The purpose of this presentation is to describe the nursing arm of an initiative to increase healthcare provider competence and confidence in identification and management of substance use disorders by integrating an evidence-based Screening, Brief Intervention, Referral to Treatment (SBIRT) curriculum into health professions training programs at a large Southeastern university. Trainees included graduate nursing, social work, and rehabilitation counseling students and medical residents. The training was supported by a 3-year Substance Abuse and Mental Health Services Administration completed in 2016. The success of the initiative led to additional funding which has allowed the training to continue. These training efforts are consistent with global and national objectives to reduce the social and health burdens associated with harmful levels of alcohol consumption and drug abuse.
Drug and alcohol abuse is a pervasive public health problem with multiple adverse medical, legal and psychosocial consequences. Across the globe, an estimated 16% of drinkers age 15 and older engage in heavy episodic alcohol use and nearly 6% of all deaths are related to alcohol consumption (World Health Organization [WHO], 2014). Alcohol is noted to be a component cause of more than 200 ICD-10 disease and injury coded conditions (WHO, 2014). In the United States, excessive alcohol use was responsible for approximately 1 in 10 deaths of adults aged 20-64 years between 2006-2010 (Stahre, Roeber, Kanny, Brewer, & Zhang, 2014), including 31% of driving fatalities (US Department of Transportation, 2017). An estimated 1 in 6 adults binge drinks at least 4 times per month (Kanny, Liu, Brewer, & Lu, 2013). Although most are not alcohol dependent, misuse of alcohol has numerous immediate and long-term health risks, including eventual dependence. The economic costs of excessive alcohol use in the United States exceeded $249 million in one year alone (Sacks, Gonzales, Bouchery, Tomedi, & Brewer, 2015). Use of legal and illegal drugs adds to the global burden of substance abuse. Worldwide, approximately 5% of individuals aged 15-64 years engage in illicit drug use (United Nations Office on Drugs and Crime, 2017). In the United States, opiod-related fatalities are growing at alarming rates, with a reported 33,000 deaths in 2015 (Centers for Disease Control, 2017). Nearly half of these involved the misuse of prescription drugs.
Early identification and management of individuals at risk for substance-related problems, with referral to specialty treatment services when necessary, improve health outcomes and use of available resources. Unfortunately, only 1 in 6 individuals report speaking with a healthcare provider about their substance use (Centers for Disease Control, 2014). Because most health professional training provides minimal instruction in assessment and treatment of substance use disorders, few providers enter practice prepared to address this need. Universal screening in SBIRT allows providers to assess levels of risk among individuals who report substance use and respond accordingly with reinforcement, education, brief focused awareness-raising conversations to elicit change, or referral to higher levels of care, if appropriate.
To increase student and resident readiness to provide comprehensive patient care, faculty in nursing, medicine, social work, and rehabilitation counseling collaborated to customize the evidence-based SAMHSA SBIRT curriculum for implementation into their respective programs. Training was conducted using 6 online modules that included multimedia didactic instruction on substance use, motivational interviewing techniques, the SBIRT model, skills demonstration vignettes, and resources such as screening tools and patient teaching aids. After working through the modules at their own pace, students demonstrated competency through a standardized role play with faculty. Knowledge about substance use and intervention, confidence in screen for and manage substance use, and attitudes about substance abuse intervention were assessed before and after SBIRT training.
For nursing, SBIRT training was incorporated as an assignment into the advanced health assessment course required for nurse practitioner (NP) students. This strategy allowed faculty to access students within all of the specialty programs and provided students with a tool that they could utilize in their upcoming clinical courses. Because the didactic portions of the NP courses are delivered online, it was not feasible to require students to come to campus for skills demonstrations; therefore, students had the option to meet with faculty face-to-face or virtually. The completed grant supported the training of 251 NP students, and the current grant is projected to reach a similar number. About one-third of the nursing cohort reported little or no training or experience working with patients with alcohol and drug problems. After completion of the curriculum, knowledge scores increased from 76% (pre) to 95% (post). Confidence improved in ability to screen for alcohol and drug problems, in ability to discuss substance use, and in ability to assess readiness for change. Students experienced an increase in perceptions of understanding of substance abuse, and decreases in perceptions that addressing substance use issues was too time consuming or might be poorly received by patients. All changes were significant at p=.001 level, except for attitudes related to time constraints (p =.05). There were no differences noted in outcomes between students who performed skills demonstrations virtually compared to those who completed face-to-face demonstrations. Nurse practitioner students achieved the highest overall post-training knowledge scores, and confidence and attitudes outcomes were comparable to those of other disciplines. Satisfaction surveys revealed that students found the content easy to understand and relevant to their clinical experiences and future practice. Anecdotally, many students noted that motivational interviewing techniques were similarly applicable to practice when other lifestyle modifications were indicated.
This interprofessional initiative has proved to be an effective model in the academic arena. Next steps for nursing include engaging additional faculty/preceptors to ensure curriculum sustainability and provide ongoing support for SBIRT skills development throughout clinical rotations. Additionally, students will be followed at select points during the remainder of their program of study to assess whether SBIRT skills have been successfully implemented in their interactions with patients in their clinical settings.