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

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