Attitudes of nursing students facing questions related to alcohol, alcoholism and the alcoholic

ORIGINAL ARTICLE

Attitudes of nursing students facing questions related to alcohol, alcoholism and the alcoholic*

Atitudes de estudantes de enfermagem frente questões relacionadas ao álcool, alcoolismo e alcoolista

Actitudes de estudiantes de enfermería frente a cuestiones relacionadas al álcool, alcoolismo e alcoolista

Divane de Vargas

Ph.D. in Nursing. Faculty, Maternal-Infant and Psychiatric Nursing Department, University of São Paulo School of Nursing - USP - São Paulo (SP), Brazil.

Corresponding Author

ABSTRACT

OBJECTIVE: To examine the attitudes of a sample of nursing students toward alcohol, alcoholism and the alcoholic.

METHODS: An exploratory study conducted with 144 students in their final year of undergraduate nursing in two private schools in the city of Ribeirão Preto - SP. For data collection, we used the scale of attitudes towards alcohol, alcoholism and the alcoholic.

RESULTS: Attitudes toward alcohol were more negative than those that have been reported in the literature. The majority of participants considered the alcoholic to blame for his health problems and preferred not to work with this type of patient.

CONCLUSION: The students' attitudes to questions related to alcohol and alcoholism tended toward ambivalence and negativity, which can be attributed to lack of preparation received during their education. Despite recommendations made by specialists in the country, little has been invested in nursing education on alcohol and other drugs, especially in private schools.

Keywords: Students, nursing; Attitudes; Alcohol; Alcoholism; Alcoholics

RESUMO

OBJETIVO: Examinar as atitudes de uma amostra de estudantes de enfermagem frente ao álcool, alcoolismo e alcoolista.

MÉTODOS: Estudo exploratório realizado com 144 estudantes do último ano de graduação em enfermagem de duas escolas do setor privado da cidade de Ribeirão Preto - SP. Para a coleta de dados, utilizou-se a Escala de atitudes frente álcool, alcoolismo e alcoolista.

RESULTADOS: as atitudes frente ao alcoolista foram mais negativas do que aquelas que vêm sendo reportadas na literatura. A maioria dos participantes considerou o alcoolista culpado por seus problemas de saúde e preferiu não trabalhar com esse tipo de paciente.

CONCLUSÃO: As atitudes dos estudantes frente às questões relacionadas ao álcool e alcoolismo tendem à ambivalência e à negatividade, o que pode ser atribuído à falta de preparo recebida durante a graduação. Apesar das recomendações feitas pelos especialistas no País pouco tem sido investido na formação do enfermeiro em álcool e outras drogas sobretudo nas escolas privadas.

Descritores: Estudantes de enfermagem; Atitudes; Álcool; Alcoolismo; Alcoolicos

RESUMEN

OBJETIVO: Examinar las actitudes de una muestra de estudiantes de enfermería frente al alcohol, alcoholismo y al alcohólico.

MÉTODOS: Estudio exploratorio realizado con 144 estudiantes del último año del pregrado en enfermería de dos escuelas del sector privado de la ciudad de Ribeirão Preto - SP. Para la recolección de datos, se utilizó la Escala de Actitudes frente al alcohol, alcoholismo y alcohólico. RESULTADOS: las actitudes frente al alcoholismo fueron más negativas que aquellas que vienen siendo reportadas en la literatura. La mayoría de los participantes consideró al alcohólico culpable por sus problemas de salud y prefirió no trabajar con este tipo de paciente.

CONCLUSIÓN: Las actitudes de los estudiantes frente a las cuestiones relacionadas al alcohol y alcoholismo tienden a la ambivalencia y a la negatividad, el que puede ser atribuído a la falta de preparación recibida durante el pregrado. A pesar de las recomendaciones realizadas por los especialistas en el País poco ha sido invertido en la formación del enfermero en alcohol y otras drogas sobre todo en las escuelas privadas.

Descriptores: Estudiantes de enfermería; Actitud; Alcohol; Alcoholismo; Alcohólicos

INTRODUCTION

According to global health reports, alcohol was responsible for 4% of the disease burden and 3.2% (1.8 million) of all deaths around the world in 2000. Among the 26 risk factors the World Health Organization assesses, it ranked fifth in terms of importance for premature deaths and disabilities. In the Americas, in 2000, it represented the most important risk factor for health, in developing countries like Brazil and Mexico as well as in developed countries like the United States and Canada⁽¹⁾. Alcohol consumption in the Americas in approximately 40% higher than the global average, which can justify the fact that the continent constitutes the only region in the world where alcohol ranked first among risk factors for premature deaths and disabilities⁽¹⁾.

In Brazil⁽²⁾, in a large survey developed in the 108 largest cities, it was identified that 12.3% of people between 12 and 65 years of age are alcohol addicts, and that 74.6% have already consumed it in their lifetime. As for the use of other drugs, the same study appointed that, in the study population, 44% used tobacco, 8.8% cannabis, 6.1% solvents, 4.1% appetite inhibitors, 2.9% cocaine and 0.7% crack, verifying a rapid increase in the use and abuse of legal and illegal psychoactive drugs in the last five years. This phenomenon has contributed to the increase in physical, psychic and social problems in the population, bringing about the increased demands patients with problems related to psychoactive substance use and abuse, mainly alcohol, pose to health services. Hence, this increases nurses' contact with this population, a phenomenon that had demanded problem-coping skills.

Despite this new demand imposed on nursing practice, various studies^(3-5) appoint that Brazilian nursing students are not being adequately prepared for care delivery to and coping with psychoactive substance-related problems. These professionals have received little education in the field of alcohol and other drugs with a view to care practice⁽³⁾. This phenomenon has been observed not only in Brazil. Studies accomplished in the United States⁽⁶⁾, Australia⁽⁷⁾ and England^(8-9) reveal that contents involving psychoactive substance use and abuse in nursing curricula are inadequate. Nurses and nursing students' lack of preparation to work with chemical addicts can entail negative attitudes when they are confronted with situations involving the use of alcohol and other drugs^(5,10-11), which ends up influencing the quality of care delivery^(5,12-14).

Studies on this theme have revealed that nursing students demonstrate negative attitudes towards chemical addicts⁽¹⁵⁾. Research also appoints that contact with these patients during education enhances students' acceptance of addicts⁽¹⁶⁾. A British study⁽⁹⁾ assessed the impact of an educative program on alcohol and drugs on nursing students' knowledge acquisition and attitude change. The results suggest that the educative program on alcohol and drugs influenced the nursing students' attitudes as, on the post-test, most participants demonstrated more positive attitudes towards chemical addicts and were more optimistic, considering alcohol and drugs addiction as a treatable condition.

A study developed in Brazil⁽⁵⁾ to examine nursing students' knowledge and attitudes towards psychoactive substance addicts evidences that students had a positive attitude towards this type of patient, as the majority rejected the stereotype that these are unpleasant to work with and that alcoholism was related to a weak character.

Although studies have been accomplished in other countries for more than two decades^(10,17-18), in Brazil, little research has been done on nursing students' attitudes towards chemical addiction issues⁽⁴⁾. Brazilian literature lacks publications on the issue^(4-5), a fact that has made experts on the theme^(4-5) recommend further research, with a view to identifying nurses and nursing students' attitudes towards psychoactive substance users and related problems. In view of the above and the increased demand alcoholic patients pose at health services, entailing nursing students' greater contact with this population, this study was developed to examine attitudes towards alcohol, alcoholism and alcoholics in a sample of Brazilian nursing students. It is presupposed that the results will support possible actions aimed at disclosing the need to include obligatory subjects on the theme in Brazilian nursing curricula.

METHODS

An exploratory and descriptive study was conducted in a sample of 144 fourth-year nursing students from two private colleges in Ribeirão Preto - São Paulo, Brazil. Final-year students were chosen because these had already concluded most of the curriculum, which presupposes that they received contents on the theme and clinical experiences involving patients with alcohol and alcoholism-related problems. Out of this total, 84 belonged to "School A" and 60 to "School B". Sample inclusion criteria were taking the final year of the undergraduate nursing program and accepting to participate in the study.

The following ethical aspects were observed in the development of this research: approval of the project by the Institutional Review Board at the University of São Paulo Medical School Hospital das Clínicas (Protocol No 12476/2004) and the subjects' signing of the free and informed consent term.

The nursing students' attitudes towards alcohol, alcoholism and alcoholics were measured through the Attitude Scale Towards Alcohol, Alcoholism and Alcoholics - EAFAAA⁽¹⁹⁾. Vargas constructed and validated this scale in Brazil in 2008⁽¹⁹⁾ and presented a reliability ratio of 0.90, comprising 84 items that cover five factors: Factor 1: The alcoholic: work and interpersonal relations; Factor 2: Etiology; Factor 3: Disease; Factor 4: Repercussions deriving from alcohol use and abuse; Factor 5: The Alcoholic Beverage. Together with the attitude scale, a two-section socio-demographic questionnaire elaborated by the researcher was applied. Section 1 contained questions on demographic characteristics, such as gender and age; Section 2 comprised questions related to preparation in the psychoactive substance field, received during nursing education. To apply the scale, the author presented the instrument to the subject group in class, using a single booklet with the 84 questionnaire items, which were randomly distributed. Questions could be answered on a three-point Likert scale, in which the students should express their opinion on each assertion, as follows: (1= I disagree 2 = Indifferent; 3 = I agree). Maximum response time was 30 minutes and all subjects accepted to participate. Data were stored in a database elaborated in Statistical Package for Social Science (SPSS) version 18.0, used for all analyses.

RESULTS

Sample characteristics

Most of the sample consisted of women (85%), with a mean age of 27.4 years (SD= 6.82), single (68%); white (89%). As for their preparation to work with chemical addicts, the participants informed they had received two to three hours of classes on the theme in their undergraduate program. Answers related to the students' attitudes towards alcohol, alcoholics and alcoholism are displayed in Tables 1 to ³.

The results evidenced the predominance of subjects' positive attitudes towards alcohol and its consumption. The majority (58%) agreed with the fact that people should drink if they want to as, according to 43% of the students, alcoholic beverages are present and offer wellbeing, while 55% saw alcohol consumption as something normal. Besides, 54% disagree that any amount of alcohol consumed can cause dependence, a result that is consistent with attitudes towards moderate drinking, as it was observed that 41% showed they were favorable to this type of (moderate) use and 56% endorsed the idea that moderate drinking is not harmful. Most participants (74%) agreed that some people drink and are able to control their alcohol intake. When taking a stand towards the fact that small doses of alcohol can cause addiction, 60% demonstrated they were not that certain about this fact, despite disagreeing from the previous item that any amount of alcohol consumed can cause addiction.

Data in Table 2 show results regarding the nursing students' attitudes towards alcoholic patients. Most participants (72%) agree that these are people without limits, 74% consider they are psychologically disturbed, 88% agree that they are ill and 97% that these patients need help; 67% rejected the conception that alcoholics are immoral people, although 41% believe they are guilty of their health problems. No defined attitude was observed as to whether alcoholics are violent patients, similar to the conception that these patients are weak, as 42% of participants agreed with this view and 41% disagreed.

As for relating with alcoholics, 41% of the study subjects agreed that these patients are difficult to have contact with. When they assessed the possibility of trusting these patients, 39% endorsed this attitude and 49% reveal that they are afraid of the alcoholics' aggressiveness, although 75% deny these feeling if they needed to address the drinking problem with alcoholic patients. The analysis of items related to working with this type of patients showed that the participants displayed ambivalent attitudes towards the issue. Fifty percent of participants would not know how to conduct the situation if they would have to attend to an alcoholic patient and 52% express no preference with regard to care delivery to these patients. The majority (43%) agreed that these patients cause a lot of work for nursing, 65% said they should take care of alcoholics even against their will and 81% that they would not give up helping them though. With regard to treatment, most participants (44%) agreed that alcoholics take treatment seriously and 83.3% that they are capable of giving a satisfactory treatment response.

With regard to the students' attitudes towards alcoholism, it was observed that the majority (84%) conceives it as a disease, and 77% do not endorse the opinion that patients can control it. In line with these results, 95% of participants agreed that it causes physical and psychic addiction. Most of them (67%) agreed that it leads to a loss of identity and morale and, according to 66%, alcohol can lead to madness and death. The analysis of trends in the students' attitudes towards the etiology of alcoholism showed that 64% of the interviewees attribute its origin to family disagreements, 52% to influence from friends, and 64% agree that depression leads to alcoholism. Besides, according to 38% of the students, the probability exists that people without a fixed job and who are experiencing financial difficulties will develop alcoholism, 77% agreed that lack of self-control leads to alcoholism and 40% agreed that a gene exists which determines its development.

DISCUSSION

Various studies^(4-5) indicate that Brazilian nursing students' preparation regarding alcohol and other drugs is insufficient. The present study data support these observations, as the participants revealed that, during their education, the average class and training time to work in the area is three hours at most. This hour load is lower than the mean time dedicated to the theme in earlier studies, ranging between four and six hours^(3-4). As these earlier studies^(3-4) involved samples of public college students, the results demonstrate that the alcohol and other drugs theme has received even less attention at private colleges. This is a source of concern, as most nursing schools are affiliated with private colleges in Brazil.

Concerning the nursing students' attitudes towards alcohol, these are predominantly positive, as they demonstrated they were favorable to drinking, agreeing that people should drink if they want to, a behavior considered normal. These positive attitudes seem to be restricted to moderate alcohol use though, which does not apply to people with drinking problems as, according to the participants, some people drink and know how to control their alcohol intake. Thus, these positive attitudes may not extend to people who are unable to control this behavior. In addition, although they are favorable to moderate alcohol use, the students were not free from risk, as they demonstrate doubt when they need to take a stand as to whether small doses can cause addiction.

In line with other research results^(5,9), these results showed that the students' attitudes towards alcoholics tend to be positive. Although ambivalence has been observed, as they do not endorse the view that alcoholics are immoral and weak people and conceive them as ill, a significant part of the students agreed that these are people without limits, guilty of their health problems and who do not really want to take care of themselves. This result supports findings from a similar study involving US nursing students⁽¹⁶⁾, which evidences the prevalence of health professionals' negative attitudes towards issues related to alcoholism, independently of whether they consider this a disease or not.

The fact that alcoholics are seen as people with unlimited drinking is consistent with findings from an earlier study⁽⁵⁾, in which the students conceived alcoholics as people incapable of adopting controlled drinking. When considering they are to blame for their disease, these students reinforce the conception that alcoholics are intentionally ill, attributing them with the voluntariness of drinking and holding them accountable for their health problems. This view can entail students' rejection of alcoholic patients, in line with observations among students who demonstrated their preference for not taking care of this type of patients. In a literature review on nurses' attitudes towards alcohol-related issues⁽²⁰⁾, the authors concluded that, despite the changes occurred in recent years, leading to the nurses' greater acceptance of addicts, a significant part still considers them immoral, weak and with a low chance of recovery.

Concerning work with alcoholics, the students believe that these patients are difficult to deal with and treat and cause a lot of work for nursing. A Brazilian study⁽⁵⁾ involving nursing students evidenced that they found it difficult to address the substance use and abuse problem with the addicts. According to the research authors⁽⁵⁾, this fact can reflect the lack of preparation and knowledge to work with psychoactive substance users. Although the students consider these patients difficult to work with, they believe that, even if they refuse treatment, they should continue receiving care and demonstrated their willingness to continue taking care of these patients, revealing more positive attitudes regarding care for alcoholic patients than regarding patients themselves.

Most participants revealed that they prefer not to work with alcoholic patients, in line with other research findings^(13,19,21). Some studies^(5,9) evidence students' more positive attitudes towards alcoholics though, as they did not consider them unpleasant patients and would like to work with these patients if they had the opportunity⁽⁸⁾. The results showed that these students have more negative attitudes towards working with alcoholics than those found in other studies^(5,9,18). This can be attributed to two reasons; the first is related to the stigma established with regard to this type of patient, and the second to the little preparation they received to work in this context, which can make the students feel insecure about this activity and try to avoid it^(5,22), in line with the fact that most students revealed they would not know how to deal with the situation if they had to work with alcoholics. These results are in line with findings from previous studies^(5,14) that evidence nurses and nursing students' lack of adequacy, knowledge and competency to work with psychoactive substance addicts. A research developed in the 1990's⁽²³⁾ found that the nursing students were less willing to work with alcoholics than with physically weakened patients and that they preferred working with addicted and communicative patients. Thus, the issue about students' preference to work with other patients than alcoholic may be related, besides the fact that they are not prepared for this work, with alcoholic patients' characteristics, who in most cases show their independence from nursing care, due to their denial of the disease. Thus, if the students do not recognize this mechanism, they will probably avoid this type of patient and, consequently, prefer not to take care of them.

Among the etiological factors of alcoholism, the participants agreed that it can be caused by social factors like unemployment, financial difficulties and family disagreements; psychological factors like depression and lack of self-control; and biological factors, in the belief that a gene exists which is responsible for the illness. Similar data were found in an earlier study⁽⁵⁾, in which the students considered alcoholism was a genetic disease.

The students almost unanimously believed that alcoholism causes physical and psychic addiction; this result should be considered positive as, in a way, it mitigates the moral nature attributed to alcoholism, endorsing the conception that it is caused by the lack of self-control or triggered by the alcoholics' own fault. When acknowledging that alcohol can cause addiction, alcoholism gains another nature that does not depend on the individual but can truly be seen as a disease.

This study comes with many limitations, including the sample size and the fact that it was conducted at two private nursing schools in one Brazilian region only, whose data cannot be generalized. It offers advances for Brazilian and international nursing though, as it significantly contributes to Brazilian literature, in view of the lack of research on nurses and nursing students' attitudes towards the issue in Brazil and Latin America.

Besides, it permits mapping this population's attitudes in regions and institutions that have not been mapped yet, contributing to knowledge about this area, presenting evidence that can serve as the base for future research related to nursing teaching and care in the field of psychoactive substances. It also permits acknowledging that, despite the discussions and recommendations of the 1 National Conference of Psychiatric Nursing Specialists in alcohol and other drugs, held in 2000, which considered that the integration and inclusion of contents on psychoactive substances should gain priority in nursing curricula⁽²⁴⁾, little has been achieved in this respect in Brazil ten years after these recommendations. Schools have actually incorporated few actions, and actions that were incorporated mainly happened in public schools.

CONCLUSION

Most private schools continue paying little or no attention to the psychoactive substance issue in nursing education. Brazilian addiction specialists need to get mobilized to exert pressure on public authorities with a view to guaranteeing the inclusion of these contents into education laws that address nursing education, as these contents currently are not obligatory in the nursing curriculum and, thus, remain secondary at most educational institutions. The results confirm earlier study findings that little attention has been paid to the issue of alcohol and other drugs in Brazilian nursing education, also revealing that the situation is more concerning among private schools, in view of the finding that the number of hours dedicated to this theme at the two schools studied was less than that observed in studies that involved public school samples. These students' attitudes were more negative towards alcoholics than observed in other studies, leading to the premise that education has exerted little influence on students' attitudes towards the theme as, although they may accept the concept of alcoholism as an illness, believing that these patients want to recover, prejudiced ideas and negative attitudes towards alcoholics continue, which teaching has not managed to eliminate. These results may reflect the little importance that has been attributed to the psychoactive substance issue in Brazilian undergraduate Nursing curricula, reinforce findings that education and preparation to cope with the psychoactive substance problem enhance the adequacy of nurses' role to work in the area and serve as the base for more positive attitudes towards these clients.

REFERENCES

• 1. Rehm J, Monteiro M. Alcohol consumption and burdenof disease in the Americas: implications for alcohol policy.Rev Panam Salud Publica. 2005;18(4-5):241-8.
• 2. Carlini EA, Galduróz JC, Noto AR, Nappo SA. IILevantamento domiciliar sobre uso de drogaspsicotrópicas no Brasil: estudo envolvendo as 108 maiorescidades do país: 2005. São Paulo: Centro Brasileiro deInformações sobre Drogas Psicotrópicas (CEBRID);Departamento de Psicobiologia da Universidade Federalde São Paulo; 2006.
• 3. Pillon SC, Ramos LH, Villar-Luis MA, Rassool GH. Nursing students' perceptions of the curricula content ondrug and alcohol education in Brazil: an exploratory study.J Addict Nurs. 2004;15(3):133-7.
• 4. Rassool GH, Villar-Luis M. Tackling drug and alcoholmisuse in Brazil: priorities and challenges for nurses. IntNurs Rev. 2004;51(4):201-7.
• 5. Rassool GH, Villar-Luis M, Carraro TE, Lopes G.Undergraduate nursing students' perceptions of substanceuse and misuse: a Brazilian position. J Psychiatr MentHealth Nurs. 2006;13(1):85-9.
• 6. Sullivan EJ, Handley SM. Alcohol and drug abuse in nurses.Annu Rev Nurs Res. 1992;10:113-25.
• 7. Pols RG, Cape MP, Ashenden R, Bush RA. Proceedings:National Workshop on Evaluation of Tertiary Educationand Training on Alcohol and other Drugs. Adelaide:National Centre for Education and Training on Addiction,Flinders University of South Australia;1993.
• 8. Rassool GH. International perspectives the educationalexperiences and previous orientation of undergraduatenursing students in alcohol and drug: the english context.J Addict Nurs. 2007;18(1):47-52.
• 9. Rassool GH, Rawaf S. Predictors of educational outcomes of undergraduate nursing students in alcohol and drugeducation. Nurse Educ Today. 2008;28(6):691-701.
• 10. Arthur D. The effects of the problem-based alcohol early-intervention education package on the knowledge andattitudes of students of nursing. J Nurs Educ. 2001;40(2):63-72.
• 11. Rassool GH. Addiction: future directions and respondingto the challenges. Complacency or commitment? J Addict Nurs. 2009;19(4):179-81.
• 12. Arthur D. The effects of an alcohol early interventioneducation package on the knowledge, attitudes and skillsof students of nursing [PhD thesis]. Newcastle: TheUniversity of Newcastle. Faculty Education; 1996.
• 13. Rassool GH. Nursing and substance misuse: respondingto the challenge. J Adv Nurs. 1993;18(9):1401-7.
• 14. Hagemaster J, Handley S, Plumlee A, Sullivan E, Stanley S.Developing educational programmes for nurses that meettoday's addiction challenges. Nurse Educ Today.1993;13(6):421-5.
• 15. Davidhizar R, Golightly J. Student nurse change atittudestoward alcoholic clients. Alcohol Health Res World. 1983;3:37-8.
• 16. Farnsworth B, Bairan A. The difference in pre- andpostaffiliation attitudes of student nurses toward alcoholand people with alcohol-related problems. J Addict Nurs.1990;2(3):23-7.
• 17. Engs RC. Medical, nursing, and pharmacy students'attitudes towards alcoholism in Queensland, Australia. Alcohol Clin Exp Res. 1982;6(2):225-9.
• 18. Harlow PE, Goby MJ. Changing nursing students'attitudes toward alcoholic patients: examining effects of aclinical practicum. Nurs Res. 1980;29(1):59-60.
• 19. Vargas D, Villar-Luis MA. Development and validationof a scale of attitudes towards alcohol, alcoholism and alcoholics. Rev Latinoam Enferm. 2008;16(5):895-902.
• 20. Howard MO, Chung SS. Nurses' attitudes towardsubstance misusers. I. Surveys. Subst Use Misuse. 2000;35(3):347-65.
• 21. Happell B, Taylor C. Drug and alcohol education for nurses:have we examined the whole problem? J AddictNurs.1999;11(4):180-5.
• 22. Happell B, Taylor C. Negative attitudes towards clients withdrug and alcohol related problems: finding the elusivesolution. Aust N Z J Ment Health Nurs. 2001;10(2):87-96.
• 23. Antai-Otong D. Helping the alcoholic patient recover. AmJ Nurs. 1995;95(8):22-9; quiz 30. Review.
• 24. Villar-Luis MA. Specialist nurses in addiction in Brazil:academic and clinical development. The way forward. JAddict Nurs. 2001;13(3):173-5.

Publication Dates

• Publication in this collection
  02 Dec 2011
• Date of issue
  2011

History

• Accepted
  17 May 2011
• Received
  22 July 2010