Nursing Training Followup Survey - word

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Six-Month Follow-up Training Survey

A few months ago you participated in a training on fetal alcohol spectrum disorders. We would like your feedback on how useful the training has been in your practice with your patients/clients. 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.

This survey will take approximately 9 minutes to complete and your responses will be kept secure. Any information you provide will be presented in aggregate in a report and no individual identifying information will be included. Your participation in this survey is voluntary and you may decline to answer any question and you have the right to stop the survey at any time.

Thank you.

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: |___|

For each statement, please check the response which applies to you or your practice setting.

1. I include prevention of alcohol misuse when talking with my patients/clients or their caregivers.

• Never

• Rarely

• Sometimes

• Often

• Always

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.

2. The effects of FASDs are always visible.

 True

 False

 Don’t know

2. 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.

2. 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

2. 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

2. 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

2. 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 11. Otherwise, please continue.

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

• Never

• Annually

• At every 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

10. I have been able to convince at least one person in my profession of the importance of screening for alcohol use.

• Yes

• No

10. I have developed or changed at least one policy in my practice to focus on prevention, identification, or care/treatment for patients/clients who have or may have one of the FASDs.

• Yes

• No

10. 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

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

10. 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

10. 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

10. 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 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) _______________________________________________

10. Is the practice setting in which you currently work the same as the practice setting in which you worked at the time you took the training?

 Yes

 No

Thank you for completing this survey.

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