Nursing Post-training Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Immediate Post-Training Survey

Thank you for completing the training. 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: |___|

1. I have an increased understanding of fetal alcohol spectrum disorders (FASDs) after the training.

• Strongly Disagree

• Disagree

• Neutral

• Agree

• Strongly Agree

2. I have an increased understanding of alcohol screening and brief intervention (SBI) after the training.

• Strongly Disagree

• Disagree

• Neutral

• Agree

• Strongly Agree

3. 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.

4. The effects of FASDs are always visible.

 True

 False

 Don’t know

5. 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.

6. 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

7. 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

8. 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

9. 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.

10. 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

11. On a scale from 1 to 5 where 1 means “Not at all confident in my skills” and 5 means “Totally confident in my 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

12. 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

13. Has your practice experienced any of the following barriers to effective implementation of alcohol screening and brief intervention? (Check all that apply).

 No barriers; we screen and intervene consistently and well

 Time limitations during patient/client visits

 It is not required; lack of incentive

 Attitudes of providers and/or staff about substance use/abuse

 Workforce needs education and training on screening and brief intervention

 Not easily accessible in the Electronic Health Record

 Concerns about damaging rapport with patients/clients

 Patient reluctance to be honest about alcohol use, or resistance to treatment

 Concerns about confidentiality and reporting requirements (example: to social services agency)

 Inadequate referral sources and/or system for making referrals

 Billing for alcohol screening, assessment, and counseling/intervention is not in place

 Patient/client inability to pay for treatment

 Other (please specify) _______________________________________________

14. 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
This training increased my understanding of the effects of prenatal alcohol exposure on the developing fetus.	1	2	3	4	5
The training concepts were presented clearly.	1	2	3	4	5
The training was presented in a culturally competent and sensitive manner.	1	2	3	4	5
The content will be useful to me professionally.	1	2	3	4	5
I would recommend this training to others.	1	2	3	4	5
Overall, I am satisfied with the quality of this training.	1	2	3	4	5
This training increased my awareness of considerations related to working with individuals who are lesbian, gay, bisexual, or transgender	1	2	3	4	5
This training increased my awareness of considerations related to working with adolescents	1	2	3	4	5
This training increased my awareness of considerations related to working with elderly individuals	1	2	3	4	5
This training increased my awareness of considerations related to working with individuals who are veterans	1	2	3	4	5

15. What about this training could be improved? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

16. Additional comments: __________________________________________________________________________________________________________________________________________________________

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).