SBIRT Implementation Training for Undergraduate Nursing Students

Monday, 30 October 2017

Dawn Marie VanRuler, MS1
Heidi A. Mennenga, PhD1
Mary Lou Mylant, PhD2
Cynthia Anderson Elverson, PhD3
(1)Undergraduate Nursing Department, South Dakota State University, Brookings SD, Brookings, SD, USA
(2)Undergraduate Nursing, South Dakota State University, Rapid City, SD, Rapid City, SD, USA
(3)College of Nursing, South Dakota State University, Sioux Falls, SD, USA

Background: Substance use disorders are a substantial problem in the United States that is inadequately addressed. The United States (US) Preventative Task Force (USPTF) recommends clinicians screen all individuals 18 years and older for problem alcohol use (USPTF, 2016). Screening, brief intervention, and referral to treatment (SBIRT) can improve identification of individuals with problem alcohol use so referral and recommendations to treatment can be completed (Seale et al., 2012). This training project targets SBIRT educational strategies to improve competence of nursing students to use screening and brief assessment in clinical settings.

An estimated 20.3 million or 8.5% of adults were identified as having a substance use disorder in the United States in 2013 (Substance Abuse and Mental Health Services Administration, 2014). There are low rates of alcohol screening 16% and intervention 3% for alcohol use disorders (Cunningham et al., 2010; Madras et al, 2009). Treatment rates remain low for individuals with alcohol use disorders despite available effective treatments. Treatment is offered to 1-2 of every 10 individuals with alcohol use disorders (Vaeth, Wang-Schweig, & Caetano, 2017). Only 15% of hospitals report using formal screening and intervention processes, such as SBIRT in their emergency departments (Cunningham et al., 2010). Improving the rates of screening for alcohol use disorders can improve awareness of problems with use and can facilitate referral to treatment.

There has been an ongoing call for more education for nurses regarding alcohol use screening and referral techniques, but little improvement in rates of trained nurses to administer brief screening has occurred (Murphy-Parker, 2013). Undergraduate nursing education incorporates limited content on substance abuse screening (Savage, Dyehouse, & Marcus, 2014). Nurses report lack of adequate knowledge and competence in alcohol use screening and referral (Tran, Stone, Fernandez, Giffiths, & Johnson, 2010). Implementing SBIRT into educational programs can result in increases in SBIRT-related knowledge and self-efficacy for using SBIRT process (Stoner, Mjikko, & Carpenter, 2014).

SBIRT is a patient centered, stepped care approach suited to multiple settings (Agerwala, 2012; Braxter et al., 2014; Mitchell et al., 2013; Ripor, 2009). Nurses find SBIRT acceptable and relevant to their nursing role (FInnel, 2012; Johnson, 2014). Brief screening related to improved mental health, housing, and employment among those who use alcohol (Agerwala & McCance-Katz, 2012). There was a 0.38% percent reduction in heavy alcohol use in patients receiving SBIRT at six months (Madras et al., 2009). Use of SBIRT can counteract lack of self-efficacy to implement brief screening for problem substance use (Braxton et al., 2014; Johnson et al., 2014; Mitchell et al., 2013; Seale et al., 2012). Improvement in negative attitudes and stigma about those who use substances can occur with SBIRT application (Broyles et al., 2013). SBIRT can also improve communication and encourage prioritizing of substance use screening in clinical settings (Rahm et al., 2015). Nurses are in an ideal position to implement brief screening for substance use disorders to generate positive health benefits (Puskar, 2012).

Purpose/Aim: The purpose of this project was to adapt and implement evidence based SBIRT curriculum for use with pre-licensure nursing students to provide skills necessary to screen and refer patients who are at risk related to alcohol use.

Objectives: The first objective was to describe formative processes of adaption and implementation of SBIRT curriculum for nursing students. The second objective was to evaluate if there is an increase in perception of importance and acceptability of SBIRT implementation in nursing student participants trained in SBIRT.

Approaches/Methods: Formative evaluation was conducted of an adaption of SBIRT material incorporated into nursing student education in third year (level III) nursing student’s course. Simulation scenarios were implemented which gave nursing students hands on experience to use the SBIRT skills. Secondly, integration of the SBIRT material in mandatory coursework was evaluated regarding its acceptability and perceived importance in the nursing clinical setting and community.

SBIRT educational material was implemented with third year (level III) nursing students during mental health nursing substance use content areas. Formative outcomes planned to be measured include: number of trained students, demographic information, and perceived efficacy for the SBIRT process. Development and evaluation of SBIRT simulation scenarios has been completed. The in-class role plays and simulation scenarios were designed to provide hands-on practice of SBIRT techniques by nursing students. No major revisions were necessary to incorporate core components of SBIRT training into the nursing curriculum. All students in the nursing program at this Mid-Western United State University are targeted to be trained in SBIRT and to complete the simulation scenario using SBIRT techniques. Nursing faculty providing the educational material were trained by a one day live SBIRT training. Students engaged in both an in-class role play using SBIRT principles and a hands-on simulation session designed to promote student’s application of the SBIRT process. The simulation required students to apply SBIRT process to a complex situation in which a post-partum breast feeding mother was found to be using alcohol.

Technology transfer process theory was applied to the training project. The five steps of the technology transfer process are: development, translation, dissemination, and adoption and implementation (Burns et al., 2012). The project plans to use resources from Substance Abuse Mental Health Services Administration (SAMHSA) that had been developed and translated for educational use (SAMHSA, 2014). The Technology transfer process also provides foundation for the educational components that encouraged dissemination, adoption, and implementation of SBIRT by nursing students into clinical settings.

Results/Analysis: Early analysis of the implementation of SBIRT training with nursing students finds that students were highly satisfied with the SBIRT training materials. Participants are reporting positively that they believe the training will be useful in dealing with individuals with substance abuse in clinical settings. Many feel they will be able to effectively apply SBIRT with patients after the training.

Relevance to Nursing: This study lends further support to the finding that SBIRT is found to be relevant to nursing practice (Johnson, 2014). Undergraduate nursing education has low baseline alcohol use assessment levels by students of screening for alcohol use (Tanner, Wilhelm, Rossie, & Metcalf, 2012). Following training in skills of SBIRT, nursing students have increased rates of assessment and brief intervention in those with substance misuse (Tanner et al., 2012). SBIRT use in undergraduate nursing education also increases student awareness of alcohol use (Baez, 2005), improves Identification of at risk drinking behavior aspects (Kane et al., 2014), and facilitates identification of stigma toward problem users of alcohol (Burns et al., 2012). Education in SBIRT does not always result in positively perceived ability to apply SBIRT in nurses, thus improved understanding of SBIRT training needs in nurses is important (Tran et al., 2009).

Discussion: The SBIRT training, previously was found to help nursing students deal with substance abusers (Tran et al., 2009). The combination of in class theory content and simulation scenarios planned will add to existing research which has used primarily written materials to equip students to use SBIRT. Attitudes and perceptions of those who use alcohol were targeted for improvement with this SBIRT classroom didactic material and simulation application of SBIRT. This training program will add further understanding to use of didactic and simulation to improve nursing student’s knowledge, acceptance, and eventual implementation of SBIRT in patient care. It is also hypothesized that this educational project will improve improved attitudes and perceptions of students toward individuals that use substances, as prior study has shown (Puskar et al., 2016). Adoption phase of the technology transfer process is likely to be more difficult than the didactic and simulation portion of the process. This is an area for future study and evaluation.

Confidence in the reasons to use SBIRT was found preliminarily to be increased in those who participate in SBIRT training. These formative findings of the SBIRT training project align with previous research showing improve self-efficacy of abilities to apply SBIRT to clinical situations after SBIRT training (Seale et al., 2012; Stoner et al., 2014; Tanner et al., 2012). Increased self-efficacy regarding the use of SBIRT may foster increased application of the technique, eventual improved outcomes, and reduced mortality for those who use substances.

 “This project is/was supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services (HHS) under grant number 5H79TI025987-02: Implementation of Screening, Brief Intervention, and Referral to Treatment Education for Health Professionals in South Dakota for $546,971. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.”