Drug and Alcohol Dependence, 3 (1978) 77 - 83 0 Elsevier Sequoia S.A., Lausanne - Printed in the Netherlands

77

VETERANS ADMINISTRATION HOSPITAL STAFF ATTITUDES TOWARD ALCOHOLISM

ANTONIO V. LEMOS

Menninger Foundation, Topeka, Kansas (U.S.A.)

JEFFREY MORAN

Veterans Administration Hospital, Topeka, Kansas (U.S.A.)

(Received April 25, 1977)

Summary

Attitudes toward alcoholism among psychiatrists, psychologists, social workers, registered nurses, licensed practical nurses, and nursing assistants (464 subjects) were surveyed. A nine-factor questionnaire was utilized (emo- tional difficulties, character defect, social status, illness conception, harmless indulgence and addiction liability).

All groups were homogeneous in their perceptions about emotional difficulties contributing to alcoholism, alcoholics not coming from the lower socioeconomic strata of society, and the belief that alcoholics did recover and could be helped by treatment. Age, sex, and special training in the treat- ment of alcoholism did not have any significant influence on attitudes. All groups believed that periodic excessive drinkers could be alcoholics. None of the groups believed that the alcoholic had a character defect. Psychologists disbelieved the concepts of illness and addiction liability. All groups disagreed with harmless indulgence. Nursing assistants tended to see the alcoholic as a harmless heavy drinker.

Working on a special alcoholism treatment unit did not alter the percep- tions of psychiatrists, psychologists and nursing assistants. Social workers and registered nurses showed only a minor trend toward a positive attitude change, while the trend went in the opposite direction for licensed practical nurses.

This survey was done at the Topeka Veterans Administration Hospital, a hospital setting with 463 general psychiatric beds, 390 general medical, long-term and surgical beds, and a 55-bed chemical problems treatment unit. This unit offers 2 - 3 - week detoxification and “definitive” 6-week treat- ment programs to approximately 1200 patients a year. About 60% of the admissions to medical and surgical units are for alcohol-related problems.

Method

The “Alcoholism Questionnaire” developed by Marcus [l] was utilized. This questionnaire is based on a factor analytic study of attitudes toward alcoholism and consists of 40 statements to which the person responds by checking a position on a 1 to 7 scale (“completely disagree” to “completely agree”). It yields nine mean factor scores (see table 1).

Subjects included medical and surgical staff physicians, psychiatrists (staff and residents), psychologists (staff and graduate trainees), social workers (staff and graduate trainees), registered nurses (R.N.%), licensed practical nurses (L.P.N.‘s), and nursing assistants (psychiatric aides). The study was done in March and April of 1976. A total of 616 questionnaires were distributed, of which 476 (77%) were returned. Physicians in the med- ical and surgical units were eliminated as a group owing to the small return.

Data were coded and keypunched onto standard IBM cards, and analyses of variance were performed to detect any differences between groups. Sex, age, and the influence of special alcoholism training and/or experience were also examined.

Results

The six professional groups surveyed were represented as follows: psy- chiatrists 25 (5.38%), psychologists 22 (4.74%), social workers 35 (7.54%), R.N.% 128 (27.59%), L.P.N.‘s 40 (8.62%), and nursing assistants 214 (46.12%). The sample was predominantly female (175 males, 289 females). Age ranged from under 20 to 59 years. Two-thirds of the subjects (322) had never worked on a special alcoholism unit, and the same proportion (320) had never had any special training in the treatment of alcoholism.

Table 2 summarizes analyses of variance performed to examine differ- ences between professional groups, treatment experience, and the interaction between those professional groups and treatment experience.

There were no significant differences among the six groups for factors I (emotional difficulties), III (prognosis for recovery), and VI (social status). In addition, age and sex did not have any significant effect. Differences were found on the other six factors. Table 3 depicts those differences.

(1) Nursing staff (R.N.%, L.P.N.?, nursing assistants) scored higher on factor II, which indicates the belief that the alcoholic is unable to control his drinking behavior, as compared to the other three groups (psychiatrists, psy- chologists, social workers).

(2) All six groups scored high on factor IV, sharing the belief that periodic excessive drinkers can be alcoholics. R.N.% and psychiatrists scored significantly higher than the other groups.

(3) A low score on factor V characterized all the groups surveyed, indi- cating the belief that the alcoholic is not a weak-willed person; social workers had the lowest score, a significant difference.

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TABLE: 1

Factors: definition and interpretation

___

Factor Interpretation - a high score indicates the belief that:

I Emotional difficulties

II L40ss of control

III Prognosis for recovery

IV The alcoholic as a steady drinker

V Alcoholism and character defect

VI Social status of the alcoholic

VII Alcoholism as an illness

VIII Harmless voluntary indulgence

IX Addiction liability

Emotional difficulties or psychological problems are an important contributing factor in the development of alcoholism

Alcoholic is unable to control his behavior

Alcoholics do not, and can not, be helped to recover from alcoholism

Periodic excessive drinkers can be alcoholics - a low score indicates that a person must be a continual excessive drinker to be classified as an alcoholic

The alcoholic is a weak-willed person

Alcoholics come from the lower socioeconomic strata of society

Alcoholism is not an illness

The alcoholic is a harmless heavy drinker whose drinking is motivated only by his fondness for alcohol

Alcohol is a highly addicting substance

(4) For factor VII all groups, with the exception of psychologists, indi- cated the belief that alcoholism is indeed an illness.

(5) The six groups, except for psychologists, scored high on factor IX, sharing the belief that alcohol is a highly addicting substance. Nursing staff scored significantly higher than psychiatrists and social workers.

(6) Disagreement with the belief that the alcoholic is a harmless heavy drinker (factor VIII) was shared by all groups. However, among the six groups, nursing assistants tended to consider the alcoholic to be more harmless.

(7) Special training in the treatment of alcoholism did not yield any significant differences for any of the groups. Experience on an alcoholism treatment unit yielded only minor differences for some groups on factor IX, chosen because three groups emerged : (a) psychologists; (b) psychiatrists and social workers, and (c) nursing staff (R.N.%, L.P.N.‘s, nursing assistants). Comparing staff with experience on the alcoholism unit with those without specialized experience showed that the perceptions of psychiatrists, psychol- ogists, and nursing assistants were not significantly different. Social workers and R..N.‘s who had worked on an alcoholism unit scored higher that those who had not, a trend toward a positive attitude change, according to Marcus; L.P.N.3 who had worked on the unit scored lower, a trend toward a negative attitude change.

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TABLE 2

Analyses of variance*

Factor I

DF F MS

Factor II

P DF F MS P

G 5443 1.808 2.300 ns. 5443 6.506 10.56 0.001 T 1443 0.673 0.856 n.s. 1443 4.121 6.689 0.043 GT 5443 0.938 1.193 n.s. 5443 0.709 1.150 ns.

Factor III

DF F MS

Factor IV

P DF F MS P

G 5443 0.934 1.282 n.s. 5443 5.405 8.005 0.001 T 1443 4.294 5.891 0.039 1443 1.035 1.533 ns. GT 5443 0.416 0.570 n.s. 5443 0.775 1.148 n.s.

Factor V

DF F MS

Factor VI

P DF F MS P

G T GT

5443 3.814 1443 2.479 5443 0.366

Factor VII

DF F

7.872 5.117 0.756

MS

0.002 5443 0.609 0.579 n.s. n.s. 1443 0.639 0.607 n.s. n.s. 5443 0.628 0.597 n.s.

Factor VIII

P DF F MS P

G 5443 13.949 19.561 0.001 5443 4.019 3.745 0.001 T 1443 2.007 2.815 n.s. 1443 9.837 9.166 0.002 GT 5443 0.246 0.346 n.s. 5443 0.612 0.571 n.s.

Factor IX

DF F MS

Multivariate _

P DF F P

G 5443 7.841 10.181 0.001 45.1949 4.374 0.001 T 1443 0.281 0.365 n.s. 9.435 1.730 n.s. GT 5443 1.098 1.425 ns. 45.1949 0.757 ns.

*University of North Carolina Psychometric Laboratory. G, Group = professional qualification. T, Training = treatment experience on a specialized alcoholism unit. GT, Group training = interaction between professionals and treatment experience. n.s., not significant.

TA

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G

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K4

SD

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ii

i SD

5.03

8 4.

708

4.56

8 5.

068

4.92

0 4.

635

5.13

0 5.

136

5.21

6 4.

932

4.87

4 4.

876

1.29

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343

0.85

9 0.

582

0.99

8 1.

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1.06

7 0.

878

1.23

3 1.

397

1.23

8 1.

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4.23

1 4.

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4.09

1 3.

159

3.88

6 4.

192

4.75

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4.58

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932

4.63

5 4.

817

1.44

9 1.

491

0.90

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735

1.25

5 1.

114

1.17

8 1.

141

1.32

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888

1.35

7 1.

298

1.92

3 2.

563

2.72

7 2.

864

2.45

5 2.

215

2.57

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465

2.21

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795

2.7

24

2.48

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0.55

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1.25

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0.85

8 0.

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1.17

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1.19

5 1.

234

5.76

9 6.

104

5.04

5 5.

114

5.05

9 5.

581

5.73

4 5.

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5.56

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5.18

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0.92

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7 1.

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1.34

9 1.

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2.69

2 2.

688

3.09

1 2.

977

2.44

3 2.

288

3.27

2 2.

730

3.03

4 3.

455

3.47

4 3.

336

1.38

9 1.

293

1.14

2 1.

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1.01

5 1.

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1.42

7 1.

350

1.48

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746

1.58

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2.07

7 2.

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2.59

1 2.

273

2.24

8 2.

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2.38

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1.94

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295

2.40

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241

0.77

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0.72

7 0.

575

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0.86

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2.90

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4.70

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545

2.91

8 2.

827

2.47

8 2.

318

2.37

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2.75

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568

0.96

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0.76

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0.98

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825

1.20

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1.88

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2.28

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1.93

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0.68

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733

1.14

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984

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895

1.28

6 1.

153

Soc

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wor

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No

Yes

R.N

.

No

Yes

L.P

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No

Yes

N

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No

= h

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82

Discussion

At the outset, it was noted that there was a high correlation between factors, which leads us to question the validity of the questionnaire, and suggest further factor analysis to check for discreteness of the factors.

Contrary to what has been reported in the literature [2 - 51, five of six groups, except psychologists, did believe in the concept of alcoholism as an illness. Previous surveys by Knox [ 61 among V.A. psychologists indicated that the disease concept was not widely accepted, which corresponds with our findings. Psychologists at the Topeka V.A. Hospital stood out for their disbelief in the concepts of illness and addiction liability.

It was interesting to note that psychiatrists and R.N.? tended to diagnose heavy drinkers as alcoholics more than any of the other groups; this may be related to the influence of the psychiatrists’ and nurses’ training which empha- sizes early diagnosis. Our findings were in this respect different from those reported by Glatt [7], who concluded that nurses, as well as other profes- sionals and the general public, delayed the diagnosis until the condition had reached a late stage.

Social workers were characterized by their disbelief that the alcoholic has a character defect, which may be related to their training and tendency to think in terms of social systems and interactions rather than individuals.

Nursing assistants tend to see the alcoholic more as a harmless heavy drinker than any of the other disciplines represented in the typical Topeka V.A. Hospital team. These different viewpoints shared by professionals repre- sented in such teams could lead to inconsistently defined management criteria and have treatment implications. However, we think that team members have different influences. Psychiatrists, as team leaders, and often R.N.%, deal with the consultative aspects of treatment and are more indirectly involved with patient care, while nursing assistants are in direct contact with the patient for prolonged periods. Psychologists and social workers also have less direct and prolonged contact with treatment. We believe that nursing assis- tants have the most influence because of the direct and intimate nature of their contact with the patient. Their tendency to see the alcoholic more as a harmless heavy drinker could well lead to “unintentional enabling of the pathological drinking”, a concept coined by Weinberg [ 81 and attributed to physicians. It also makes careful screening of nursing assistants assigned to the alcoholism unit a must.

The results of this survey show consistent homogeneous perceptions in the area of emotional-psychological problems contributing to the develop- ment of alcoholism, the belief that alcoholics do not come from the lower socioeconomic strata of society, and the important concept that alcoholics do recover and can be helped, a rather surprising finding in view of the pessi- mism often expressed by professionals about alcoholics and their chances for recovery.

We found, as has been reported elsewhere [9 - 121, that training in the treatment of alcoholism did not bring about attitude change for any of the

83

groups surveyed. Alcoholism is an emotionally charged issue because of the high incidence of alcoholism among the general public; 7% of the adult population of the United States are alcohol abusers and they touch the lives of nearly 40 million Americans [ 21 ; moreover, among health professionals, 400 doctors are lost from the medical profession each year because of alco- holism, and nurses have as high an incidence of drinking problems as do physicians [ 21. We believe that deeply engrained attitudes toward such issues are not modified by the classical “workshop-seminar” approach, and that more intensive individual work is necessary to modify such attitudes. It also follows that efforts should be concentrated on nursing assistants, the most influential members of the team, in terms of attitude and its bearing on treatment.

Data obtained in a unit specializing in the treatment of alcoholism [ 11 brought about a minor trend @ < 0.10) toward a positive attitude change for social workers and R.N.%, while the trend (p < 0.10) was a negative one for L.P.N.‘s. Furthermore, attitudes of psychiatrists, psychologists, and nursing assistants remained the same.

References

1 A. Marcus, Alcoholism Questionnaire, Alcohol and Drug Addiction Research Founda- tion, Toronto, Canada (mimeographed), 1963.

2 M. E. Chafetz, Alcoholism, Psychiatric Ann., 6( 3) (1976) 10 - 93. 3 E. Ferneau and R. Gertler, Attitudes regarding alcoholism: effect of the first year of

the psychiatric residency, Brit. J. Addiction, 66 (1971) 257 - 260. 4 W. J. Knox, Attitudes of psychiatrists and psychologists toward alcoholism, Amer. J.

Psychiat., 127 (1971) 1675 - 1679. 5 I. Wolf et al., Social factors in the diagnosis of alcoholism. II. Attitudes of physicians,

Quart. J. Studies Ale., 26 (1965) 72 - 79. 6 W. J. Knox, Attitudes of psychologists toward alcoholism, J. Clin. Psychol., 29

(1969) 446 - 450. 7 M. M. Glatt, The alcoholisms-l. A complex interdisciplinary disorder, Nursing Times,

71 (May) (1975) 680 - 682. 8 J. R. Weinberg, Chemical dependency. Is pessimism about alcoholics justified? Minne-

sota Med., 57 (Sept.) (1974) 728 731. 9 M. B. Bailey, Attitudes toward alcoholism before and after a training program for

social caseworkers, Quart. J. Studies Ale., 31 (1970) 669 683. 10 G. Dorsch and R. Talley, Responses to alcoholics by the helping professions in Denver.

A three-year follow-up, Quart. J. Studies Ale., 34 (1973) 165 172. 11 N. Schmid and D. T. Schmid, Nursing students’ attitude toward alcoholics, Nursing

Res., 22 (May-June) (1973) 246 - 248. ! 2 M. L. Waring, The impact of specialized training in alcoholism on management-level

professionals, J. Studies Ale., 36(3) (1975) 406 - 415.