- Email: [email protected]
Overcoming mixed messages on alcohol consumption: A teaching strategy
Nurse Education in Practice 10 (2010) 279–284
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Overcoming mixed messages on alcohol consumption: A teaching strategy Kerre A. Willsher * University of South Australia, Nursing and Rural Health Unit, 111 Nicolson Ave, Whyalla, South Australia 5600, Australia
a r t i c l e
i n f o
Article history: Accepted 19 January 2010
Keywords: Health education Health promotion Teaching
a b s t r a c t The aim of this discussion paper is to outline the teaching of nursing students using a health promotion approach to guide young people on issues involving alcohol consumption. Health promotion uses a holistic approach involving the individual, attempts to understand complexities of human behaviour and attempts to address environmental and social issues which impact upon health. There are several models of health promotion but the health assessment tool chosen was HEEADSSS which focuses upon assessment of the Home environment, Education and Employment, eating disorders, peer related activities, Drugs, Sexuality, Suicide/depression and Safety from injury or violence . Society’s approach to alcohol consumption is considered ambiguous therefore it is essential to teach health promotion. Research based on demographic and epidemiological information and anecdotal media reports indicates a high incidence of binge drinking among young people on the Eyre Peninsula. The plan was to develop and provide developmentally appropriate health promotion using the Australian National Health and Medical Research Council Recommendations on alcohol consumption and the Australian Nursing and Midwifery Council Competencies for the Registered Nurse. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction The aim of this paper is to discuss the education of Australian nursing students using a health promotion approach to guide young people on issues involving alcohol consumption The problem of alcohol abuse among teenagers in Australia is extreme compared to similarly developed countries threatening to overload the health care system according to Toumbourou et al. (2007), however, their studies revealed that brief health promotion interventions were effective. Bonomo et al. (2004) concur maintaining that alcohol intervention strategies for teenagers need to address the factors that influence high risk alcohol consumption including alcohol supply. Reports on the incidence of binge drinking by young people locally on the Eyre Peninsula Population Health Profile (Eyre Peninsula Division of General Practice, Australia, 2005) further confirmed the studies. Whitehead (2001) regards health education as authoritarian and therefore regarded negatively in many sectors of the community, young people for example, and maintains that there needs to be astute recognition and understanding of human development and behaviour. Health promotion uses a holistic approach involving the individual and entire communities attempting to understand the complexities of human behaviour and attempting to address environmental and social issues that impact upon health using ongoing follow-up. Bonomo (2005) asserts that society’s * Tel.: +61 8 86476097; fax: +61 8 86476014. E-mail address: [email protected] 1471-5953/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2010.01.003
approach to alcohol consumption is ambiguous and sends mixed messages, for example, advertisements about the legal blood alcohol levels for drivers and then the publicity given to prominent personalities who drink to excess. Many health professionals argue that active promotion of alcohol has led to increased consumption particularly among young people, leading to a wide range of alcohol induced problems (Duff, 2003). Mixed messages on alcohol are just one factor influencing the decision to drink. Young people learn partly through sharing experiences with their peers and through interacting with adults (Lewis et al., 2002). Alcohol consumption is considered the norm in Australia and alcohol has become easier to access. Young people are drinking more and alcohol related illnesses are occurring in younger people (Brown, 2007). The aim of the paper The aim of this discussion paper is to discuss the teaching of a health promotion strategy on alcohol consumption while fulfilling the multiple objectives of an undergraduate course in both 2007 and 2008. Literature review There are several health promotion models including Rosenstock’s Health Belief Model which explores the reasons people do not participate in health education programs (Bastable, 2003).
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The success of The Health Belief Model is based upon the belief that health is highly valued and the individual and community are highly motivated to participate. Bastable (2003) cites several nursing studies in the area of drug and alcohol education supporting the validity of this model and maintains that nurses as educators need to use or develop resources that address barriers to the uptake of health education. Bandura’s Concept of Self Efficacy (Bastable, 2003, DeBarr; 2004 and Davies, 2006) is a motivational theory using the belief that the individual can accomplish a certain behaviour evidenced by previous similar behavioural accomplishments, observing the same success in others, verbal encouragement by others who present realistic beliefs that the person is capable of achieving the expected behaviour and emotional arousal through self-judgement of experiences. There is a reciprocal relationship between the person’s perceived abilities, behaviour and the environment. The Stages of Change Model (Prochaska and DiClemente, 1982 and Bastable, 2003, p. 176) was developed in the area of addiction and involves six stages- ‘‘precontemplation, contemplation, preparation, action, maintenance, and termination”. The use of The Stages of Change Model is beneficial in developing health promotion strategies to enable successful completion of specific changes. Rush (1997) challenges the ideology that the individual alone is responsible for their health and maintains that nurses should critically examine health promotion theories considering social, political and environmental determinants of health as well as behaviour. This is confirmed by Whitehead (2004) who calls for further application of health promotion theories to nursing practice. The theories of health promotion are often complex, overlap and often cannot be separated from one another. Nursing students often struggle with the complexities of health promotion and engage in soul searching. However, it is essential for nurses to adapt to health promotion roles and educational reform is central to achieving this (The World Health Organization, 1999; Whitehead, 2002 and Wallerstein, 2006). Chinn and Kramer (2008) call for the use of praxis (thoughtful reflection and practice) to identify social issues and to find ways to address them. This is confirmed by Turner et al., 2007) who maintain that critical reflection is essential in nursing theory and practice. Holt and Warne (2007) in their explorative study found that health promotion theory used in the nursing curriculum does not link to what the students actually experience when undertaking experiential learning. Holt and Warne (2007) argue that nurse educators and experiential learning providers need to engage more extensively with one another to link theory and practice providing opportunities for the implementation and assessment of health promotion strategies by nursing students. Hubell and Burman (2006) concur maintaining that partnerships need to be developed using the organisations’ mission statements and values to develop mutually agreed upon goals. Scenario based teaching involving academics and clinicians allowing students to use and act out issues that they have encountered could assist in linking health promotion theory to practice (Holt and Warne, 2007). It is essential for learning to be intellectually stimulating and Cleary et al. (2006) maintain that role play, reflection, case studies and the use of creative skills enhance learning if students are motivated to participate and if there is demonstrated relevance. Boyer’s (1990) framework expands upon the definition of scholarship to include ‘‘the domains of discovery, integration, application and teaching” (p. 16). Arbuthnot et al., 2007) in their study of health promotion in the early detection of bowel cancer further illustrates the practical application of Boyer’s framework assisting in the creation of this particular teaching strategy using inquiry built upon the nursing knowledge of health promotion and developmental behaviour (discovery), transfer of knowledge about standard alcoholic drinks to students (scholarship of teaching), the advancement of clinical knowledge on the effects
of and management of excessive alcohol consumption (scholarship of application) and the development of interdisciplinary collaboration with a social worker and a drug and alcohol counsellor (scholarship of integration). The teaching process The course Health of Infants, Children and Young People (2007, 2008) was a second year course in a three year undergraduate nursing program at the University of South Australia and the aims and objectives were to-. Explain the role of the Registered Nurse in family-centred care in relevant health care settings Gather, evaluate and deploy a range of evidence to design and evaluate health interventions (primary and tertiary). Undertake a health assessment of a child or young person by engaging them in health promotion activities, taking baseline observations and a simple nutrition, sleep, exercise and family social history as part of formal assessment. Demonstrate an understanding of the interventions required identifying and improving the self esteem/social and emotional well-being needs of infants, children and young people. Demonstrate an understanding of the specific needs of the sick infant, child and young person and their family incorporating the philosophy of partnership-in-care. Demonstrate skills in assessing and evaluating the suitability of health education and social services available for infants, children and young people and their families. Demonstrate ethical and legal principles in the care of infants, children and young people and Demonstrate understanding of the meeting the cultural needs, rights and expectations of infants, children and young people and their families in diverse settings. A prerequisite for the course was Determining Australia’s Health, a first year course investigating the social determinants of health, community resources, epidemiology and public health. The students now had the opportunity to develop a practical application from these concepts (Arbuthnot et al., 2007). Stages of the course and the teaching strategies used
Week 1- Family-centred care/role of child health and paediatric nurses-lecture, tutorial, focus group discussions. Week 2-Communication and holistic assessment-lecture, tutorial, pre reading and role play. Week 3- Focus of care-the school-aged child-guest lecturer, research and presentations by the students. Week 4- Mental health issues-guest lecturer, students presented media articles for peer critique, as part of assessment one the students prepared open ended questions to obtain a history from a child. Week 5- Hospitalization/pain assessment and management. Lecture, tutorial, review of previous lectures, role play using pain assessment tools, group work critiquing journal articles. Week 6- Legal issues-guest lecturer, review of mandated reporting of child abuse, consent, scenario based group activities, development of suitable health promotion materials in preparation for a visit to the campus by school aged children.
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Week 7- School children visit the campus and are assessed. Week 8-Immunization and the safe administration of medications. Lecture, tutorial, review of epidemiology topics, work through online drug calculation program with tests with feedback given by the lecturer. Week 9- Focus of care- the infant, toddler and preschool child- lecture, tutorial, revision of previous topics, scenario based DVDs, research on the developmental needs of children and young people and reporting back. Review of media items. ****Week 10- Focus of care-the young person. Guest lecturers-social workers from youth mental health service- Lecture, tutorial, appraisal of media items, students prepare and present the role play which is appraised by the social workers and student colleagues. The appraisals are collated to develop further teaching materials.**** Week 11- Asthma-epidemiology and management. Guest lecturer, tutorial using online materials and a scenario based practical session. Week 12-Management of children with Type One DiabetesGuest lecturer, tutorial using group research and presentations, scenario based practical session with students using checklists to provide peer appraisal of clinical procedures. Week 13- The impact of severe chronic illness and its management. The mother of a child with a chronic condition addressed the students, tutorial with students researching childhood cancers, cystic fibrosis and cardiovascular conditions, practical session on medication administration, scenario based activities on nutrition, mental health and parenteral therapy. Pre-reading was required before each lecture and handouts were developed.
Discussion of the aims and objectives The course had a large communication teaching component in regard to the application of knowledge on growth and development. The learning objectives for the component ‘‘focus of carethe young person” were the application of knowledge about growth and development of the young person and the link with risk taking behaviours including alcohol consumption. The relationship between determinants of health such as age, gender, culture, income, education level, geographic location, access to services and risk factors was examined then used to design the strategy (Arbuthnot et al., 2007). The students then developed a teaching plan in regard to nutrition, drug and alcohol consumption, sexual health, mental health, physical fitness and personal safety and to identify appropriate health services for young people (Arbuthnot et al., 2007; Boyer, 1990). The nursing students themselves were undergraduates in the second year of the nursing program, mainly young people and as such would be targets for alcohol advertising as well as role models for others, developing the ability to provide health promotion on drug and alcohol consumption. Consideration also needs to be given to high levels of stress that nursing students face during their undergraduate education due to work and study load, caring for acutely ill patients whilst developing their own clinical knowledge and skills, therefore risking ‘‘burnout” and the temptation of alcohol (Frank and Halstead, 2005). It is essential for the nursing students themselves to have adequate social supports. Many of the students discussed their own experiences of friends who had died or who had been seriously injured as a result of excessive alcohol
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consumption. The tutorials were also an opportunity to debrief and obtain support in what Lawson and Flocke (in press, 2008) regards as a ‘‘teachable moment” and Boyer regards as scholarship of application and scholarship of integration encouraging reflection and highlighting relevance linking to the behavioural theories of health promotion. The Australian Nursing and Midwifery Council Competencies for the Registered Nurse (2006) were used as the framework to educate nursing students to conduct health promotion on alcohol consumption for young people. The Australian Nursing and Midwifery Council works in conjunction with state and territory regulatory bodies to develop standards by which nurses are assessed. The Competencies form a basis in curriculum development and provide relevant information to health consumers on the standards that are to be expected from registered nurses. Competency 7.7 from Domain three –Provision and Coordination of Care formed the basis for this health promotion teaching strategy.
Australian Nursing and Midwifery Council Competency 7.7. Identifying and documenting specific educational requirements and requests of individuals/ groups. Undertaking formal and informal education sessions with individuals/groups as necessary. Identifying appropriate educational resources, including other health professionals
(Australian Nursing and Midwifery Council, 2006, National Competency Standards for the Registered Nurse, Australian Nursing and Midwifery Council, Canberra). The 2001 Australian Alcohol Guidelines Health Risks and Benefits as endorsed by the National Health and Medical Research Council link to the course aims and objectives and Australian Nursing and Midwifery Council (2006) Competency 7.7 particularly in regard to gathering and evaluating evidence and health promotion. Preparation for the teaching activity The tutorial for ‘‘focus of care-the young person” involved the discussion of media items located by the students on the situation of young people from the age of twelve to twenty-four. The students were encouraged to investigate advertising from manufacturers, government media releases and other media activities and to view ‘‘Under the Influence” a topic debate on Insight” a current affairs program on SBS television broadcasting a debate on whether hotels or liquor outlets should be open twenty-four hours a day. The tutorial The learning experience provided a review of the key points about the growth, development and social interaction of the young person. Key influences in the lives of young people identified by the students were role models, for example, parents, television and sporting stars and the Australian alcohol consumption culture with excessive intake by young people being considered a rite of passage into adulthood. The students discussed risk taking and testing limits as part of the development of the teenager and the strong need by the teenager to be accepted by their peers. It was noted that the most common causes of death in young people were accidents and poisoning. Lack of knowledge of the short and long term affects of excessive alcohol intake was also considered (Scholarship of Discovery, Boyer, 1990).
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The students presented articles on sporting stars with drug problems and several maintained that sensationalising the matter made the social problem of alcohol consumption worse. Sponsorship of sporting and musical events was also noted. In 2008 the Australian Federal Government introduced a tax on ‘‘Alco pops” or premixed alcoholic drinks, this provoked intense debate among the students with many concluding that consumers would become more resourceful and mix their own drinks possibly accentuating ill effects of alcohol consumption. The students had covered issues involving the supply of alcohol and reduction of demand. The nursing students asserted that a coordinated approach from the community was required to promote safe levels of alcohol consumption. A particular mixed message identified by the students was that people advocating safe levels of alcohol consumption are often considered on moral ‘‘high ground”, however several students argued that the nurse should provide opportunistic health education using appropriate teaching materials and support systems (Lawson and Flocke, in press) in order to prevent future health problems. The students asserted that nurses should consider their own attitudes and avoid moralising in agreement with Brown’s discussion (2007), that of Indig et al. (2008) and highlighted the targeting of young women, glamour and sophistication, peer pressure, the promise of temporary relief from life pressures and that several alcohol advertisements encourage young people to go to extremes. Duff (2003) has contended that the approach by the media is a series of complex interactions between it and the viewer and that the effect is far from straightforward and obvious. Discussion and implications The students discussed the findings of Vere-Jones (2007) and Toumbourou et al. (2007) outlining many of the issues caused by alcohol misuse, for example, seventy percent of admissions to hospital casualty departments in the United Kingdom and Australia are alcohol related and young people are consuming twice as much alcohol as they did ten years ago with predicted rises in the incidence of diseases such as cirrhosis of the liver, cancers and brain disorders. Advertising and easy availability of alcohol are strong factors in the drinking habits of young people with binge drinking to intoxication being most common among fourteen to twenty year olds. The discussion was facilitated by the lecturer and social workers with students observing that the three leading causes of death among young people in Australia-accidents, homicides and suicide- can be attributed to alcohol consumption. Inexperience with alcohol places young people at risk of violence, accidents and sexual coercion (Australian Alcohol Guidelines Fact Sheet, nd). What did the students learn from the National Health and Medical Research Council Guidelines on alcohol consumption? The students had developed awareness of media influences from their own research and reflections with reference to the Australian Government Department of Health and Aging Alcohol Guidelines (2001). The Guidelines urge young people not to drink beyond the levels outlined for low risk alcohol consumption by adults. Young people should be supported in their decision not to drink and should be supervised by adults at all times in situations where alcohol is available to them. Young people up to the age of eighteen are more vulnerable to the affects of alcohol due to their smaller size and decreased physical ability to process alcohol and they are psychologically inexperienced about the affects of alcohol. Women process alcohol much less effectively than men (Scholarship of Discovery, Boyer, 1990). An Australian Standard drink is regarded as one that contains 10 grams of alcohol compared with 8 grams in the United Kingdom
and 14 grams in the United States of America (International Center for Alcohol Policies, undated). The 2001 Australian Alcohol Guidelines recommended for men no more than four standard drinks a day on average, no more than six standard drinks on any one day and one or two alcohol-free per week. Women should have no more than two standard drinks a day on average, no more than four standard drinks in any one day and should have one or two alcohol-free days a week. The health promotion scenario The health promotion tool chosen was Goldenring and Rosen’s (2004) HEEADSSS method of interviewing that focuses upon Home environment, Education and Employment, Eating, peer related Activities, Drugs, Sexuality, Suicide/depression and Safety from injury and violence. The HEEADSSS tool has a relationship with Prochaska and DiClemente’s Stages of Change Model with motivational interviewing, has been used extensively with proven success since 1972 providing a focus on human needs (Davies, 2006) and behavioural and environmental factors (Whitehead, 2001 and Whitehead, 2004). Goldenring and Rosen’s tool is an example of Scholarship of Application (Arbuthnot et al., 2007and Boyer, 1990) demonstrating a holistic method of assessment using determinants of health. The issue of harm reduction was covered here but it became clear that several nursing students did not know what a standard drink was or what constituted at risk alcohol consumption. The students maintained that it is often hard to estimate the alcohol content of drinks due to different proportions of alcohol per volume, size of glasses, glasses being topped up and sharing of casks and flagons. The National Health and Medical Research Council (2001) guidelines and diagrams were provided; there was discussion on the interpretation of these with the students highlighting the inconsistencies. The health promotion scenario was then devised revolving around a seventeen year old youth and his friends who had presented at a hospital casualty department with injuries from a fight, alcohol was involved. The teenagers had requested resources to address alcohol and drug issues. Health promotion was devised using Australian Nursing and Midwifery Council Competencies for the Registered Nurse to identify the educational requirements of the youth and his peers and provide opportunistic informal education using the National Health and Medical Research Council Guidelines (2001). The students believed that the education needed to be opportunistic due to the heavy workload of hospital casualty departments and that the approach would be different in a community health centre. However, they were acutely aware that health behaviours of clients operate within a complex system of interacting influences and of the need to investigate how health is understood and experienced in every day life by these teenagers (Whitehead, 2001). The nursing students also found it essential to address their own beliefs on alcohol consumption in order to implement screening and intervention strategies. The students used a critical analytical approach to gain the confidence of the teenager, finding out about his home situation, his activities and peer –relationships, drug use and safety taking care with confidentiality and legal issues. There was the need to take care of the teenager’s immediate needs of nutrition, shelter, treatment of the injuries and safety. The imperative issues were providing empathy, talking about drug and alcohol issues whilst being aware of their own prejudices, knowing who to refer the teenager to and when. It was apparent that the teenager’s peers would also need to be treated in a respectful manner, congratulated on their ‘‘presence of mind” and provided with suitable health promotion. The problems of lack of services and stigma attached to using services in rural areas were also revealed.
K.A. Willsher / Nurse Education in Practice 10 (2010) 279–284
During the role play of this scenario there was valuable input from the youth social worker of a local community health service. She reiterated the importance of health workers showing respect for each other and for the teenager and his peers advocating the importance of listening to them to ascertain what solutions they had for the problems. She highlighted the importance of appropriate intervention and coordination of services (Scholarship of Integration-Boyer, 1990). Out to battle the bottle” (Vere-Jones, 2007) about a registered nurse working with the police providing health promotion on safe levels of alcohol consumption at venues frequented by young people highlighted the importance of ensuring that health promotion on drug and alcohol issues was taught in the undergraduate curriculum despite competing demands. Conclusion The nursing students investigated the developmental tasks required of young people, how to apply these to health promotion, the many mixed messages young people receive on alcohol and the effects these mixed messages have. The Australian Nursing and Midwifery Council Competencies for the Registered Nurse, HEEADDSSS and the National Health and Medical Research Council Guidelines (2001) on alcohol were used to develop a holistic approach based on critical analytical analysis. Positive feedback was provided to the students by the lecturer and the social workers as the scenario unfolded. The students expressed immense satisfaction with the teaching strategy and their responses on examination and in follow-up scenarios indicated enhanced competence in the development of the therapeutic relationship and the application of health promotion theory to practice (Arbuthnot et al., 2007). They expressed concern about the contextual nature of their practice, the likelihood of success in health promotion and their ability to provide follow-up care. However, the student evaluations revealed that ‘‘the scenario was relevant and interesting”, ‘‘provided the tools for further research”, ‘‘was fun but relevant” and ‘‘provided direction in an area that I feel that I lack confidence in”. The students requested the opportunity to develop further skills in the areas of assessment, intervention and motivational interviewing with clients who consume alcohol at hazardous or harmful levels and this feedback has been incorporated into teaching activities on campus and experiential learning activities. The role play scenario based strategy could be developed in the clinical setting possibly in a partnership strategy with universities as Indig et al. (2009) in their study found that 58% of emergency department nurses studied expressed lack of knowledge and confidence in assisting clients with alcohol related problems. Role play has been used successfully in other areas of the University undergraduate nursing curriculum and the nursing students have incorporated role play into health promotion activities at local schools. Scenario based role play is increasingly undergoing development for software packages and online activities. Studies such as those of Arbuthnot et al. (2007) and Bell et al. (2007) maintain that it is essential to develop programs that are sensitive and responsive to the needs of the students and consumers of health care. This discussion paper has highlighted mixed messages on alcohol consumption, the issues and imperatives of teaching health promotion with regard to alcohol consumption and illustrated how this can be achieved. Acknowlegement Dr Julie Watkinson, Team Leader, Nursing and Rural Health Unit, University of South Australia.
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References Arbuthnot, E., Hansen-Ketchum, P., Jewers, H., Moseley, J., Wilson, C., 2007. Bringing theory to life: engaging nursing students in a collaborative population- based screening project. International Journal of Nursing Education Scholarship 4 (1), 1–11. Australian Alcohol Guidelines Fact Sheet-Alcohol and Young People, undated The Australian Government Department of Health and Aging, Canberra, viewed 8 May 2007,
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Toumbourou, J., Stockwell, T., Neighbours, C., Marlatt, G., Sturge, J., Rehm, J., 2007. Interventions to reduce harm associated with adolescent substance abuse. The Lancet 369 (9570), 1391–1401. Turner, de S., Beddoes, L., 2007. Using reflective models to enhance learning: Experiences of staff and students. Nurse Education in Practice 7, 135–140. Under the influence, 2007, television program, SBS television, Sydney, 15 May. Vere-Jones, E., 2007. Out to battle the bottle. Nursing Times 103 (9), 20–21. Wallerstein, N., 2006. What is the evidence on effectiveness of empowerment to improve health? The Health Evidence Network Report. World Health Regional
Office for Europe: Copenhagen. Viewed 6 May, 2009 at www.euro.who.int/ Document/E88086.pdf. Whitehead, D., 2001. Health education, behavioural change and social psychology: nursing’s contribution to health promotion? Journal of Advanced Nursing 34 (6), 822–832. Whitehead, D., 2002. The ‘health promotional’ role of a pre-registration student cohort in the UK: a grounded-theory study. Nurse Education in Practice 2, 197–207. Whitehead, D., 2004. Health promotion and health education: Advancing the concepts. Journal of Advanced Nursing 47 (3), 311–320.
Contents lists available at ScienceDirect
Nurse Education in Practice journal homepage: www.elsevier.com/nepr
Overcoming mixed messages on alcohol consumption: A teaching strategy Kerre A. Willsher * University of South Australia, Nursing and Rural Health Unit, 111 Nicolson Ave, Whyalla, South Australia 5600, Australia
a r t i c l e
i n f o
Article history: Accepted 19 January 2010
Keywords: Health education Health promotion Teaching
a b s t r a c t The aim of this discussion paper is to outline the teaching of nursing students using a health promotion approach to guide young people on issues involving alcohol consumption. Health promotion uses a holistic approach involving the individual, attempts to understand complexities of human behaviour and attempts to address environmental and social issues which impact upon health. There are several models of health promotion but the health assessment tool chosen was HEEADSSS which focuses upon assessment of the Home environment, Education and Employment, eating disorders, peer related activities, Drugs, Sexuality, Suicide/depression and Safety from injury or violence . Society’s approach to alcohol consumption is considered ambiguous therefore it is essential to teach health promotion. Research based on demographic and epidemiological information and anecdotal media reports indicates a high incidence of binge drinking among young people on the Eyre Peninsula. The plan was to develop and provide developmentally appropriate health promotion using the Australian National Health and Medical Research Council Recommendations on alcohol consumption and the Australian Nursing and Midwifery Council Competencies for the Registered Nurse. Ó 2010 Elsevier Ltd. All rights reserved.
Introduction The aim of this paper is to discuss the education of Australian nursing students using a health promotion approach to guide young people on issues involving alcohol consumption The problem of alcohol abuse among teenagers in Australia is extreme compared to similarly developed countries threatening to overload the health care system according to Toumbourou et al. (2007), however, their studies revealed that brief health promotion interventions were effective. Bonomo et al. (2004) concur maintaining that alcohol intervention strategies for teenagers need to address the factors that influence high risk alcohol consumption including alcohol supply. Reports on the incidence of binge drinking by young people locally on the Eyre Peninsula Population Health Profile (Eyre Peninsula Division of General Practice, Australia, 2005) further confirmed the studies. Whitehead (2001) regards health education as authoritarian and therefore regarded negatively in many sectors of the community, young people for example, and maintains that there needs to be astute recognition and understanding of human development and behaviour. Health promotion uses a holistic approach involving the individual and entire communities attempting to understand the complexities of human behaviour and attempting to address environmental and social issues that impact upon health using ongoing follow-up. Bonomo (2005) asserts that society’s * Tel.: +61 8 86476097; fax: +61 8 86476014. E-mail address: [email protected] 1471-5953/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2010.01.003
approach to alcohol consumption is ambiguous and sends mixed messages, for example, advertisements about the legal blood alcohol levels for drivers and then the publicity given to prominent personalities who drink to excess. Many health professionals argue that active promotion of alcohol has led to increased consumption particularly among young people, leading to a wide range of alcohol induced problems (Duff, 2003). Mixed messages on alcohol are just one factor influencing the decision to drink. Young people learn partly through sharing experiences with their peers and through interacting with adults (Lewis et al., 2002). Alcohol consumption is considered the norm in Australia and alcohol has become easier to access. Young people are drinking more and alcohol related illnesses are occurring in younger people (Brown, 2007). The aim of the paper The aim of this discussion paper is to discuss the teaching of a health promotion strategy on alcohol consumption while fulfilling the multiple objectives of an undergraduate course in both 2007 and 2008. Literature review There are several health promotion models including Rosenstock’s Health Belief Model which explores the reasons people do not participate in health education programs (Bastable, 2003).
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K.A. Willsher / Nurse Education in Practice 10 (2010) 279–284
The success of The Health Belief Model is based upon the belief that health is highly valued and the individual and community are highly motivated to participate. Bastable (2003) cites several nursing studies in the area of drug and alcohol education supporting the validity of this model and maintains that nurses as educators need to use or develop resources that address barriers to the uptake of health education. Bandura’s Concept of Self Efficacy (Bastable, 2003, DeBarr; 2004 and Davies, 2006) is a motivational theory using the belief that the individual can accomplish a certain behaviour evidenced by previous similar behavioural accomplishments, observing the same success in others, verbal encouragement by others who present realistic beliefs that the person is capable of achieving the expected behaviour and emotional arousal through self-judgement of experiences. There is a reciprocal relationship between the person’s perceived abilities, behaviour and the environment. The Stages of Change Model (Prochaska and DiClemente, 1982 and Bastable, 2003, p. 176) was developed in the area of addiction and involves six stages- ‘‘precontemplation, contemplation, preparation, action, maintenance, and termination”. The use of The Stages of Change Model is beneficial in developing health promotion strategies to enable successful completion of specific changes. Rush (1997) challenges the ideology that the individual alone is responsible for their health and maintains that nurses should critically examine health promotion theories considering social, political and environmental determinants of health as well as behaviour. This is confirmed by Whitehead (2004) who calls for further application of health promotion theories to nursing practice. The theories of health promotion are often complex, overlap and often cannot be separated from one another. Nursing students often struggle with the complexities of health promotion and engage in soul searching. However, it is essential for nurses to adapt to health promotion roles and educational reform is central to achieving this (The World Health Organization, 1999; Whitehead, 2002 and Wallerstein, 2006). Chinn and Kramer (2008) call for the use of praxis (thoughtful reflection and practice) to identify social issues and to find ways to address them. This is confirmed by Turner et al., 2007) who maintain that critical reflection is essential in nursing theory and practice. Holt and Warne (2007) in their explorative study found that health promotion theory used in the nursing curriculum does not link to what the students actually experience when undertaking experiential learning. Holt and Warne (2007) argue that nurse educators and experiential learning providers need to engage more extensively with one another to link theory and practice providing opportunities for the implementation and assessment of health promotion strategies by nursing students. Hubell and Burman (2006) concur maintaining that partnerships need to be developed using the organisations’ mission statements and values to develop mutually agreed upon goals. Scenario based teaching involving academics and clinicians allowing students to use and act out issues that they have encountered could assist in linking health promotion theory to practice (Holt and Warne, 2007). It is essential for learning to be intellectually stimulating and Cleary et al. (2006) maintain that role play, reflection, case studies and the use of creative skills enhance learning if students are motivated to participate and if there is demonstrated relevance. Boyer’s (1990) framework expands upon the definition of scholarship to include ‘‘the domains of discovery, integration, application and teaching” (p. 16). Arbuthnot et al., 2007) in their study of health promotion in the early detection of bowel cancer further illustrates the practical application of Boyer’s framework assisting in the creation of this particular teaching strategy using inquiry built upon the nursing knowledge of health promotion and developmental behaviour (discovery), transfer of knowledge about standard alcoholic drinks to students (scholarship of teaching), the advancement of clinical knowledge on the effects
of and management of excessive alcohol consumption (scholarship of application) and the development of interdisciplinary collaboration with a social worker and a drug and alcohol counsellor (scholarship of integration). The teaching process The course Health of Infants, Children and Young People (2007, 2008) was a second year course in a three year undergraduate nursing program at the University of South Australia and the aims and objectives were to-. Explain the role of the Registered Nurse in family-centred care in relevant health care settings Gather, evaluate and deploy a range of evidence to design and evaluate health interventions (primary and tertiary). Undertake a health assessment of a child or young person by engaging them in health promotion activities, taking baseline observations and a simple nutrition, sleep, exercise and family social history as part of formal assessment. Demonstrate an understanding of the interventions required identifying and improving the self esteem/social and emotional well-being needs of infants, children and young people. Demonstrate an understanding of the specific needs of the sick infant, child and young person and their family incorporating the philosophy of partnership-in-care. Demonstrate skills in assessing and evaluating the suitability of health education and social services available for infants, children and young people and their families. Demonstrate ethical and legal principles in the care of infants, children and young people and Demonstrate understanding of the meeting the cultural needs, rights and expectations of infants, children and young people and their families in diverse settings. A prerequisite for the course was Determining Australia’s Health, a first year course investigating the social determinants of health, community resources, epidemiology and public health. The students now had the opportunity to develop a practical application from these concepts (Arbuthnot et al., 2007). Stages of the course and the teaching strategies used
Week 1- Family-centred care/role of child health and paediatric nurses-lecture, tutorial, focus group discussions. Week 2-Communication and holistic assessment-lecture, tutorial, pre reading and role play. Week 3- Focus of care-the school-aged child-guest lecturer, research and presentations by the students. Week 4- Mental health issues-guest lecturer, students presented media articles for peer critique, as part of assessment one the students prepared open ended questions to obtain a history from a child. Week 5- Hospitalization/pain assessment and management. Lecture, tutorial, review of previous lectures, role play using pain assessment tools, group work critiquing journal articles. Week 6- Legal issues-guest lecturer, review of mandated reporting of child abuse, consent, scenario based group activities, development of suitable health promotion materials in preparation for a visit to the campus by school aged children.
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Week 7- School children visit the campus and are assessed. Week 8-Immunization and the safe administration of medications. Lecture, tutorial, review of epidemiology topics, work through online drug calculation program with tests with feedback given by the lecturer. Week 9- Focus of care- the infant, toddler and preschool child- lecture, tutorial, revision of previous topics, scenario based DVDs, research on the developmental needs of children and young people and reporting back. Review of media items. ****Week 10- Focus of care-the young person. Guest lecturers-social workers from youth mental health service- Lecture, tutorial, appraisal of media items, students prepare and present the role play which is appraised by the social workers and student colleagues. The appraisals are collated to develop further teaching materials.**** Week 11- Asthma-epidemiology and management. Guest lecturer, tutorial using online materials and a scenario based practical session. Week 12-Management of children with Type One DiabetesGuest lecturer, tutorial using group research and presentations, scenario based practical session with students using checklists to provide peer appraisal of clinical procedures. Week 13- The impact of severe chronic illness and its management. The mother of a child with a chronic condition addressed the students, tutorial with students researching childhood cancers, cystic fibrosis and cardiovascular conditions, practical session on medication administration, scenario based activities on nutrition, mental health and parenteral therapy. Pre-reading was required before each lecture and handouts were developed.
Discussion of the aims and objectives The course had a large communication teaching component in regard to the application of knowledge on growth and development. The learning objectives for the component ‘‘focus of carethe young person” were the application of knowledge about growth and development of the young person and the link with risk taking behaviours including alcohol consumption. The relationship between determinants of health such as age, gender, culture, income, education level, geographic location, access to services and risk factors was examined then used to design the strategy (Arbuthnot et al., 2007). The students then developed a teaching plan in regard to nutrition, drug and alcohol consumption, sexual health, mental health, physical fitness and personal safety and to identify appropriate health services for young people (Arbuthnot et al., 2007; Boyer, 1990). The nursing students themselves were undergraduates in the second year of the nursing program, mainly young people and as such would be targets for alcohol advertising as well as role models for others, developing the ability to provide health promotion on drug and alcohol consumption. Consideration also needs to be given to high levels of stress that nursing students face during their undergraduate education due to work and study load, caring for acutely ill patients whilst developing their own clinical knowledge and skills, therefore risking ‘‘burnout” and the temptation of alcohol (Frank and Halstead, 2005). It is essential for the nursing students themselves to have adequate social supports. Many of the students discussed their own experiences of friends who had died or who had been seriously injured as a result of excessive alcohol
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consumption. The tutorials were also an opportunity to debrief and obtain support in what Lawson and Flocke (in press, 2008) regards as a ‘‘teachable moment” and Boyer regards as scholarship of application and scholarship of integration encouraging reflection and highlighting relevance linking to the behavioural theories of health promotion. The Australian Nursing and Midwifery Council Competencies for the Registered Nurse (2006) were used as the framework to educate nursing students to conduct health promotion on alcohol consumption for young people. The Australian Nursing and Midwifery Council works in conjunction with state and territory regulatory bodies to develop standards by which nurses are assessed. The Competencies form a basis in curriculum development and provide relevant information to health consumers on the standards that are to be expected from registered nurses. Competency 7.7 from Domain three –Provision and Coordination of Care formed the basis for this health promotion teaching strategy.
Australian Nursing and Midwifery Council Competency 7.7. Identifying and documenting specific educational requirements and requests of individuals/ groups. Undertaking formal and informal education sessions with individuals/groups as necessary. Identifying appropriate educational resources, including other health professionals
(Australian Nursing and Midwifery Council, 2006, National Competency Standards for the Registered Nurse, Australian Nursing and Midwifery Council, Canberra). The 2001 Australian Alcohol Guidelines Health Risks and Benefits as endorsed by the National Health and Medical Research Council link to the course aims and objectives and Australian Nursing and Midwifery Council (2006) Competency 7.7 particularly in regard to gathering and evaluating evidence and health promotion. Preparation for the teaching activity The tutorial for ‘‘focus of care-the young person” involved the discussion of media items located by the students on the situation of young people from the age of twelve to twenty-four. The students were encouraged to investigate advertising from manufacturers, government media releases and other media activities and to view ‘‘Under the Influence” a topic debate on Insight” a current affairs program on SBS television broadcasting a debate on whether hotels or liquor outlets should be open twenty-four hours a day. The tutorial The learning experience provided a review of the key points about the growth, development and social interaction of the young person. Key influences in the lives of young people identified by the students were role models, for example, parents, television and sporting stars and the Australian alcohol consumption culture with excessive intake by young people being considered a rite of passage into adulthood. The students discussed risk taking and testing limits as part of the development of the teenager and the strong need by the teenager to be accepted by their peers. It was noted that the most common causes of death in young people were accidents and poisoning. Lack of knowledge of the short and long term affects of excessive alcohol intake was also considered (Scholarship of Discovery, Boyer, 1990).
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The students presented articles on sporting stars with drug problems and several maintained that sensationalising the matter made the social problem of alcohol consumption worse. Sponsorship of sporting and musical events was also noted. In 2008 the Australian Federal Government introduced a tax on ‘‘Alco pops” or premixed alcoholic drinks, this provoked intense debate among the students with many concluding that consumers would become more resourceful and mix their own drinks possibly accentuating ill effects of alcohol consumption. The students had covered issues involving the supply of alcohol and reduction of demand. The nursing students asserted that a coordinated approach from the community was required to promote safe levels of alcohol consumption. A particular mixed message identified by the students was that people advocating safe levels of alcohol consumption are often considered on moral ‘‘high ground”, however several students argued that the nurse should provide opportunistic health education using appropriate teaching materials and support systems (Lawson and Flocke, in press) in order to prevent future health problems. The students asserted that nurses should consider their own attitudes and avoid moralising in agreement with Brown’s discussion (2007), that of Indig et al. (2008) and highlighted the targeting of young women, glamour and sophistication, peer pressure, the promise of temporary relief from life pressures and that several alcohol advertisements encourage young people to go to extremes. Duff (2003) has contended that the approach by the media is a series of complex interactions between it and the viewer and that the effect is far from straightforward and obvious. Discussion and implications The students discussed the findings of Vere-Jones (2007) and Toumbourou et al. (2007) outlining many of the issues caused by alcohol misuse, for example, seventy percent of admissions to hospital casualty departments in the United Kingdom and Australia are alcohol related and young people are consuming twice as much alcohol as they did ten years ago with predicted rises in the incidence of diseases such as cirrhosis of the liver, cancers and brain disorders. Advertising and easy availability of alcohol are strong factors in the drinking habits of young people with binge drinking to intoxication being most common among fourteen to twenty year olds. The discussion was facilitated by the lecturer and social workers with students observing that the three leading causes of death among young people in Australia-accidents, homicides and suicide- can be attributed to alcohol consumption. Inexperience with alcohol places young people at risk of violence, accidents and sexual coercion (Australian Alcohol Guidelines Fact Sheet, nd). What did the students learn from the National Health and Medical Research Council Guidelines on alcohol consumption? The students had developed awareness of media influences from their own research and reflections with reference to the Australian Government Department of Health and Aging Alcohol Guidelines (2001). The Guidelines urge young people not to drink beyond the levels outlined for low risk alcohol consumption by adults. Young people should be supported in their decision not to drink and should be supervised by adults at all times in situations where alcohol is available to them. Young people up to the age of eighteen are more vulnerable to the affects of alcohol due to their smaller size and decreased physical ability to process alcohol and they are psychologically inexperienced about the affects of alcohol. Women process alcohol much less effectively than men (Scholarship of Discovery, Boyer, 1990). An Australian Standard drink is regarded as one that contains 10 grams of alcohol compared with 8 grams in the United Kingdom
and 14 grams in the United States of America (International Center for Alcohol Policies, undated). The 2001 Australian Alcohol Guidelines recommended for men no more than four standard drinks a day on average, no more than six standard drinks on any one day and one or two alcohol-free per week. Women should have no more than two standard drinks a day on average, no more than four standard drinks in any one day and should have one or two alcohol-free days a week. The health promotion scenario The health promotion tool chosen was Goldenring and Rosen’s (2004) HEEADSSS method of interviewing that focuses upon Home environment, Education and Employment, Eating, peer related Activities, Drugs, Sexuality, Suicide/depression and Safety from injury and violence. The HEEADSSS tool has a relationship with Prochaska and DiClemente’s Stages of Change Model with motivational interviewing, has been used extensively with proven success since 1972 providing a focus on human needs (Davies, 2006) and behavioural and environmental factors (Whitehead, 2001 and Whitehead, 2004). Goldenring and Rosen’s tool is an example of Scholarship of Application (Arbuthnot et al., 2007and Boyer, 1990) demonstrating a holistic method of assessment using determinants of health. The issue of harm reduction was covered here but it became clear that several nursing students did not know what a standard drink was or what constituted at risk alcohol consumption. The students maintained that it is often hard to estimate the alcohol content of drinks due to different proportions of alcohol per volume, size of glasses, glasses being topped up and sharing of casks and flagons. The National Health and Medical Research Council (2001) guidelines and diagrams were provided; there was discussion on the interpretation of these with the students highlighting the inconsistencies. The health promotion scenario was then devised revolving around a seventeen year old youth and his friends who had presented at a hospital casualty department with injuries from a fight, alcohol was involved. The teenagers had requested resources to address alcohol and drug issues. Health promotion was devised using Australian Nursing and Midwifery Council Competencies for the Registered Nurse to identify the educational requirements of the youth and his peers and provide opportunistic informal education using the National Health and Medical Research Council Guidelines (2001). The students believed that the education needed to be opportunistic due to the heavy workload of hospital casualty departments and that the approach would be different in a community health centre. However, they were acutely aware that health behaviours of clients operate within a complex system of interacting influences and of the need to investigate how health is understood and experienced in every day life by these teenagers (Whitehead, 2001). The nursing students also found it essential to address their own beliefs on alcohol consumption in order to implement screening and intervention strategies. The students used a critical analytical approach to gain the confidence of the teenager, finding out about his home situation, his activities and peer –relationships, drug use and safety taking care with confidentiality and legal issues. There was the need to take care of the teenager’s immediate needs of nutrition, shelter, treatment of the injuries and safety. The imperative issues were providing empathy, talking about drug and alcohol issues whilst being aware of their own prejudices, knowing who to refer the teenager to and when. It was apparent that the teenager’s peers would also need to be treated in a respectful manner, congratulated on their ‘‘presence of mind” and provided with suitable health promotion. The problems of lack of services and stigma attached to using services in rural areas were also revealed.
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During the role play of this scenario there was valuable input from the youth social worker of a local community health service. She reiterated the importance of health workers showing respect for each other and for the teenager and his peers advocating the importance of listening to them to ascertain what solutions they had for the problems. She highlighted the importance of appropriate intervention and coordination of services (Scholarship of Integration-Boyer, 1990). Out to battle the bottle” (Vere-Jones, 2007) about a registered nurse working with the police providing health promotion on safe levels of alcohol consumption at venues frequented by young people highlighted the importance of ensuring that health promotion on drug and alcohol issues was taught in the undergraduate curriculum despite competing demands. Conclusion The nursing students investigated the developmental tasks required of young people, how to apply these to health promotion, the many mixed messages young people receive on alcohol and the effects these mixed messages have. The Australian Nursing and Midwifery Council Competencies for the Registered Nurse, HEEADDSSS and the National Health and Medical Research Council Guidelines (2001) on alcohol were used to develop a holistic approach based on critical analytical analysis. Positive feedback was provided to the students by the lecturer and the social workers as the scenario unfolded. The students expressed immense satisfaction with the teaching strategy and their responses on examination and in follow-up scenarios indicated enhanced competence in the development of the therapeutic relationship and the application of health promotion theory to practice (Arbuthnot et al., 2007). They expressed concern about the contextual nature of their practice, the likelihood of success in health promotion and their ability to provide follow-up care. However, the student evaluations revealed that ‘‘the scenario was relevant and interesting”, ‘‘provided the tools for further research”, ‘‘was fun but relevant” and ‘‘provided direction in an area that I feel that I lack confidence in”. The students requested the opportunity to develop further skills in the areas of assessment, intervention and motivational interviewing with clients who consume alcohol at hazardous or harmful levels and this feedback has been incorporated into teaching activities on campus and experiential learning activities. The role play scenario based strategy could be developed in the clinical setting possibly in a partnership strategy with universities as Indig et al. (2009) in their study found that 58% of emergency department nurses studied expressed lack of knowledge and confidence in assisting clients with alcohol related problems. Role play has been used successfully in other areas of the University undergraduate nursing curriculum and the nursing students have incorporated role play into health promotion activities at local schools. Scenario based role play is increasingly undergoing development for software packages and online activities. Studies such as those of Arbuthnot et al. (2007) and Bell et al. (2007) maintain that it is essential to develop programs that are sensitive and responsive to the needs of the students and consumers of health care. This discussion paper has highlighted mixed messages on alcohol consumption, the issues and imperatives of teaching health promotion with regard to alcohol consumption and illustrated how this can be achieved. Acknowlegement Dr Julie Watkinson, Team Leader, Nursing and Rural Health Unit, University of South Australia.
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References Arbuthnot, E., Hansen-Ketchum, P., Jewers, H., Moseley, J., Wilson, C., 2007. Bringing theory to life: engaging nursing students in a collaborative population- based screening project. International Journal of Nursing Education Scholarship 4 (1), 1–11. Australian Alcohol Guidelines Fact Sheet-Alcohol and Young People, undated The Australian Government Department of Health and Aging, Canberra, viewed 8 May 2007,
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