Validation of the SM-GIBED Scale : Attitudes of Emergency and Mental Health Nurses about Alcoholics and Other Drug-Dependent Patients

1Nursing and Phisiotherapy Department, University of Balearic Island, 07122 Palma, Spain 2A&E Department, Balearic Health System, Hospital of Manacor, 07500 Manacor, Spain †Author for correspondences: Dr. Jesús Molina Mula, Universitat de les Illes Balears Ctra. Valldemossa Km 7,507122 Palma de Mallorca, Illes Balears, Spain, Tel: 0034-971173123; Fax: 0034-971172810; email: jesus.molina@uib.es ABSTRACT

Research Dr. Jesús Molina Mula   It is interesting to describe the distinction that various studies found concerning the attitudes of professionals depending on emergency or mental health units.Pinikahana [20] indicated that mental health professionals have non-discriminatory attitudes towards drug-dependent patients and do not believe they should be excluded from treatment even after several relapses; alternatively Kelleher [21] found that emergency staff consider patients with several relapses as untreatable.
A study by Carroll [11] showed a correlation between the degree of motivation and attitude.Professionals who choose to work with these patients have a more positive attitude than those who have been imposed to work with drugdependent patients.Carroll also concluded that professionals who had previously worked with drug-dependent patients had less fear and anxiety.
A series of studies that began in the 1960s provide important information to understand the evolution of perceptions and attitudes toward drug-dependent patients.Blane and Hill [22] reported that nurses had negative attitudes about alcoholics, considered them violent, and related alcohol consumption to character disorders.In a study on the factors that affect the care of alcoholic patients, Johnson observed that 80% of nurses were more tolerant and empathic and better understood these patients than did the previous research.A literature review by Howard and Chung [17] ( MEDLINE, 1966-2000, and Nursing and Allied Health, 1982-2000) evaluated 68 studies published on several groups of nurses.Their research found that a one third of nurses continued to consider substance-related disorders as immoral and a result of a weak and defective character.

Introduction
Substance abuse is currently considered a growing social problem in terms of public health and has an impact on the family, cultural patterns, and the economy.The Foundation for Help against Drug Addiction (FAD) and other authors [1][2][3] believe that substance use is conditioned by customs and cultural patterns.These aspects also shape the attitudes of healthcare professionals about drug addicts.
Balearic Nursing Research Group on Drug-Dependence (Spanish abbreviation, GIBED) published an in-depth bibliographical review on the perceptions and attitudes of emergency and psychiatry nurses about drug addicts [4][5][6][7][8].This review reveals several aspects concerning belief and attitudes about drug-dependences, such as: (1) individual beliefs, age, gender, ethnicity, and professed religion influence attitudes towards drug addicts [9,10], (2) professionals' attitudes vary based on different roles, socialisation, and the type and nature of contact with these patients [11]; (3) the institution where one works affects care [12]; (4) professionals should reconsider their preconceived ideas when dealing with the needs of drug addicts [13]; (5) there is a lack of training in drug addiction [10], (6) it is necessary to change the training that is currently being provided [14,15] to furnish early detection and preventive intervention [15,16].and (7) nurses have historically paid greater attention to drug addicts than other groups of health professionals and are key players [17].

Attitudes of health professionals in the care of drug-dependent patients
According to scientific evidence, the attitudes of health professionals can affect the quality of care provided to drug-dependent patients.A certain differentiation has been observed in professional attitudes according to the substance consumed, addressing the substance abuse in general and in others clearly differentiating alcohol.However, in general it has been observed that it seems difficult for professionals to understand that substancedependence can be considered a disease [1].
Indig and Anderson [17,18] highlighted in their research that many professionals do not have the confidence, knowledge, skills, and sense of full and adequate responsibility to manage patients with substance-related disorders [19].According to a bibliographic review by Kelleher in 2007 [19] and corroborated by GIBED in 2015 [4,6,8] it is evident that professionals' knowledge and attitudes can be less or more empathetic and closer.

Research
Validation of the SM-GIBED Scale: Attitudes of Emergency and Mental Health Nurses about Alcoholics and Other Drug-Dependent Patients boring, annoying, disgusting, deceitful, false, and liars.They described them as unwilling to recover, reckless and irresponsible, cowards when it came to fighting for themselves, and uncooperative with treatment [24].
According to Heinemann and Rhodes higherranking nurses, better trained and younger with less professional experience, had more positive attitudes and greater knowledge of drug-dependence than did their colleagues.Moody concluded that middleclass nurses with more authoritarian attitudes were less willing to work with alcoholic patients.It is interesting to note how the cause of substance abuse can modify a nurse's attitude.
It has been observed that to the extent that patient's nurses see as aggressive and distort their work increasing your workloads, the attitudes of professionals become more intolerant and pessimistic about the success of treatment.According to Vargas et al. [25] this is due to a lack of professional technical preparation for treating drug-dependent patients.
Cannon and Brown described how nurses tried not to have moralistic attitudes and understood that stereotypes should be avoided about substance-related disorders to improve the quality of care and success of treatment.Professionals admit there is a lack of training and the need to modify certain behaviours, treating drug-dependent patients with respect and equal to those with other pathologies.
In the 1990s, studies began to appear, such as that of Allen [26,27], that identified a gradual abandonment of the nurses' attitudes that drug addicts were low-status patients, socially or professionally.In this regard, a more positive attitude was noted in male nurses than in female nurses, and nurses under 30 years of age had more positive attitudes than those over 50.We begin to see how the nurses describe dependence as a disease [25].
In general, evidence has revealed that nurses consider working with drug-dependent patients less rewarding than with other groups of patients and hold the former accountable for their situation as they collaborate in care.Grief & Elliot concluded that nurses felt better taking care of some patients than others; they least liked alcoholics, drug addicts, those who had accidents under the influence of alcohol, and those who were emergency room regulars.
There is insufficient scientific evidence to analyse in depth how the attitudes of health professional impacts the quality of care.Most studies describe only the different types of professional behaviours and attitudes, but not their influence on the types of care.

Instruments that measure the perception and attitudes of health professionals concerning drug dependents
The main instruments available to measure the attitudes of professionals towards drugdependent patients were analysed in a literature review of the Balearic Research Group on Nursing in Drug Addiction, GIBED [7].
The EPSD is Tortajada's adaptation of a survey used by the Help for Drug Addiction Foundation (FAD) and the Sociological Research Team (EDIS).It consists of 44 questions and is validated and divided into different thematic areas: perception of the measures for the substance use, image of drugs and consumers, perception and assessment of the danger, and values and attitudes towards the substances.
The AAPPQ is a questionnaire about the perception of alcohol problems.There is no record of its validation.The Addiction Psychiatry Survey was designed to assess changes in attitudes among residents for whom the questionnaire is available; there are no data on its validation.The ATSMQ-10 and AICSS-16 questionnaires assess attitudes and skills, respectively.The article does not provide the questionnaires or the scales used, although it does mention them with no bibliographic reference.
The Marcus Alcoholism Questionnaire evaluates the attitudes of professionals about alcoholism.It was developed in Canada, and no evidence has been found that it has been validated elsewhere.The EAFAAA is a scale based on the Seaman-Mannello scale that measures nurses' attitudes Research Dr. Jesús Molina Mula the SM-GIBED survey about nurses' attitudes and perceptions in emergency services and mental health units toward alcoholic patients in the context of Spanish hospitals.

Data-collection procedures
Nurses from emergency services and mental health units were selected for the following reasons: (1) Substance abusers are more likely to use emergency services and mental health units.This can generate different types of attitudes depending on the care burdens, staffing, and relationships with other hospital services that can provide more information about the phenomenon under study.(2) These are services that, despite their specialisation, serve other types of patients and, in the case of mental health units, have more specialised training in drug-dependent patients compared to professionals in emergency services.This reveals the different care provided to patients depending on the complexity.

Inclusion and exclusion criteria
The inclusion criteria were: (1) nursing professionals from emergency services and mental health units with more than six months of experience, enough time to acquire certain professional skills in these units; and (2) they agreed to participate in the study and provided informed consent.

Sample
The sample corresponded to the population universe of nurses (257) of the emergency services and mental health units in five hospitals in the Balearic Islands in Spain from February 1 to December 1, 2015.The nurses in these services were easy to manage, so the total number of staff of each of the services was included.
The scale validated to the adapted Spanish SM-GIBED was provided to each professional from the original Seaman-Mannello scale [3,5,[10][11][12] which measures the knowledge and attitudes of nursing professionals in relation to alcoholism and alcohol consumption.
In addition, for the evaluation of attitudes towards other drugs, a self-questionnaire was used in which they were asked to mark the characteristic they considered to be the best defined drug dependent in general and the alcoholic in particular.It is important to note that at the beginning of the SM-GIBED questionnaire, nurses were asked to clarify that they imagined a patient as an alcoholic only and not with other drug dependents.Similarly, when referring to the perception of other substances.The SAAS is a survey developed and validated in English by Chapel that measures attitudes towards various abuses of alcohol and other substances.It was used by several authors but was in none of the reference articles that have been translated into Spanish.
The SAKS is an instrument developed in English by Hughes and Gerace.It measures knowledge in the field of substance abuse and addiction and consists of 30 multiple-choice questions.The SAES is another instrument developed in English by Hughes and Gerace that evaluates the educational training in substance abuse and past experiences with patients in whom substance abuse.Also included is a clinical confidence scale survey that consists of questions about alcoholand drug-related clinical skills.
The Seaman-Mannello scale specifically measures the attitudes of professionals regarding the treatment of alcoholism and alcohol consumption.It was created and validated in English by the authors in Buffalo (New York, USA) and in Portuguese in Brazil by Pillon.In order to apply it in Bolivia, Villar back-translated the questionnaire into Spanish.
The objective of this study is to analyse nurses' attitudes and perceptions about alcoholic patients in emergency and mental health services by adapting the SM-GIBED scale to a specialised clinical context in Spain.

Design
This study is cross-sectional and a validation of the adaptation of the Seaman-Mannello scale to

Research
Validation of the SM-GIBED Scale: Attitudes of Emergency and Mental Health Nurses about Alcoholics and Other Drug-Dependent Patients

Study variables
The study variables were: (1) the sociodemographic characteristics of age, sex, professional experience, experience in emergency services and mental health units, and undergraduate and postgraduate training; (2) attitude variables on paternalism/ empathy; (3) the variables of perception towards alcoholic and drug-dependent patients; (4) the variables on difficulties in treating alcoholic and drug-dependent patients; and (5) the variables of the SM-GIBED scale.

Measure
The present study used the Seaman-Mannello scale [30] as a tool, since only shortened versions of the original scales have been published and this is the only complete edition validated in Spanish [4].In addition, it is a tool that specifically measures nurses' attitudes in relation to alcoholism and alcohol consumption [7].
The Seaman-Mannello scale [1,7,5,30] is a multidimensional construct of a subjective perception of reality that describes nurses' perceptions and attitudes about alcohol consumers [15].It was created and validated by Seaman and Mannello in Buffalo (New York, USA).It was later validated in Brazil by Pillon [31] and then translated from Portuguese into Spanish by Villar.In the next stage of backtranslation, the scale in English was translated into Spanish by an official translator of the Bolivarian American Centre (Ministry of Health and Social Welfare of Bolivia, Strategic Health Plan for the Fight against Poverty, La Paz, 1997) [31].This scale consists of 30 items.The interviewers must rank according to their degree of agreement or disagreement with the proposed statements using a 5-point Likert scale.Although the questionnaire has not been designed to generate a global index, it allows the calculation of different dimensions.
All of the items are grouped into five subscales of six items each, which enables the evaluation of five dimensions that relate knowledge and attitudes, such as (1) inclination in relation to therapy vs punishment, (2) personal/professional satisfaction in their work with alcoholics, (3) inclination to identify their ability to help alcoholic patients, (4) perceptions of personal characteristics of alcoholics, and (5) personal attitudes towards drinking.
The Seaman-Mannello scale generated a Cronbach's alpha of 0.693 for items referring to the personal satisfaction of a professional working with alcoholics, 0.691 for the perception of dependence, and 0.775 for attitudes towards alcohol consumption.The factor analysis explained most factors up to 65%.Although the scale has been used in Spanish, until now it has not been contextualised in a hospitallevel environment in Spain.Due to the cultural characteristics and the model of the health system, a new analysis of the scale is necessary.
For this reason, the scale was piloted in emergency and mental health nurses.The expressions of some questions were modified because to increase understanding by Spanish nurses in adapting the Seaman-Mannello scale to the SM-GIBED version.

Data analyses
A descriptive analysis of the sociodemographic characteristics, attitude, perception towards alcoholic and drug-dependent patients, difficulties in treating alcoholic and drug-dependent patients and SM-GIBED scale were performed.In addition, chi-square was established to analyse the association between sociodemographic characteristics and nurses' attitudes.
The analyses were based on the behaviour of the type of variables using SPSS version 21.0.The 30 questions of the Seaman-Mannello scale and its 5 subscales were analysed, attributing 1 and 2 points for unfavourable responses, 3 for intermediate categories, and 4 and 5 points for favourable categories.The mean and its corresponding standard deviation were calculated, and the results were interpreted according to the authors of the instrument; p<0.05 was considered statistically significant.Psychometric analyses were performed to validate the scale in a hospital context in Spain.These included: (1) a qualitative evaluation of the content validity index and cognitive pre-test items, (2) a statistical analysis of the items of non-response and the ceiling and floor effect, (3) a study of the dimensionality of the exploratory factor analysis instrument, (4) an estimate of the reliability of Cronbach's alpha, and (5) external evidence of validity.
The statistical analysis of the relationships between the attitude of the professionals and the study variables included an exploratory analysis of the data (outliers, non-response, and assumptions of normality and homoscedasticity) and a general analysis with the description of the subjects studied, existence of association, adjustment of confounding factors, and an analysis of the subgroups.

Ethical considerations
This research used completely anonymised sources and data.The current legislation on data protection was enforced, such as patient autonomy and information and clinical documentation.There were no conflicts of interest between the participants and the researchers, and the principal researcher and collaborators were responsible for the ethical implications of the study.
Informed consent was requested from all of the study participants, and the authorisations of the centres and the Research Ethics Committee were obtained.

Sociodemographic characteristics
Of the 257 nurses at 5 hospitals in the Balearic Islands in Spain, 209 were from emergency units and 48 from mental health service.Of these 170 agreed to participate, 129 emergency nurses (61.7%) and 41 mental health nurses (85.4%).Their mean age was 34.7 years (σ=6.34),117 (68.8%) were women, and 38 (22.3%) had a postgraduate degree, master's degree, or official specialisation.
The mean professional experience as a nurse was 11.19 years (σ=5.8),with 6.5 years (σ=4.4)mean profession service in the emergency and menatl health unit.It should be noted that 151 nurses (88.8%) had had contact with drug-dependent patents in the prior 6 months, 87.1% (148) with alcohol users.However, only half of the nurses worked habitually with these patients.

Nurses' perceptions and attitudes towards drug-dependent patients
Overall, 65.9% (112) of the nurses empathised with their alcohol-and drug-addicted patients without adopting a paternalistic attitude.Overall, 80.4% (79) of the emergency nurses presented a paternalistic attitude compared to 21.7% (23) of the mental health nurses, although no significant association was found (chi square=8.325,df=4, p=0.08).
From a list of characteristics that defined the alcoholic, the nurses classified them into 74.1% (126) such as sick, 37.1% (63) like unhappy, and 19.4% (33) such as a normal person.Although the percentages were low, some of the nurses thought that alcoholics were vicious, marginalised, and asocial.Only 6.5% (11) identified them as guilty of their dependence compared to 19.4% (33) who considered them victims (Table 1).
The perception of alcoholics was compared to the perception of drug-dependents in general with the same characteristics without distinguishing a specific substance.A significant association of p<0.000 was found in all with chi-squar.Table 1 shows how the perception of drug addicts is similar to alcoholics.There were no significant differences with chisquar between the emergency and mental health nurses regarding their perception of alcoholics and drug addicts by unit (Table 2).
Analysis of the difficulties faced by nurses in the clinical setting in caring for drug-dependent patients reveals that lack of knowledge is the most prevalent limitation, followed by the organisation of the unit and the professional attitude toward these patients, the perception and social stigma of substance-related disorders, and the personal opinions of the professionals.Table 3 shows the results on a scale of 1 to 5, where the 1 is the greatest difficulty and 5 the least.
No significant variation with chi-squar in the definition of the difficulties in treating drugdependent patients was observed in the different unit analysis.
Table 4 shows the association between the educational level, professional experience, work situation, and years in the unit and the nurses' perception of drug addicts and their satisfaction in working with these patients.

SM-GIBED scale
In general, negative personal attitudes predominate with respect to alcohol or towards drinking.Overall, 44.5% (76) disagreed that moderate alcohol was beneficial to health and 46.2% (78)-also disagreed about the claim that there was nothing wrong with consuming moderate amounts of alcohol.
The nurses considered the life of the alcoholic as unpleasant, and their physical health 40.4% (69) lower than normal.Overall, 70.7% (119) thought that an alcoholic patient needs psychiatric help and 73.1% (124) believed that obtaining pharmacological treatment was sufcient.
In relation to the satisfaction of working with alcoholic patients, 42.7% (73) disagreed, although 57.9% (98) believed that alcoholics were just as worthy of hospitalisation as other patients.A total of 30.4% (52) reported not feeling comfortable working with alcoholics.
It should be noted that 46.2% (78) of the nurses thought that alcoholic patients must seek Research Dr. Jesús Molina Mula The psychometric analysis of the SM-GIBED scale in the Spanish context obtained values of KMO=0.655 and Bartlett's test p<0.000.The goodness of fit was measured using the chisquared test at 399.274 with 295 degrees of freedom and p<0.000.

Research
Validation of the SM-GIBED Scale: Attitudes of Emergency and Mental Health Nurses about Alcoholics and Other Drug-Dependent Patients Cronbach's alpha of 0.738 was obtained using reliability analysis.No item on the scale was eliminated, as the unidimensionality criterion was modified and the alpha decreased.Table 6 expresses the reliability analysis of each of the questions on the SM-GIBED scale, which in no case was less than 0.71.
The factorial analysis of the SM-GIBED scale using an orthogonal varimax rotation was carried out based on 5 factors corresponding to the scale's 5 subscales.A total variance of 35.94% was found from these 5 extracted factors.

Discussion
A comparison of this study's data to that of de Vargas and others [18,32,15,20] revealed important similarities.The common denominator is that there is a personal rejection of moderate alcohol users, and nurses are willing to help patients even when they continue to drink.Furthermore, nurses believe that alcoholics are sensitive people with severe emotional difficulties and an inferiority complex whose lives are unpleasant and who lack good physical health.
Both our study and others found that nurses are uncomfortable working with these patients because they do not provide similar satisfaction to other types of patients.
In both de Vargas' research and others [18,32,15] and in the present study, the score of subscale 1 of the Seaman-Mannello questionnaire [20] presented values considered high, indicating that nurses believe that alcoholics are physically ill patients who need medical treatment.
Subscale 2 presented a score considered low, which indicates feelings of dissatisfaction and dislike on the part of the nurses when working with people who have problems related to alcohol [19].Subscale 5 indicated that the nurses see any quantity of alcohol as dangerous and harmful as well as morally wrong [20].
Regarding the validation of the SM-GIBED scale, Crothers and Dorrian [33] obtained a Cronbach's alpha of 0.775, which in our study was 0.738.Therefore, the SM-GIBED scale has been validated to reveal the attitudes of emergency and mental health nurses toward alcoholic patients in Spain.
In addition, as in other studies [34][35][36][37], difficulties treating alcoholics have been evidenced by lack of knowledge.Professional attitudes and social perceptions influence the treatment of alcoholics, and there is a decisive lack of communication skills.
This study may have the limitations of participation and sam.ple size, as well as the bias inherent in the application of the scales.However, we obtained significant results that suggest certain associations between the study variables.We must emphasise that being a descriptive design, the possible associations found are not valid to establish a causal relationship between the variables, but can lead to future analytical studies aimed at investigating and contrasting the corresponding hypotheses.

Conclusion
In conclusion, as positive aspects, the nurses displayed ingratiating attitudes and satisfactory subject-to-subject communication when they self-define as empathic and non-paternalistic.Among the negative aspects, the nurses demonstrated a lack of communication skills and assertiveness with these patients.This highlights a certain degree of resignation and dissatisfaction when working with drug dependents.
about alcoholism.It was validated in Portuguese and translated into English by Vargas.It includes the following categories: the alcoholic person, the disease and the alcoholic against alcoholism, interpersonal work with alcoholics, aetiology of alcoholism, and the social repercussions of the use and abuse of alcohol.The NEADA is a survey on nursing education related to alcohol and drugs.It consists of the following categories: individual characteristics, attitudes, beliefs, and knowledge regarding substances (Nursing Education in Other Drugs, PROJECT NEADA, Nursing Education in Alcohol and Drug Education, Storrs, Connecticut: Connecticut School of Nursing, 1985).It was validated and translated into English and Spanish, but the Spanish version has not been located.