Nursing Pre-training Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Pre-Training Survey

You are invited to take part in a survey for health professionals. The purpose of this survey is to understand the opinions and practices of health professionals around their patients’/clients’ alcohol use and on the prevention, identification, and treatment of fetal alcohol spectrum disorders. Your feedback is important as it will help assess the efficacy of trainings and identify the needs of health professionals to better address the services they provide to patients/clients around alcohol consumption and/or the effects of alcohol use during pregnancy.

This survey will take approximately 9 minutes to complete and your responses will be kept secure. You will be asked to create a unique identity code which will be used to invite you to take a similar survey after six months to assess how useful this training has been in your practice with your patients/clients regarding their alcohol use.

Your participation is voluntary; you may decline to answer any question and you have the right to stop the survey at any time. Any information you provide will be presented in aggregate in a report and no individual identifying information will be included. There will be no costs for participating, nor will you benefit from participating.

The anonymous linkage code below will be used to match data from different evaluation forms without using your name or information that can identify you.

Please complete the following items for your anonymous code:

First letter in mother’s first name: |___| First letter in father’s first name: |___|

First digit in your social security number: |___| Last digit in your social security number: |___|

PRE-TRAINING SURVEY

1. I found out about this training from: (Check all that apply.)

• A professional organization

1. Please provide name of the professional organization from which you found out about this training: ______________________

2. How did you find out about this training from the professional organization? (Check all that apply.)

• Website

• Email

• At a conference

• Other, please specify __________________

• A recognized leader in my field

• A colleague at my practice setting

• Other, please specify __________________

2. Fetal alcohol spectrum disorders are: (Check only one response.)

• Disorders a pregnant woman experiences when she drinks alcohol.

• Disorders that affect the ability of a pregnant woman who drinks alcohol to go full term.

• Physical disorders that affect a fetus when a pregnant woman drinks alcohol.

• The range of effects that can occur in an individual who was exposed prenatally to alcohol.

3. The effects of FASDs are always visible. (Check only one response.)

• True

• False

• Don’t know

4. FASDs are certain to be prevented when: (Check only one response.)

• a woman quits drinking as soon as she knows she is pregnant.

• a woman who is pregnant or may become pregnant does not consume alcohol.

• a woman does not take drugs other than alcohol during her pregnancy.

• a woman stops drinking once she starts breastfeeding her baby.

5. Which of the following are the primary facial dysmorphic features associated with Fetal Alcohol Syndrome? (Check all that apply.)

• Wide inner canthal distance

• Short palpebral fissures

• Full lips

• Smooth philtrum

• Thin upper lip

• Flaring nares

• Don’t know/unsure

6. What advice would you give your patient/client about how much alcohol is safe to drink during pregnancy? (Check only one response.)

• One glass of wine per day

• One light beer per day

• One shot of hard alcohol per day

• There is no known safe amount of alcohol consumption during pregnancy.

7. When is it safe to drink alcohol during pregnancy? (Check only one response.)

• During the first three months

• During the last three months

• Once in a while

• Never

8. What is the most effective strategy to reduce fetal alcohol spectrum disorders (FASDs)? (Check only one response.)

• Enact laws and other policy strategies that punish pregnant women for drinking alcohol.

• Screen all women of child bearing age for alcohol use and provide intervention as appropriate.

• Tell women who you think may have a drinking problem to get help.

• Conduct health fairs and other educational events for new mothers that focus on binge drinking.

If you are a student, please skip to Question 12. Otherwise, please continue.

9. When do you (or someone in your practice) ask your patients/clients or their parents/caregivers about their alcohol use? (Check only one response.)

• Never

• Annually

• At each visit

• When indicated (please describe: ____________________)

• Other, please specify____________

10. My practice has a consistent process to screen or obtain information from all patients/clients about their alcohol use. (Check only one response.)

• Yes

• No

• Don’t Know

• Not applicable to the patients/clients in my practice setting

If yes, please continue. Otherwise, skip to Question 11.

1. What does initial patient/client screening for alcohol use consist of in your practice setting? (Check only one response.)

• Informal questions (Do you drink? How often/much do you drink?, etc.).

• Formal screening tool or evidence-based/ validated screening instrument (AUDIT, AUDIT-C, DAST, CAGE, CRAFFT, NIAAA Youth Alcohol Screen, etc.).

• I don't know.

2. Who generally conducts the initial screening for alcohol? (Check all that apply.)

• Nurse (including nurse practitioner)

• Social worker

• Behavioral health specialist (coach)

• Psychologist

• Physician

• Physician’s Assistant

• Medical Assistant

• Other, please specify ____________________

3. Is screening for alcohol use followed by some type of intervention in your practice setting? (Check all that apply.)

• No, there is no patient/client education or intervention done following the initial screening

• Yes, all patients/clients are given educational materials/information on “safe” levels of alcohol and health risks associated with consuming too much alcohol

• Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided brief counseling.

• Yes, patients/clients who screen positive for risky alcohol use are asked follow-up questions and provided with additional resources (e.g., a list of treatment and/or counseling services in the community).

• Not sure if there is an intervention following the initial screening.

4. Who generally does the intervention in your practice setting? (Check all that apply.)

• Nurse (including nurse practitioner)

• Social worker

• Behavioral health specialist (coach)

• Psychologist

• Physician

• Physician’s Assistant

• Medical Assistant

• Other, please specify _________________

5. Does your practice bill for screening and brief intervention services? (Check only one response.)

• Yes

• No

• Not sure

11. In your current position, do you provide services to individuals who may have fetal alcohol spectrum disorders (FASDs)? (Check only one response.)

• Yes

• No

• Not sure

12. On a scale from 1 to 5 where 1 means you strongly disagree with the statement and 5 means you strongly agree, to what extent do you disagree or agree with the following statements. (Select one number per row).

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
It is important to routinely screen all patients/clients for alcohol use	1	2	3	4	5
Screening a person for alcohol use confers a stigma to the person being screened	1	2	3	4	5
It is important to screen all pregnant women for alcohol use	1	2	3	4	5
It is important to screen all women of reproductive age for alcohol use	1	2	3	4	5
It is important to educate women of reproductive age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
It is important to inquire about and document potential prenatal exposure for all pediatric patients	1	2	3	4	5
Diagnosis of one of the FASDs may confer a stigma to a child and/or his or her family	1	2	3	4	5

13. On a scale from 1 to 5 where 1 means you are not confident in your skills and 5 means you are totally confident in your skills, how confident are you in your skills to do the following? (Select one number per row).

	Not at all confident in my skills	Slightly confident in my skills	Moderately confident in my skills	Very confident in my skills	Totally confident in my skills
Asking women, including pregnant women, about their alcohol use	1	2	3	4	5
Having a conversation with patients/clients who indicate risky alcohol use	1	2	3	4	5
Educating women of childbearing age, including those who are pregnant, about the effects of alcohol on a developing fetus	1	2	3	4	5
Conducting brief interventions for reducing alcohol use	1	2	3	4	5
Utilizing resources to refer patients/clients who need formal treatment for alcohol abuse	1	2	3	4	5
Inquiring about potential prenatal alcohol exposure for my patients/clients	1	2	3	4	5
Identifying persons who may have one of the FASDs	1	2	3	4	5
Diagnosing persons who may have one of the FASDs	1	2	3	4	5
Referring patients/clients for diagnosis and/or treatment services for an FASD or alcohol use disorder	1	2	3	4	5
Managing/coordinating the treatment and care of persons who have one of the FASDs	1	2	3	4	5

14. The questions in this section are designed to explore the attitudes of staff working with people who drink alcohol. There are no right or wrong answers. On a scale of 1 to 5 where 1 means you are strongly disagree and 5 means you strongly agree, please indicate your response to the following statements.

	Strongly agree	Agree	Neither agree or disagree	Disagree	Strongly disagree
I feel I know enough about causes of drinking problems to carry out my role when working with individuals who drink alcohol	1	2	3	4	5
I feel I can appropriately advise my patients about alcohol use and its effects	1	2	3	4	5
I feel I do not have much to be proud of when working with individuals who drink alcohol	1	2	3	4	5
All in all I am inclined to feel I am a failure with individuals who drink alcohol	1	2	3	4	5
I want to work with individuals who drink alcohol	1	2	3	4	5
Pessimism is the most realistic attitude to take towards individuals who drink alcohol	1	2	3	4	5
I feel I have the right to ask patients questions about their alcohol use when necessary	1	2	3	4	5
I feel that my patients believe I have the right to ask them questions about their alcohol use when necessary	1	2	3	4	5
In general, it is rewarding to work with individuals who drink alcohol	1	2	3	4	5
In general I like individuals who drink alcohol	1	2	3	4	5

Please check the response that best represents your current position:

NURSE

• Certified Nurse Midwife

• Psychiatric Nurse Practitioner

• Public Health Nurse

• Women’s Health Nurse Practitioner

• Other Nurse Practitioner (Advanced Practice Nurse)

• Other MSN-level Nurse

• Other BSN-level Nurse

• RN, LPN, NA

PHYSICIAN

• OB/GYN

• Geneticist

• Pediatrician/pediatric sub-specialist

• Psychiatrist

• Family Physician

• Internist

• Preventive Medicine

• Occupational Medicine

• Addiction Medicine

• Physician, other, please specify ____________

OTHER MEDICAL

• Medical Resident

• Dentist

• Physician Assistant

• Medical Assistant

• Other Medical, please specify _____________

ALLIED HEALTH

• Psychologist (unspecified)

• Rehabilitation Psychologist

• Clinical Psychologist

• Community Psychologist

• Counselor (including AODA Counselor)

• Social worker

• OT/PT/SLP

• Medical Technologist

• Other allied health professional, please specify _____________

OTHER

• Public Health Specialist

• Special Educator

• Other Educator

• Administrator

• Corrections

• Lawyer/Judge

• Scientist

• Prevention Specialist

• Other, please specify ______________

STUDENT

• Nursing student (DNP)

• Nursing student (MSN)

• Nursing student (RN Diploma)

• Medical student

• Medical assistant student

• Social work student

• Psychology/Counseling student

• Other allied health student (OT/PT/SLP/etc.)

• Other, please specify ______________

In what year did you complete your professional training? (If you are a student, please indicate the year you expect to complete your professional training.) _________

Are you interested in receiving CEUs/CNEs?

• Yes

• No

If you are a nurse, please answer the below questions. Otherwise, please turn to the next page.

Are you a member of any of the following nursing organizations? (Check all that apply.)

• American Nurses Association (ANA)

• American College of Nurse Midwives (ACNM)

• American Psychiatric Nurses Association (APNA)

• Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN)

• International Nurses Society on Addictions (IntNSA)

• International Society of Psychiatric-Mental Health Nurses (ISPN)

• Nurse Practitioners in Women’s Health (NPWH)

What is your current education level?

• DNP

• MSN

• BSN

• RN Diploma

DEMOGRAPHICS

1. Are you (check one):

• Male

• Female

• Transgender

2. In which state(s) do you provide services or go to school?

 AL

 AK

 AZ

 AR

 CA

 CO

 CT

 DE

 DC

 FL

 FM

 GA

 GU

 HI

 ID

 IL

 IN

 IA

 KS

 KY

 LA

 ME

 MD

 MA

 MH

 MI

 MN

 MP

 MS

 MO

 MT

 NE

 NV

 NH

 NJ

 NM

 NY

 NC

 ND

 OH

 OK

 OR

 PA

 PR

 PW

 RI

 SC

 SD

 TN

 TX

 UT

 VT

 VI

 VA

 WA

 WV

 WI

 WY

 Not applicable

3. Are you Hispanic/Latino(a)?

• Yes

• No

4. How would you describe your race? (Check all that apply.)

• American Indian/Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White

5. Are you the parent/caregiver of a child with FAS/FASD?

• Yes

• No

6. The age group of the patients/clients that you see is: (Check all that apply.)

• newborn to < 1 month

• 1 month to < 9 years

• 9 years to < 18 years

• 18 years to < 65 years

• 65 years and above

• Not applicable

Thank you for completing this survey.

CDC estimates the average public reporting burden for this collection of information as 9 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS

D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).