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Personal and Contextual Predictors of Nurses’ Motivation to Work with Patients

Who Use Alcohol : An Exploratory Study

Khadejah F. Mahmoud, PhD Candidate, MSN

The International Nurses Society on Addictions 41st Annual Educational Conference, Orlando, Florida.

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PROJECT TEAM

Khadejah F. Mahmoud, PhD Candidate, MSN University of Pittsburgh School of Nursing*

Susan Sereika, PhD University of Pittsburgh School of Nursing

Dawn Lindsay, PhD Institute for Research, Education, and

Training in Addictions (IRETA)

Kathy Puskar, DrPH, RN, FAAN University of Pittsburgh School of Nursing

Ann M. Mitchell, PhD, RN, FAAN University of Pittsburgh School of Nursing

* Funding for this study provided by Award Ruth and Bill Fincke, PhD Student Research Award, Universityof PittsburghSchool of Nursing and The Foundation for Addictions Nursing.

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The speakers have no conflict of interest.

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LEARNING OUTCOMES

• Demonstrate understanding of the consequences associated with

nurses’ low motivation.

• Identify specific personal and contextual predictors associated with

nurses’ motivation to work with individuals who use alcohol.

• Propose future implications that can guide research and clinical

practices to increase nurses’ motivation.

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• Centers for Disease Control and Prevention. (2015). Alcohol and Public Health. Data and Maps. Available at: https://www.cdc.gov/alcohol/data-stats.htm. Accessed August 21, 2017. 5

ALCOHOL

• Alcohol is socially accepted and widely used in most countries

• Alcohol is classified as a CNS depressant and hypnotic

• Dissolves easily in water but can also pass the BBB

• Oral ingestion

takes ~1 hour for 90 % to get into bloodstream

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BAC Behavior Associated with BAC

0.02-0.03 Minimal effects: Mood elevation. Slight muscle relaxation.

0.05-0.06 Increased reaction time. Decreased alertness. Relaxation.

Decreased fine muscle coordination. Mild impaired judgment

0.08-0.10 Impaired balance, speech, vision, hearing, muscle coordination.

Euphoria. Less caution. Slower reaction times

0.14-0.15 Major impairment of physical and mental control. Slurred

speech. Serious loss of judgment.

0.20-0.30 Severely intoxicated. Very little control of mind or body.

Unaware of surrounding

0.40-0.50 Unconscious. Deep coma. Death from respiratory depression

BLOOD ALCOHOL CONCENTRATION (BAC) & ITS EFFECT ON BEHAVIOR

Leg

al Lim

it

• National Institute of Alcohol Abuse and Alcoholism. Retrieved from: https://pubs.niaaa.nih.gov/publications/alcoholoverdosefactsheet/overdosefact.htm 6

ALCOHOL METABOLISM

• 95 % of alcohol is metabolized in the

liver and 5% evaporates through the

lungs

• Rate of metabolism is constant over

time and is not associated with the

BAC.

– Food

– Gender

– Type of alcohol consumed

– Body fat proportion to muscle mass

• Cederbaum, A. I. (2012). Alcohol metabolism. Clinics in Liver Disease, 16(4), 667–685. http://doi.org/10.1016/j.cld.2012.08.002• http://dui.findlaw.com/dui-arrests/alcohol-metabolism-rate-and-your-dui.html 7

As a CNS depressant alcohol decreases brain activity by:

•Activates GABA:

� Alcohol increases inhibitory neurotransmission (GABA)

•Inhabits Glutamate:

� Alcohol decreases excitatory neurotransmission (Glutamate)

MECHANISM OF ACTION

8• Gilpin, N. W., & Koob, G. F. Neurobiology of Alchohol Dependence. Retrived from: https://pubs.niaaa.nih.gov/publications/arh313/185-195.htm

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• Behavioral Disinhibition (Prefrontal Cortex):

� Reduces anxiety and stress

� Enhances social interactions and confidence

� Increase risk-taking and poor decisions

• Memory (Hippocampus):

� Loss of short-term memory functions

� Decrease the ability to learn new information

EFFECTS OF ALCOHOL ON BRAIN

• National Institute of Alcohol Abuse and Alcoholism. Retrieved from: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption

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• Alcohol (ethanol) exposure increases dopamine release in the nucleus accumbens

• Alcohol increases endorphin release in the Ventral Tegmental Area

REINFORCEMENT

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• Positive reinforcing effects:

� Gain pleasure

� Conform to behavior of peers

• Negative reinforcing effects:

� Relief of stress and negative emotions

� Relief of withdrawal symptoms

• Neuro-adaptation:

• Tolerance and withdrawal

REINFORCEMENT

• Gilpin, N. W., & Koob, G. F. Neurobiology of Alchohol Dependence. Retrived from: https://pubs.niaaa.nih.gov/publications/arh313/185-195.htm

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Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D, Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.),

Fundamental Neuroscience, 3rd edition, Academic Press, Amsterdam, 2008, pp. 987-1016. 12

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IMPORTANT DEFINITIONS

• Low-risk Use: “consumption of an amount of alcohol or other drug below the amount

identified as hazardous; use in circumstances not defined as hazardous” (p.2)1

• Hazardous Use: “patterns of use that puts the individual at increased risk for harm1

• Harmful use: “use with health consequences in the absence of addiction.” (p.4)1

• Alcohol Misuse:

� “Consuming alcohol beyond recommended limits, with consumption being either hazardous, harmful, or dependent in nature”(p.564)2

� “A range of behaviors and consists of three main patterns of alcohol consumption

that include hazardous drinking, harmful drinking, and dependent drinking” (p.72)3

� A collective term for defining problems or conditions related to alcohol use. More specifically, it refers to any alcohol drinking behavior that increases an individual's

risk for negative health and social consequences” (p.407)4

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REFERENCE: Mahmoud, K. F., Finnell, D., Savage, C. L., Puskar, K. R., & Mitchell, A. M. (2017). A concept analysis of substance misuse to inform contemporary terminology. Archives of Psychiatric Nursing.

Antecedents

Perception about Substance

Existence of Physical or Psychological

Complaints or Needs

Individual Characteristics and

Genetic Predispositions

Substance related Factors

1. Pattern of Use

2. Reason for Use

3. Increased Risk for

Harm

Substance Misuse

Social, Economic, and Legal Consequences

Individual Consequences: Physical and Psychological

Consequences

Social Factors

IMPORTANT DEFINITIONS

• At-risk Use: “any level of alcohol consumption that increases the risk

of harm to a person's health or well-being or that increases the risk of

harm to others” (p. 1)5

• Alcohol Use Disorder (AUD): “A medical condition that doctors diagnose when a patient’s drinking causes distress or harm”6-7.

The presence of at least 2 of the 11 symptoms specified in the DSM V.

� Mild: The presence of 2 to 3 symptoms

� Moderate: The presence of 4 to 5 symptoms

� Severe: The presence of 6 or more symptoms

• Finnell, D., Mitchell, A.M., Savage, C. L., Kane, I., Kearns, R., Poole, N., ... Coulson, S. (2015). Alcohol screening a brief intervention: A self-

paced program for nurses. Addiction Science & Clinical Practice, 10(2), 1. http://dx.doi.org/10.1186/1940-0640- 10-S2-O18.• American Psychiatric Association (2013a). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

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CONSEQUENCE OF ALCOHOL USE

-200 physical and psychological diseases-Driving under the influence (DUI) -Child abuse and neglect-Reduced quality of life-Increase crime and violence-Increased motor vehicles crashes

Physical & Psychological Consequences 7-9

-$ 249 billion -Includes: Loss of productivity, healthcare expenses and criminal justice costs.

Economic Burden 5-7

-At-risk alcohol use contributes to 88,000 deaths in the United States each year.-Fifth leading cause for premature death between the ages of 15 and 49 and first between the age group 20–39 years.-Approximately 25 percent of the total deaths are alcohol attributable

Death 9

• National Institute on Alcohol Abuse and Alcoholism. Rethinking drinking. Available at: http://rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Is-your-drinkingpattern- risky/Whats-Low-Risk-Drinking.aspx. Accessed August 18, 2017.

• Centers for Disease Control and Prevention. (2015). Alcohol poisoning deaths. Vital signs: Alcohol poisoning kills six people each day. Available at: http://www.cdc.gov/ media/dpk/2015/dpk-vs-alcohol-poisoning.html. Accessed December 15, 2016.

70-90% of these consequences are reported by individuals who do not meet the diagnostic

criteria of AUD22

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Screening, Brief Intervention, & Referral to Treatment (SBIRT)

� SBIRT is a universal screening and early intervention tool for

patients with risky alcohol use

� SBIRT implementation has been strongly associated with

decreased alcohol use

• Puskar, K., Gotham, H. J., Terhorst, L., Hagle, H., Mitchell, A. M., Braxter, B., ... & Burns, H. K. (2013). Effects of Screening, Brief Intervention, and Referral to Treatment (SBIRT) education and training on nursing students’ attitudes toward working with patients who use alcohol and drugs. Substance Abuse, 34(2), 122-128.

• Murphy-Parker, D. (2013). Screening, Brief Intervention, and Referral to Treatment: A need for educational reform in nursing. Nursing Clinics of North America, 48(3), 485-489.

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TARGET POPULATION

• Babor, T. F., Higgins-Biddle, J. C., & World Health Organization. (2001). Brief intervention for hazardous and harmful drinking: A manual for use in primary care.

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WHY SBIRT?

� SBIRT is associated with decreased alcohol use and

health care use:

- 74% of individuals who use alcohol reported lowering their alcohol

consumption

- 48% reported completely stopping

� SBIRT is cost-effective:

- For every dollar spent on SBIRT, $4 are saved in primary care,

trauma center, and ED healthcare

- Reduce hospitalization-related cost by approximately $1000

• CuijpersP, Riper H, LemmersL. The effects on mortality of brief interventions for problem drinking: a meta-analysis. Addiction. 2004;99(7):839-845.• Substance abuse treatment. Health Partners of Western Ohio Website. http:// hpwohio.org/services/substance-use-abuse/. Accessed February 24,

2016.

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ROLE OF RNS AND HEALTHCARE PROFESSIONAL IN ALCOHOL : SBIRT

1. Identify use, misuse, and problematic use:

Screen with simple direct methods.

2. Connect use/misuse to health-related issues:

chief complaint.

3. Brief Intervention:

provide + reinforcement; consumption reduction.

4. Referral to treatment:

or a formal assessment.

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� According to recent Gallup Polls (2013, 2014, 2015) nurses remain

the most trustworthy health care professionals.

� Nurses can play a significant role in early recognition and intervention

for individuals who use alcohol.

NURSES ROLE

• Cund, A. (2013). Alcohol education revisited: Exploring how much time we devote to alcohol education in the nursing curriculum. Nurse Education In Practice, 13(1), 35-39.

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WHY NURSES

• Nurses have always been on the frontier of tackling critical health issues andtaking the lead in addressing health inequity and disparities among vulnerable

populations.

• Nurses have been proposed to be a key partner in the World HealthOrganization (WHO) and Institute of Medicine (IOM) strategies of addressing

alcohol and opioids use continuum through early identification and briefintervention and referral to treatment implementation.

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• Center for Disease Control and Prevention (CDC). (2017). Retrieved from: https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html

• WHO (2017). Health statistics and information systems, Global Health Estimates (GHE). Retrieved from: http://www.who.int/healthinfo/global_burden_disease/en/

• Naegle, M. A. (2017). Brief Report: First World Health Organization Forum on Alcohol Drugs and Addictive Behaviors: Enhancing Public Health Actions Through Partnerships

and Collaboration. Journal of Addictions Nursing, 28(3), 150-151.

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NURSE’S MOTIVATION

� Education and training had less impact on changing nurses’

motivation towards working with this population12, 17-18.

� Nurses and other healthcare providers still expressed unwillingness or inability to work with or even be involved in

the treatment and care of individuals who use alcohol 19-20.

• Mitchell, A. M., Mahmoud, K. F., Puskar, K., Hagle, H., Lindsay, D., & Knapp, E. (2016). Teaching Screening, Brief Intervention, and Referral to Treatment Techniques to Nurse Practitioner Students. The Journal for Nurse Practitioners, 12(7), e311- e317.

• Van Boekel, L. C., Brouwers, E. P., van Weeghel, J., & Garretsen, H. F. (2014). Healthcare professionals’ regard towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and specialist addiction services. Drug & Alcohol Dependence, 134, 92-98. 25

So What?

Patient Outcome:

• Delaying the identification of patients with at-risk alcohol use and delay access

to treatment34-37

• Increased drop out and relapse rates among patients with alcohol use problems

• Willingness to provide lower quality of care to this patient population34-37

• Diminished therapeutic engagement, use of more avoidant and task-oriented approach and shorter visits, which resulted in poorer patient treatment

outcomes19

• Mitchell, A. M., Mahmoud, K. F., Puskar, K., Hagle, H., Lindsay, D., & Knapp, E. (2016). Teaching Screening, Brief Intervention, and Referral to Treatment Techniques to Nurse Practitioner Students. The Journal for Nurse Practitioners, 12(7), e311- e317.

• Van Boekel, L. C., Brouwers, E. P., van Weeghel, J., & Garretsen, H. F. (2014). Healthcare professionals’ regard towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and specialist addiction services. Drug & Alcohol Dependence, 134, 92-98. 26

METHODS

• Secondary analysis that employs a cross-sectional design

• A sample of 1202 from five independent single-group pretest-post-test

intervention studies using SBIRT baseline data:

- BSN students (n= 394)

- Emergency Nurses (n=158)

- Nurse Practitioner students (n=123)

- Nurse Anesthetists students (n=285)

- Registered Nurses & HCPs (n=243)

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SCALES

� Personal Factors Included: Age, gender, race, student status,

primary work setting and profession

� Contextual Factors Included: Role adequacy, role legitimacy, role

support, task-specific self-esteem and work satisfaction.

� Contextual factors were measured using Alcohol and Alcohol

Problems Perception Questionnaire (AAPPQ).– 30 items, Likert scale 1 = Strongly Disagree, 7 = Strongly Agree

– 6 subscales

– Acceptable reliability, Cronbach’s Alpha .69 - .90

• Gorman, D. M., & Cartwright, A. K. J. (1991). Implications of using the composite and short versions of the Alcohol and Alcohol Problems Perception

Questionnaire (AAPPQ). British Journal of Addiction, 86(3), 327-334. doi: 10.1111/j.1360-0443.1991.tb01786.x.

• Shaw, S., Cartwright, A., Spratley, T., & Harwin, J. (1978). Responding to Drinking Problems. London: Croom Helm. 28

AAPPQ - SUBSCALES

• Role Adequacy

– I feel I have a working knowledge of alcohol and alcohol related

problems

• Role Legitimacy

– I feel I have the right to ask patients questions about their

drinking when necessary

• Role Support

– If I felt the need when working with patients who use alcohol I

could easily find someone who would help me clarify my professional responsibilities

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AAPPQ - SUBSCALES

• Motivation

– I feel there is little I can do to help patients who use alcohol

• Task-Specific Self-Esteem

– At times I feel I am no good at all with patients who use alcohol

• Work Satisfaction

– In general, it is rewarding to work with patients who use alcohol

• Gorman, D. M., & Cartwright, A. K. J. (1991). Implications of using the composite and short versions of the Alcohol and Alcohol Problems Perception Questionnaire

(AAPPQ). British Journal of Addiction, 86(3), 327-334. doi: 10.1111/j.1360-0443.1991.tb01786.x.

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DEMOGRAPHICS

%

Gender

Female 77.2%

Male 22.8%

Hispanic/Latino 1.1%

Race

African American 3.5%

Asian 4.9%

White 78.9%

Other 12.7

N=1202

M (SD) Min Max

Age 29.6 (10.94) 18.0 75.0

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PERSONAL PREDICTORS (N=1202)

B sr2 t p 95%CI

Older Age-.004 -.061 -2.89 .004

-.007 – -.001

Female.088 .056 .2.65 .008

.023 – .154

Student Status .182 .059 2.81 .005

.055 – .309

ER Workplace -.201 -.041 -1.98 .048

-.401 – -.002

IPCP Group-.176 -.062 -2.96 .003

-.292 – -.059

ER Group-.338 -.060 -2.86 .004

-.569 – -.106

Nurse Anesthesia Group -.251 -.080 -3.81 .000

-.380 – -.122

N=1202

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CONTEXTUAL PREDICTORS AFTER CONTROLLING FOR PERSONAL PREDICTORS (N=1202)

B sr2 t p 95%CI

Role Adequacy .042 .037 1.77 .078

-.005 – -.089

Role Legitimacy .071 .057 2.74 .006

.020 – .122

Role Support.022 .024 1.17 .243

-.015 – .059

Task-specific Self-esteem .284 .208 9.92 .000

.228 – .341

Work Satisfaction .360 .273 13.04 .000

.306 – .414

N=1202

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RESULTS

� Two-steps hierarchical regression was used.

� Personal factors (age, gender, student status, ER workplace

and group affiliation) contributed significantly to the

regression model, (F (14, 1187) = 16.625, p< .05). Personal

factors accounted for 15.4 % of the variation in Motivation.

� After controlling for personal factors, contextual factors (rolelegitimacy, task-specific self-esteem, and work satisfaction)

contributed significantly to the model. Contextual factors

explained an additional 31.9 % of variation in Motivation, (F(19, 1182)= 57.727, p< .05).

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CONCLUSIONS

� This study provides insights to potential personal and contextual

predictors that may influence nurses motivation to work with patients who use alcohol.

� Understanding the impact of such factors on nurses’ motivation is

instrumental to developing future intervention to promote early

identification of patients with at-risk alcohol use.

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FUTURE IMPLICATIONS

� Perhaps developing SBIRT education and training that targets

nurses’ motivation towards working with patients who use

alcohol.

� More work (including a qualitative analysis) of issues related to nurses’ motivation needs to be done.

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AS NURSES

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Are we doing enough to help patients who use alcohol?

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REFERENCES

1.American Society of Addiction Medicine (2013). Terminology related to the spectrum of unhealthy substance use. (Retrieved from http://www.asam.org/advocacy/find-apolicy- statement/view-policy-statement/public-policy-statements/2016/010/16/terminology-related-tothe-spectrum-of-unhealthy-substance-use).

2. Kolar, C., & von Treuer, K. (2015). Alcohol misuse interventions in the workplace: A systematic review of workplace and sports management alcohol interventions. International Journal of Mental Health and Addiction, 13(5), 563–583. http://dx.doi. org/10.1007/s11469-015-9558-x.

3.Nair, J.M., Nemeth, L. S.,Williams, P. H., Newman, S. D., & Sommers, M. S. (2015). Alcohol misuse among nursing students. Journal of Addictions Nursing, 26(2), 71–80. http://dx. doi.org/10.1097/JAN.0000000000000082.

4.Green, K. T., Beckham, J. C., Youssef, N., & Elbogen, E. B. (2014). Alcohol misuse and psychological resilience among U.S., Iraq, and Afghanistan era veterans. Addictive Behaviors, 39(2), 406–413. http://dx.doi.org/10.1016/j.addbeh.2013.08.024.

5.Finnell, D., Mitchell, A.M., Savage, C. L., Kane, I., Kearns, R., Poole, N., ... Coulson, S. (2015). Alcohol screening a brief intervention: A self- paced program for nurses. Addiction Science & Clinical Practice, 10(2), http://dx.doi.org/10.1186/1940-0640- 10-S2-O18.

6.American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

7.National Institutes of Health. (2014). Alcohol Use Disorder: A Comparison Between DSM—IV and DSM–5.

8.National Institute on Alcohol Abuse and Alcoholism. Rethinking drinking. Available at: http://rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Is-your-drinkingpattern- risky/Whats-Low-Risk-Drinking.aspx. Accessed August 18, 2017.

9.Centers for Disease Control and Prevention. (2014). Excessive drinking costs US $249 billion. Available at:

http://www.ncbi.nlm.nih.gov/pubmed/26477807/. Accessed December 15 2016.

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CONTI… REFERENCES9. Centers for Disease Control and Prevention. (2015). Alcohol and Public Health. Data and Maps. Available at:

https://www.cdc.gov/alcohol/data-stats.htm. Accessed August 21, 2017.

10. Centers for Disease Control and Prevention. (2015). Alcohol poisoning deaths. Vital signs: Alcohol poisoning kills six

people each day. Available at: http://www.cdc.gov/media/dpk/2015/dpk-vs-alcohol-poisoning.html. Accessed

December 15, 2016.

11. World Health Organization (WHO) (2014). Retrieved from: http://www.who.int/mediacentre/factsheets/fs349/en/

12. National Institute on Alcohol Abuse and Alcoholism. (2015). Retrieved from: https://www.niaaa.nih.gov/alcohol-

facts-and-statistics

13. Cund, A. (2013). Alcohol education revisited: Exploring how much time we devote to alcohol education in the

nursing curriculum. Nurse Education In Practice, 13(1), 35-39.

14. Puskar, K., Gotham, H. J., Terhorst, L., Hagle, H., Mitchell, A. M., Braxter, B., ... & Burns, H. K. (2013). Effects of

Screening, Brief Intervention, and Referral to Treatment (SBIRT) education and training on nursing students’

attitudes toward working with patients who use alcohol and drugs. Substance Abuse, 34(2), 122-128.

15. Murphy-Parker, D. (2013). Screening, Brief Intervention, and Referral to Treatment: A need for educational reform in

nursing. Nursing Clinics of North America, 48(3), 485-489

16. Babor, T. F., Higgins-Biddle, J. C., & World Health Organization. (2001). Brief intervention for hazardous and

harmful drinking: A manual for use in primary care.

17. Cuijpers P, Riper H, Lemmers L. The effects on mortality of brief interventions for problem drinking: a meta-analysis.

Addiction. 2004;99(7):839-845

18. Substance abuse treatment. Health Partners of Western Ohio Website. http:// hpwohio.org/services/substance-use-

abuse/. Accessed February 24, 2016.

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CONTI… REFERENCES19. Mitchell, A. M., Puskar, K., Hagle, H., Gotham, H. J., Talcott, K. S., Terhorst, L., ... & Burns, H. K. (2013). Screening,

brief intervention, and referral to treatment: overview of and student satisfaction with an undergraduate addiction

training program for nurses. Journal of Psychosocial Nursing & Mental Health Services, 51(10), 29-37.

20. Mitchell, A. M., Mahmoud, K. F., Puskar, K., Hagle, H., Lindsay, D., & Knapp, E. (2016). Teaching Screening, Brief

Intervention, and Referral to Treatment Techniques to Nurse Practitioner Students. The Journal for Nurse

Practitioners, 12(7), e311- e317.

21. Gilchrist, G., Moskalewicz, J., Slezakova, S., Okruhlica, L., Torrens, M., Vajd, R., & Baldacchino, A. (2011). Staff

regard towards working with substance users: a European multi‐centre study. Addiction, 106(6), 1114-1125.

22. Van Boekel, L. C., Brouwers, E. P., van Weeghel, J., & Garretsen, H. F. (2014). Healthcare professionals’ regard \

towards working with patients with substance use disorders: Comparison of primary care, general psychiatry and

specialist addiction services. Drug & Alcohol Dependence, 134, 92-98

23. Gorman, D. M., & Cartwright, A. K. J. (1991). Implications of using the composite and short versions of the Alcohol and

Alcohol Problems Perception Questionnaire (AAPPQ). British Journal of Addiction, 86(3), 327-334. doi:10.1111/j.1360-0443.1991.tb01786.x

24. Shaw, S., Cartwright,A., Spratley, T., & Harwin, J. (1978).Responding to Drinking Problems. London: Croom Helm

25. Mclellan, A. T. (2017). Substance Misuse and Substance use Disorders: Why do they Matter in

Healthcare?Transactions of the American Clinical and Climatological Association, 128, 112-130.

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