Nurse Education Today (2008) 28, 691–701

Nurse
Education
Today
www.elsevier.com/nedt

Predictors of educational outcomes

of undergraduate nursing students in alcohol
and drug education
a,b,1,* c
G. Hussein Rassool , Salman Rawaf

a
Visiting Professor of Addiction and Mental Health, Departamento de Enfermagem Psiquiatrica e Ciencias
Humanas da Universidade de Sao Paulo – EERP, USP, Centro Colaborador da OMS, para o Desenvolvimento
da Pesquisa em Enfermagem, Laboratorio de Pesquisa em Alcool e Drogas, Ribeirâo Preto, Sao Paulo,
Brazil
b
Federal Universidade de Minas Gerais, Brazil
c
Professor and Director of Public Health, Wandsworth Primary Care Trust, London, UK

Accepted 14 November 2007

KEYWORDS Summary This paper reports a study which aimed to evaluate the impact of an
Alcohol; educational programme on alcohol and drug on knowledge acquisition, changes in
Drug; attitude and intervention confidence skills of undergraduate nursing students and
Education; identify the influence of selected demographic variables on educational outcomes.
Evaluation; Despite the high levels of morbidity and mortality resulting from substance misuse,
Quantitative research; few nurses have been adequately prepared to respond effectively. There remains a
Undergraduate nurses dearth 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 this
field. A quasi-experimental, pre-post-test design was used using with a purposive
sample of four cohorts of undergraduate nursing students (n = 110) in England.
Pre-tests and post-tests after the educational intervention on alcohol and drug were
administered to measure the educational outcomes. The data was collected
between 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 knowledge
mean 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). Within
the multi-layered hypothesis, the results indicate that only ethnicity was found to

* Corresponding author. Present address: Educational/Psychological Consultant, Intercultural Therapy Centre, Morcellement
Raffray, Avenue Perroquet 3, Les Guibies, Pailles, Mauritius. Tel./fax: +2302861734.
E-mail address: p9800003@sgul.ac.uk (G.H. Rassool).
1
Independent Educational Consultation in Addiction.


0260-6917/$ - see front matter c 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.nedt.2007.11.005
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 on
alcohol and drug can be effective in improving educational outcomes. Further
research should be undertaken with undergraduate nurses specialising in different
branch of nursing.
c 2007 Elsevier Ltd. All rights reserved.

Introduction there is evidence to suggest that attitudes of

Alcohol and drug misuse are a major public health
problem and continue to threaten the health and
socio-economic fabrics of society. The United Na-
tions Office for Drug Control and Prevention (UN-
ODC, 2006) estimated that some 200 million
people, or 5% of the world’s population age 15–
64, have used drugs at least once in the last 12
months. For most of Europe and Asia, opiates con-
tinued to be the main problem drug, accounting for
62% of all treatment demand. In South-America,
drug-related treatment demand continued to be
mainly linked to the use of cocaine (59% of all
treatment demand). In Africa, the bulk of all treat-
ment demand is linked to cannabis (64%). Alcohol
misuse causes 1.8 million deaths worldwide and is
one of the 10 leading causes of disability (WHO,
2004).
In recent years, there have been increasing
emphases on the contribution nurses can make in
the provision of effective interventions with alco-
hol and drug misusers (ICN, 1995; Prime Minister’s
Strategy Unit, 2004). Despite the high levels of
mortality and morbidity resulting from the misuse
of alcohol and drug, few nurses have been ade-
quately prepared to respond effectively. An exten-
sive review of drug and alcohol content within
nursing curricula at both undergraduate and post-
graduate levels in England (Rassool, 1993; O’Gara
et 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 (Rassool
and Villar-Luis, 2004; Rassool et al., 2006) revealed
that the contents of substance use and misuse edu-
cation in nursing curricula are inadequate. This
lack of educational preparation of undergraduate
nurses in alcohol and drug education may be re-
flected in research studies which showed that
nurses have negative attitude towards substance
misusers and may be moralistic, punitive, pessimis-
tic and prone to stereotyping (Wennerstrom and
Rooda, 1996; Selleck and Redding, 1998) and had
the lowest level of skills and knowledge (Brown
et al., 1997; Selleck and Redding, 1998). However,
nurses 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 and
working 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 dealing
with substance misuse is the job of a specialist
(Rassool, 2000). There is a paucity of the literature
on the educational interventions of programmes in
alcohol and drug with undergraduate nursing stu-
dents and the lack of evaluation research has
prompted the basis of this study. The aims of the
paper are to evaluate the impact of an educational
programme on alcohol and drug on knowledge
acquisition, changes in attitude and intervention
confidence skills of undergraduate nursing students
and identify the influence of selected demographic
variables 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 from
1962 to 1982 by (Ewan and Whaite, 1982) revealed
that that all educational programmes in substance
misuse succeeded in increasing knowledge in the
short-term. The most common methods of assess-
ment of knowledge gain were multiple-choice tests
administered before and immediately after the
course programmes. Randall and Wong (1976) in
comprehensive review of educational programme
in alcohol and drug between 1967 and 1976 re-
ported that most of the educational programmes
lacked any meaningful evaluations that could pro-
vide guidelines in the curriculum development of
future educational programmes. The following sec-
tion present a brief overview of the literature on
the evaluation studies undertaken in the 1990s to
the present.
Predictors of educational outcomes of undergraduate nursing students in alcohol
Hagemaster et al. (1993) study’s aims were to
plan and develop materials for an alcohol and drug
misuse curriculum, to assess the effectiveness of
the programme and to refine the curriculum based
on the evaluation. A workshop was presented in
two and one half days over a 2-week period.
Fifty-eight nurses, attended the course and were
administered the substance abuse attitude scale
(Chappel et al. (1985) and the substance abuse
knowledge scale (SAKS). The findings showed that
psychiatric-mental health nurses had higher pre-
test knowledge scores compared to other nursing
specialities. The participants were also found to
have positive attitude in treatment and optimistic
about treatment. The findings also indicated that
participants with more knowledge were more opti-
mistic regarding intervention strategies and more
non-moralistic toward substance misusers. Gerace
et al. (1995) reported an evaluation of an educa-
tional programme for nurses (n = 32) designed to
improve their recognition of and responses to sub-
stance-related problems. The findings showed that
there were significant improvements in knowledge
and clinical intervention skills.
A study by Selleck and Redding (1998) made an
attempt to explore the knowledge and attitudes
and determine the relationships between selected
demographic variables and nurses’ (n = 393) knowl-
edge and attitudes toward perinatal substance mis-
use. The results indicated that substance misuse
education was the only key predictor of knowledge
and attitudes. That is, those who had undertaken
an educational programme had more knowledge
and positive attitude towards substance misusers
than nurses without any formal educational pro-
grammes. Perry (1999) reported a study in which
nurses (n = 23) received an alcohol education pro-
gramme. The results indicated that the educational
programme was effective in achieving an improve-
ment in the level of alcohol screening. The author
reported that nurses also became more positive to-
wards alcohol screening when they are trained and
supported. A study in the examination of nurses’
knowledge and attitudes toward problem drinkers
(n = 212) by Arthur (2001) showed that there was
a significant improvement in the students’ knowl-
edge about alcohol early intervention as a result
of an educational intervention.
Goddard (2003) evaluated the effectiveness of
an educational presentation (2 h) in changing atti-
tudes of drug and alcohol professionals (n = 137) to-
wards harm reduction. The results indicated that
attitudes towards harm reduction were significantly
more favourable after the educational intervention
even among those professionals with a different
treatment orientation (Alcoholic Anonymous).
693
A summary of the nursing research studies on
educational interventions in alcohol and drug
showed that they were influential in knowledge
acquisition, attitude changes and in improving
nurses’ confidence skills. The above research stud-
ies showed that knowledge and attitudes may be
altered following educational intervention and
there is some evidence of the transfer of learning
into clinical practice. However, the length of the
educational programme ranged from 2 h to 5
weeks. In addition, the studies had small size sam-
ples, use of different measures in the assessment
of knowledge, attitude and confidence, the use of
instruments that have not been subjected for their
psychometric properties and the lack of detail of
the control group made it difficult to compare with
other studies. Despite the lack of rigour in the
methodology of the research studies the educa-
tional interventions reviewed provided an agenda
for 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 on
alcohol and drug on knowledge acquisition,
changes in attitude and intervention confidence
skills of undergraduate nursing students; (2) iden-
tify the influence of selected demographic vari-
ables on educational outcomes. The following
hypothesis was tested: Selected demographic pro-
file of students such as gender, age, and ethnicity
will have an effect on knowledge acquisition,
changes in attitude and intervention confidence
skills.
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 to
evaluation researchers (Trochim and Cappelleri,
1992). Such a design is useful in determining out-
comes and level of impact on whether or not the
programme, treatment or intervention has brought
about some desired change. According to Kumar
(1999) ‘‘a before-and-after design can be described
as two sets of cross-sectional observation on the
same population to find out the change in the phe-
nomenon or variable (s) between two points in
694
time’’ (p. 83). Many threats to the internal validity
can be ruled out with the inclusion of a control
group. However, in this study, this was not possible
and practical due to ethical issues. In order to min-
imise the threats to the internal validity, a number
of 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 the
variable with power set at 80% and significance le-
vel at (one-tailed) p < 0.05, the minimum sample
size 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 nursing
students was recruited from two metropolitan
and one rural academic institution. The partici-
pants were made up from four cohorts of students
(n = 110) and following the second year of their
educational programme in the mental health
branch. The inclusion criteria to participate in
the study include: undergraduate nursing students;
completed the common foundation programme
(CFP); following the mental health branch; and no
previous formal educational programme in sub-
stance use education.
Educational intervention
The educational framework for the educational pro-
gramme was based on the curriculum guidelines for
substance misuse education in undergraduate nurs-
ing education programmes English National Board
for Nurses (ENB), 1996. The educational interven-
tions were presented by different facilitators who
were familiar with the educational programme.
The objectives of the educational interventions
were to: Recognise own attitudes towards sub-
stance misuse; drug use and the stereotypes that
are applied; Describe briefly the method of use
and the effects of commonly misuse psychoactive
substances; Identify 3 screening methods for use
in alcohol and drug; Carry out a basic drug and alco-
hol assessment, Outline the prevention strategies
and treatment options available for substance mis-
users; and Discuss the role of the nurse in the assess-
ment and treatment of substance misuse. The
structure, content and methods of teaching and
learning of the education module were:
 Session 1: Introduction to the module, learning
outcomes, attitude towards substance misusers.
Exploring own attitude towards the use of alco-
G.H. Rassool, S. Rawaf
hol, drug and tobacco. What is the difference
between own drug use and substance misusers?
Stereotypes (Small group work, self-awareness
exercise and discussion).
 Session 2: Concept of drug and alcohol. Nature
of 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 misuse
substances. Reasons why people use psychoac-
tive substances and why they continue to do so
(Short lecture and discussion).
 Session 3: Screening and Assessment. Basic
screening methods. Generic assessment. How
to take a substance misuse history. Health edu-
cation and prevention strategies (Short lecture
and Role play).
 Session 4: Special needs of young people, women
and ethnic minorities (Short lecture and
discussion).
 Session 5: Nursing care and management: critical
incidents, withdrawal symptoms, overdose,
dealing with intoxicated (Short lecture and
discussion).
 Session 6: Intervention Strategies. Different
models 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 substance
misuse. 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 (small
group work, group discussion).
This educational programme was supplemented
with a study guide prior to course initiation which
included: 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 and
experiences. 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
of the core areas of the educational programme
were reflected in the coverage of the test items
and were based on the following categories: con-
cepts, effects of specific psychoactive substances,
assessment and treatment, special populations,
prevention and health education. The Knowledge
instrument (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 to mea-
sure specific attitude towards substance misusers. A
Cronbach’s a of 0.80 was obtained for the attitude
questionnaire (ATSMQ-10 items). A Likert -type re-
sponse format (Likert, 1932) was chosen. All items
were measured on a 5-point scale from ‘‘strongly
agree’’ to ‘‘strongly disagree’’ with scores ranging
from 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 intervention
confidence skills. The AICSS, with 16 items, is based
on a horizontal visual analogue scale (VAS) (Waltz
et al., 1991). The VAS is a straight line of 10 cm long
and has a series of confidence categories with 1–4
representing low level of confidence, 5–6 repre-
senting moderate level of confidence and 7–10 rep-
resenting high level of confidence. The AICSS-16
showed a strong measure of internal consistency
(a coefficient 0.94) and face and content validity.
Procedures
In collaboration with course directors, a schedule
was developed to meet with the different cohorts
to explain the purpose of the study. In order to
achieve a maximum response, and to answer ques-
tions students may have regarding the study, the
questionnaires were administered in the controlled
environment of formal class time and under the
supervision of the author or module leader.
At the beginning of semester 4 or 7, depending
on the educational institutions, the students from
each cohort who consented to take part in the
study were provided an information sheet about
the study and asked to complete the consent form.
There were two measurements points for the co-
horts: a baseline (pre-test) before the implementa-
695
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 the
educational intervention. After 8–10 weeks after
the educational intervention, the knowledge ques-
tionnaire, attitude questionnaire and the confi-
dence skills scale were repeated.
Ethics
Ethical approval for this study was sought and
granted by the Institutions’ Research Ethics Com-
mittee. General information sheet and a consent
form about the study were provided to the stu-
dents. Prior to the commencement of the study,
the students signed a consent form and a guarantee
of anonymity of the data was guaranteed. A further
proviso was that withdrawing from the study would
be in no way affected their current educational
programmes.
Statistical analysis
The demographic variables were summarised using
frequency distributions and percentages. The
means and standard deviations were determined
for all the variables. Paired t-tests were used to
examine the differences between pre- and post-test
scores of knowledge, attitude and intervention con-
fidence skills. A series of analysis of covariance (AN-
COVA) were carried out to measure the differences
among group means of knowledge, attitude and
intervention confidence skills and to control for
threats to the internal validity of the study. In this
study, the pre-tests mean scores of knowledge, atti-
tude and intervention confidence skills were chosen
as covariates. This source of variations had to be
partitioned 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. Multiple
regressions (linear) were used to test the prediction
equations of knowledge acquisition, changes in atti-
tude and intervention confidence skills. Statistical
analyses 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 showing
that the majority of the sample was female (57%).
696 G.H. Rassool, S. Rawaf

Table 1 Demographics of sample (n = 110)

Hypothesis testing
Variable Description Influence of gender on educational
Age Age range = 20–55 outcomes
Mean age = 32.9
SD = 7.98, n = 110 The findings showed that there was no signif-
Gender Male = 43% icant influence of gender on knowledge acquisi-
Female = 57%
tion (F(1, 107) = .463, p = 0.498) on attitude change
Ethnicity White = 40.9%
(F(1, 107) = .315, p = 0.576) and in intervention
Black (African &
Caribbean) = 44.5% confidence skills (F(1, 107) = .221, p = 0.639).
Asian & Other = 14.5%
Educational attainment GCSE & A Level = 44.5% Influence of age on educational outcomes
Diploma = 30.9%
Degree = 24.5% 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
The mean age of the sample was 33 (SD = 7.98) with (F(2, 106) = .271, p = 0.763).
a range of 20–55 years. The largest ethnic group
was Black African & Caribbean (45%), followed by Influence of ethnicity on educational
White (41%) and Asian & Other (15%).The educa- outcomes
tional attainments of the students ranged from
GSCE to university degrees. The findings showed that ethnicity had a statisti-
cally significant influence on knowledge acquisition
(F(2, 106) = 6.594, p = 0.002) and intervention
Changes in educational outcomes
confidence skills (F(2, 106) = 14.992, p = 0.000)
but no significant influence on attitude change
Fig. 1 displays the comparison of mean scores be-
(F(2, 106) = .556, p = 0.575).
tween Pre-Post-Tests knowledge, attitude and
In order to determine which ethnic group had
intervention confidence skills. The results showed
more influence on knowledge acquisition and inter-
that there were statistically significant differences
vention confidence, a Bonferroni post-hoc analysis
between the mean scores of the pre-test and post-
was conducted (a = .05). Fig. 2 presents the esti-
test knowledge (t = .4.61, d.f. = 109, p = 0.000),
mates means scores and standard error of means
attitude (t = 2.356, d.f. = 109, p = 0.02) and inter-
for knowledge acquisition across the ethnic groups.
vention confidence skills (t = 9.754, d.f. = 109,
The findings showed that the White ethnicity stu-
p = 0.000).
dents had a slightly higher mean score (mean
14.2) than the Black (mean 12.3) and Asian (mean
13.1) ethnicity groups in the knowledge domain.
The Pairwise Comparisons showed that there was
70
60.5
60
Mean Score

50 43.2 16
14.2
Knowledge Mean

40 14 13.1
12.3
30.1 31.3
30 12
10
20
11.9 13.2 8
10 6
0 4
Pre-Test Post-Test Pre-Test Post-Test Pre-Test Post-Test 2 0.59 0.34
0.36
0
*AKQ-20 *ATSMQ-10 *AICSS-16
Mean Std. Mean Std. Mean Std.
Figure 1 Comparison of Mean Scores of AKQ-20, Error Error Error

ATSMQ-10 and AICSS-16 Pre-Post-Tests (n = 110). *AKQ- White Asian Black

20 – Addiction Knowledge Questionnaire; *ATSMQ-10 – Ethnicity
Attitude Toward Substance Misusers Questionnaire;
*AICSS-16 – Addiction Intervention Confidence Skills Figure 2 Mean scores and standard error for knowledge
Scale. acquisition. Std. Error, standard error.
Predictors of educational outcomes of undergraduate nursing students in alcohol 697

Intervention Confidence Skills

70 66.2 65.4
60 53.2
50

Mean
40
30
20
10 2.9 1.7 1.7
0
Mean Std. Error Mean Std. Error Mean Std. Error
Asian Black White
Ethnicity

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

a statistically significant mean difference between significant factor in this study when compared to
White ethnicity and Black ethnicity (p = 0.001). the national average of about 11% male (NMC,
However, no statistically significant mean differ- 2005). However, the sample of students in this
ences were found between White ethnicity and study have elected to follow the mental health op-
Asian ethnicity and between Black ethnicity and tion of the nursing programme and shows the gen-
Asian ethnicity. der balance when compared to the national
Fig. 3 presents the estimates means scores and average (Female = 63%, Male = 37%) (NMC, 2005).
standard error of means for intervention confi- However, the composition of this sample of stu-
dence skills across the ethnic groups. The findings dents in relation to gender and ethnicity may be
showed that Asian ethnicity had higher mean score different from those following other branch of
in the intervention confidence skills compared to nursing such as Adult, Children or Learning Disabil-
the Black African & Caribbean ethnicity and the ity nursing. The mean age of the subjects in this
White ethnicity. The findings of the Pairwise Com- study was 33 years which reflects changing patterns
parisons showed that there were statistically signif- in the student body entering the nursing profes-
icant mean differences between Asian ethnicity sion. The students could be described as ‘‘mature’’
and White ethnicity (p = 0.001) and between Black as opposed to school-leavers. This ‘‘mature age’’
ethnicity and White ethnicity (p = 0.000). group may also be reflective of the educational
The findings from the multiple regression attainment of the sample. About 31% of the sample
showed that White ethnicity was the significant had a Diploma and 25% were university graduates.
predictor of knowledge acquisition (b = 0.329, It is reported that the age, gender and ethnicity
p = 0.000) with an R value of 0.57 but a negative profiles are changing with greater number of males
significant predictor (b = 0.462, p = 0.001) with and mature students entering nursing education
an R value of 0.48 in intervention confidence skills. programmes (NMC, 2005).
The linear regression equation for predicting The findings indicate that the educational pro-
knowledge acquisition (KA) is KA = 8.2 + 1.87 gramme on alcohol and drug had an impact in
(White ethnicity) and intervention confidence skills enhancing the knowledge, attitude change and
(ICS) is ICS = 63.4 12.16 (White ethnicity). intervention confidence skills of undergraduate
nursing students. This is congruent with the find-
ings from the studies of Rassool (1994) and Gerace
Discussion et al. (1995). However, further examination re-
vealed that two of the key individual items in the
The multi-ethnic composition of the students in the knowledge domain were ‘Nursing Assessment’ and
study probably reflects the ethnic diversity of the ‘Taking a drug and alcohol history’. These two
geographical locations where the students were re- items of ‘‘brief interventions’’ would by them-
cruited. The Asian group in this study consisted selves be an effective gamut of skills in enabling
mainly of Chinese and Indians. However, compared change in patients with potential alcohol- and
to the two other ethnic groups, Asian people are drug-related problems (Watson, 1999). In this
generally under-represented in nursing (Depart- study, the assessment of knowledge was measured
ment of Health, 2002). In relation to gender, the with the AKQ-20 which was solely developed for
male group which made up 43% of the sample is a this study with a specific conceptual model of drug
698
and alcohol use and misuse. Thus, what is reported
as a an increase in knowledge as a result of pre- and
post-test condition in one study using one particu-
lar conceptual framework might not be considered
so in another study which employs a different
approach.
In addition to knowledge acquisition, the higher
mean scores observed in the post-test attitude
questionnaire indicate more positive attitude to-
wards substance misusers. The findings suggest
that the educational programme on alcohol and
drug had an impact on the attitude of the under-
graduate nursing students towards substance mis-
users. The findings are congruent with the results
of other studies which support that the develop-
ment of a more positive attitude, confidence and
skills in working with substance misuse may be
partly related to the provision of alcohol and drug
education (Hagemaster et al., 1993; Rassool,
2004).
In this study, the majority of the participants
held positive views towards substance misusers
and they were optimistic that drug and alcohol
dependence were treatable illnesses. The notions
of positive views towards substance misusers and
therapeutic optimism are supported by the findings
from the studies of Gerace et al. (1995) and Pini-
kahana et al. (2002). This would undoubtedly en-
hance the nurse–patient relationships in the
provision of appropriate care and intervention
strategies. In addition, positive attitudes conveyed
to individuals with alcohol and drug problems
would further enable substance misusers who are
contemplating to change their alcohol or drug
behaviours to remain in the treatment system.
The intervention confidence skills of undergrad-
uate nursing students improved significantly in
relation to both alcohol and drug-related clinical
skills. High level of confidence were gained in:
the provision of alcohol, drug and tobacco educa-
tion and prevention information, recognising the
signs and symptoms of alcohol and drug problems,
talking to patients about risks of alcohol and drug
misuse, taking a drug and alcohol history, refer pa-
tients for alcohol and drug problems, providing
care for patients with alcohol and drug problems,
giving health risks information about prescribed
medication, informing smokers about the health
risk of tobacco smoking and knowledge of drug
and alcohol services.
Three important key skills in working with sub-
stance misusers were identified: recognising the
signs and symptoms of alcohol and drug, taking
an alcohol and a drug history and referring patients
for alcohol treatment and drug treatment. These
key skills in intervention confidence were compara-
G.H. Rassool, S. Rawaf
ble to the gain observed in the knowledge domain.
This suggests that the undergraduate students
have gained the requisite knowledge and
intervention confidence skills in similar areas of
competence in working with substance misusers.
There are limited studies in measuring intervention
confidence level amongst nurses to compare the
findings of this study. The findings from Gerace
et al., study (1995), indicated that an educational
intervention was influential in improving nurses’
confidence in caring for substance misusers.
The hypothesis which stated that selected
demographic profile of students such as gender,
age, and ethnicity will have an effect on knowledge
acquisition and changes in attitude and interven-
tion confidence skills was rejected. However as this
is a multi-layered hypothesis, only ethnicity was
found to have a significant influence on both knowl-
edge acquisition and in intervention confidence
skills. The educational programme on alcohol and
drug had significant impact on the White ethnic
group in knowledge acquisition. Whereas the Asian
& Other and Black (African & Caribbean) ethnic
groups had better performance in intervention con-
fidence skills domain. A plausible explanation may
indicate that White ethnic group may be more
adaptable to the ‘‘theoretical’’ aspects of the edu-
cational programme compared to the Black and
Asian who showed more enhanced ‘‘skills’’ based
dimensions. It may be feasible that the White eth-
nic group are more knowledgeable or having wider
personal and professional exposure to alcohol and
drug compared to the Black and Asian groups. Per-
sonal and clinical experiences may also have influ-
enced the educational outcomes. This is confirmed
from a study by Selleck and Redding (1998) who
found that having personal experiences or a family
history of substance misuse explained 4% of the
variance in knowledge about substance misuse.
However, due to the limited content of alcohol
and drug education in the nursing curriculum, clin-
ical experiences, continuing education and profes-
sional journals were found to be the primary
sources of substance use knowledge for most
nurses (American Nurses Association, 1986; Selleck
and Redding, 1998). It may also be possible that
students in the White ethnicity group have been
more exposed to these multiple experiences com-
pared to the other two groups.
In relation to intervention confidence skills, the
performance 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 study
are 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
gramme. Thus, the modes of learning may have en-
hanced their practical or clinical skills compared to
the White ethnicity group. Another plausible expla-
nation for the findings is the use of the Visual Ana-
logue Scale for the measurement of intervention
confidence skills. The Asian & Other and Black
(African & (Caribbean) ethnic groups may have
low adaptation to a more ‘‘concrete’’ style of
assessment such as multiple-choice items but are
more sensitive to the AICSS-16 measuring the inter-
vention confidence skills dimension. As discussed
previously, academic success may be attributed
to multiple experiences for undergraduate nursing
students. The findings from the multiple regression
showed that White ethnicity was the significant
predictor of knowledge acquisition but was a nega-
tive significant predictor in intervention confidence
skills.
Study limitations
The sample used in the study is based on four sub-
populations of undergraduate nursing students in 2
metropolitan areas of a large city and one rural
area. The choice of educational institutions for
the experimental sites was determined by accessi-
bility and willingness to participate in the study.
The collection of data during formal attendance
to a wider educational programme, student moti-
vations, module assignments and the personality
and teaching styles of those delivering the educa-
tional programme may serve as potential limita-
tions. Other extraneous variables may have
influenced the results of this study such as prior
enrolment in a university programme other than
nursing and prior work experiences.
A methodological consideration is the nature of
the sample itself. This group of students have
elected to undertake the mental health branch of
the nursing educational programme. This ‘‘self-se-
lected’’ group of students may be different in per-
sonality, interest and motivation in working with
alcohol and drug misusers compared to those fol-
lowing other specialist branch of nursing. Thus,
the generalisations of these findings to other
undergraduate nursing students are limited. Ideally
probability sampling from large clusters of under-
graduate nursing students would have been pre-
ferred, but this was not practical and possible
due 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 the
inability to assess whether or not the differences
due to the educational programme or to confound-
699
ing extraneous variables. It is subject to such
threats to validity as history (events intervening
between pre-test and post-test), maturation
(changes in the subjects), regression toward the
mean (the tendency of extremes to revert toward
averages), testing (the learning effect on the
post-test of having taken the pre-test),Many
threats to the internal validity can be ruled out
with the inclusion of a control group.
Though the use of the visual analogue scale is an
innovation in educational research in this study, it
is based on self-report in the measurement of the
level of confidence in alcohol and drug-related
skills. The limitations of self-report are one of
the methodological concerns that are apparent in
this study. It has been suggested that that self-re-
ported perceptions of basic skills gain are inflated
by the normal human tendency to answer with so-
cially acceptable responses and reluctance to say
unfavorable things in an evaluation of educational
programme (Beder, 2005). The reliability and valid-
ity of self-report are also dependent upon whether
the report is based on attributional biases or the
lack 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 drug
can be effective in increasing knowledge, change
in attitude and intervention confidence skills. In
addition, ethnicity was found to be a key predictor
of educational outcomes. This has important impli-
cations for nurse education. This ‘bolt on’ educa-
tional programme could be implemented without
too much disruption to an overloaded nursing cur-
riculum. However, it is argued that the ‘bolt on’
approach is not the educational solution. What is
needed is a vertical integration approach which fo-
cuses on teaching aspects of alcohol and drug in
conjunction with the content of the nursing curric-
ula (Rassool, 1993). One of most important aspect
of an educational programme is not only about
knowledge acquisition, changes in attitudes and
skills development but the transfer of ‘learning’
in clinical practice for the delivery of quality care
to those with substance misuse problems. The
attainment of positive educational outcomes is
only 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 with
undergraduate nurses specialising in different
700
branch of nursing. Finally, studies on the influences
of diversity, as part of the ‘hidden curriculum’ such
as gender, age and ethnicity, on educational out-
comes in nursing education as a result of the chang-
ing demographic profile of students entering the
nursing profession are fully warranted.
Acknowledgements
We would like to thank the Florence Nightingale
Foundation for providing a Foundation Scholarship
to GHR and for funding this research study.
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