ORIGINAL ARTICLE
DOI: 10.11606/issn.1806-6976.smad.2018.000405

 

Attitudes of undergraduate novice nursing students before alcoholic patients

 

Actitudes de iniciantes de la graduación en enfermería frente al paciente alcohólico

 

 

Samuel Barroso Rodrigues^I; Jacqueline de Souza^I

^IUniversidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, PAHO/WHO Collaborating Centre for Nursing Research Development, Ribeirão Preto, SP, Brazil

 

 

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ABSTRACT

OBJECTIVE: to analyze the attitudes of novice nursing students before alcoholic patients.
METHOD: qualitative quantitative study with application of the Scale of attitudes toward alcohol and alcoholism, a socio-demographic questionnaire, and a realistic simulation.
RESULTS: the attitudes were positive and there was a significant association between attitude and age of the students (p = 0.014). Three categories were identified: 1) Aspects of behavioral nature; 2) Aspects of conceptual nature; and 3) Aspects of emotional nature.
CONCLUSION: it is important to know the attitudes of students before alcoholic people by means of qualitative approaches so that educational practices may ensure a more appropriate preparation of students to provide care to this specific clientele.

Descriptors: Alcohol-Related Disorders; Alcoholism; Students, Nursing; Health Knowledge, Attitudes, Practice.

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RESUMEN

OBJETIVO: Analizar la actitud de los alumnos principiantes del curso de graduación en enfermería frente al alcohólico.
MÉTODO: Estudio mixed-method en el cual se aplicó la Escala de Actitudes Frente al Alcohol y al Alcoolista, un cuestionario sociodemográfico y realizada una simulación realista.
RESULTADOS: Las actitudes fueron más positivas y hubo una asociación significativa entre la actitud y el grupo de edad (p = 0,014). Se identificaron tres categorías: 1) Aspectos de comportamiento conductual; 2) Aspectos de ámbito conceptual y 3) Aspectos de Ámbito emocional.
CONCLUSIÓN: Es importante conocer las actitudes de los estudiantes frente al alcohólico a través de enfoques también cualitativos a fin de que las prácticas educativas les aseguren una preparación más adecuada en el cuidado prestado a esta clientela.

Descriptores: Trastornos Relacionados con Alcohol; Alcoholismo; Estudiantes de Enfermería; Conocimientos; Actitudes y Práctica en Salud.

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Introduction

Alcohol use has become frequent in the nursing routine in different care settings, such as clinical, surgical, general hospital and primary care⁽¹⁾.

In general, when patients seek care in the health units, their first contacts are nursing professionals. Thus, the attitude of these professionals towards patients has an impact in the whole course of treatment, especially in cases of alcohol users who may present both organic and psychic problems, as well as low adherence to work⁽²⁾.

Although this is a subject widely studied and the fruit of numerous definitions, the term attitude still does not have a precise meaning. For some authors, attitudes are behaviors resulting from values ​​derived from other more basic values which were internalized during development in childhood or daily life⁽³⁾. The Health Sciences Descriptors (DeCS) define attitude as an acquired and lasting predisposition to always act in the same way before a certain class of objects, based on the way they are conceived.

Thus, considering that nurses are key professionals for the identification of individuals with alcohol-related problems, due to their privileged position in the staff and in the emabracement of users in health services, it is important that these professionals assist the patients free from negative attitudes, that is, without any sort of discrimination, prejudice and or influence of moral values, including those that stigmatize individuals who consume alcoholic beverages⁽⁴⁾.

Few studies have had the goal of studying the attitudes of undergraduate nursing students. There is, therefore, a need to analyze this phenomenon in greater depth^(1-2,5-7). However, because of the complexity of this theme, the exclusive use of quantitative components may not be enough to access subjective aspects of attitudes.

Thus, we believe that the present study is relevant because it generates objective data (of quantitative nature) regarding the attitudes of novice students of the undergraduate nursing course towards alcoholic patients, as well as qualitative data through the spontaneous capture of subjective and attitudinal aspects of the individuals.

 

Objective

To evaluate the attitudes of undergraduate novice nursng students of before alcoholic patients.

 

Materials and Method

This study had a mixed-method, allowing the combination of quantitative and qualitative techniques in the same study^(8-9). The study was carried out with first and second year students of the nursing course of a Nursing School in the countryside of São Paulo.

At first, the SATAA (Scale of attitudes toward alcohol and alcoholism) and a sociodemographic questionnaire were applied. The SATAA is subdivided into 4 factors, including the Factor 2: Persons with alcohol-related disorders, composed of 12 items that involve opinions and feelings of the students regarding the physical and psychic characteristics of alcoholic people⁽¹⁰⁾. The sociodemographic questionnaire covered issues such as gender, age, participation in events about alcoholism, among others. The participants were recruited through invitation in the classroom.

In a second moment, 20 students were randomly selected to participate in a simulation strategy with simulated patients. In order to observe all the students, the simulation was carried out in three days for an equivalent number of students and its operation had the contribution of an actor (duly qualified and standardized to simulate a script previously prepared for the planned scenario) and the technique was videotaped and had two participating observers. The footage was transcribed verbatim, and the observers made a field diary.

At this stage the recruitment of participants was by lot and the invitation was made via e-mail. The collection was carried out in the Laboratory of Primary Care (simulated House) of the university⁽¹¹⁾.

The inclusion criteria were to be regularly enrolled in the Bachelor or Bachelor/Licentiate course of Nursing of the EERP-USP and have at least 18 full years of age at the time of data collection. After applying the inclusion and exclusion criteria, a sample of 170 participants were obtained in the quantitative step and 19 participants in the qualitative step.

Regarding the analysis of quantitative data, descriptive analyses were made to identify the correlation between socio-demographic variables and attitudes based on the SATAA factor 2 ("Person with alcohol-related disorders"). Its possible minimum score is 1 and maximum 5, and the closer to 5 the more positive the attitude is. Regarding the qualitative data, the records of the participant observations and the transcripts of the videos were submitted to content analysis⁽¹²⁾.

Based on Resolution 466/2012 of the National Health Council on the guidelines and norms regulating research involving human beings, the project was approved by the Research Ethics Committee (REC) of the Ribeirão Preto College of Nursing (EERP-USP) under Opinion CAAE 56421516.9.0000.5393.

 

Results

The average age of the students was 20.1 years (SD = 3.5), the majority was female (145, 85.3%), non-Catholic (protestant, spiritist, agnostic, others, or without religion) or non-religious (88; 51.85%); and had no partner (163; 95.9%). Current or previous socialization with alcoholic people was reported by 118 (69.4%) students. As for professional aspects, most reported having no job, or additional training in the health area (149, 87.6%) or participation of events on alcoholism (154; 90.6%) (Table 1).

 

 

In the SATAA Factor 2 ("Person with alcohol-related disorders"), the students obtained an average of 3.66 (median = 3.62, SD = 0.49). There was a statistically significant difference between the SATAA Factor 2 and age (p = 0.011). As for the other sociodemographic characteristics (sex, age, marital status, living with an alcoholic person, work or additional training in the health area and participation in events about alcoholism), there was no statistically significant difference between the pattern of alcohol use and SATAA Factor 2.

In the set of participant observations and transcribed videos, 61 units of meaning and 10 codes were identified and grouped into three specific categories: 1) Aspects of behavioral nature of the student; 2) Aspects of conceptual nature of the student and; 3) Aspects of emotional nature of the student (Figure 1).

Regarding the data volume, the category with the most recurrent units of meaning was "Aspects of conceptual nature" (26; 42.6%), followed by the categories of "Aspects of emotional nature" (20, 32.8% ) and "Aspects of behavioral nature" (15, 24.6%).

Category 1: Aspects of emotional nature of the student before alcoholic people

The attitudes in this category reflect the affective field of the students, that is, those related to the way the emotions are expressed before the stimuli of the scenario. In this category, the analysis of the data set (speeches and transcriptions of videos) suggested that during the scenario, the students mentioned or had body postures that suggested some restlessness and anxiety.

In order to differentiate the statements and excerpts from the transcripts and observations of the three days of simulation, the following codes were assigned: S₁ (Simulation 1); S₂ (Simulation 2); S₃ (Simulation 3). Each student received a different sequential numbering (from 1 to 19) in front of the letter "NS" (Novice Student).

In general, the students appeared restless and anxious during the visit to the patient. Those who were actively participating in the scene kept their hands between their legs much of the time, the voice was shaky and the bodies were restless (S₁).

I was stucked. We were a bit anxious and nervous too, so much so that sometimes the moment of silence was kind of ... uncomfortable, you know? (NS₂; S₂).

If I was the one who was in charge of giving care, I would feel very anxious and insecure, because even if I had other people with me, I don’t know, something could happen to me (NS₃; S₁).

The students also mentioned the feeling of fear of violence from the alcoholic patient: At the beginning of the visit I was feeling a little scared so, you know, if I would take a slap in the face. (NS₂; S₁).

An episode of crying was observed:

I have two close family members: one who uses more serious drugs and one who uses alcoholic beverages... [crying] so ... for the experience, for the interaction I have with them, I would do differently. Oh, guys... I’m sorry, I get very emotional when I talk about this. (NS₃; S₃).

As observed, both speech and body expression of the students denoted different emotions that were concentrated in this category.

Category 2: Aspects of conceptual nature of the student before alcoholic people

This category encompassed characteristics related both to the student’s understanding of alcohol users, alcoholic beverages and their use. The data set suggests that the view of students about alcoholism considers the comprehensive conception of health because they were concerned with investigating biopsychosocial aspects of the individual during the home visit:

We will talk more, see what’s happening (...) we will take care of your injuries and think about the treatment so that you stop drinking and recover (NS₁; S₁).

Besides the bruises, is there anything else you’ve been feeling lately? Any other emotional symptoms? (...) Do you feel good when you see yourself in the mirror? (NS₂; S₁).

There was also concern on the part of some students about the consequences of the pattern of problematic use of alcohol, suggesting that they had notions about the losses implied:

How do you get when you drink? Do you get aggressive? Or do you stay calm, are you happy? How is it? (NS₁; S₁).

Some students mentioned conceptions based on common sense, such as: believing that the alcoholic subject is an unpredictable individual who does not seek help and who says lies:

I, as a student watching them to provide care, I did not know if the patient would have a fit of rage and beat the students or have a crying crisis. He was very unpredictable (NS₁; S₁).

These people who use alcohol do not seek help in the health unit, they do not schedule consultations, you know?
I think it is very hard for you make contact with them (NS⁵, S₁).

You never know if the fact that he was bitten is a story he’s making up, you think it could be a lot of things (NS₃; S₂).

Some speeches suggest that some students understand alcoholism as a disease:

We have to understand that alcoholism is a disease, not a contagious disease, but subjective disease (NS₅; S₃).

We never know how the patient will be in the next visit. Alcoholism is not the same as an organic disease, such as a wound, but it is a disease, because the patient is not well with himself (NS₂; S₃).

Some students pointed out that some concerns are needed when dealing with alcoholic people:

You have to be careful about what to say, because if you slip into talking to him, the way you speak to him, and even your posture, the posture you assume can compromise you (NS₃; S₂).

We have to know how to hold back, you know, not only in relation to this, but with respect to our feelings, too (NS₃; S₃).

As noted, this category brought together the main concepts that students seem to have regarding alcoholism and alcoholic people, illustrating a number of issues of common sense, unpredictability, liars, dislikes of work, and so on. On the other hand, they also presented notions about comprehensive care, consequences of alcohol use, conception of alcoholism as a disease of psychosocial causality, and concerns about the treatment of alcohol users.

Category 3: Aspects of behavioral nature of the students before alcoholic people

This category covered the behavioral aspects of the participants in relation to the stimuli of the scenario. Some students performed warmly and politely before the patient.

[Students knock on the door]: Good morning, Mister João! We are students from the nursing school and we came here to pay a visit to see how you are doing. Can we talk for a little bit? (...). It’s going to be fast (NS₂; S₁).

When the patient is about to get up, NS₁ asks if he wants help and extends her hand, while the E₂ offers her hands to help him stand up. They thank and leave. (S₂).

However, other students had less educated attitudes:

[João opens the door and NS₂ keeps silent and does not verbally greet the patient. None of the students on the scene shake John’s hand to greet him] (S₁).

[At the door, neither of the two students greets by touching John’s hands, they just fix their eyes slightly on his face and then lower their heads] (S₃).

As presented, this category focused on the main behaviors that students seem to have toward alcoholic individuals, illustrating both welcoming and educated attitudes, and other less welcoming and/or less educated attitudes.

 

Discussion

The majority of the students were enrolled in the first year of nursing (86, 50.6%), the average age was 20.1 years, the majority was female (145, 85.30%) and of the Catholic religion (82, 48.2%). As the research was carried out with undergraduate and graduate courses in the health area, it was expected that the age group found in this study was predominantly young, and that most of participants were female, in agreement with other studies^{(1,13- 15)}.

In both steps of the study, the majority of the participants reported having or having had a relationship with an alcoholic patient (69.4%; 118). These findings reveal that alcoholism is a phenomenon quite common and closer to the reality of people than we can imagine, being indistinctly present in different societies and social strata, even surpassing the geographical and cultural limits of each people⁽¹⁶⁾.

A statistically significant association was identified between SATAA Factor 2 and age (p = 0.011), and the average attitudes of students aged 18 to 19 years was 3.76 and that of students aged over 19 years was 3.57.

These data is in line with another study carried out with older students, therefore enrolled in more advanced semesters of the course. Although they had more knowledge about the theme and confidence to deal with the patients, they had more negative attitudes, predominantly expressing the belief that being an alcoholic person can only be treated when she is "deep down" and that the problem of alcoholism is restricted to the user only⁽¹⁷⁾. In spite of this, this difference cannot be analyzed in isolation, and does not serve as a parameter to infer whether the older age alone influences negatively attitudes.

With regard to qualitative data, three categories were identified in relation to the students’ attitudes towards alcoholic people. They addressed emotional, conceptual and behavioral aspects, namely:

Category 1 - Aspects of emotional nature of the students before alcoholic people

In this category, there was a predominance of negative meanings before alcoholic patients, since most of the situations observed involved feelings of restlessness and anxiety, fear of violence and crying before the patient.

The WHO proposes that care to patients in mental health should be established upon simple and clear communication, without hesitation or fear. It should be empathetic and respond to the patients’ demands appropriately, especially to information about them that is private or embarrassing during the home visit (such as aggressions, consumption habits, or life)⁽¹⁸⁾.

In this sense, it is important that nursing students, as future health professionals, be as free of prejudices and judgments as possible. By doing so, the care provided will not be influenced by their emotional reactions, either by the impact of seeing the patients in situations of vulnerability or due to subjective aspects that occasionally cause discomfort in the care providers.

This feeling of restlessness and anxiety seems to be quite recurrent, even in situations outside the context of the simulation. A study carried out with last-semester medical and nursing students in Scotland showed that the students felt insecure to advise and deal with alcoholic patients, especially because they had little knowledge about the subject⁽¹⁹⁾.

The fear of being hit by the alcoholic patient seems to be a typical feeling of the students. In another study, for example, 49% of the students reported being afraid of aggressiveness, although 75% denied such feeling, and half reported not being able to handle the situation⁽²⁾. Similarly, in another study, the participants reported fear of the unexpected and insecurity to deal with alcohol users⁽⁷⁾.

In view of the above, it is necessary to implement teaching strategies in the undergraduate training of nurses (such as gradual immersion in activities that bring them as close to practical reality as possible) so that they can live such experiences since the beginning of the course and throughout their training feel more emotionally prepared to deal with this clientele.

Category 2 - Aspects of conceptual nature of the students before alcoholic people

Attitudes that deal with issues of a conceptual scope (how they conceive by the alcoholic person) were more positively. The students had a comprehensive conception of health and of the consequences of alcohol use, as if they understand alcoholism as a disease.

Comprehensive health care is the right of people to be assisted according to their real needs. Thus, professionals must assist individuals in an integral way, seeing them "as a whole" through actions of health promotion, prevention of diseases, and healing and rehabilitation⁽²⁰⁾.

Therefore, it was noticed that the students were able to point the importance of treatment, setting goals, respecting the patient’s preferences, informing him about the duration of treatment. Moreover, they demonstrated concern about the patient’s alcohol consumption, giving importance to adherence to treatment, and facilitated the referral of the user to specialists⁽¹⁸⁾.

With respect to the connotation of disease attributed by students to alcoholism, this is in agreement with another study⁽²⁾. This perception was understood as a positive attitude, because the students’ speeches in the present study suggested that the problematic use of alcohol goes beyond the organic question; it is not a disease that comes from the outside to the inside, such as an infection, for example, but it happens from the inside out.

Regarding the conceptions about alcoholism, WHO provides good clinical practice for interactions among mental health professionals through the General Principles of Care (GPC). The PGC proposes that during a mental health care, the professionals must be free of discrimination based on race, color, sex, language, religion, political opinion or other sort of opinion, nationality, ethnic/indigenous/social origin, and economic status or birth order. Therefore, under any circumstances should the professional express judgments, and should respond to the patients’ demands in a way free of prejudice and stigmatization⁽¹⁸⁾.

Thus, the importance of introducing basic concepts about mental health knowledge and practices since the beginning of undergraduate training is emphasized, so that the notion of comprehensiveness is improved and preserved.

Category 3 - Aspects of behavioral nature of the students before alcoholic people

This category made it possible to identify that the students presented a polite, ethical and professional and welcoming attitude, although, at times, they presented less welcoming and educated attitudes.

Effective care should be based on an empathetic approach, where the professional is friendly at all times, regardless of age, sex, culture and language differences. Nurses must provide care in a dignified and holistic manner, responding to the demands, being sensitive, educated and understanding, respecting the privacy of the patient, and maintaining a good relationship with the patients⁽²¹⁾.

One of the limitations of this study is the fact that the simulation technique was used, which, no matter how true to the reality it was, and even being scrutinized by specialists in the area before implementation, it was not a real case. In other words, the fact that the participants had the knowledge that it was a simulation and that they were being observed may have reproduced some behaviors that do not correspond to their real attitudes, leading them to act according to what is advocated by the profession.

In view of the above, the importance of teaching strategies aimed at understanding alcoholism as a disease from the biopsychosocial perspective stands out. Such strategies will contribute to prepare undergraduate students, as future nurses, to deal more positively with alcoholic individuals, supported by a care practice based on ethical, human and comprehensive principles of health care.

 

Conclusion

It was identified that the attitudes of novice students, in general, tended to be more positive. The students assumed most of the time a polite and professional stance; they knew how to emphasize the importance of treatment to the individual, set goals and respected his preferences. The results of this research can provide support for the development of further studies in the area, highlighting the importance of broadening the understanding of attitudes of students at different levels of nursing training toward alcoholic people.

 

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Received: July 26^th 2017
Accepted: July 31^st 2018

Corresponding author:
Samuel Barroso Rodrigues
E-mail: samuelbarroso88@gmail.com
 https://orcid.org/0000-0002-9832-5510