women at risk for an alcohol exposed pregnancy. Prior to the training, student nurses had a total confidence mean score of 4.14 and nurses had a total confidence mean score of 4.01. The nurses reported a higher increase in confidence in their skills to screen and provide brief intervention as a result of the training than the students. Following training, the student confidence mean score was 5.77 while the nurse mean score was 6.25. More specifically, nurses post-training were significantly more likely than students to report a higher level of confidence in ability to screen women for risky or hazardous drinking (M ¼ 5.81, SD ¼ 3.14 vs. M ¼ 5.79, SD ¼ 3.78) (X2 ¼ 4.709; p < .05). The nurses were also significantly more likely to report a higher level of confidence in ability to educate pregnant Table 3 Alcohol use screening tools *p < .01, **p < .05, ns ¼ not significant. Students (n ¼ 228) %

Nurses (n ¼ 26) %

P-value

Which validated alcohol risk screening tool do you use most commonly for women of childbearing age? T-ACE/TWEAK CAGE AUDIT/AUDIT-C Other None Not applicable

65 (28.5%) 112 (49.1%) 19 (8.3%) 0% 7 (3.1%) 13 (5.7%)

*p < .01, **p < .05, ns ¼ not significant.

10 (38.5%) 4 (15.4%) 3 (11.5%) 2 (7.7%) 3 (11.5%) 4 (15.4%)

ns .01 ns .01 .05 ns

women about the effects of alcohol on their babies (M ¼ 6.79, SD ¼ 3.03 vs. M ¼ 6.06, SD ¼ 3.73) (X2 ¼ 4.621; p < .05) (Table 4). The participants were also asked to rate themselves on their confidence in skills to diagnose and treat FASDs. Prior to training, the nursing students had a total confidence mean score of 2.77 and nurses had a total confidence mean score of 3.00. The increase in confidence ratings as a result of the training was relatively the same in FASD diagnosis and treatment among the students and the nurses. Following training, the student confidence mean score was 5.39 and the nurse mean score was 5.65. Although the total mean scores were not much different, there were a few significant differences found according to specific area of confidence. Nurses were significantly more likely to report higher confidence in their ability to identify persons with possible FAS or other prenatal alcohol-related disorders (M ¼ 6.09 vs. M ¼ 5.72) (X2 ¼ 10.934; p < .01) and utilize resources to refer persons for diagnosis and/or treatment services (M ¼ 6.28 vs. M ¼ 5.55) (X2 ¼ 9.328; p < .01). Students, however, reported significantly higher confidence than nurses post-training in their ability to manage/coordinate the treatment of persons with FASDs (M ¼ 5.24 vs. M ¼ 5.12) (X2 ¼ 4.589; p < .05) (Table 5). Barriers to practice The participants were asked to select from a list of factors found to be the most common barriers to providers screening for alcohol use and/or providing brief intervention for women at risk of an alcohol exposed pregnancy. Compared to nurses, nursing students were significantly more likely to report women’s denial or resistance to treatment (85.1% vs. 56.5%) (X2 ¼ 10.714; p < .01); time limitations (82.4% vs. 56.5%) (X2 ¼ 8.041; p < .01); women’s sensitivity to this topic (74.3% vs. 52.2%) (X2 ¼ 4.777; p < .05); and lack of financial reimbursement for alcohol screening, assessment, and counseling (66.2% vs. 39.1%) (X2 ¼ 6.236; p < .05) as barriers to screening for alcohol use and/or providing brief intervention (Table 6). The participants were asked to select from a list of factors found to be the most common barriers to providers not making the diagnosis of FAS or related conditions in their practice. The most common barrier for both the student nurses (81%) and nurses (86.2%) was a lack of specific training to make the diagnosis. This was followed by lack of comfort making a diagnosis (students 70.4%; nurses 55.2%) and lack of time needed to make a diagnosis (students 65.1%; nurses 55.2%). The students were significantly more likely to report lack of financial reimbursement as a barriers than nurses (45% vs. 24.1%) (X2 ¼ 4.475; p < .05) (Table 7). Discussion Findings indicate that nurses and student nurses in the U.S.A. would benefit from more education and training on how to provide alcohol screening and brief intervention to women at risk of having an FASD-affected child and on FASD diagnostic criteria and treatment. The findings further suggest that though both benefit, nurse training results in more increased knowledge when compared to students from 1-h training sessions. Nursing school programs should be placing more emphasis on curriculum that educates students on the consequences of prenatal consumption of alcohol. These results indicate a variety of possible educational modifications: 1) improved training materials, 2) shorter or longer initial training sessions individualized for target audiences, 3) follow-up booster session(s), 4) interactive or experiential learning to actively engage the target audience and 5) internet-based delivery of educational intervention. Prior studies of nurses in the U.S.A. regarding care for those with alcohol-related problems found

Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

R.J. Zoorob et al. / Nurse Education in Practice xxx (2013) 1e7

5

Table 4 Confidence in screening and brief intervention. (Scale 0e10)

Pre-test

Screen women for risky or hazardous drinking Educate pregnant women about the effects of alcohol on their babies Conduct brief interventions for reducing alcohol consumption Utilize resources to refer patients who need formal treatment for alcohol abuse Total mean

Post-test

Students (n ¼ 155) M(SD)

Nurses (n ¼ 58) M(SD)

P-value

Students (n ¼ 163) M(SD)

Nurses(n ¼ 78) M(SD)

P-value

3.94 (3.64) 4.65 (3.49)

3.86 (3.17) 4.90 (3.25)

ns ns

5.79 (3.78) 6.06 (3.73)

5.81 (3.14) 6.79 (3.03)

.05 .05

3.81 (3.39)

3.43 (2.84)

ns

5.57 (3.72)

6.07(3.18)

ns

4.17 (3.48)

3.83 (2.94)

ns

5.64 (3.74)

6.30 (3.09)

ns

4.14

4.01

5.77

6.24

*p < .01, **p < .05, ns ¼ not significant.

Table 5 Confidence in FASD diagnoses and treatment *p < .01, **p < .05, ns ¼ not significant. (Scale 0e10)

Pre-test

Identify persons with possible FAS or other prenatal alcohol-related disorders Diagnose persons with possible FAS or other prenatal alcohol-related disorders Utilize resources to refer patients for diagnosis and/or treatment services Manage/coordinate the treatment of persons with FASDs Total mean

Post-test

Students (n ¼ 199) M(SD)

Nurses (n ¼ 73) M(SD)

P-value

Students (n ¼ 163) M(SD)

Nurses (n ¼ 78) M(SD)

P-value

3.14 (2.99)

3.07 (2.95)

ns

5.72 (3.63)

6.09 (2.46)

.01

2.07 (2.80)

2.52 (2.73)

ns

5.04 (3.79)

5.12 (3.26)

ns

3.44 (3.31)

3.63 (3.28)

ns

5.55 (3.72)

6.28 (2.55)

.01

2.44(3.02) 2.77

2.78(2.80) 3

ns

5.24(3.78) 5.39

5.12(2.98) 5.65

.05

*p < .01, **p < .05, ns ¼ not significant.

significant positive change in nurses’ attitudes, beliefs and confidence levels regarding alcohol use, screening and treatment after a brief educational intervention (Peltzer et al., 2006; Vadlamudi et al., 2008). With the ever increasing health care knowledge base, educators across disciplines are challenged to prioritize which content is compressed, added, or deleted from the curriculum (Vadlamudi et al., 2008). Additionally, educators across disciplines are tasked with identifying the best educational methods to deliver curricular content in a time-efficient, effective manner. Collectively these findings indicate the need to explore effective, time-efficient teaching strategies and delivery methods for student nurses to gain the full benefit of the core-competency training methods development by the CDC. Table 6 Barriers to screening and brief intervention. In your opinion, which of the following factors may contribute to many providers not screening for alcohol use and/or providing brief intervention for women at risk of an alcohol-exposed pregnancy.

Students Nurses P-value (n ¼ 148) % (n ¼ 23) %

Patient denial or resistance to treatment Time limitations Patient sensitivity to this topic Lack of financial reimbursement for alcohol screening, assessment, and counseling in my state Patient inability to pay for treatment Need for additional training to enhance ascertainment skills Lack of referral resources for adequately dealing with prenatal alcohol use problems once identified Concern about confidentiality issues (of this kind of information about the patient)

85.1% 82.4% 74.3% 66.2%

56.5% 56.5% 52.2% 39.1%

.01 .01 .05 .05

57.4% 56.8%

47.8% 65.2%

ns ns

56.8%

43.5%

ns

39.2%

21.7%

ns

*p < .01, **p < .05, ns ¼ not significant.

The findings of this study also stress the need to provide student nurses with the best practices information, resources, and training for alcohol risk assessment and brief intervention. It was an unexpected finding that the students reported significantly higher confidence than nurses post-training in their ability to manage/ coordinate the treatment of persons with FASDs, as the nurses consistently had greater knowledge and confidence on all prior items. For the nursing students to have a significantly higher score on “managing & coordinating the treatment” is likely attributed to the nurses’ focus on recognizing, diagnosing and referring for services of specialists on this disorder by comparison to student nurses who may be overconfident in their perceived ability to manage/ coordinate the treatment of persons with FASDs. This perception may be a result of increased confidence based on newly acquired knowledge, their lack of practical experience in understanding the complexities of managing and coordinating treatment, and their reliance on other professionals involved in the person’s care,

Table 7 Barriers to FASD diagnoses and treatment. In your opinion, which of the following factors may contribute to many providers not making the diagnosis of FAS or related conditions in their practice.

Students (n ¼ 189) %

Nurses (n ¼ 29) %

P-value

Lack of specific training to make the diagnosis Lack of comfort making a diagnosis Lack of time needed to make diagnosis Patient sensitivity Lack of referral sources Lack of financial reimbursement Belief that making the diagnosis will not make a difference to the individual Confidentiality issues

81%

86.2%

ns

70.4% 65.1% 55% 45.5% 45% 39.7%

55.2% 55.2% 37.9% 37.9% 24.1% 24.1%

ns ns ns ns .05 ns

32.3%

27.6%

ns

*p < .01, **p < .05, ns ¼ not significant.

Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

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including other health providers. Another interesting finding was that the students were significantly more likely to report that lack of financial reimbursement was a barrier compared to nurses. Since students are typically less concerned about reimbursement issues, perhaps this was stressed in the teaching somehow or these students were part of interdisciplinary audience where lack of financial reimbursement for services was mentioned to be a barrier. This study has limitations. Certain demographic information, such as the stage of nurse training, for student nurses was not obtained. It is conceivable that student nurses in their second or third year compared to students in their first year may have been exposed to this content through their training program and thus may have more baseline knowledge, affecting overall results. The participants may have provided socially desirable answers to some questions, particularly in response to sensitive questions such as confidence before and after the training. This study did not assess whether knowledge regarding FASD was retained over time or whether the knowledge actually changed nursing practice (using a delayed post-test assessment). Another limitation concerns restrictions regarding the nature of the survey questions. In efforts to increase pre-test and post-test response rates, the length of the questionnaire was kept relatively brief; therefore, some information regarding prenatal alcohol use knowledge and current practices could not be collected. However, the brevity of the pre- and post-educational intervention survey may have increased participation by reducing the perceived subject burden of time to complete the survey. Conclusion In conclusion, future studies should continue to evaluate training effectiveness for this population. Nurses as well as students should be encouraged to familiarize themselves with the latest recommendations on identifying and screening for FASD in order to identify those at high risk (Caley et al., 2006). Additionally, nurses in practice should have a readily-available referral list of agencies and practitioners who have expertise in dealing with the problems associated with FASD (Caley et al., 2006). Johnson et al. (2010) suggest that one avenue for increasing communication about FASD prevention and intervention to nurses may be clinical messaging: an electronic system set up to educate them about the consequences of prenatal alcohol exposure or prompting them to screen for alcohol use with women who may be at risk of an alcohol-exposed pregnancy (Johnson et al., 2010). If nurses in the U.S.A. do not make women aware of the condition and its consequences, the likelihood of implementing prevention and treatment services is reduced (Caley et al., 2010). Moreover, the absence of these services may have a detrimental effect on individuals who are at risk for an alcohol exposed pregnancy and may result in a greater number of FASD births. The adverse effects of FASDs are seen throughout the lifespan and affect individuals, families, communities, and society. Conflicts of interest The authors have disclosed no potential conflicts of interest, financial or otherwise. References Andrew, G., 2011. Diagnosis of FASD: an overview. In: Riley, E.P., Clarren, S., Weinberg, J., Jonsson, E. (Eds.), Fetal Alcohol Spectrum Disorder: Management and Policy Perspectives of FASD. Wiley-Blackwell Press, Weinheim, Germany, pp. 127e142. Astley, S.J., 2004. Diagnostic Guide for Fetal Alcohol Spectrum Disorders: the 4-digit Diagnostic Code. University of Washington, Seattle, WA.

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Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

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Please cite this article in press as: Zoorob, R.J., et al., Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders, Nurse Education in Practice (2013), http://dx.doi.org/10.1016/j.nepr.2013.11.009

Training nurses and nursing students about prevention, diagnoses, and treatment of fetal alcohol spectrum disorders.

Alcohol consumption during pregnancy can result in birth defects known as fetal alcohol spectrum disorders. This study examined whether 1-h training s...
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