The Development and Evaluation of Addressing Nurse Impairment Seminar for Nursing Students 1 David M. Cadiz, MBA, PhD Oregon Nurses Foundation Chris O’Neill, R.N., DMin Oregon Nurses Foundation 1 Funding for the development of the Addressing Nurse Impairment training was provided by the Oregon Health Authority (OHA) and the Oregon Nurses Foundation. The views expressed in this document do not reflect the official policies of the funders; nor does mention of trade names, commercial practices, or organizations imply endorsement by them.
Transcript
The Development and Evaluation of Addressing Nurse Impairment Seminar for Nursing Students1
David M. Cadiz, MBA, PhD Oregon Nurses Foundation
Chris O’Neill, R.N., DMin Oregon Nurses Foundation
1 Funding for the development of the Addressing Nurse Impairment training was provided by the Oregon Health Authority (OHA) and the Oregon Nurses Foundation. The views expressed in this document do not reflect the official policies of the funders; nor does mention of trade names, commercial practices, or organizations imply endorsement by them.
Brief Overview
This technical report describes the systematic development and evaluation of a seminar
for nursing students focused on substance use disorders and impaired practice in nursing. We
called the educational intervention “Addressing Nurse Impairment” and we anticipated that it
would have a significant effect on knowledge acquisition, change self-confidence to intervene,
and change substance abuse stigma. We describe the adaption of an evidence-based prevention
program called Team Awareness which provided the framework of the seminar. The adaption
process included conducting two focus groups and a pilot session. Once the adaption process
was completed, we used a quasi-experimental pre-post-test design to evaluate the impact of the
seminar. When comparing the control and experimental groups, the results indicated the seminar
significantly affected knowledge and self-efficacy to intervene, but did not significantly impact
stigma. The evaluation results support the effectiveness of the seminar as a nursing student
intervention that fills the current gap that exists in student nurse education about the risks of
addiction within the profession and how to deal with a colleague suspected of having a substance
use disorder. Our research also contributes to building the body of evidence related to
educational interventions on substance abuse with nursing students.
TABLE OF CONTENTS
Introduction………………………………………………………………..1
Adaptation of Team Awareness……………………..…………………….2
Quasi-Experimental Evaluation of the Seminar……………………….…..8
Results……………………………………………………………………..11
Discussion and Implications……..………………………………………...16
Potential Limitations and Future Directions……………………………….17
Conclusion…………………………………………………………………18
References…………………………………………………………………19
Appendix A: Focus Group Protocol.………………………………………22
Appendix B: Focus Group Content Analysis Results……………………..24
Appendix C: Pilot Study Measures………………………………………..25
Prevalence for substance use disorders has been estimated at 6 to 8 percent of nurses, about the same as the general public (Snow & Hughes, 2003). Evidence suggests that younger health professionals may be at higher risk (Kenna & Lewis, 2008). Risk factors include routine access to drugs in their practice and efforts to cope with the stressful nature of their job (Trinkoff, Storr, & Wall, 1999). Additionally, student nurses are not immune to substance use disorders. Indeed, nursing academic faculty report having frequent encounters with student nurses they suspect of a substance use disorder (Kornegay, Bugle, Jackson, & Rives, 2004). Therefore, student nurses may encounter a peer or colleague whose performance impacts related to a substance use disorder in nursing school.
However, those in the health care profession generally lack the awareness and skill set to recognize or assist a colleague with a substance abuse problem (Quinlan, 2003). In fact, nurses report feeling unprepared to identify and deal with substance use disorders (Rassool, 2004). The lack of preparedness for dealing with this issue often results in colleagues not speaking up or intervening when they suspect a colleague has performance problems that may be related to a substance use disorder. Nurse colleagues often enable nurses suspected of being impaired to continue unprofessional behavior and performance by making excuses, ignoring problems, covering up mistakes, and accepting incomplete work (Quinlan, 2003). Thus, there is the potential for compromising patient safety when a nurse fails to intervene with a colleague’s unsafe practice in a timely way. Moreover, the nurse with a substance use disorder may delay or avoid altogether getting needed help.
The nursing profession has spoken clearly about the need for education. The National
Student Nurses Association and the American Nurses Association passed resolutions that called for greater education of student nurses about the risk of addiction (NSNA, 2002; ANA, 2002). There is evidence that education and training can develop a more positive and non-judgmental attitude toward people diagnosed with substance use disorders, confidence to intervene when impairment is present, and skills to identify and assist people with a substance use disorder (Hagemaster et al., 1993; Rasool, 2004). However, there is limited evidence for educational interventions for student nurses. Rasool and Rawaf (2008) concluded that the limited nursing research that does exist generally supports the efficacy of educational interventions in affecting
knowledge acquisition, attitude changes, and in improving nurses’ confidence to intervene. This technical report describes an educational intervention called Addressing Nurse
Impairment that was developed, implemented, and evaluated at a school of nursing located in the Pacific Northwest. We describe the process used to develop the seminar content, the training approach used in the implementation of the seminar, the quasi-experimental research method used to evaluate the seminar, and we discuss the results and implications of our findings.
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Adaptation of Team Awareness
We utilized a systematic approach to develop the content for the 2-hour Addressing Nurse Impairment seminar. The content development process included a literature review for evidence-base practices, two focus groups, and a pilot intervention. The combination of these development activities resulted in an evidence-based, student nurse specific seminar focused on nurse impairment awareness and how to intervene.
Literature review
We reviewed the literature concerning substance and alcohol use education interventions and identified an evidence-based training program called Team Awareness (Bennett, Lehman, & Reynolds, 2000) that seemed to appropriately fit the focus of the training—to provide a balanced approach to building awareness about substance abuse while also developing the communication skills needed to intervene when a colleague is displaying behaviors associated with impaired practice. In fact, peer enabling by nurse coworkers (i.e., overlooking performance problems because a colleague is also a friend, “picking up the slack”, not speaking up) has been identified as a workplace risk factor for nurses who develop a substance abuse disorder (Clark, 1988).
Team Awareness is a training program rooted in research showing that coworker cohesion is a protective factor against workplace substance misuse whereas the workplace culture that tolerates workplace substance use and other misuse is a risk factor. The program focuses on increasing positive social interactions to promote a healthy work culture and reduce the stigma associated with seeking help for substance use and mental health disorders (Bennett et al., 2000). The program has been effectively adapted and used in several work contexts including with electricians (Einspruch, O’Neill, Jarvis, Vander Ley, & Raya-Carlton, 2011), restaurant workers (Bennett, Aden, Broome, Mitchell, & Rigdon, 2010), and municipal workers (Bennett & Lehman, 2001). Indeed, Team Awareness has been scientifically reviewed and entered into the National Registry of Evidence-Based Programs and Practices (2002, 2007). Because a majority of the interventions using team awareness is with younger workers in a team environment, we felt that student nurses would be an effective target for this prevention effort because student nurses are generally younger adults about to enter a workforce where a team-based work model is prevalent. However, to our knowledge, the Team Awareness framework and program has not been adapted and applied with student nurses. Thus, the concept and training content associated with Team Awareness needed to be adapted for student nurses.
Focus groups
We utilized focus groups to guide the adaptation process. Focus groups can be an effective way to generate rich content including capturing information about the culture, vocabulary, relevant examples, and concerns or issues specific to the academic institution. We conducted a 1-hour focus group with faculty for a baccalaureate program and another focus group with student nurses who were about to graduate. The focus group protocol consisted of
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four sections to capture participant current awareness and experiences with substance abuse, identifying resources available at the school, identifying behaviors associated with substance abuse, and identifying the potential causes of substance abuse disorders. Please see Appendix A for the focus group protocol.
The information collected from the focus groups was independently content analyzed (by the first author and second author) and a summary report was reviewed by the research team. Please see Appendix B for the detailed summary of the focus groups. Several common themes emerged from the analysis that guided adaptation of the training content. For example, we found that there was a general lack of awareness as to the school policy associated with students identified with a substance abuse disorder. In addition, participants identified several obstacles to both seeking help or and also intervening when concerned about a colleague’s performance. Finally, the students were concerned with lax confidentiality which may result in someone who seeks treatment for a substance use disorder being stigmatized by faculty and peers. Content development summary
Both the literature review and focus group analysis provided the content to adapt the Team Awareness program to create the Addressing Nurse Impairment seminar. The content of the seminar includes a review the prevalence statistics associated with substance use and mental health disorders in the nursing profession, the legal and ethical responsibilities of a nurse when faced with a colleague whose performance problems may be related to a substance abuse disorder. The seminar is capped with a 45-minute role play practice session that teaches the Team Awareness NUDGE communication skills. Practice with the NUDGE skill is intended to increase student confidence to speak up when impaired performance is suspected in order to overcome tolerance and fear of intervening.
Additionally, the seminar includes information about stigma associated with addiction
and the effectiveness of treatment and an individual’s potential for recovery. Indeed, stigma reduction has been successful for changing stigmatizing beliefs and attitudes toward substance use and mental health disorders (Corrigan et al., 2001).
Finally, to make the training more engaging for the student nurses, the seminar utilizes
several educational methods including lecture, discussion, and behavioral role modeling. In a quantitative review assessing the effectiveness of training programs in organizations, Arthur et al. (2003) observed that multi-method training approaches are effective in producing changes in knowledge, skill-based, and affective outcomes. Lecture is the most popular training method and has a positive effect on training performance (Callahan et al., 2003). Moreover, behavioral role modeling is rooted in social learning theory and focuses on a trainee’s ability to acquire knowledge through observing someone else performing the task (Bandura, 1977). The effectiveness of behavioral role modeling as an effective method for learning skills is supported meta-analytically (Taylor et al., 2005).
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Pilot Study
We conducted a pilot study to assess the relevance and effectiveness of our initial training content development, the presentation of the material, and to test our outcome measures on a sample of student nurses in their last semester. Method
A pre-post online survey design was the data collection process implemented. Appendix C provides the measures used in the evaluation. Online surveys were distributed prior to the seminar and immediately after the seminar. Participant recruitment was coordinated by two of the coauthors who were instructors for the class that was selected for the training seminar. Two weeks prior to the seminar, the nurse students were contacted by email through a class listserve and alerted to expect an upcoming opportunity to participate in the evaluation of a training seminar they were going to be attending. The following day, an email survey invitation was sent to each student in the class through an online survey website. A follow up reminder invitation was emailed by the instructors to the class listserve a week after the initial survey invitation. A final reminder invitation was emailed two days prior to the seminar to the participants who had not yet responded. The Time 2 data collection process followed the same procedure. An email invitation was distributed immediately after the completion of the seminar. The instructors followed up with a reminder one week later and then one day before the survey was closed. Participants were offered a chance to win a $50 gift card as an incentive to participate. Participants were notified that in order to qualify for the raffle for the $50 gift card they were had required to participate in the pre and post surveys. Participants
There were 64 email invitations distributed at both Time 1 (pre-seminar) and Time 2 (post seminar). At Time 1, we received a total of 59 responses to the survey which is a 92% response rate. At Time 2, we received a total of 45 responses, which is a 70% response rate. However, two of the respondents did not respond to any of the items on the survey so they were removed from the data set leaving a total of 43 responses. The matched data from Time 1 and Time 2 resulted in total sample of 43 responses. The mean age of the sample is 30.6 years old and 76% of the sample is female. The sample is 83% Caucasian, 13% Asian/Pacific Islander, 2% Filipino, and 2% indicated mixed ethnicity. Results Using paired samples t-tests, we observed significant mean changes in declarative knowledge (t = 3.62, df = 39, p < .01), self-rated knowledge (t = 10.31, df = 39, p < .01), and self-efficacy (t = 6.93, df = 39, p < .01). However, we did not find significant changes in attitudes toward those with a substance abuse problem (t = -1.31, df = 35, ns). We generally received positive feedback about the training, but we did receive several suggestions to spend more time on the practice and skill-building part of the seminar.
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Figure 1. Comparison of Pre and Post Seminar Outcome Variables
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Table 1. Responses to the Satisfaction with Training Items
Mean Strongly Disagree Disagree Neutral Agree
Strongly Agree
1. The training met my expectations 3.64 0% 12% 24% 52% 12%
2. The training increased my competence
3.67 0% 9% 24% 57% 10%
3. I got some useful ideas 3.83 0% 7% 14% 67% 12%
4. I learned something new 4.10 0% 0% 10% 71% 19%
5. The content was current and up-to-date
4.12 0% 0% 5% 53% 14%
6. Presentation of the content was thorough
3.90 0% 45% 17% 62% 17%
7. The training format and activities were stimulating
3.56 0% 15% 29% 42% 15%
8.The training handouts and other materials were valuable
3.64 0% 7% 33% 48% 12%
9. Instructors had command of the subject
4.21 0% 0% 7% 64% 29%
10. Instructors were well-prepared 4.26 0% 0% 5% 64% 31%
11. Instructors made the subject interesting
3.83 0% 5% 26% 50% 19%
12. Instructors were approachable 4.24 0% 0% 7% 62% 31%
13. The pace of the training was just right
3.86 0% 7% 24% 45% 24%
14. The difficulty of the material was just right
3.76 0% 7% 26% 50% 17%
15. The amount of material covered was just right
3.67 0% 10% 31% 43% 17%
16. Overall, I feel the quality of the seminar was excellent
3.64 0% 12% 31% 38% 19%
17. Overall, I would recommend this seminar to my colleagues
3.79 0% 7% 24% 52% 17%
18. The training program is useful for my development.
3.83 0% 2% 29% 52% 17%
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Table 2. Responses to the Training Effectiveness Items
Mean SD N
Strongly
Disagree Disagree Neutral Agree
Strongly
Agree
1. I improved my skills to identify and deal with nurse impairment.
3.57 .74 42 0% 7% 36% 50% 7%
2. I feel that it's important to learn about nurse impairment.
4.21 .56 42 0% 0% 7% 64% 29%
3. I think it’s important to learn to identify nurse impairment.
4.24 .58 42 0% 0% 7% 62% 31%
4. My completion of this training will make me a better nurse.
3.76 .69 42 0% 0% 38% 48% 14%
5. I will be able to apply what I learned in my nurse practice.
4.00 .54 42 0% 0% 14% 71% 14%
6. Gaining the skills provided by this training will positively affect my practice.
3.95 .62 42 0% 2% 14% 69% 14%
7. I will be more effective in my practice as a result of this training.
3.76 .73 42 0% 5% 26% 57% 12%
Discussion
Overall, the results from the pilot were promising. We observed significant changes in knowledge and confidence to intervene. In addition, the student nurses responded favorably to the measures assessing their opinions about their satisfaction with the training and their perceptions about seminar’s effectiveness. However, we did not observe a significant change in substance abuse stigma which was something we tried to address in the updated version of the seminar. To address stigma, we added more emphasis on the content discussing substance use disorders as being a disease, and if treatment is sought, recovery is possible. Based on student feedback, we also made two adjustments to the seminar content and presentation. First, the content was adjusted to increase the emphasis on the importance of having a more non-judgmental attitude toward colleagues with a substance use disorder to try to affect stigma. Second, we increased the time for the exercise modeling and practice from 30 minutes to 1 hour because students felt they would benefit even more from additional behavioral modeling and practice time. Both of these changes were implemented in the educational intervention that we subsequently evaluated and report on below.
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Quasi-Experimental Evaluation of the Seminar
We used a non-equivalent control group pretest-posttest design with a sample of student nurses to examine the effectiveness of the two-hour Nurse Impairment Awareness seminar. We selected this design because random assignment to experimental and control groups was not feasible. However, by collecting pre-intervention data, we were able to statistically control for differences between the groups (Cook, Campbell, & Paracchio, 1990). For instance, we can control for differences on the pre-assessments on all of the outcome variables. Moreover, to address threats to validity like history, the control group participants are from same institution and are only one semester behind the experimental group in the program so they are exposed to the same curriculum and institutional events. We were not concerned with maturation because the entire evaluation process was contained within a four week span. Finally, by collecting pre- and post-intervention data for all participants, we can statistically examine testing and reactivity effects stemming from being exposed to the same measures twice (Cook et al., 1990).
Procedure
There were several processes involved to implement the quasi-experimental pre-post survey design. First, we conducted two phases of participant recruitment. The recruitment for the experimental group was coordinated by one of the instructors of the seminar course. The recruitment of the control group consisted of the first author speaking with permission to the two classes of students who would graduate the following semester. A description of the research
project was provided, questions about the research were answered, and additional information
was provided in handouts from the course instructor at the end of the class. Second, we had to distribute the surveys and implement a follow-up procedure to
increase the response rate. Two weeks prior to the seminar, an invitation to an online survey was emailed to each student enrolled in one of the three courses. Participants who chose to participate would click on the embedded link which would take them to the informed consent letter which they were instructed to read. To insure that the participant acknowledged their rights as a research participant we required the participant to click on a button stating they read and understood their rights as a research participant before continuing to the survey. A reminder invitation was emailed to student nurses one week after the original survey invitation was distributed. A final reminder invitation was emailed two days prior to the seminar to the students who had not yet responded. The post intervention survey data collection process followed the same distribution and follow up process. The survey items on the two surveys were the same except for two main differences—demographic data were collected only in the pre-seminar survey and self-rated knowledge was collected only in the post-seminar survey.
Incentives were also offered to increase the rate of participation in the research project.
Participants were offered the chance to be entered into a random drawing to win one of three $50 gift cards. Participants were notified that in order to qualify for the random drawing for the $50 gift card they had to participate in both the pre and post surveys. A random drawing occurred
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after the post survey was closed and the three winning participants were notified and given the gift card by the third and fourth authors.
Participants
We distributed 173 email invitations to the survey (107 to the experimental group and 66 to the control group) at both Time 1 (pre-seminar) and Time 2 (post-seminar). At Time 1, we received a total of 112 responses (74 experimental and 38 controls) to the survey which is a 65% response rate. At Time 2, we received a total of 99 responses (64 experimental and 35 control), which is a 57% response rate. The matched data from Time 1 and Time 2 resulted in total sample of 86 responses (56 experimental and 30 controls) which is a 50% response rate. The mean age of the sample is 28.34 years old (SD = 7.19) and 90% of the sample is female. The sample is 71% Caucasian, 8% Asian/Pacific Islander, 10% Hispanic, 3% Native American, 1% African American, and 8% indicated mixed ethnicity. We used ANOVAs to examine whether there any differences between the two samples on age and gender. We found that the control group was significantly older (Mcontrol = 32.81 and Mexp = 26.26; F(1, 99) = 21.99, p < .01) and had more males than the experimental group (Control = 22% and Experimental = 4%; F(1, 100) = 8.15, p
< .01) . Given these results we controlled for age and gender in our analyses.
Measures
Based on the results from similar educational interventions (e.g., Rasool & Rawaf, 2008), we expected to observe three positive changes: (1) knowledge and awareness of substance use disorders in the workplace; (2) increased self-efficacy (self-confidence) to intervene if a colleague is practicing unsafely; and (3) reduced negative attitudes (i.e., stigma) held about colleagues with a substance abuse disorder. In addition to these outcomes, we also assessed participants’ feelings about the effectiveness and utility of the seminar. Finally, we collected demographics and personal experiences with alcohol and drug use. Appendix D lists the measures used in the evaluation.
Demographics. In the pre-seminar survey we collected several variables to gather
descriptive information about the participants. We asked participants for their age, gender, and ethnicity.
Personal experiences with substance use. In the pre-seminar survey we used four items
to collect information about participants’ experience with substance use. The questions asked about whether the participant had ever been impaired while working, known someone else who was impaired while working, suspected that someone at work was impaired, and asked about their current alcohol and drug use.
Knowledge test. Ten knowledge test items were developed to sample training content and were adapted from a previous evaluation of a similar training program (Truxillo, Cadiz, & O’Neill, 2011). The knowledge test items were developed using a multiple-choice format with 3
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or 4 response alternatives each. Participants were asked to take the knowledge test in the pre and post survey.
Self-rated knowledge. Eleven self-rated knowledge items were developed to measure
participant assessment of their level of knowledge, understanding of the training goals and skills taught in the training. As with the knowledge test items, the self-rated knowledge items were adapted from previous training evaluations of a similar training program (Truxillo, Cadiz, & O’Neill, 2011). After the training (Time 2), trainees were asked to retrospectively assess their pre-training level of knowledge and understanding and their post-training level of knowledge and understanding. Trainees responded to these items using a 5-point Likert-type scale where response anchors ranged from Very Low to Very High. The Cronbach’s alpha reliability for self ratings associated with the pre-training knowledge and post training knowledge were .94 and .95, respectively.
Self-efficacy. We measured self-efficacy because it has been shown to be a consistent predictor of training success (e.g., Baldwin & Ford, 1988; Colquitt et al., 2000). Self-efficacy was assessed using 8 items focused on capturing a participant’s confidence to identify impairment, intervene, and respond to resistance during an intervention. A sample item is “I am confident in my ability to communicate a caring message of concern to a colleague I suspect of having a substance abuse problem.” Trainees responded to these items using a 5-point Likert-type scale where response anchors ranged from Strongly Disagree to Strong Agree. Self-efficacy was collected at both Time 1 and Time 2. The Cronbach’s alpha reliability for Time 1 and Time 2 were .82 and .86, respectively.
Substance abuse stigma. Substance abuse stigma was assessed with 7 items from the perceived substance abuse stigma scale developed by Luoma et al. (2007). These items assessed the trainee’s perceptions about the amount of stigma that they felt a recovering person would face in the workplace. Trainees responded to these items using a 5-point Likert-type scale where response anchors ranged from Strongly Disagree to Strong Agree. Stigma was collected at both Time 1 and Time 2. The Cronbach’s alpha reliability for Time 1 and Time 2 were .79 and .81, respectively.
Training effectiveness. Training effectiveness was measured with 7 items that ask
participants to evaluate different elements of the seminar including the clarity of the information, the pace, the organization of the content, the level of engagement, and the importance of the skills that were taught. Trainees responded to these items using a 5-point Likert-type scale where response anchors ranged from Strongly Disagree to Strong Agree. The Cronbach’s alpha reliability for the measure was .91.
Training Utility. Training utility was measured with 4 items that assessed whether the students nurses felt they could apply the material in the seminar to their practice. After the training (Time 2), trainees were asked to retrospectively assess their pre-training level of knowledge and understanding and their post-training level of knowledge and understanding. Trainees responded to these items using a 5-point Likert-type scale where response anchors
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ranged from Strongly Disagree to Strongly Agree. The Cronbach’s alpha reliability for self-rated pre-training knowledge and post training knowledge were .82 and .58, respectively.
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Results
Analysis strategy
We ran basic descriptive statics on all of the measures and report this information in Tables 3 and 4 below. A series of analysis of covariance (ANCOVA) was carried out to examine the differences between the control and experimental group on knowledge, self-efficacy, and stigma. This type of analysis allows us to control for threats to the internal validity of the study by including variables that could impact the interpretation of our results. In this study, the pre-survey mean scores of knowledge, self-efficacy, and stigma were chosen as covariates. These sources of variations were accounted for to limit the effects of previous alcohol and drug education and personal and professional experiences. Thus, the pre-tests acted as covariates to provide a baseline for the statistical validity of the study. Statistical analyses were conducted using SPSS version 17.0. Statistical significance was set at p < 0.05. The expectation was that there would be significant increases for the knowledge, self-rated knowledge, and self-efficacy. A significant decrease was expected for substance abuse stigma. Individual descriptions of the results for each outcome are provided below.
Table 3. Study Variables Means and Standard Deviations
Measure N Min Max Mean SD
Pre-Seminar Knowledge Test 104 3.00 10.00 6.10 1.40
Post Seminar Knowledge Test 91 2.00 10.00 7.19 1.79
Post Seminar Substance Abuse Stigma 90 1.71 5.00 3.13 .61
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Table 4. Reported Frequency of Personal Experiences with Substance Use
You
Impaired
Other
impaired
Other
suspected Current Alcohol Current Drug
Mean 1.07 1.54 1.51 1.72 1.04
Std Deviation 0.25 0.5 0.5 0.45 0.2
Sample Size 102 102 102 102 102
No 93% 46% 49% - -
Yes 7% 54% 51% - -
Non-User - - - 28% 96%
Recreational - - - 72% 4%
Knowledge
Knowledge has two dimensions in this study: (1) knowledge test of the course material, and (2) self-rated understanding of the material.
Knowledge test. Results indicated that a participant’s knowledge of the seminar material
was higher after the seminar than it was before the seminar. We observed a significant difference between the control (M = 6.13) and experimental groups (M = 7.81) on the post-seminar knowledge test after controlling for mean score on the pre-seminar knowledge test, age, and gender (F (1, 69) = 19.14, p < .01). The partial eta-squared associated with this difference is .22, which means that 22% of the variance in the post knowledge test can be attributed to participating in the seminar. Figure 2 provides a graphical representation of the mean comparisons between the control and experiemental groups on the pre-and post knowledge test.
Figure 2. Group Comparison of Knowledge Test Changes Before and After the Seminar
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Self-rated knowledge. Results indicated that participant’s assessment of their level of understanding of the seminar material increased when retrospectively comparing it to before the seminar. We observed a significant difference between the control (M = 2.84) and experimental (M = 4.02) groups on the post-seminar assessment of understanding the seminar material (F(1, 68) = 53.13, p < .01). The partial eta-squared associated with this difference is .44, which means that 44% of the variance in the post seminar self-assessed knowledge can be attributed to participating in the seminar. Figure 3 provides a graphical representation of the mean comparisons between the control and experiemental groups on the pre-and post self-rated knowledge.
Figure 3. Group Comparison of Self-Rated Knowledge Changes Before and After the
Seminar
Self-efficacy
Results indicated that participants’ confidence to identify and intervene in cases where fitness to practice is in question were higher after the seminar compared to before the seminar. We observed a significant difference between the control (M = 3.45) and experiemental (M = 3.93) groups on the post seminar measure of self-efficacy (F(1, 70) = 11.20, p < .01). The partial eta-squared associated with this difference is .14, which means that 14% of the variance in self-efficacy after the seminar can be attributed to attending the seminar. Figures 4 provides a graphical representation of the mean comparisons between the control and experiemental groups on the pre-and post surveys for self-efficacy.
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Figure 4. Group Comparison of Self-Efficacy Changes Before and After the Seminar
Stigma
Results indicated that the seminar did not significantly reduce a training participant’s perceived substance abuse stigma. We did not observe a significant difference between the control (M = 3.15) and experimental (M = 3.38) groups on the post seminar measure of perceived substance abuse stigma (F(1, 69) = 2.33, ns). Training Effectiveness
The results indicated that the participants felt the seminar was effective. The majority of participants responded favorably to all of the items training effectiveness items. The lowest rated item was related to the pace of the seminar (M = 3.79). We acknowledge that the two hours allotted for the seminar may be insufficient to present the information and still allow enough time to practice the communication skills that are introduced. However, the seminar did fit within the constraints of the course schedule.
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Table 5. Experimental Group Responses to the Training Effectiveness Items
Mean SD N Strongly
Disagree Disagree Neutral Agree
Strongly
Agree
The purpose of the workshop was clear.
4.33 .735 58 2% 7% 57% 25% 0
The presentation was well-paced.
3.79 1.039 58 2% 12% 19% 40% 28%
I had enough opportunities to be involved.
3.91 .823 58 0 5% 22% 48% 24%
The presenters were well organized.
3.97 .898 58 2% 5% 16% 50% 28%
The presenters explained things clearly.
4.10 .831 58 2% 3% 9% 55% 31%
The presenters were engaging and approachable.
4.10 .872 58 2% 3% 12% 48% 35%
The skills taught were important for my role.
4.12 .919 58 2% 5% 10% 45% 38%
Training Utility
The results indicated that participants felt more positively about the utility of the training after the training than before the training. A paired samples t-test showed that the mean rating after (M = 3.46) the seminar was significantly higher than the mean rating before (M = 2.27) the seminar (t = 14.72, p < .01).
Table 6. Experimental Group Responses to the Training Utility Items
Mean Difference (After - Before)
t N p-value
The importance of skills to identify and deal with nurse impairment.
1.26 12.57 57 .000
The seminar was useful for my development. 1.02 7.36 56 .000
The material in seminar was relevant to skills I had hoped to develop.
1.23 8.81 56 .000
The time spent in the seminar was worthwhile. 1.09 6.25 56 .000
My expectation about my ability to apply to my practice what I learned in seminar.
1.42 15.20 56 .000
My expectation I will have opportunities to use the skills that I learned in the seminar in my practice.
1.18 9.02 56 .000
Overall training utility (sum of all items) 1.20 14.72 56 .000
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Discussion and Implications
The results support the effectiveness of the “Addressing Nurse Impairment” seminar to affect knowledge about substance use disorders and a nurse’s ethical role in intervening when a colleague is displaying behaviors associated with impaired practice. Moreover, we found that the seminar increased student nurses’ confidence to address colleagues whose unsafe practice may be related to a substance use disorder. In addition to positive changes in knowledge and confidence, we also observed that the nursing students rated the training as being useful and effective. Therefore, these findings contribute to addressing the existing gap in student nurse education about the risks of addiction within the profession and how to deal with a colleague suspected of having a substance use disorder. Additionally, the seminar fulfills the call from ANA and ASNA for greater education of student nurses about the risks of addiction (NSNA, 2002; ANA, 2002). Ultimately, the knowledge, skills, and confidence gained from the seminar could reduce the potential for compromising patient safety when a nurse fails to intervene with a colleague’s unsafe practice in a timely way. Moreover, it may also increase the chance that a nurse colleague suffering from a substance use disorder may be directed to the help they need.
The non-equivalent control group pretest-posttest design strengthens our confidence that
the seminar is an effective educational intervention. By collecting pre-intervention data from the control group we were able to statistically account for pre-existing differences between the groups on the measures of interest. In addition, collecting pre- and post-seminar control group data allowed us to investigate testing effects (i.e., score improvement due to taking the same knowledge test twice). No significant differences were observed in the control group between Time 1 and Time 2 on the knowledge test (t = .94, ns). Therefore, the results support the efficacy of the seminar as an evidence-based educational intervention for schools of nursing to increase knowledge and confidence to deal with colleagues with substance use disorders as well as colleagues displaying impaired practice.
Finally, we also showed that through a systematic process that included focus groups and
a pilot study, the Team Awareness (Bennett et al., 2000) alcohol and drug prevention program could be effectively adapted and utilized with student nurses. Introducing an already established evidence-based program about substance use prevention into the nursing curriculum is an important and timely contribution because it provides a “best practice” that was identified as generally lacking in the recently released guidelines about substance use disorders in nursing by the National Council of State Boards of Nursing (NCSBN, 2011). Moreover, Team Awareness is is especially valuable because focuses on the social context as a way to prevent substance use disorders and impaired practice. It may help drive a cultural change with regard to help seeking and proactively addressing practice concerns in the workplace.
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Potential Limitations and Future Directions
As with all research, there are potential limitations that could have affected our results. First, the generalizability of our results could be of concern because we had a relatively small sample size which could mean that the effects that we observed could be related to the type of student that participated in the study rather than the training seminar itself. However, we did conduct a pilot study and observed similar results that, at a minimum, provide initial evidence that the results were not specific to the cohort of students that we examined. Future research should examine the effectiveness of the training seminar at additional institutions.
Second, we used a cross-sectional design in that we did not survey students after a length
of time to assess whether the changes that were observed last and whether their behavior was affected once they entered the workforce. Future research should implement a longitudinal design to see if erosion occurs with regard to knowledge and awareness and whether the seminar affects behavior.
Finally, the non-significant change in substance abuse stigma could be attributed to the
difficulty in measuring the construct of stigma. Stigma is a difficult construct to capture in a self-rated measure because most people answer the items in a socially-desirable way which may be the reason we did not see significant change. Moreover, the seminar was only one event that spanned two hours and changing stigmatized attitudes could need a more extensive training program. Future research should explore better ways to measure substance abuse stigma and investigate whether multiple interventions over time could have more impact on changing stigmatized attitudes.
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Conclusion
A gap exists in student nurse education about the risks of addiction within the profession and how to deal with a colleague suspected of having a substance use disorder. There is limited evidence related to educational interventions on substance abuse with nursing students. We have contributed to building a body of evidence in this field of research through the systematic development and evaluation of the Addressing Nurse Impairment seminar. We invite future research to continue to continue to investigate evidence-based substance abuse prevention programs with student nurses in order to proactively address this difficult issue that challenges the nursing profession and the healthcare industry in general.
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References
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organizations: A meta-analysis of design and evaluation features. Journal of Applied
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research. Personnel Psychology, 41, 63–105. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice Hall.
Bennett, J. B., Aden, C., Broome, K., Mitchell, K., & Rigdon, W. (2010). Team resilience for young restaurant workers: Research-to-practice adaptation and assessment. Journal of
Occupational Health Psychology, 15, 223–236.
Bennett, J. B., & Lehman, W. E. K. (2000). Workplace substance abuse prevention and help-seeking: Comparing a team-oriented and informational training. Journal of Occupational
Health Psychology, 6, 243–254.
Bennett, J. B., Lehman, W. E., & Reynolds, G. S. (2000). Team awareness for workplace substance abuse prevention: The empirical and conceptual development of a training program. Prevention Science, 1, 157–172.
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Hagemaster J., Handley S., Plumlee A., Sullivan E., & Stanley S. (1993) Developing educational programmes for nursing that meet today's addiction challenges. 0urse Education Today
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facultys’ lived experience of encounters with chemically dependent nursing students. Journal of Addictions 0ursing 15, 125-132.
Luoma, J.B., Twohig, M.P., Waltz, T., Hayes, S.C., Roget, N., Padilla, M., & Fisher, G. (2007).
An investigation of stigma in individuals receiving treatment for substance abuse. Addictive Behaviors, 32, 1331-1346.
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substance abuse and mental health programs for every community. Available from http://www.modelprograms.samhsa.gov
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National Student Nurses Association (NSNA). (2002, April). Resolution: In support of nursing
school policies to assist and advocate for nursing students experiencing impaired practice. Resolution presented at the NSNA House of Delegates, Philadelphia, PA.
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Quinlan, D. (2003). Impaired nursing practice: A national perspective on peer assistance. U.S.
Journal of Addictions 0ursing, 14, 149-155. Rassool, G. H., (2004). Curriculum model, course development and evaluation of substance
misuse education for health care professionals. Journal of Addictions 0ursing, 15, 85–90. Rasool, G. H., & Rawaf, S. (2008). Predictors of educational outcomes of undergraduate nursing
students in alcohol and drug education. 0urse Education Today, 28, 691-701. Taylor, P.J., Russ-Eft, D.F., & Chan, D.W.L. (2005). A meta-analytic review of behavioral
modeling. Journal of Applied Psychology, 90, 692-709. Trinkoff, A. M., Storr, C. L., Wall, M. P. (1999). Prescription-type drug misuse and workplace
access among nurses. Journal of Addictive Diseases, 18, 9-17. Truxillo, D. M., Cadiz, D., & O’Neill, C. (2011). Evaluation of a Substance Abuse Training
Program for Healthcare Supervisors. Technical Report for WorkHealthy Oregon,
Portland, OR
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Appendix A: Focus Group Protocol Session Introduction: Thank you for taking the time out of your busy schedules to participate in this focus group. My name is Dave Cadiz and Chris O’Neill will also be assisting me in this focus group. We are from the Oregon Nurses Foundation and are interested in gathering information about people’s current awareness and experiences with substance abuse, how to identify those who are suspected of being impaired, and nursing student stressors that could potential lead to drug abuse issues in order to develop a training seminar about nurse drug abuse that will be offered in the fall and spring semesters. The purpose of the training seminar is to bring awareness to nursing students about nurse drug abuse issues and there consequences, provide behaviorally-based indicators to help a nursing student assess potential drug abuse issues, and improve a nursing student’s confidence to intervene if a colleague is suspected of having drug abuse issues. This focus group will last approximately 1 hour, and we encourage open communication. We have broken this session into 3 sections. All data that comes from this focus group will be reported in summary form, and any identifying characteristics will be removed in the report. In order to have an open environment for a candid conversation about your experiences, we expect that everyone will respect each other’s opinions, and we would like that only one person speak at a time. Additionally, it is very important that everyone else respect the confidentiality of what is said in this room. Therefore, what is said in this room needs to stay in this room. I would also like to let you know that your participation is voluntary and you may leave at any time. You may also refuse to share your thoughts and experiences if you do not feel comfortable doing so. I would also like to emphasize that by participating in this focus group you are under no obligation to participate in any future research activities involved with this study. Since we are talking about a sensitive issue, if at any point you feel that you may need to talk to someone, I have contact information I can provide you for counseling resources. Are there any questions? Before we start, I am handing out a document that we would like you to sign as an extra step to insure that you understand your rights as a participant and to get your agreement to not divulge any information that is shared in this focus group outside of this room. I am handing out some note cards so that everyone is able to write down any ideas that may come to mind as I introduce each section and ask a question associated with that section. Note that I will ask you to return these note cards with your notes at the end of today’s session. It would be very helpful if you would put the # of the section that your notes coincide with. Section #1 (20 minutes): What are your current experiences with someone who had a substance abuse problem (legal or illegal substances)? These experiences could be about current or past
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colleagues, friends/family, and workplace experiences. Please take a few minutes to write these on your cards. [after 3 minutes] Now I will ask each person to share these with the group. When you are sharing, try to refrain from providing the group any identifying information about the person that you are talking about. Follow-up question: How did your feelings or perspective about the person change knowing that they had a substance abuse issue? Section #2 (25 minutes): We will spend the remaining time discussing the potential causes of substance abuse in nursing students. One potential source of substance abuse could be from school-related stressors. What are potential school-related stressors that could lead to substance abuse issues? I will give you a few moments to write a response [go around the table and ask them to share these.] Follow-up Questions: What are potential personal life causes for nursing students to abuse substances? Is there anything else you feel we should have asked? Or something else we should know? Do you think student nurses should have the same responsibilities and opportunities for enrollment in the Health Professionals’ Services Program—they monitor nurses and other health professionals for safe practice—and if yes, why? Section #3 (15 minutes): What are the resources available to you if you are personally having issues or if you concerned for someone else? Follow up question: How did you hear about the resource? What would be potential obstacles to use the resources available to you? Concluding remarks: Thank you for your participation. The information you have provided will be extremely helpful for the development of the student nurse seminar. If anything we discussed today made you feel uncomfortable and you feel like you need to talk to someone, I have information about counseling resources that are available to you. Please contact Lisa Burch, Director of Student Services, Loveridge Hall 1st floor, 503-413-7562.
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Appendix B: Summary of the Focus Groups
Identification that there is a formal policy in place (termed “structured enrollment”) where students that have been identified as having a substance abuse issue may become re-engaged with the school of nursing. However, faculty awareness of formal policy and resources available to students may be lacking, which was identified by the students but seem to also be implied by some of the discussion in the faculty focus group. Both focus groups acknowledged the trend of “less traditional” students making up a greater amount of the student nurse population at Linfield. Less traditional student describes the increased number of students who already have a bachelor degree and/or are changing careers. This means that the students are a bit older and potentially have more role responsibilities, which increases the potential for role conflict and stress. Although posed as two different questions, the answer to obstacles for substance abuse self-referral was very similar across the focus groups. Essentially both groups identified concern for confidentiality. From the student perspective, the concern for confidentiality stems from a lack of trust that faculty will not keep discussions confidential. Although there a couple people that were identified as people who the students trusted and that is because the people were seen as “third parties” and not linked to the academic side of the program (i.e., director of learning support and student services contact). There was a difference in how the two focus groups talked about their personal experiences with substance abuse. The students mainly discussed family and friends as sources of substance abuse experiences. The faculty strictly focused on students and colleagues. They noted that fluctuation of behavior and peers approaching them with concerns are the two common ways that substance abuse was identified. The groups identified similar categories of student stressors. These categories include role conflicts (family/friends, work, school), workload (time pressures), academic performance, intrapersonal stressors (self-identity changes), financial stressors, lack of confidence about nurse competencies. The faculty talked about several resources that are available to students to support them if they are concerned that they personally have a problem or a peer is thought to have a problem. However, the students were only able to identify counseling services as the resource available to them with regard to substance abuse treatment. They noted that the reason they knew about the counseling services was from the email that was sent out to the students. However, they were able to identify several other community resources that are available and this was from their personal experiences from volunteering and working at facilities or from their social network. The students did state that they would like to have more information and discussion about substance abuse especially in peers/colleagues because they have a general sense that it is not seen as a problem that occurs in the program.
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Appendix C: Pilot Survey Measures Knowledge Test
1) The prevalence of substance use among nurses and pharmacists is: a. Less than the general public
b. About the same as the general public
c. Double (200%) that of the general public d. Triple (300%) that of the general public
2) For nurses who work in the Emergency Department, the risk for abusing which drug may be as much as 3.5 X (350%) higher than nurses who practice in other settings?
a. Tobacco b. Binge drinking
c. Marijuana
d. Oxycodone
3) In general, in which age group are nurses at higher risk for substance use problems?
a. 21-34 years
b. 35-54 years c. 55-65 years d. 66 years and older
4) Which of the following is not a service of the Health Professionals’ Services Program? a. Confidentially enrolling self-referring licensees without notifying the appropriate
licensing board
b. Conducting a clinical evaluation of each licensee to determine a diagnosis
c. Assessing the capacity of employers to supervise a licensee who is returning to the practice setting
d. Reporting substantial non-compliance of a licensee with terms of their monitoring agreement
5) Which one of the following statements does not reflect the guidance provided in the Code of Ethics for Nurses?
a. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
b. The nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by a member of the healthcare team.
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c. In a situation where a nurse suspects another’s practice may be impaired, the nurse’s duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimum function.
d. When a nurse states her concern to another nurse about her unsafe or
unprofessional practice, it is not necessary for the nurse to report it up the chain
of command if the performance improves.
6) John has enrolled in the Health Professionals’ Services Program confidential monitoring program and is participating in treatment out of town. As his closest friend, you are aware of what has occurred. The unit supervisor has explained at a staff meeting that he will be away for a while and they expect him to return next month. A coworker persists in asking you as his friend, “What’s going on with John?” Which of the following is the best statement to make?
a. John is on a “medical leave” and plans to return after he gets out. b. Well, you know the problem John has. He’ll return when they let him go.
c. I don’t have any additional information to share than what we heard in the unit
meeting.
d. John is a really good nurse and doing the best he can; we should help him when he completes treatment.
Self-efficacy
Please indicate how much YOU agree with the
following statements using a scale of 1 to 5, with 1
being "strongly disagree" and 5 being "strongly
agree."
Strongly Agree
Agree
@either Agree nor Disagree
Disagree
Strongly Disagree
1. I am confident in my ability to prepare for a meeting with a subordinate about his/her performance problems.
1 2 3 4 5
2. I am confident in my ability to communicate with a subordinate about their performance problems.
1 2 3 4 5
3. I am confident in my ability to give feedback to a nurse enrolled in the monitoring program.
1 2 3 4 5
4. I am confident in my ability to respond to employee resistance when confronting a subordinate about their fitness to perform.
1 2 3 4 5
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Self-rated Knowledge
Please rate YOUR level of knowledge, awareness, or understanding on each of the following dimensions before and after completing the Fit to Perform training. Please circle the appropriate rating using the following scale:
Please rate YOUR level of knowledge, awareness, or
understanding on each of the following dimensions of the
@urse Impairment training. Please click on the
appropriate rating using the following scale:
Very High
High
Moderate
Low
Very Low
My legal responsibilities as a nurse to report unsafe and/or unprofessional practice by another health professional.
1 2 3 4 5
What is meant by "objective observations" of nurse performance. 1 2 3 4 5
How to prepare for a meeting with a colleague about my concerns about their performance.
1 2 3 4 5
What issues to focus on during a meeting with a colleague about my concerns about their performance.
1 2 3 4 5
The steps to take during a meeting with a colleague about my concerns about their performance.
1 2 3 4 5
What reactions to prepare for when I discuss with a colleague my concerns about their performance.
1 2 3 4 5
How to report to my supervisor when I suspect unsafe or unprofessional practice by another health professional.
1 2 3 4 5
How to give feedback to nurses who exhibit signs of unsafe or unprofessional practice.
1 2 3 4 5
The concept of "fitness for practice." 1 2 3 4 5
Confidential monitoring of licensed health professionals with substance use or mental health disorders in the Health Professionals’ Services Program.
1 2 3 4 5
My ethical responsibilities when a nurse colleague may be impaired because of a mental health or substance use problem.
1 2 3 4 5
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Substance Abuse Stigma
Using the following scale, please respond to the following statements circling the appropriate number to the right of each item.
Strongly Agree
Agree
@either Agree nor Disagree
Disagree
Strongly Disagree
1. Most people would be unwilling to accept a person in recovery as a coworker.
1 2 3 4 5
2. Most people believe that nurses in recovery are less trustworthy than their other coworkers.
1 2 3 4 5
3. Most people feel that entering substance abuse treatment is a sign of personal failure.
1 2 3 4 5
4. Most people think less of a person who has been in substance abuse treatment.
1 2 3 4 5
5. Most healthcare organizations would not hire a person in recovery even if he or she is qualified for the job.
1 2 3 4 5
6. Most people at my work would treat a person in recovery differently. 1 2 3 4 5
7. Once coworkers know a person was in substance abuse treatment, they expect less from him/her.
1 2 3 4 5
Training Satisfaction
Your attitudes about the training: Now that you have completed the training program, we are interested in learning more about your feelings and attitudes about it.
Please think about the training you just completed. Indicate the extent to which you agree or disagree with each of the following statements.
Strongly Agree
Agree
@eutral
Disagree
Strongly
Disagree
1. The training met my expectations 1 2 3 4 5
2. The training increased my competence 1 2 3 4 5
3. I got some useful ideas 1 2 3 4 5
4. I learned something new 1 2 3 4 5
5. The content was current and up-to-date 1 2 3 4 5
6. Presentation of the content was thorough 1 2 3 4 5
7. The training format and activities were stimulating 1 2 3 4 5
8. The training handouts and other materials were valuable 1 2 3 4 5
9. Instructors had command of the subject 1 2 3 4 5
10. Instructors were well-prepared 1 2 3 4 5
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11. Instructors made the subject interesting 1 2 3 4 5
12. Instructors were approachable 1 2 3 4 5
13. The pace of the training was just right 1 2 3 4 5
14. The difficulty of the material was just right 1 2 3 4 5
15. The amount of material covered was just right 1 2 3 4 5
16. Overall, I feel the quality of the seminar was excellent 1 2 3 4 5
17. Overall, I would recommend this seminar to my colleagues 1 2 3 4 5
18. The training program is useful for my development. 1 2 3 4 5
Training Effectiveness
Your attitudes about the Training Seminar: We are interested in learning more about your feelings and attitudes about the training before you start.
Indicate the extent to which you agree or disagree with each of the following statements.
Strongly Agree
Agree
@eutral
Disagree
Strongly Disagree
1. I improved my skills to identify and deal with nurse impairment. 1 2 3 4 5
2. I feel that it's important to learn about nurse impairment. 1 2 3 4 5
3. I think it’s important to learn to identify nurse impairment. 1 2 3 4 5
4. My completion of this training will make me a better nurse. 1 2 3 4 5
5. I will be able to apply what I learned in my nurse practice. 1 2 3 4 5
6. Gaining the skills provided by this training will positively affect my practice.
1 2 3 4 5
7. I will be more effective in my practice as a result of this training. 1 2 3 4 5
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Personal Experiences with Substance Use
Next we will ask about your experience with drugs and alcohol. Please remember that we will
be removing your contact information from our database.
Have you ever been impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes
Have you ever known someone who was impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes Have you ever suspected that someone was impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes
How would you describe yourself in terms of drug or alcohol use at this point in your life? (Check one)
□ Non-user □ Recreational user □ Heavy user Demographics
Age (or birth year): Gender: Ethnicity: 1 African American 2 Asian/Pacific Islander 3 Caucasian 4 Filipino 5 Hispanic 6 Native American 7 Other (please specify)
1) The prevalence of substance use among nurses and pharmacists is:
a. Less than the general public
b. About the same as the general public
c. Double (200%) that of the general public d. Triple (300%) that of the general public
2) For nurses who work in the Emergency Department, the risk for abusing which drug may be
as much as 3.5 X (350%) higher than nurses who practice in other settings? a. Tobacco b. Binge drinking
c. Marijuana
d. Oxycodone 3) In general, in which age group are nurses at higher risk for substance use problems?
a. 21-34 years
b. 35-54 years c. 55-65 years d. 66 years and older
4) Which of the following is not a service of the Health Professionals’ Services Program?
a. Confidentially enrolling self-referring licensees without notifying the appropriate licensing board
b. Conducting a clinical evaluation of each licensee to determine a diagnosis
c. Assessing the capacity of employers to supervise a licensee who is returning to the practice setting
d. Reporting substantial non-compliance of a licensee with terms of their monitoring agreement
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5) Which one of the following statements does not reflect the guidance provided in the Code of
Ethics for Nurses?
a. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.
b. The nurse must be alert to and take appropriate action regarding any instances of incompetent, unethical, illegal, or impaired practice by a member of the healthcare team.
c. In a situation where a nurse suspects another’s practice may be impaired, the nurse’s duty is to take action designed both to protect patients and to assure that the impaired individual receives assistance in regaining optimum function.
d. When a nurse states her concern to another nurse about her unsafe or
unprofessional practice, it is not necessary for the nurse to report it up the chain
of command if the performance improves.
6) John has enrolled in the Health Professionals’ Services Program confidential monitoring program and is participating in treatment out of town. As his closest friend, you are aware of what has occurred. The unit supervisor has explained at a staff meeting that he will be away for a while and they expect him to return next month. A coworker persists in asking you as his friend, “What’s going on with John?” Which of the following is the best statement to make?
a. John is on a “medical leave” and plans to return after he gets out. b. Well, you know the problem John has. He’ll return when they let him go.
c. I don’t have any additional information to share than what we heard in the unit
meeting.
d. John is a really good nurse and doing the best he can; we should help him when he completes treatment.
7) What does "fit to practice" mean?
a. An employee is not under the influence of alcohol or drugs while on the job and thus is unable to perform the job safely. b. An employee is physically, emotionally, and cognitively able to perform the job
safely.
c. An employee is physically able to perform the job.
8) When considering the concept of structured observation, which of the following would be considered a subjective observation
a. Explanations b. Conclusions c. Theories d. b and c
e. All of the above
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9) Which of the following should be used as guidance when a nurse is faced with addressing a potential fitness to practice issue?
a. Nurse Practice Act b. American Nurses Association Code of Ethics for Nurses c. Organizational policies d. a and b
e. All of the above
10) Which of the following was not mentioned as team risk factors that affect colleagues with
potential substance use problems?
a. Coworker intolerance for deviant, suspicious, or unethical behavior
b. Inconsistent enforcement of employer policy c. Stigmatizing attitudes and comments d. Low team cohesion
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Post-Training Knowledge/Confidence
Very Low (1) Low (2) Moderate (3) High (4) Very High (5)
Please rate YOUR level of knowledge, awareness, or understanding on each of the following dimensions before and after completing the Addressing Nurse Impairment seminar.
My knowledge, awareness, or understanding
before completing this training
My knowledge, awareness, or
understanding after completing this
training
1) My legal responsibilities as a nurse to report unsafe and/or unprofessional practice by another health professional.
1 2 3 4 5 1 2 3 4 5
2) What is meant by "objective observations" of nurse performance.
1 2 3 4 5 1 2 3 4 5
3) How to prepare for a meeting with a colleague about my concerns about their performance.
1 2 3 4 5 1 2 3 4 5
4) What issues to focus on during a meeting with a colleague about my concerns about their performance.
1 2 3 4 5 1 2 3 4 5
5) The steps to take during a meeting with a colleague about my concerns about their performance.
1 2 3 4 5 1 2 3 4 5
6) What reactions to prepare for when I discuss with a colleague my concerns about their performance.
1 2 3 4 5 1 2 3 4 5
7) How to report to my supervisor when I suspect unsafe or unprofessional practice by another health professional.
1 2 3 4 5 1 2 3 4 5
8) How to give feedback to nurses who exhibit signs of unsafe or unprofessional practice.
1 2 3 4 5 1 2 3 4 5
9) The concept of "fitness for practice." 1 2 3 4 5 1 2 3 4 5
10) Confidential monitoring of licensed health professionals with substance use or mental health disorders in the Health Professionals’ Services Program.
1 2 3 4 5 1 2 3 4 5
11) My ethical responsibilities when a nurse colleague may be impaired because of a mental health or substance use problem.
1 2 3 4 5 1 2 3 4 5
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Self-Efficacy
Indicate the extent to which you agree or disagree with each of the following statements.
Strongly Agree
Agree
@eutral
Disagree
Strongly Disagree
1) I can effectively deal with colleagues I suspect of not being fit to practice. 1 2 3 4 5
2) I am confident in my ability to recognize unsafe or unprofessional practice by a colleague.
1 2 3 4 5
3) I am confident in my skills to communicate through the proper chain of command about a colleague’s fitness to practice.
1 2 3 4 5
4) I am confident in my ability to communicate a caring message of concern to a colleague I suspect of having a substance abuse problem.
1 2 3 4 5
5) I am confident in my ability to effectively refer a colleague to seek resources to deal with a potential substance abuse problem.
1 2 3 4 5
6) I am confident in my ability to respond to employee resistance when confronting a subordinate about their fitness to perform.
1 2 3 4 5
7) If I suspected a colleague of being impaired at work, I would immediately report it to my supervisor.
1 2 3 4 5
8) If I was concerned that a colleague was not fit to practice, I would report it to my supervisor.
1 2 3 4 5
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Substance Abuse Stigma
Using the following scale, please respond to the following statements circling the appropriate number to the right of each item.
Strongly Agree
Agree
@either Agree nor Disagree
Disagree
Strongly Disagree
1. Most people would be unwilling to accept a person in recovery as a coworker.
1 2 3 4 5
2. Most people believe that nurses in recovery are less trustworthy than their other coworkers.
1 2 3 4 5
3. Most people feel that entering substance abuse treatment is a sign of personal failure.
1 2 3 4 5
4. Most people think less of a person who has been in substance abuse treatment.
1 2 3 4 5
5. Most healthcare organizations would not hire a person in recovery even if he or she is qualified for the job.
1 2 3 4 5
6. Most people at my work would treat a person in recovery differently.
1 2 3 4 5
7. Once coworkers know a person was in substance abuse treatment, they expect less from him/her.
1 2 3 4 5
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Training Utility
Please rate YOUR opinion for each of the following statements before and after completing the Fit to Perform training. Please circle the appropriate rating using the following scale:
Strongly Disagree (1)
Disagree (2) Neither Agree
nor Disagree (3) Agree (4) Strongly Agree (5)
Dimension
Before completing this
training
After completing this
training
7) I improved my skills to identify and deal with nurse impairment.
1 2 3 4 5 1 2 3 4 5
8) The training program was useful for my development.
1 2 3 4 5 1 2 3 4 5
9) The material in training program was relevant to skills I had hoped to develop.
1 2 3 4 5 1 2 3 4 5
10) The time spent in the training program was worthwhile.
1 2 3 4 5 1 2 3 4 5
11) I expect to be able to apply to my practice what I learned in training.
1 2 3 4 5 1 2 3 4 5
12) I expect to have opportunities to use the skills that I learned in training in my practice.
1 2 3 4 5 1 2 3 4 5
Training Effectiveness
Using the following scale, please respond to the following statement circling the appropriate number to the right of each item.
Strongly Agree
Agree
@either Agree nor Disagree
Disagree
Strongly Disagree
13) The purpose of the workshop was clear. 1 2 3 4 5
14) The presentation was well-paced. 1 2 3 4 5
15) I had enough opportunities to be involved. 1 2 3 4 5
16) The presenters were well organized. 1 2 3 4 5
17) The presenters explained things clearly. 1 2 3 4 5
18) The presenters were engaging and approachable. 1 2 3 4 5
19) The skills taught were important for my role. 1 2 3 4 5
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Personal Experiences with Substance Use
Next we will ask about your experience with drugs and alcohol. Please remember that we will
be removing your contact information from our database.
Have you ever been impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes
Have you ever known someone who was impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes
Have you ever suspected that someone was impaired due to using drugs or alcohol while working? (Check one)
□ No □ Yes
How would you describe yourself in terms of drug use at this point in your life? (Check one) □ Non-user □ Recreational user □ Heavy user
How would you describe yourself in terms of alcohol use at this point in your life? (Check one)
□ Non-user □ Recreational user □ Heavy user Demographics
Age (or birth year): Gender: Ethnicity: 1 African American 2 Asian/Pacific Islander 3 Caucasian 4 Filipino 5 Hispanic 6 Native American 7 Other (please specify)
