Journal of Addictive Behaviors,Therapy & RehabilitationISSN: 2324-9005

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Short Communication, J Addict Behav Ther Rehabil Vol: 6 Issue: 1

Consider the Setting: Challenges in Integrating Screening, Brief Intervention, and Referral to Treatment into Nursing and Social Work Students’ Clinical Practice

Knopf-Amelung S*, Gotham H and Kuofie A
School of Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, USA
Corresponding author : Sarah Knopf-Amelung
Senior Research Associate, School of Nursing and Health Studies, University of Missouri-Kansas City, 2464 Charlotte St., Kansas City, MO 64108, USA
Tel: 816-235-6982
E-mail: [email protected]
Received: November 21, 2016 Accepted: January 02, 2017 Published: January 09, 2017
Citation: Knopf-Amelung, Gotham H, Kuofie A (2017) Consider the Setting: Challenges in Integrating Screening, Brief Intervention, and Referral to Treatment into Nursing and Social Work Students’ Clinical Practice. J Addict Behav Ther Rehabil 6:1. doi: 10.4172/2324-9005.1000160

Abstract

Objective: Substantial funds are being invested into training health professions students to provide screening, brief intervention, and referral to treatment (SBIRT) for substance use, but will the newly trained workforce be ahead of its future employers? The goal of this study was to explore implementation facilitators and barriers.
Methods: This project educated 541 baccalaureate nursing (BSN), advanced practice nursing (NP), and master of social work (MSW) students through didactics, role plays, standardized patient practice, and clinical experience to help students achieve competency. One month after training, students were surveyed regarding their use of SBIRT in clinical practice and barriers/facilitators to their use of SBIRT.
Results: Efforts to integrate SBIRT into students’ clinical experiences were met with numerous challenges. Follow-up surveys revealed a number of barriers to practicing SBIRT during clinical rotations, including feeling a lack of authority to implement, clinic policies not allowing SBIRT, clinic staff lacking SBIRT awareness and training, perceptions that SBIRT was inappropriate for the patient populations served, lack of time, and fear of patient reaction. Facilitators included faculty and supervisor support of SBIRT, clinic policies allowing SBIRT, acceptance of SBIRT by clinic staff, having a framework to discuss substance use, and having SBIRT practice as a course requirement.
Conclusion: Without clinical site buy-in, students do not receive adequate opportunities to practice with patients. Therefore, clinical site attitudes and policies need to be considered prior to implementing student practice so students can sustain gains in knowledge, attitudes, and skills.

Keywords: Substance use disorders; Nursing education; Social work education; Competency based education

Keywords

Substance use disorders; Nursing education; Social work education; Competency based education

Background

Substance use is a prevalent health concern that impacts the work of health professionals from all disciplines. Yet, a systematic review found that health professionals often hold discriminatory or stigmatizing views of patients with substance use disorders, which may be partially attributed to inadequate academic preparation resulting in a lack of knowledge and skills to address substance use [1]. Screening, brief intervention, and referral to treatment (SBIRT) for substance use is an evidence-based practice that provides a standardized framework for screening and intervening with patients using substances at risky or harmful levels [2]. It combines universal and targeted screening with a 5- to 15-minute motivational interviewing-based brief intervention to enhance patient motivation to change substance use. Patients with severe substance use who may have a substance use disorder receive a warm handoff referral to specialty addiction treatment.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has been funding SBIRT medical residency and health professions training grants since 2008. In addition to didactics, a critical requirement of these grants is to provide students with opportunities to conduct SBIRT with patients during clinical rotations or field placements. SBIRT, like any other evidence-based practice, requires significant repetition and rehearsal to achieve competency. Application of SBIRT skills is particularly important for health professions students who require hands-on, clinical skill-building to achieve “readiness to practice” upon graduation [3,4]. Previous SBIRT training projects have highlighted the importance of clinical practice, along with supervision and feedback, in achieving competency [5]. Braxter et al. [6] found that after practicing SBIRT with patients during clinical rotations, baccalaureate-level students reported an increase in feeling that discussing substance use was a nursing responsibility and part of routine clinical care.
SBIRT training program
The goal of the University of Missouri-Kansas City (UMKC)- SBIRT training project was to help students achieve competency in practicing SBIRT, including universal and targeted screening for substance use (universal screening questions [7,8]; AUDIT and DAST [9,10]), delivering a brief negotiated interview [11], and referring patients to treatment when appropriate. From 2013-2016, the UMKC-SBIRT project educated baccalaureate nursing (BSN), advanced practice nursing (NP), and master of social work (MSW) students through didactics threaded throughout coursework; role plays with classmates; standardized patient practice; and clinical experience to help students achieve competency. Didactics were 4 to 6 hours long, conducted either in person or using an interactive online course (www.sbirt.care), and covered what is SBIRT, screening for substance use, communication style (emphasis on motivational interviewing [12]), brief negotiated interview model of a brief intervention, and referral to treatment. Following didactics, all students completed 1-2 hours of role plays with classmates using case scenarios. They also completed SBIRT with two standardized patient actors in our simulation lab. Most students received immediate verbal feedback from a trained coach who sat in on the first session and scored the session using a competency rating form developed for the project. Then, the second session was audio-recorded and students received written feedback from expert coaches/raters using the same form (a few cohorts in the first year only received written feedback). Finally, students were expected to deliver screening and a brief intervention to at least one patient during a semester-long clinical experience or field placement. Clinical sites included hospitals, primary care clinics, and social service and behavioral health agencies. A few clinical sites did not allow SBIRT implementation with patients due to concerns about documentation, role of the student, or patients becoming distressed at being asked about substance use. In these instances, students completed SBIRT with classmates instead. The clinical practice was observed and rated by the clinical supervisor or field instructor if that person was SBIRT-trained, or students completed a self-rating if their supervisor/instructor did not have SBIRT training.

Methods

Thirty days following training, students completed a survey that included items on training satisfaction and implementation of SBIRT. Training satisfaction was assessed with the 25-item Center for Substance Abuse Treatment (CSAT) Training Satisfaction Survey [13]. Items ask about satisfaction with the quality of the training, instruction, and materials; whether training enhanced skills; whether training content was applied to their work; and whether training information and materials were shared with others. Implementation was assessed with 8 items developed for the study that covered whether students were using SBIRT, how many screenings and brief interventions had been performed since training, if universal screening had been implemented, the usefulness of SBIRT, and facilitators and barriers to implementing SBIRT. These evaluation methodologies were approved by the university’s Institutional Review Board.

Results

Across three years, 256 BSN students, 160 NP students, and 125 MSW students were trained. The majority of students were white (76%) and female (84%). Thirty days post-training, most students reported high satisfaction with the training (85.9%). A vast majority reported that the training enhanced their skills (89.6%) and was relevant to their career (88.1%). Nearly three-quarters of the students (72.8%) reported sharing training information with others. However, only about half of students (53.6%) reported applying what they learned to their work, and only a third (31.1%) reported using SBIRT with patients.
Students noted a number of barriers to implementing SBIRT in their clinical experience, including the following. Some students felt a lack of authority to implement: “As a student- I am not able to ‘change’ how my preceptors’ practices do screenings- I have to go by what they use;” “not enough authority as a student nurse.” Clinic policies did not allow SBIRT: “I have not got[ten] the chance to due to facility not allowing it, but if a facility allowed it I would try to use it;” “I am shy to use SBIRT without it being welcomed as an appropriate intervention in my agency.” Clinic staff lacked SBIRT awareness and training: “[lack of] knowledge at practice site;” “some hospitals do not desire to use SBIRT, or have not yet trained their staff to use it.” Some students perceived that SBIRT was inappropriate for patient populations served (e.g., children, inpatient mental health unit, and hospice). Some students felt time constraints: “Short time frame with the patient.” Finally, some students feared patients’ reactions: “Patients may not be comfortable talking about the subject at all, let alone with a student.”
Students who were successfully practicing SBIRT noted a number of facilitators. Some students reported faculty and supervisor support of SBIRT: “Faculty advisor’s excitement;” “Professor’s help.” Some clinical sites’ policies were conducive to SBIRT: “If it is allowed at the facility I am working at.” Some clinical staff accepted SBIRT: “Other providers I work with were willing to discuss and use the items I had brought back from my training in SBIRT.” Students reported that SBIRT provided a framework to discuss substance use: “It was a new skill and I did not know how to approach the conversation prior to the training.” Finally, students reported that having SBIRT practice as a course requirement facilitated its use: “Well right now we have to as a requirement for class, but I feel that I will use it in the future.”

Discussion

Many SBIRT training programs and subsequent evaluations have focused on increasing students’ knowledge, positive attitudes, confidence, and competence. Prior studies have found that students’ self-perceived competence and confidence predicted their implementation of SBIRT [4,14]. While these factors are important, the findings of this study demonstrate the need to also consider systemic factors, namely conditions at clinical sites. In a study on implementing SBIRT in social work students’ fieldwork settings, Ogden et al. [15] found agency-level factors to be an influential dynamic in students’ practice experiences; these factors included populations served, theoretical orientation, established approaches to substance use, consequences for clients, bureaucratic processes, flexibility, agency support, and fieldwork instructor support. Nearly all of these factors were present in the facilitators and barriers identified in the present study. Muench et al. [16] discussed the importance of providing SBIRT-trained students with clinical sites that are supportive of SBIRT in order to sustain gains in attitudes and competence. Students in this study who were assigned to clinical sites with unsupportive SBIRT policies did not receive the same breadth of training experience as students at clinical sites that allowed or even encouraged SBIRT implementation.
Regardless of the quality of SBIRT training and positive changes in knowledge, attitudes, and skills, these results suggest that without clinical site buy-in, students do not receive adequate opportunities to practice with patients. Clinical site attitudes and policies must be addressed proactively to ensure students can apply their learning, or future uptake of SBIRT may be stunted.

Acknowledgment

This work is supported by grant TI025355 from the Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

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