Angela Nash PhD, APRN, CPNP-PC, PMHS Assistant Professor of Nursing
University of Texas Health Science Center Houston
School of Nursing
Addressing Stigma for Patients with Alcohol or Drug Related Problems through an
Innovative Nursing Community Practicum
Learning Objectives
As a result of attending this session learners should
be able to:
• Describe the adverse health effects of stigma
and discrimination for patients with alcohol or
drug related problems.
• Discuss the role nurses’ attitudes play in
producing or reducing stigma.
• List at least 3 strategies for changing students’
attitudes and therapeutic commitment for
working with patients with alcohol or drug
related problems
Background • Americans have shorter lives & poorer health
than other industrialized nations
• For 3 decades, US health statistics have steadily
declined
• The majority of deficiencies directly or indirectly
relate to abuse of alcohol or drugs (AOD). (Institute of Medicine, 2013)
Areas of Health Deficiency
Infant mortality & LBW HIV & AIDS
Injuries & homicides Drug related deaths
Teen Pregnancy Obesity & Diabetes
Sexually Transmitted
Infections
Heart disease
Disability Chronic lung disease
Strategy
• If identified, AOD problems can be prevented or
treated, and affected people can recover.
• One effective strategy: boost early identification,
intervention and access to care for patients with
AOD related problems
• Two significant barriers:
• Stigma and discrimination by health care
professionals
• Insufficient training on addressing AOD use in
clinical settings
Stigma Stigma is a social process in which people are labeled, set apart, and linked to undesirable characteristics, and rationales are constructed for devaluing, rejection and exclusion
Five interrelated components:
• People identify and label differences based on social selection
• Stereotyping: Labeled person is linked to undesirable characteristics
• Separation of stigmatized “them” from “us”
• Stigmatized people experience discrimination & loss of status
• Always involves power differentials
Health Related Stigma
Adverse social judgment of patients with certain
health issues base upon causal attribution beliefs
This leads Health Care Professionals (HCPs) to:
• Have more intolerant judgments
• Be less personally engaged
• Demonstrate diminished empathy
• Provide only task oriented care
• Provide suboptimal care
Patients with AOD problems
• Stigma leads to significant mental, physical and
social consequences for affected patients
• They incorporate the negative label into sense of self →
o Decreased self-esteem
o Strained social interactions
o Compromised quality of life
o Depressive symptoms
• Stigma or fear of being stigmatized is source of
shame and chronic stress →
o Increased risk for other stress related illnesses
o Worsened course of presenting illness
Judgment & Discrimination
Patients presenting with AOD related problems report experiencing blame, judgment and discrimination from HCPs
Perceived discrimination by HCPs leads to
oDecreased self-esteem
oDiminished personal empowerment
oMistrust and avoidance of health care
oPoor provider-patient collaboration
oDelays in access to care
oDecreased likelihood of completing treatment
Nursing’s Role
Nurses are key players in the strategy for early identification and access to care for patients with AOD related problems
• Nursing is the most trusted profession and therapeutic relationship is a hallmark of nursing care yet
• Nurses often report insufficient training, limited institutional support, and low self-efficacy for addressing AOD issues in clinical settings
• Nurses typically report negative attitudes and poor motivation for working with patients who present with AOD related problems
Training • Studies demonstrate
o HCP’s training, experience, and confidence levels
are directly related to their regard for AOD-affected
patients.
oNursing students trained in empathy, relationship
building, and advocacy demonstrated increased
self-efficacy for providing compassionate care
o Nursing schools average only 11.3 hours of AOD-
related content hours for BSN students, with 90% of
content focused singularly on the treatment of
addictive disorders.
• Addressing this educational gap could improve
health outcomes for 60.1 million Americans with
risky levels of alcohol use and 24.6 million who use
illicit drugs.
Educational Intervention
AOD curriculum and experiences integrated into
BSN Community Public Health Nursing (CPHN)
practicum. Designed to:
oMeet required CPHN Practicum course
objectives
o Improve students’ attitudes and therapeutic
commitment for working with AOD affected
patients
oPrepare students to provide high quality
nursing care for patients at all levels of the
continuum of AOD use
The Institution
• 1,490 students Fall 2016
• Pacesetter BSN Program (4 semesters - 15 months)
• 88 Full-time and 18 part time faculty
• Among Top 5% nursing graduate schools
• Highest ranked in Houston & Gulf Coast area
The BSN CPHN Practicum • Senior level, Semester 3 (of 4)
• 120 students per semester (10 students per clinical site)
• Focus on integration of professional nursing and public health principles/methods
• Students collaborate with community partners in health promotion and disease prevention in a population
• Students apply CPHN skills:
• Community Assessment
• Identify community health problems
• Plan and carry out interventions
• Evaluate outcomes
Clinical Experience
• Students complete 135 clinical hours
• 10 students per Faculty
• Instructors partner with community agencies
• Students self select clinical rotation sites based
on their preference of
o Population served
o Clinical Instructor
o Proximity to their home
.
Setting: Santa Maria Hostel, Inc.
• Residential SUD treatment center for low-income women
• One of largest in Texas
• Children stay with mothers during treatment
Santa Maria Hostel, Inc. http://www.santamariahostel.org
Broad continuum of services and levels of care
• Residential detoxification
• Residential intensive and supportive
treatment
• Intensive outpatient
• Supportive living services
• Two programs provide residential treatment
for women involved with criminal justice
system
Integrated AOD Curriculum
Application of CPHN skills to the population of women with SUD & their children
To prepare them to serve AOD affected women
and their children, integrate up to 30 hours of
AOD-related educational experiences
• Community agency visits
• Media
• Expert Speakers
• Skills workshops
• Observational Experiences
Topics • The neuroscience and experience of addiction
• Recovery and the role of peer recovery supports
• The physical and mental health effects of adverse
childhood events and trauma
• Fetal alcohol spectrum disorders
• Neonatal Abstinence Syndrome
• Opiate Epidemic
• The impaired health professional and peer
assistance programs
• Motivational interviewing
• Screening, brief intervention, and referral to
treatment (SBIRT)
• Social-political issues related to substance abuse
(e.g., human trafficking, criminal justice issues,
domestic violence, child abuse, etc.).
Community Agency Visits
Houston Center for Sobriety
Houston Police Dept. Mental Health Division
Outreach, Screening, Assessment & Referral Center
Children’s services
Adolescent Services
Pregnant and Parenting Women Services
Elderly Services
Archway Academy Recovery High School
Expert Speakers • Director of Behavioral Health Institute The Neuroscience
of Adolescent Risk Behaviors
• CEO of one Recovery Support Model: History of Alternative Peer Groups
• Director & students: Recovery High Schools
• Director Collegiate Recovery program
• Professor Emerita UTHealth: Addiction Nursing
• Human Trafficking survivor and various agencies
• Addiction Medicine Physician: Detoxification and Opioid overdose rescue kits
• Professor University of Houston: Motivational Interviewing
• Representatives Drug Court & Texas Peer Assistance Program
• Licensed Marriage & Family Therapist: The experience of co-occurring SUD and mental health disorder
Media
Films designed to teach the following:
• Population health
• The science of addiction
• The Adverse Childhood Experiences study
• Promotion of resilience and mental health in traumatized or substance affected children
• Fetal Alcohol Spectrum Disorders
• Care of infants with prenatal opioid exposure
• Health Literacy
Observational Experiences
To enrich and broaden the clinical experience
beyond a single group of clients:
• Students self select from a variety of AOD or
Recovery-oriented community observational
experiences (8-10 hours)
• A variety of 12 Step meetings
• Peer recovery support activities
• Advocacy or outreach activities
Skills Building
• Community Assessment
• Demographics, Epidemiology, and Health
Disparities
• Composing behavioral objectives with
evaluation in mind
• Health Literacy
• Motivational Interviewing
• Screening, Brief Intervention and Referral to
Treatment (SBIRT)
Direct Work with Clients
Assigned to 1 of 3 groups of residential clients,
students:
• Shadow and experience clients’ daily schedule of
therapy and classes
• Observe or collaborate with inter-professional
teams on a variety of interventions
• Provide weekly 1 hour educational interventions to
their respective group of clients
oAssess community needs
oPlan and implement the activity tailored to client
needs
o Integrate activities to evaluate the interventions
Examples of Student led Topics
• Sexually Transmitted Infections
• Impact of prenatal AOD exposure on children and adults
• Relational parenting skills
• Infant & child Safety
• Nutrition and exercise
• Stress management
• Resume writing and interviewing skills
• Professional dress and behavior
• Home care of sick children
• Organization skills
• Time management
Milestone pic
• Diet & Exercise
session
• “Calorie-
count”
game
• 5 Workout
routine
• Childhood
Milestones
lecture
• Targeted
age groups
• Q&A session
on effective
parenting
skills
• Created an
educational game
about common STIs
• Over the course of
three weeks we did a
lesson on nutrition,
newborn basics, and
contraception
Reflection Activities To promote intercultural competence
and to prompt students to explore their
personal attitudes and beliefs
Written Reflections
To verify attendance at observational experience
students obtain signatures and write reflective essays
on each type experience
• Their positive or negative reaction to the experience
• How it builds upon or contrasts with their prior
knowledge or beliefs
• How they plan to implement the new knowledge in
o Their work at Santa Maria Hostel
o Their professional nursing practice
Weekly Verbal Reflections
In weekly post clinical conferences the instructor
leads students to reflect on:
• Issues that arose in group counseling sessions
• Student led educational interventions
• Community crises faced by clients
• New knowledge gained in outside observational
activities
Post Clinical Reflective Forum
On the last clinical day the Instructor holds a forum in which students reflect on the following questions:
• What has changed in you (personally or professionally)?
• Please describe a few things you learned in this practicum that you did not learn elsewhere in your nursing curriculum?
• How will (or not) the content influence your professional practice?
• What elements of the practicum are solid and should be continued?
• Which elements do you believe should be changed or dropped?
Educational Activities Breakdown
Educational Activity Percent Effort
Alcohol or Drug Related Curriculum Agency Visits, Media, Expert Speakers 15%
Observational Experiences 5%
MI and SBIRT Skills Building 5%
Community Public Health Nursing CPHN Skills Building 15%
Direct contact with Santa Maria Hostel 55%
Verbal and Written Reflection Activities 5%
Evaluation
Quantitative Evaluation To measure change in students’ attitudes and therapeutic commitment for working with patients with AOD-related problems Pre and Post Practicum confidential surveys were administered
• S-AAPPQ (Short Alcohol & Alcohol Problems Perceptions Questionnaire)
• 10 items
• Rate level of agreement on 7 point Likert Scale from (Strongly Agree ) to 7 (Strongly Disagree)
• Higher scores reflect more positive attitudes
• DDPPQ (Drug & Drug-Related Problems Perceptions Questionnaire)
• 22 Items
• Rate level of agreement on 7 point Likert Scale from (Strongly Agree ) to 7 (Strongly Disagree)
• Lower scores reflect more positive attitudes
,
Theoretical Foundation Both surveys assess the constructs of
• Role adequacy
• Role legitimacy
• Motivation
• Work Satisfaction
• Self-esteem
Two composite scores for caring for AOD affected
patients:
• Role security (Sense that I am able & have the right)
• Therapeutic Commitment (my motivation, work
satisfaction and self-esteem)
Results
As of August 2016, 100 students completed the practicum and 61 completed the pre and post clinical surveys
• Demographics
o 90% Female
o 80% ages 18 to 29 years
• Prior Experience
o 70% reported prior experience in personal life with someone with AOD problems
o > 80% reported experience in professional life with AOD affected patients (primarily in psychiatric rotation)
Statistics
Construct M score Test statistic Significance
S-AAPPQ higher scores = more positive attitudes
Total Score Pre: 51.3
Post: 57.6 Z = -4.59 p < .001
• Role Security Pre: 20
Post: 23.7 Z = -4.58 p < .001
• Therapeutic
Commitment
Pre: 31
Post: 33.7 Z = -3.45 p < .001
DDPPQ lower scores = more positive attitudes
Total Score Pre: 65.1
Post: 47.4 Z = -4.55 p < .001
• Role Security Pre: 43.9
Post: 29.5 Z = -4.67 p < .001
• Therapeutic
Commitment
Pre: 21
Post: 17.7 Z = -3.50 p < .001
Wilcoxon signed ranks test
Qualitative Themes • Growth in professional role
o Therapeutic communication
o Self-efficacy for asking “difficult questions”
o Confidence in ability to effect change through health
education
• New understanding of the complex determinants
of substance use disorder (e.g.)
o Trauma
o Prenatal alcohol exposure
o Use of substances in adolescence
o Generational patterns
• Changed attitudes and growth in empathy and
respect for AOD affected patients
Growth in professional role
• I know as nurses we're supposed to ask the difficult
questions, but I realize in taking this clinical that
sometimes we bypass those questions so we don't
feel uncomfortable or, like we're prying into their
personal lives. The reality is that we as nurses have
to ask some of these very personal and private
questions. It may save someone's life one day.
• I have acquired a wealth of knowledge that I will
carry over into my nursing practice. I feel that I will
be able to identify the needs of patents who may
suffer from a substance abuse condition, as well as
provide therapeutic interventions for them.
Understanding health determinants of addiction • I learned about the long-term manifestations of fetal
alcohol spectrum disorders and its effect on managing finances, time, and everyday tasks. I learned about trauma and how it unfortunately recurs in a cyclical manner throughout generations.
• Prior to this course, we had only touched on substance abuse. This course taught me about the roots of substance abuse and addiction and gave me tons of knowledge on the myriad of options out there for those in recovery. I'm sorry my other classmates did not have the opportunity to really learn about those struggling with substance abuse and the best practices to help them.
Growth in Empathy
• I learned what it was like day to day for people with addiction to drugs and alcohol. I learned that no single addict is like another and more than anything, they need support, not criticism.
• I learned not to judge others because there’s always a story behind each person (good or bad). There are things we can control and things we cannot, I just need to do my best and try to help as much as I can to all patients.
• Empathy for patients cannot possibly be taught in a classroom. I learned first hand how to have empathy for my clients and their situation.
Conclusion • Nurses are crucial players in the strategy for earlier
identification and access to care for AOD
affected patients
• Faculty can integrate AOD content into a
required course(in this case Community Health),
enriching the overall BSN curriculum and
addressing two significant barriers to the strategy:
• Stigma
• Insufficient preparation for addressing AOD issues in
clinical practice
References (in order of appearance)
1. Institute of Medicine. U.S. health in international perspective: Shorter lives, poorer health. National Academies Press; 2013:424
2. Institute of Medicine, ed. Improving the quality of health care for mental and substance-use conditions. Washington, D.C.: National Academies Press; 2006. Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders., ed. Quality Chasm Series.
3. Vadlamudi RS, Adams S, Hogan B, Wu T, Wahid Z. Nurses' attitudes, beliefs and confidence levels regarding care for those who abuse alcohol: Impact of educational intervention. Nurse Educ Pract. 2008;8(4):290-298. doi: S1471-5953(07)00099-6 [pii].
4. Wood E, Samet JH, Volkow ND. Physician education in addiction medicine. JAMA - Journal of the American Medical Association. 2013;310(16):1673-1674. Accessed 9 July 2014.
5. Ahern J, Stuber J, Galea S. Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 2007;88(2–3):188-196. http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S0376871606004133.
6. Leis R, Rosenbloom D. The road from addiction recovery to productivity: Ending discrimination against people with alcohol and drug problems. Family Court Review, 47: 274–285. doi:10.1111/j.1744-1617.2009.01254.x
Reference (page 2) 7. Link BG, Phelan JC. Stigma and its public health implications. Lancet.
2006;367(9509):528-529. doi: S0140-6736(06)68184-1 [pii].
8. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Stigma among
health professionals towards patients with substance use disorders and its
consequences for healthcare delivery: Systematic review. Drug Alcohol
Depend. 2013; 131(2): 23-35.
9. McFarling L, D'Angelo M, Drain M, Gibbs DA, Olmsted KL. Stigma as a barrier
to substance abuse and mental health treatment. military psychology, 23 (1):1-
5. DOI. Military Psychology. 2011;23(1):1-5.
10. Storti SA. The lived experience of women in addiction recovery: The
haunting specter of stigma in nurse-patient interactions (2002). [PhD Nursing].
University of Connecticut; 2002.
11. Brener L, Hippel WV, Kippax S, Preacher KJ. The role of physician and nurse
attitudes in the health care of injecting drug users. Subst Use Misuse.
2010;45(7):1007-1018.
http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=50197
281&site=ehost-live. doi: 10.3109/10826081003659543.
12.van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Healthcare
professionals regard towards working with patients with substance use
disorders: Comparison of primary care, general psychiatry and specialist
addiction services. Drug Alcohol Depend. 2014;134(0):92-98. Retrieved from:
http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/
S0376871613003748.
References (page 3)
13. Henderson S, Stacey CL, Dohan D. Social stigma and the dilemmas of providing care to substance users in a safety-net emergency department. Journal of health care for the poor and underserved. 2008;19(4):1336-4.
14. Vadlamudi RS, Adams S, Hogan B, Wu T, Wahid Z. Nurses' attitudes, beliefs and confidence levels regarding care for those who abuse alcohol: Impact of educational intervention. Nurse Educ Pract. 2008;8(4):290-298. doi: S1471-5953(07)00099-6 [pii].
15. van Boekel LC, Brouwers EPM, van Weeghel J, Garretsen HFL. Healthcare professionals regard towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and specialist addiction services. Drug Alcohol Depend. 2014;134(0):92-98. Retrieved from: http://www.sciencedirect.com.ezproxyhost.library.tmc.edu/science/article/pii/S0376871613003748.
16. Pauly B. Toward cultural safety nurse and patient perceptions of illicit substance use in a hospitalized setting. Advances in nursing science. 2015;38(2):121; 121-135; 135.
17. Adam D, Taylor R. Compassionate care: Empowering students through nurse education. Nurse Educ Today. 2014;34(9):1242-1245. doi: http://dx.doi.org/10.1016/j.nedt.2013.07.011.
18. Savage C, Dyehouse J, Marcus M. Alcohol and health content in nursing baccalaureate degree curricula. Journal of Addictions Nursing. 2014;25(1):28-34. Retrieved from: http://journals.lww.com/jan/Fulltext/2014/01000/Alcohol_and_Health_Content_in_Nursing.6.aspx. doi: 10.1097/JAN.0000000000000018.
19.Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: Summary of national findings. . 2014;NSDUH Series H-48; HHS Publication No. (SMA) 14-4863.
References (page 4) 20. Santa Maria Hostel, Inc. Retrieved from: http://www.santamariahostel.org/ 21. Gorman D, Cartwright A. Implications of using the composite and short versions of the alcohol and alcohol problems perception questionnaire (AAPPQ). Br J Addict. 1991;86(3):327-334.
22. Terhorst L, Gotham HJ, Puskar KR, et al. Confirming the factor structure of the alcohol and alcohol problems questionnaire (AAPPQ) in a sample of baccalaureate nursing students. Res Nurs Health. 2013;36(4):412-422. doi: 10.1002/nur.21537. 23. Watson H, Maclaran W, Shaw F, Nolan A. Measuring staff attitudes to poeople with drug problems: The development of a tool. [Scottish Government: Publications]. 2003:1-23. 24. Watson H, Maclaren W, Kerr S. Staff attitudes towards working with drug users: Development of the drug problems perceptions questionnaire. Addiction. 2007;102(2):206-215. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=23687372&site=ehost-live. doi: 10.1111/j.1360-0443.2006.01686.x. 25. Cartwright AKJ. Processes involved in changing the therapeutic attitudes of clinicians toward working with drinking clients. Psychotherapy research. 1993;3(2):95; 95-104; 104.
26. Cartwright A. Is the interviewer's therapeutic commitment an important factor in determining whether alcoholic clients engage in treatment? Addiction research & theory. 1996;4(3):215; 215-230; 230. 27. Cartwright AKJ. The attitudes of helping agents towards the alcoholic client: The influence of experience, support, training, and self-esteem. Br J Addict. 1980;75(4):413-431. http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=6271349&site=ehost-live.
Top Related