Nurse Education Today (2008) 28, 691–701

Nurse

www.elsevier.com/nedt

EducationToday

Predictors of educational outcomesof undergraduate nursing students in alcoholand drug education

G. Hussein Rassool a,b,1,*, Salman Rawaf c

a Visiting Professor of Addiction and Mental Health, Departamento de Enfermagem Psiquiatrica e CienciasHumanas da Universidade de Sao Paulo – EERP, USP, Centro Colaborador da OMS, para o Desenvolvimentoda Pesquisa em Enfermagem, Laboratorio de Pesquisa em Alcool e Drogas, Ribeirao Preto, Sao Paulo,Brazilb Federal Universidade de Minas Gerais, Brazilc Professor and Director of Public Health, Wandsworth Primary Care Trust, London, UK

Accepted 14 November 2007

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KEYWORDSAlcohol;Drug;Education;Evaluation;Quantitative research;Undergraduate nurses

60-6917/$ - see front mattei:10.1016/j.nedt.2007.11.0

* Corresponding author. Prffray, Avenue Perroquet 3,E-mail address: p9800003@Independent Educational C

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esent adLes Guibsgul.ac.onsultat

Summary This paper reports a study which aimed to evaluate the impact of aneducational programme on alcohol and drug on knowledge acquisition, changes inattitude and intervention confidence skills of undergraduate nursing students andidentify the influence of selected demographic variables on educational outcomes.Despite the high levels of morbidity and mortality resulting from substance misuse,few nurses have been adequately prepared to respond effectively. There remains adearth of evidence on the educational interventions in alcohol and drug with under-graduate nursing students and this study intends to add a body of knowledge to thisfield. A quasi-experimental, pre-post-test design was used using with a purposivesample of four cohorts of undergraduate nursing students (n = 110) in England.Pre-tests and post-tests after the educational intervention on alcohol and drug wereadministered to measure the educational outcomes. The data was collectedbetween March 2002 and September 2003. The results showed the educational inter-vention on alcohol and drug had a significant impact on educational outcomes.There were significant differences between the pre-test and post-test knowledgemean score (t = �.4.61, d.f. = 109, p = 0.000), attitude (t = �2.36, d.f. = 109,p = 0.02) and intervention confidence skills (t = �9.75, d.f. = 109, p = 0.000). Withinthe multi-layered hypothesis, the results indicate that only ethnicity was found to

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dress: Educational/Psychological Consultant, Intercultural Therapy Centre, Morcellementies, Pailles, Mauritius. Tel./fax: +2302861734.uk (G.H. Rassool).ion in Addiction.

692 G.H. Rassool, S. Rawaf

have a significant influence on both knowledge acquisition (F(2,106) = 6.59, p = 0.002)and intervention confidence skills (F(2, 106) = 15.0, p = 0.000).The study provides some evidence that a short intensive educational programme onalcohol and drug can be effective in improving educational outcomes. Furtherresearch should be undertaken with undergraduate nurses specialising in differentbranch of nursing.

�c 2007 Elsevier Ltd. All rights reserved.

Introduction

Alcohol and drug misuse are a major public healthproblem and continue to threaten the health andsocio-economic fabrics of society. The United Na-tions Office for Drug Control and Prevention (UN-ODC, 2006) estimated that some 200 millionpeople, or 5% of the world’s population age 15–64, have used drugs at least once in the last 12months. For most of Europe and Asia, opiates con-tinued to be the main problem drug, accounting for62% of all treatment demand. In South-America,drug-related treatment demand continued to bemainly linked to the use of cocaine (59% of alltreatment demand). In Africa, the bulk of all treat-ment demand is linked to cannabis (64%). Alcoholmisuse causes 1.8 million deaths worldwide and isone of the 10 leading causes of disability (WHO,2004).

In recent years, there have been increasingemphases on the contribution nurses can make inthe provision of effective interventions with alco-hol and drug misusers (ICN, 1995; Prime Minister’sStrategy Unit, 2004). Despite the high levels ofmortality and morbidity resulting from the misuseof alcohol and drug, few nurses have been ade-quately prepared to respond effectively. An exten-sive review of drug and alcohol content withinnursing curricula at both undergraduate and post-graduate levels in England (Rassool, 1993; O’Garaet al., 2005), Scotland (Matheson et al., 2004), Uni-ted States of America (Hagemaster et al., 1993;Howard et al., 1997), Australia (Crespigny de,1999; Happell and Taylor, 1999) and Brazil (Rassooland Villar-Luis, 2004; Rassool et al., 2006) revealedthat the contents of substance use and misuse edu-cation in nursing curricula are inadequate. Thislack of educational preparation of undergraduatenurses in alcohol and drug education may be re-flected in research studies which showed thatnurses have negative attitude towards substancemisusers and may be moralistic, punitive, pessimis-tic and prone to stereotyping (Wennerstrom andRooda, 1996; Selleck and Redding, 1998) and hadthe lowest level of skills and knowledge (Brownet al., 1997; Selleck and Redding, 1998). However,

there is evidence to suggest that attitudes ofnurses towards substance misusers are changing(Pinikahana et al., 2002; Rassool et al., 2006).

There is evidence to suggest that the develop-ment of a more positive and non-judgemental atti-tude and confidence and skills in identifying andworking with substance misusers may be partly re-lated to the provision of education and training(Hagemaster et al., 1993; Gerace et al., 1995;Rassool, 2004). However, much professional educa-tion and training reinforces the view that dealingwith substance misuse is the job of a specialist(Rassool, 2000). There is a paucity of the literatureon the educational interventions of programmes inalcohol and drug with undergraduate nursing stu-dents and the lack of evaluation research hasprompted the basis of this study. The aims of thepaper are to evaluate the impact of an educationalprogramme on alcohol and drug on knowledgeacquisition, changes in attitude and interventionconfidence skills of undergraduate nursing studentsand identify the influence of selected demographicvariables on educational outcomes.

Background

The reviews in this section, derived from the inter-national literature, are based on nursing and non-nursing sources. A review of the literature from1962 to 1982 by (Ewan and Whaite, 1982) revealedthat that all educational programmes in substancemisuse succeeded in increasing knowledge in theshort-term. The most common methods of assess-ment of knowledge gain were multiple-choice testsadministered before and immediately after thecourse programmes. Randall and Wong (1976) incomprehensive review of educational programmein alcohol and drug between 1967 and 1976 re-ported that most of the educational programmeslacked any meaningful evaluations that could pro-vide guidelines in the curriculum development offuture educational programmes. The following sec-tion present a brief overview of the literature onthe evaluation studies undertaken in the 1990s tothe present.

Predictors of educational outcomes of undergraduate nursing students in alcohol 693

Hagemaster et al. (1993) study’s aims were toplan and develop materials for an alcohol and drugmisuse curriculum, to assess the effectiveness ofthe programme and to refine the curriculum basedon the evaluation. A workshop was presented intwo and one half days over a 2-week period.Fifty-eight nurses, attended the course and wereadministered the substance abuse attitude scale(Chappel et al. (1985) and the substance abuseknowledge scale (SAKS). The findings showed thatpsychiatric-mental health nurses had higher pre-test knowledge scores compared to other nursingspecialities. The participants were also found tohave positive attitude in treatment and optimisticabout treatment. The findings also indicated thatparticipants with more knowledge were more opti-mistic regarding intervention strategies and morenon-moralistic toward substance misusers. Geraceet al. (1995) reported an evaluation of an educa-tional programme for nurses (n = 32) designed toimprove their recognition of and responses to sub-stance-related problems. The findings showed thatthere were significant improvements in knowledgeand clinical intervention skills.

A study by Selleck and Redding (1998) made anattempt to explore the knowledge and attitudesand determine the relationships between selecteddemographic variables and nurses’ (n = 393) knowl-edge and attitudes toward perinatal substance mis-use. The results indicated that substance misuseeducation was the only key predictor of knowledgeand attitudes. That is, those who had undertakenan educational programme had more knowledgeand positive attitude towards substance misusersthan nurses without any formal educational pro-grammes. Perry (1999) reported a study in whichnurses (n = 23) received an alcohol education pro-gramme. The results indicated that the educationalprogramme was effective in achieving an improve-ment in the level of alcohol screening. The authorreported that nurses also became more positive to-wards alcohol screening when they are trained andsupported. A study in the examination of nurses’knowledge and attitudes toward problem drinkers(n = 212) by Arthur (2001) showed that there wasa significant improvement in the students’ knowl-edge about alcohol early intervention as a resultof an educational intervention.

Goddard (2003) evaluated the effectiveness ofan educational presentation (2 h) in changing atti-tudes of drug and alcohol professionals (n = 137) to-wards harm reduction. The results indicated thatattitudes towards harm reduction were significantlymore favourable after the educational interventioneven among those professionals with a differenttreatment orientation (Alcoholic Anonymous).

A summary of the nursing research studies oneducational interventions in alcohol and drugshowed that they were influential in knowledgeacquisition, attitude changes and in improvingnurses’ confidence skills. The above research stud-ies showed that knowledge and attitudes may bealtered following educational intervention andthere is some evidence of the transfer of learninginto clinical practice. However, the length of theeducational programme ranged from 2 h to 5weeks. In addition, the studies had small size sam-ples, use of different measures in the assessmentof knowledge, attitude and confidence, the use ofinstruments that have not been subjected for theirpsychometric properties and the lack of detail ofthe control group made it difficult to compare withother studies. Despite the lack of rigour in themethodology of the research studies the educa-tional interventions reviewed provided an agendafor some common themes that need further re-search investigations.

Methods

Aims

This paper reports a study which aimed to: (1) eval-uate the impact of an educational programme onalcohol and drug on knowledge acquisition,changes in attitude and intervention confidenceskills of undergraduate nursing students; (2) iden-tify the influence of selected demographic vari-ables on educational outcomes. The followinghypothesis was tested: Selected demographic pro-file of students such as gender, age, and ethnicitywill have an effect on knowledge acquisition,changes in attitude and intervention confidenceskills.

Design

The research study is a quasi-experimental, pre-and post-test design. The use of a pre- and post-test outcome measure design is realistic when ran-dom assignments to conditions are not feasible toevaluation researchers (Trochim and Cappelleri,1992). Such a design is useful in determining out-comes and level of impact on whether or not theprogramme, treatment or intervention has broughtabout some desired change. According to Kumar(1999) ‘‘a before-and-after design can be describedas two sets of cross-sectional observation on thesame population to find out the change in the phe-nomenon or variable (s) between two points in

694 G.H. Rassool, S. Rawaf

time’’ (p. 83). Many threats to the internal validitycan be ruled out with the inclusion of a controlgroup. However, in this study, this was not possibleand practical due to ethical issues. In order to min-imise the threats to the internal validity, a numberof covariants would be subjected to control.

Sample

To detect a medium effect size in proportion be-tween 40% and 60% at pre- and post-test for thevariable with power set at 80% and significance le-vel at (one-tailed) p < 0.05, the minimum samplesize of 94 subjects will be required (Pocock,1995). A one-tailed significance level was used be-cause the experimental hypothesis is directional.

A purposive sample of undergraduate nursingstudents was recruited from two metropolitanand one rural academic institution. The partici-pants were made up from four cohorts of students(n = 110) and following the second year of theireducational programme in the mental healthbranch. The inclusion criteria to participate inthe study include: undergraduate nursing students;completed the common foundation programme(CFP); following the mental health branch; and noprevious formal educational programme in sub-stance use education.

Educational intervention

The educational framework for the educational pro-gramme was based on the curriculum guidelines forsubstance misuse education in undergraduate nurs-ing education programmes English National Boardfor Nurses (ENB), 1996. The educational interven-tions were presented by different facilitators whowere familiar with the educational programme.The objectives of the educational interventionswere to: Recognise own attitudes towards sub-stance misuse; drug use and the stereotypes thatare applied; Describe briefly the method of useand the effects of commonly misuse psychoactivesubstances; Identify 3 screening methods for usein alcohol and drug; Carry out a basic drug and alco-hol assessment, Outline the prevention strategiesand treatment options available for substance mis-users; and Discuss the role of the nurse in the assess-ment and treatment of substance misuse. Thestructure, content and methods of teaching andlearning of the education module were:

� Session 1: Introduction to the module, learningoutcomes, attitude towards substance misusers.Exploring own attitude towards the use of alco-

hol, drug and tobacco. What is the differencebetween own drug use and substance misusers?Stereotypes (Small group work, self-awarenessexercise and discussion).� Session 2: Concept of drug and alcohol. Natureof drug and alcohol. Pattern of substance mis-use: experimental, recreational and dependent.Routes of administration. Brief account of short-term and long term effects of commonly misusesubstances. Reasons why people use psychoac-tive substances and why they continue to do so(Short lecture and discussion).� Session 3: Screening and Assessment. Basicscreening methods. Generic assessment. Howto take a substance misuse history. Health edu-cation and prevention strategies (Short lectureand Role play).� Session 4: Special needs of young people, womenand ethnic minorities (Short lecture anddiscussion).� Session 5: Nursing care and management: criticalincidents, withdrawal symptoms, overdose,dealing with intoxicated (Short lecture anddiscussion).� Session 6: Intervention Strategies. Differentmodels of treatment: Physical, social, psycho-logical. Detoxification: alcohol and drug Rehabil-itation. Role of Family and significant others.Self-help groups (Short lecture).� Session 7: Role of nurse in relation to substancemisuse. When to refer patients to specialist ser-vices? (small group work).� Session 8: Consolidation of Session 1–7. Discus-sion of problems and issues. Evaluation (smallgroup work, group discussion).

This educational programme was supplementedwith a study guide prior to course initiation whichincluded: indicative content, aims, learning out-comes, references and further reading.

Data collection

The self-reported measures used in the study in-clude were developed and piloted with undergrad-uate nursing students with similar norms andexperiences. The demographic questionnaire (DQ)was used for eliciting basic information including:age, gender, ethnicity and educational attainment.

Assessment of knowledge

The educational outcome of knowledge was as-sessed with a multiple-choice item format. Some

Predictors of educational outcomes of undergraduate nursing students in alcohol 695

of the core areas of the educational programmewere reflected in the coverage of the test itemsand were based on the following categories: con-cepts, effects of specific psychoactive substances,assessment and treatment, special populations,prevention and health education. The Knowledgeinstrument (AKQ-20) has a Kuder-Richardson(KR20) reliability of 0.89 and an a coefficient reli-ability of 0.91.

Assessment of attitude

The main purpose for the use of this instrument,based on a single attitudinal dimension, was tomea-sure specific attitude towards substance misusers. ACronbach’s a of 0.80 was obtained for the attitudequestionnaire (ATSMQ-10 items). A Likert -type re-sponse format (Likert, 1932) was chosen. All itemswere measured on a 5-point scale from ‘‘stronglyagree’’ to ‘‘strongly disagree’’ with scores rangingfrom 1 = strongly agree to 5 = strongly disagree.Items with negative wording were scored in reverse.

Assessment of intervention confidence skills

The addiction intervention confidence skills scale(AICSS-16), was used to measure the interventionconfidence skills. The AICSS, with 16 items, is basedon a horizontal visual analogue scale (VAS) (Waltzet al., 1991). The VAS is a straight line of 10 cm longand has a series of confidence categories with 1–4representing low level of confidence, 5–6 repre-senting moderate level of confidence and 7–10 rep-resenting high level of confidence. The AICSS-16showed a strong measure of internal consistency(a coefficient 0.94) and face and content validity.

Procedures

In collaboration with course directors, a schedulewas developed to meet with the different cohortsto explain the purpose of the study. In order toachieve a maximum response, and to answer ques-tions students may have regarding the study, thequestionnaires were administered in the controlledenvironment of formal class time and under thesupervision of the author or module leader.

At the beginning of semester 4 or 7, dependingon the educational institutions, the students fromeach cohort who consented to take part in thestudy were provided an information sheet aboutthe study and asked to complete the consent form.There were two measurements points for the co-horts: a baseline (pre-test) before the implementa-

tion of the educational programme and a post-test.The demographic questionnaire, knowledge ques-tionnaire, attitude questionnaire and the confi-dence skills scale were administered before theeducational intervention. After 8–10 weeks afterthe educational intervention, the knowledge ques-tionnaire, attitude questionnaire and the confi-dence skills scale were repeated.

Ethics

Ethical approval for this study was sought andgranted by the Institutions’ Research Ethics Com-mittee. General information sheet and a consentform about the study were provided to the stu-dents. Prior to the commencement of the study,the students signed a consent form and a guaranteeof anonymity of the data was guaranteed. A furtherproviso was that withdrawing from the study wouldbe in no way affected their current educationalprogrammes.

Statistical analysis

The demographic variables were summarised usingfrequency distributions and percentages. Themeans and standard deviations were determinedfor all the variables. Paired t-tests were used toexamine the differences between pre- and post-testscores of knowledge, attitude and intervention con-fidence skills. A series of analysis of covariance (AN-COVA) were carried out to measure the differencesamong group means of knowledge, attitude andintervention confidence skills and to control forthreats to the internal validity of the study. In thisstudy, the pre-tests mean scores of knowledge, atti-tude and intervention confidence skills were chosenas covariates. This source of variations had to bepartitioned out to limit the effects of previous ori-entation of alcohol and drug education (informal)and personal and professional experiences. Thus,the pre-tests acted as covariates to provide a base-line for the statistical validity of the study. Multipleregressions (linear) were used to test the predictionequations of knowledge acquisition, changes in atti-tude and intervention confidence skills. Statisticalanalyses were conducted using SPSS version 10.0.Statistical significance was set at p < 0.05.

Results

Sample characteristics

The sample profile is presented in Table 1 showingthat the majority of the sample was female (57%).

Table 1 Demographics of sample (n = 110)

Variable Description

Age Age range = 20–55Mean age = 32.9SD = 7.98, n = 110

Gender Male = 43%Female = 57%

Ethnicity White = 40.9%Black (African &Caribbean) = 44.5%Asian & Other = 14.5%

Educational attainment GCSE & A Level = 44.5%Diploma = 30.9%Degree = 24.5%

696 G.H. Rassool, S. Rawaf

The mean age of the sample was 33 (SD = 7.98) witha range of 20–55 years. The largest ethnic groupwas Black African & Caribbean (45%), followed byWhite (41%) and Asian & Other (15%).The educa-tional attainments of the students ranged fromGSCE to university degrees.

Changes in educational outcomes

Fig. 1 displays the comparison of mean scores be-tween Pre-Post-Tests knowledge, attitude andintervention confidence skills. The results showedthat there were statistically significant differencesbetween the mean scores of the pre-test and post-test knowledge (t = �.4.61, d.f. = 109, p = 0.000),attitude (t = �2.356, d.f. = 109, p = 0.02) and inter-vention confidence skills (t = �9.754, d.f. = 109,p = 0.000).

11.9 13.2

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*AKQ-20 *ATSMQ-10 *AICSS-16

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Figure 1 Comparison of Mean Scores of AKQ-20,ATSMQ-10 and AICSS-16 Pre-Post-Tests (n = 110). *AKQ-20 – Addiction Knowledge Questionnaire; *ATSMQ-10 –Attitude Toward Substance Misusers Questionnaire;*AICSS-16 – Addiction Intervention Confidence SkillsScale.

Hypothesis testing

Influence of gender on educationaloutcomes

The findings showed that there was no signif-icant influence of gender on knowledge acquisi-tion (F(1, 107) = .463, p = 0.498) on attitude change(F(1, 107) = .315, p = 0.576) and in interventionconfidence skills (F(1, 107) = .221, p = 0.639).

Influence of age on educational outcomes

The findings showed there was no significant influ-ence of age on knowledge acquisition (F(2, 106) =.961, p = 0.386), attitude change (F(2, 106) = 0.949,p = 0.390) and in intervention confidence skills(F(2, 106) = .271, p = 0.763).

Influence of ethnicity on educationaloutcomes

The findings showed that ethnicity had a statisti-cally significant influence on knowledge acquisition(F(2, 106) = 6.594, p = 0.002) and interventionconfidence skills (F(2, 106) = 14.992, p = 0.000)but no significant influence on attitude change(F(2, 106) = .556, p = 0.575).

In order to determine which ethnic group hadmore influence on knowledge acquisition and inter-vention confidence, a Bonferroni post-hoc analysiswas conducted (a = .05). Fig. 2 presents the esti-mates means scores and standard error of meansfor knowledge acquisition across the ethnic groups.The findings showed that the White ethnicity stu-dents had a slightly higher mean score (mean14.2) than the Black (mean 12.3) and Asian (mean13.1) ethnicity groups in the knowledge domain.The Pairwise Comparisons showed that there was

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Mean Std.Error

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Figure 2 Mean scores and standard error for knowledgeacquisition. Std. Error, standard error.

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Figure 3 Mean scores and standard error of means in intervention confidence. Std. Error, standard error.

Predictors of educational outcomes of undergraduate nursing students in alcohol 697

a statistically significant mean difference betweenWhite ethnicity and Black ethnicity (p = 0.001).However, no statistically significant mean differ-ences were found between White ethnicity andAsian ethnicity and between Black ethnicity andAsian ethnicity.

Fig. 3 presents the estimates means scores andstandard error of means for intervention confi-dence skills across the ethnic groups. The findingsshowed that Asian ethnicity had higher mean scorein the intervention confidence skills compared tothe Black African & Caribbean ethnicity and theWhite ethnicity. The findings of the Pairwise Com-parisons showed that there were statistically signif-icant mean differences between Asian ethnicityand White ethnicity (p = 0.001) and between Blackethnicity and White ethnicity (p = 0.000).

The findings from the multiple regressionshowed that White ethnicity was the significantpredictor of knowledge acquisition (b = 0.329,p = 0.000) with an R value of 0.57 but a negativesignificant predictor (b = �0.462, p = 0.001) withan R value of 0.48 in intervention confidence skills.The linear regression equation for predictingknowledge acquisition (KA) is KA = 8.2 + 1.87(White ethnicity) and intervention confidence skills(ICS) is ICS = 63.4�12.16 (White ethnicity).

Discussion

The multi-ethnic composition of the students in thestudy probably reflects the ethnic diversity of thegeographical locations where the students were re-cruited. The Asian group in this study consistedmainly of Chinese and Indians. However, comparedto the two other ethnic groups, Asian people aregenerally under-represented in nursing (Depart-ment of Health, 2002). In relation to gender, themale group which made up 43% of the sample is a

significant factor in this study when compared tothe national average of about 11% male (NMC,2005). However, the sample of students in thisstudy have elected to follow the mental health op-tion of the nursing programme and shows the gen-der balance when compared to the nationalaverage (Female = 63%, Male = 37%) (NMC, 2005).However, the composition of this sample of stu-dents in relation to gender and ethnicity may bedifferent from those following other branch ofnursing such as Adult, Children or Learning Disabil-ity nursing. The mean age of the subjects in thisstudy was 33 years which reflects changing patternsin the student body entering the nursing profes-sion. The students could be described as ‘‘mature’’as opposed to school-leavers. This ‘‘mature age’’group may also be reflective of the educationalattainment of the sample. About 31% of the samplehad a Diploma and 25% were university graduates.It is reported that the age, gender and ethnicityprofiles are changing with greater number of malesand mature students entering nursing educationprogrammes (NMC, 2005).

The findings indicate that the educational pro-gramme on alcohol and drug had an impact inenhancing the knowledge, attitude change andintervention confidence skills of undergraduatenursing students. This is congruent with the find-ings from the studies of Rassool (1994) and Geraceet al. (1995). However, further examination re-vealed that two of the key individual items in theknowledge domain were ‘Nursing Assessment’ and‘Taking a drug and alcohol history’. These twoitems of ‘‘brief interventions’’ would by them-selves be an effective gamut of skills in enablingchange in patients with potential alcohol- anddrug-related problems (Watson, 1999). In thisstudy, the assessment of knowledge was measuredwith the AKQ-20 which was solely developed forthis study with a specific conceptual model of drug

698 G.H. Rassool, S. Rawaf

and alcohol use and misuse. Thus, what is reportedas a an increase in knowledge as a result of pre- andpost-test condition in one study using one particu-lar conceptual framework might not be consideredso in another study which employs a differentapproach.

In addition to knowledge acquisition, the highermean scores observed in the post-test attitudequestionnaire indicate more positive attitude to-wards substance misusers. The findings suggestthat the educational programme on alcohol anddrug had an impact on the attitude of the under-graduate nursing students towards substance mis-users. The findings are congruent with the resultsof other studies which support that the develop-ment of a more positive attitude, confidence andskills in working with substance misuse may bepartly related to the provision of alcohol and drugeducation (Hagemaster et al., 1993; Rassool,2004).

In this study, the majority of the participantsheld positive views towards substance misusersand they were optimistic that drug and alcoholdependence were treatable illnesses. The notionsof positive views towards substance misusers andtherapeutic optimism are supported by the findingsfrom the studies of Gerace et al. (1995) and Pini-kahana et al. (2002). This would undoubtedly en-hance the nurse–patient relationships in theprovision of appropriate care and interventionstrategies. In addition, positive attitudes conveyedto individuals with alcohol and drug problemswould further enable substance misusers who arecontemplating to change their alcohol or drugbehaviours to remain in the treatment system.

The intervention confidence skills of undergrad-uate nursing students improved significantly inrelation to both alcohol and drug-related clinicalskills. High level of confidence were gained in:the provision of alcohol, drug and tobacco educa-tion and prevention information, recognising thesigns and symptoms of alcohol and drug problems,talking to patients about risks of alcohol and drugmisuse, taking a drug and alcohol history, refer pa-tients for alcohol and drug problems, providingcare for patients with alcohol and drug problems,giving health risks information about prescribedmedication, informing smokers about the healthrisk of tobacco smoking and knowledge of drugand alcohol services.

Three important key skills in working with sub-stance misusers were identified: recognising thesigns and symptoms of alcohol and drug, takingan alcohol and a drug history and referring patientsfor alcohol treatment and drug treatment. Thesekey skills in intervention confidence were compara-

ble to the gain observed in the knowledge domain.This suggests that the undergraduate studentshave gained the requisite knowledge andintervention confidence skills in similar areas ofcompetence in working with substance misusers.There are limited studies in measuring interventionconfidence level amongst nurses to compare thefindings of this study. The findings from Geraceet al., study (1995), indicated that an educationalintervention was influential in improving nurses’confidence in caring for substance misusers.

The hypothesis which stated that selecteddemographic profile of students such as gender,age, and ethnicity will have an effect on knowledgeacquisition and changes in attitude and interven-tion confidence skills was rejected. However as thisis a multi-layered hypothesis, only ethnicity wasfound to have a significant influence on both knowl-edge acquisition and in intervention confidenceskills. The educational programme on alcohol anddrug had significant impact on the White ethnicgroup in knowledge acquisition. Whereas the Asian& Other and Black (African & Caribbean) ethnicgroups had better performance in intervention con-fidence skills domain. A plausible explanation mayindicate that White ethnic group may be moreadaptable to the ‘‘theoretical’’ aspects of the edu-cational programme compared to the Black andAsian who showed more enhanced ‘‘skills’’ baseddimensions. It may be feasible that the White eth-nic group are more knowledgeable or having widerpersonal and professional exposure to alcohol anddrug compared to the Black and Asian groups. Per-sonal and clinical experiences may also have influ-enced the educational outcomes. This is confirmedfrom a study by Selleck and Redding (1998) whofound that having personal experiences or a familyhistory of substance misuse explained 4% of thevariance in knowledge about substance misuse.However, due to the limited content of alcoholand drug education in the nursing curriculum, clin-ical experiences, continuing education and profes-sional journals were found to be the primarysources of substance use knowledge for mostnurses (American Nurses Association, 1986; Selleckand Redding, 1998). It may also be possible thatstudents in the White ethnicity group have beenmore exposed to these multiple experiences com-pared to the other two groups.

In relation to intervention confidence skills, theperformance of Asian & Other and Black (African &Caribbean) ethnic groups surpassed the White eth-nicity group. It may be that Asian & Other and Black(African & Caribbean) ethnic groups in this studyare more accommodating to the methods of learn-ing the skills components of the educational pro-

Predictors of educational outcomes of undergraduate nursing students in alcohol 699

gramme. Thus, the modes of learning may have en-hanced their practical or clinical skills compared tothe White ethnicity group. Another plausible expla-nation for the findings is the use of the Visual Ana-logue Scale for the measurement of interventionconfidence skills. The Asian & Other and Black(African & (Caribbean) ethnic groups may havelow adaptation to a more ‘‘concrete’’ style ofassessment such as multiple-choice items but aremore sensitive to the AICSS-16 measuring the inter-vention confidence skills dimension. As discussedpreviously, academic success may be attributedto multiple experiences for undergraduate nursingstudents. The findings from the multiple regressionshowed that White ethnicity was the significantpredictor of knowledge acquisition but was a nega-tive significant predictor in intervention confidenceskills.

Study limitations

The sample used in the study is based on four sub-populations of undergraduate nursing students in 2metropolitan areas of a large city and one ruralarea. The choice of educational institutions forthe experimental sites was determined by accessi-bility and willingness to participate in the study.The collection of data during formal attendanceto a wider educational programme, student moti-vations, module assignments and the personalityand teaching styles of those delivering the educa-tional programme may serve as potential limita-tions. Other extraneous variables may haveinfluenced the results of this study such as priorenrolment in a university programme other thannursing and prior work experiences.

A methodological consideration is the nature ofthe sample itself. This group of students haveelected to undertake the mental health branch ofthe nursing educational programme. This ‘‘self-se-lected’’ group of students may be different in per-sonality, interest and motivation in working withalcohol and drug misusers compared to those fol-lowing other specialist branch of nursing. Thus,the generalisations of these findings to otherundergraduate nursing students are limited. Ideallyprobability sampling from large clusters of under-graduate nursing students would have been pre-ferred, but this was not practical and possibledue to the nature of the study. Hence, one must as-sume that the sample possesses some local repre-sentation as opposed to a national one.

A limitation of a pre-post-test design is theinability to assess whether or not the differencesdue to the educational programme or to confound-

ing extraneous variables. It is subject to suchthreats to validity as history (events interveningbetween pre-test and post-test), maturation(changes in the subjects), regression toward themean (the tendency of extremes to revert towardaverages), testing (the learning effect on thepost-test of having taken the pre-test),Manythreats to the internal validity can be ruled outwith the inclusion of a control group.

Though the use of the visual analogue scale is aninnovation in educational research in this study, itis based on self-report in the measurement of thelevel of confidence in alcohol and drug-relatedskills. The limitations of self-report are one ofthe methodological concerns that are apparent inthis study. It has been suggested that that self-re-ported perceptions of basic skills gain are inflatedby the normal human tendency to answer with so-cially acceptable responses and reluctance to sayunfavorable things in an evaluation of educationalprogramme (Beder, 2005). The reliability and valid-ity of self-report are also dependent upon whetherthe report is based on attributional biases or thelack of conscious awareness (Ericsson and Simon,1980; Gilovich et al., 2002).

Conclusion

The findings of this study suggest that a short inten-sive educational programme on alcohol and drugcan be effective in increasing knowledge, changein attitude and intervention confidence skills. Inaddition, ethnicity was found to be a key predictorof educational outcomes. This has important impli-cations for nurse education. This ‘bolt on’ educa-tional programme could be implemented withouttoo much disruption to an overloaded nursing cur-riculum. However, it is argued that the ‘bolt on’approach is not the educational solution. What isneeded is a vertical integration approach which fo-cuses on teaching aspects of alcohol and drug inconjunction with the content of the nursing curric-ula (Rassool, 1993). One of most important aspectof an educational programme is not only aboutknowledge acquisition, changes in attitudes andskills development but the transfer of ‘learning’in clinical practice for the delivery of quality careto those with substance misuse problems. Theattainment of positive educational outcomes isonly part of the solution but how to maintain the‘new’ experiences’ and behaviours in clinical prac-tice are the critical predicament. Research is war-ranted in this area.

Further research should be undertaken withundergraduate nurses specialising in different

700 G.H. Rassool, S. Rawaf

branch of nursing. Finally, studies on the influencesof diversity, as part of the ‘hidden curriculum’ suchas gender, age and ethnicity, on educational out-comes in nursing education as a result of the chang-ing demographic profile of students entering thenursing profession are fully warranted.

Acknowledgements

We would like to thank the Florence NightingaleFoundation for providing a Foundation Scholarshipto GHR and for funding this research study.

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