With the Centers for Disease Control and Prevention (CDC) reporting for 2006 to 2010 an estimated 88,000 alcohol-related deaths in the U.S. each year (CDC, 2014a), plus the staggering emotional and economic burden of excessive alcohol use, the time is long past due for a call to action. Alcohol use screening using evidence-based screening tools with a brief intervention using motivational interviewing techniques, or alcohol SBI, is a public health model of prevention and identification of risky use. Alcohol SBI, endorsed by the United States Preventive Service Task Force (2013), must become a routine standard of care within the health professions (Finnell, 2012). The nursing profession, the largest and most trusted sector of the health care workforce (Brennan, 2017), is perfectly poised to lead an alcohol SBI initiative to close the practice implementation gap by screening for alcohol use to identify risk, delivering a brief intervention to provide feedback on risk levels matched to the individual's use and readiness to change, if and when appropriate (Babor, Higgins-Biddle, Saunders, & Monteiro, 2011; Curtis, McLellan, & Gabellini, 2014), and encouraging and educating health colleagues and students to use alcohol SBI.
In 2014, the American Association of Colleges of Nursing (AACN) and Centers for Disease Control and Prevention (CDC) issued a call for proposals for a Workforce Improvement Project titled “Advancing Nurses' Knowledge, Practice, and Implementation of Alcohol Screening and Brief Intervention.” Three key outcomes were specified: (a) improve nurses' training and knowledge of alcohol SBI; (b) promote nurses' practice and adoption of alcohol SBI; and (c) increase nurses' advancement of system-wide provision of alcohol SBI through model curricula and strategies (AACN & CDC, 2014). Two awards were given, one to a team of experts from the University of Pittsburgh School of Nursing and national addiction training center, and a second to a team of experts at the Johns Hopkins School of Nursing ( http://www.aacnnursing.org/Population-Health-Nursing/Workforce-Improvement-Projects).
Each team included team members with extensive alcohol-related experience, including the development of various educational (including continuing education) programs for multiple levels of nursing students, nurses, and behavioral health professionals practicing in a variety of settings (Finnell & Seale, 2018; Mitchell et al., 2016; Puskar et al., 2016; Sanchez & Finnell, 2017; Savage et al., 2017). The awardees were required to use “Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices” (CDC, 2014b) in their respective projects. During an initial call with the liaison from the CDC, the awardees, well known to one another, realized the overlaps in their projects, and engaged in discussion about how to avoid duplicative efforts. The two awardees subsequently, with endorsement from the CDC, decided to partner on the project each had proposed, albeit with different target nursing groups. The purpose of this article is to present how these teams collaborated in the development of this unique, time-conscious but comprehensive online program, “Alcohol Screening and Brief Intervention,” for nurses (generalists and advanced practice) and nursing students, and for nurses in three specific roles: clinical nurse leaders, nurse administrators, and nurse informaticists.
This project was guided by a systematic instructional design model consisting of five phases: Analysis, Design, Development, Implementation, and Evaluation (ADDIE). The ADDIE model was well suited for the development of the alcohol SBI program because, according to Branch (2009), intentional learning should be learner centered, innovative, authentic, and inspirational. The goal for this self-paced online program was to increase the numbers of professional nurse leaders able to deliver alcohol SBI, support alcohol SBI implementation, and sustain alcohol SBI delivery as standard care within their respective settings. Our development of the alcohol SBI online program is described in the sections that follow.
In this phase, we identified the learning problem as the lack of alcohol-related knowledge and skills among the future and current nursing workforce (Savage, Dyehouse, & Marcus, 2014; Savage et al., 2017). Although efforts had been undertaken to close that gap among nursing students (Finnell et al., 2017; Mitchell et al., 2016; Mitchell et al., 2013), these curricular enhancements at individual schools of nursing have influenced only a small proportion of the nursing workforce. As such, the goal was to have a greater reach to current and future nurses in the United States, including those in various practice settings, as well as for those in particular roles such as clinical nurse leaders, nurse administrators, and nurse informaticists. The specialized content was intended for nurses who had not received it in their curricula and those who needed to enhance their knowledge and skills related to alcohol SBI.
Initial work began with the principal investigator from each university (A.M.M., D.S.F.) engaging in telephone meetings with representatives from the CDC. To obtain buy-in and inform the development of the project, the individual university project teams met with various stake-holders, such as clinical nurse leaders, nurse administrators, nurse informaticists, and nurses currently in practice. Goals for alcohol SBI education and implementation were reviewed and learning style preferences identified. Active listening within these stakeholder groups was key to ensuring that the program developed would be user friendly and readily used. The primary messages from nurse leaders included the need for the program to be easily accessible, cognizant of available time, and readily translated to everyday practice.
Nurse leaders are busy. Daily routines involve a multitude of tasks related to health system evolution, regulatory changes, and everyday crises. Knowing that the addition of another very important patient-centered and evidence-based standard of practice must be added to an already burdened workload of similar requisites necessitated a creative approach to effective and efficient alcohol SBI learning.
The project time line was projected over a 1-year period. However, as each project team discussed their respective goal of developing an online program accessible to all nurses, they identified areas of overlap and duplication. To maximize the grant funds, and building on our previous scholarly collaborations, the two teams focused on the development of a single product and scoped out a shared work agreement. The challenges of this collaboration are discussed in the section related to the budget, time line, and deliverables, and were addressed throughout the project phases as part of the formative evaluation.
The design phase began with a systematic process of specifying learning objectives. The CDC publication “Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use: A Step-by-Step Guide for Primary Care Practices” (CDC, 2014b, 2015) served as the framework for the development of program. Specific topics were identified for core foundational content that each team had included in their respective applications in response to the request for proposals from the AACN. For each application, one university project team had proposed a focus on nurse leaders and the other university project team had proposed a focus on alcohol SBI delivery for various populations. In collaboration with the CDC liaison, topics for 13 modules were identified and, in turn, learning objectives were specified for each module.
Instructional designers were integral members of each university team—specialists who were experienced in developing similar products. An example of an online learning program was provided during a meeting with CDC staff and the principal investigators. These instructional designers illustrated the process from the development of detailed storyboards and prototypes to help envision how the program would be made, including the graphic design, user interface, and delivery of the content.
This phase focused on the actual creation of the content and learning materials. After the project teams identified 13 unique modules that would comprise the overall program (Table), the module content was developed.
Modules for the Alcohol Screening and Brief Intervention (SBI) Online Program and Respective Project Team Authorship
Instructional designers and the project team's content experts met regularly, shared resources and materials, and maintained close communication between the teams and the CDC liaison. An example of the value of the collaboration was the development of a definition for at-risk alcohol use, defined as any level of consumption that increases the risk of harm to the individual or others (Figure 1).
Definition of at risk. Note. SBI = screening and brief intervention.
Author expertise of content combined with instructional designers programs evolved into an alcohol SBI script and storyboard, the crux of a user-friendly alcohol SBI learning module. Prepared content was regularly submitted to the CDC for review and feedback until final approval was received. After the script was confirmed, the development moved to creating and editing professional multimedia platforms. Upon content approval, the unified team started rapid development for each module beginning with agreement on the standard format, including the slide template, style and design, and stock pictures to be included. The modules were developed in accord with best practices for instructional design. Assessments were developed to engage the learner and reinforce learning. Special focus was given to the assessment portion of the e-learning modules to ensure learners would be provided with authentic assessments. Fidelity checks were conducted to ensure the content was aligned with the CDC (2014b) guide. Scripts were written and actors were hired to produce solid and realistic alcohol SBI simulations.
Learning modules were developed using Articulate Storyline®, the e-learning development platform to be later hosted on a learning management system. The modules were developed to emulate what the nurse would need to be successful when delivering alcohol SBI in practice. Module development practices followed both graphic and instructional design best practices for adult learners with design style and colors mandated by our universities as guideposts for the alcohol SBI instructional learning program. An example of a single slide for the older adult module is shown in Figure 2.
Content example for alcohol screening and brief intervention (SBI).
Learning objectives are provided for each module. As the learner progresses, the status bar at the top shows the progress of the learner through the module. Each slide is narrated; the learner can also turn on the read feature to see the text. Figure 3 portrays one slide of the storyboard for the older adult. In this example, the script is “Now that we know the meaning of risks and related limits, here are some basic demographics about older adults, the focus of this module. The older adult population (65+) numbered 43.1 million in 2012, an increase of 21% since 2002. By 2030 there will be 72.1 million older adults in the U.S.”
Storyboard content: demographics for older adults. Note. SBI = screening and brief intervention.
Various strategies were employed to engage the learner. Text-heavy slides were avoided. The example shown in Figure 4 illustrates the presentation of risk factors for older adults. Four boxes are displayed, and the learner is prompted to click on each, one at a time. When the user clicks on a box, a pop-up window provides detailed information about that risk factor.
Example of simple text boxes and detailed explanations. Note. SBI = screening and brief intervention.
The process of closing the conversation with the patient is presented in accordance with “Summarize the patient's statements in favor of change, Emphasize the patient's strengths, and What agreement was reached,” using the acronym, SEW. The SEW process is illustrated in each of the population modules. In the example shown in Figure 5 on the left, the learner drags the script example into the correct box in accord with “Summarize the patient's statements in favor of change,” “Emphasize the patient's strengths,” “What agreement was reached,” and concludes with thanking the patient for speaking with you. As each script is placed, the learner receives immediate feedback on whether the placement is correct. Multiple attempts are allowed for the learner to achieve mastery, the figure shown on the right in Figure 5.
Example of quick check for the “SEW” process. Note. SBI = screening and brief intervention.
The three role-specific modules focus on specific core competencies for either the clinical nurse leader, nurse administrator, or nurse informaticist (Figures 6–8).
Clinical nurse leader (CNL). Note. SBI = screening and brief intervention.
Nurse administrator (NA). Note. SBI = screening and brief intervention; ANA = American Nurses Association; AONE = American Organization of Nurse Executives.
Nurse informaticist. Note. SBI = screening and brief intervention; INS = informatics nurse specialist; AACN = American Association of Colleges of Nursing; QSEN = Quality and Safety Education for Nurses; ANA = American Nurses Association; TIGER = Technology Informatics Guiding Education Reform.
Through this nurse leader education, the goal of this project is to increase the number of nurses who both use and promote the use of the evidence-based alcohol SBI techniques effectively and efficiently. Directing this education to nurse leaders, as generalists or specialists, in practice settings wherever patient screenings occur, the intent of this project is to promote alcohol SBI as a routine standard of practice. This unique nursing workforce's responsibilities and accountabilities have reasonable potential to influence generations of future nurses, as well as other health care professionals, to evolve and improve the quality of alcohol SBI interprofessional collaborative care.
The project teams identified three core modules required for all learners: Alcohol SBI 101, FASD 101, and Medications 101. After completing these three modules, learners can decide what additional modules they want to complete based on their role and interest. Before starting the program, learners are asked to complete a demographic survey and 12 knowledge questions related to the content presented in the core modules. Upon completion, learners are required to answer a set of questions that will be used for the evaluation, a 30-item questionnaire about attitudes and perceptions related to caring for persons with alcohol use problems, and 12 items to rate the importance of each aspect of alcohol intervention counseling in assisting patients who drink alcohol and their confidence in intervening. Learners complete the questions related to SBI knowledge, attitude/perception, and importance/confidence after completing the three modules. A certificate of completion is provided after the learner has completed the modules, which can range from a minimum of three to a maximum of 13. At the end of each module, learners rate the degree to which they agree or disagree with statements about the content being interesting and engaging, its use in their daily work, and confidence in explaining the content to a colleague or student. In addition to the pretest–posttest evaluation, the project team will use data from the online program to determine the reach of the program (i.e., the number of users that access the program, their geographic regions) and the “dose” of the program (i.e., the minimum, maximum, and average number of modules completed).
Implementation entails putting the plan into action. The online program is accessible at https://learn.nursing.jhu.edu, where anyone who is interested can find additional information related to the overview, objectives, development and funding acknowledgements, overall training details, module details, and pricing information. Additional information about the program and how to access it will be disseminated through the marketing departments of each university and on their respective websites.
Formative evaluation is present in each stage of the ADDIE process. As mentioned in the discussion about the Analysis phase, the funding period was 1 year. Within the first few months of the project, we identified the duplications and overlaps between the two funded projects. After consulting with our CDC liaison, the project focus shifted from individual university project teams to a true collaboration between the two teams and the CDC. As such, the time line was extended to ensure time for collaboration, sharing of materials, resultant comments and revisions, and finalization of the content on storyboard. As the content was being finalized, a data-sharing agreement was initiated, along with various iterations of an interinstitutional agreement. The length of time to complete these legal agreements meant that the time line for finalizing the program was extended further. With the online program completed, the next step was to evaluate the program using feedback from users.
Initial beta testing data on the modules developed by one of the universities included 20 graduate students who completed the modules as a voluntary learning experience in one of their courses. All procedures were reviewed by the institutional review board and were deemed exempt from further review. In terms of demographic data, 80% of the sample was female, and 95% were White, with an average age of 39.4 years, generally reflecting the demographics of graduate nursing students at the university. All students completed the modules on a desktop or laptop computer. Students reported using a variety of browsers to view the modules, including Google™ Chrome (n = 8), Apple Safari® (n = 7), Microsoft® Internet Explorer (n = 5), Microsoft® Edge (n = 2), and Mozilla Firefox (n = 2). Six of the students reported minor technical difficulties (e.g., one student reported not being sure how to exit the modules), all of which were resolved, and all students were able to successfully complete the modules.
To evaluate training satisfaction, students were asked “Did you find the content of the modules useful?” A total of 23 of the 24 students responded yes to this question. The majority of the comments reflected the theme of learning new information, providing simple steps by which the students could begin to use alcohol SBI in their practice, and the modules serving as a refresher or reminder of the importance of screening for alcohol use. Examples of feedback included, “I learned a great deal of information regarding alcohol use and how to begin to explore the implementation of the SBI,” “I found the module content very informative, especially SBI 101 and FASD 101,” and “Modules were easy to follow and were broken up nicely with questions that helped to keep the viewers' attention.” The one student who responded no explained that she does not assess patients and therefore did not find it to be relevant.
In addition to offering this program to the public, the program will be used by the project teams for all students at their respective university. Nursing faculty, nurse preceptors, and nursing students, including those enrolled in programs leading to the roles of clinical nurse leader, nurse administrators, and nurse informaticists, who use this self-paced asynchronous online alcohol SBI course have access to alcohol SBI implementation experts during the entire process of the program. The online course will be incorporated into the standing modules preceptors take during new faculty orientation and as a refresher opportunity each semester for teaching faculty. Additional opportunities will be provided for students, nurses, and faculty to practice alcohol SBI skills directly with members of the project teams. Such opportunities may be through clinical simulation experiences, clinical case reviews, or classroom or professional presentations. To reinforce the importance of alcohol SBI education and application, continuing education credit is offered in addition to a choice of supplemental training.
The data obtained from learners who complete the modules will be used by the teams to evaluate the program and inform any necessary revisions. Reports will be routinely sent to both project directors, who in turn will discuss in quarterly meetings in the first year after the release of the program. Although the expenses for the first year of the launch are supported through the current grant funds, a modest charge thereafter will provide funds for subsequent required revisions and updates.
Budget, Time Line, and Deliverables Across Time
Each awardee submitted an application directed to the requirements of the funder. Although a single award was expected, two applications were funded. Each school received up to $250,000 for the 1-year project period. The awardees met individually and jointly with the CDC partners throughout the active project development period. With discovery of duplicative content, there was a clear need for a face-to-face meeting, which took place 6 months into the funding year. Although the outcome of that meeting was consensus on a single program and a clear division of labor between the two teams, it resulted in an extension of the time line for the project. The inclusive process undertaken to develop the content with review and comment from the CDC partners and project team partner also extended the time line. Each project team requested and received a 1-year no-cost extension during which the program content was completed. As the modules were assembled, it was identified that the End User Licensing Agreement (EULA) was needed for each module. These EULAs, specific for modules developed by each university, were finalized in August 2017. An interinstitutional agreement developed by the project team's respective legal departments was finalized in November 2017. With that agreement in place to protect each party and ensure data sharing, the modules could be transferred to the hosting university. Over the next several months, the instructional designer finalized the program for launch, after which team members from each site reviewed and provided detailed feedback on minor editorial changes and performance issues. With those issues resolved, the program was finalized for release to the public.
In summary, although each project was funded for a 1-year period, the ultimate outcome is a single, high-quality product, rather than two potentially duplicative products. Absent planning for such a collaboration at the onset, and not anticipating the protracted time for obtaining agreements (e.g., EULA, Interinstitutional Agreement), the scope of the project was expansive. Yet, each project team was committed to the goal of advancing the knowledge of the nation's nurses related to alcohol SBI.