Faculty on the original collaborative training project served as the curriculum committee for integrating SBIRT content. During the first 6 months of the first year, faculty reviewed SBIRT content based on a literature review, materials provided by SAMHSA, and national expert presentations. Thereafter, relevant content was identified, streamlined, and tailored to the objectives of the MSN-NP program. Upon completion, the major components of SBIRT were mapped to 10 courses in the MSN-NP program (Table 1). For integration, the course content was modified to facilitate the integration of SBIRT information.
Integration of SBIRT Components Into the MSN-NP Curriculum
Advanced Health Assessment. Students were introduced to SBIRT during their first clinical course, Advanced Health Assessment. Students viewed two tutorials that introduced the SBIRT approach and alcohol-related concepts such as a standard drink, the National Institute on Alcohol Abuse and Alcoholism's (NIAAA, 2016) established criteria for at-risk drinking, and the distinction between alcohol abuse, alcohol dependence, and at-risk drinking.
Students were taught how to screen patients for substance use disorders in a clinical setting and how to universally screen all patients for substance use disorders using the NIAAA (2007) and NIDA (2012) single-question screening tests. If a patient screened positive, students were taught to further evaluate the patient's alcohol and drug use with a standardized risk assessment tool such as:
- Alcohol Use Disorder Identification Test-Consumption (AUDIT-C).
- Drug Abuse Screening Test (DAST).
- Concern/Cut-down, Anger, Guilt, and Eye-opener (CAGE/CAGE-AID).
- Care, Relax, Alone, Forget, Friends, and Trouble (CRAFFT).
The AUDIT-C is composed of the first three questions of the longer AUDIT (Babor, de la Fuente, Saunders, & Grant, 1989) and targets identification of hazardous alcohol use (Dawson, Grant, Stinson, & Zhou, 2005). A positive AUDIT-C may lead to more thorough screening with the AUDIT, a 10-item alcohol screening instrument developed by the World Health Organization that has been validated in a variety of settings and cultures (Babor et al., 1989; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001). The DAST is a 10-item screening tool for the use of drugs (Skinner, 1982). CAGE is an acronym for its four questions about “Concern/Cut-down, Anger, Guilt, and Eye-opener” related to drinking (Ewing, 1984). A variation, the CAGE-AID, substitutes “drink” with “drink or drugs” in each of the four questions. The CRAFFT is an acronym for six topics (Care, Relax, Alone, Forget, Friends, and Trouble); this tool is a series of six questions developed to screen adolescents for high-risk alcohol and other drug use disorders simultaneously (Knight et al., 1999). High sensitivity and specificity in detecting substance use disorders have been demonstrated by the AUDIT (Richoux et al., 2011), the AUDIT-C (Blank, Connor, Gray, & Tustin, 2015), DAST (Cuneyt et al., 2013), CAGE (Richoux et al., 2011), and CRAFFT (Knight, Sherritt, Harris, Gates, & Chang, 2003; Knight, Sherritt, Shrier, Harris, & Chang, 2002).
After receiving training on how to screen patients for substance use disorders, students were introduced to the concept of brief interventions such as the BNI. The BNI is based on the model of transtheoretical behavioral change (Prochaska & DiClemente, 1983) and motivational interviewing techniques (Miller & Rollnick, 1991). The BNI provides an efficient four-step method to perform a brief intervention (D'Onofrio, Pantalon, Degutis, Fiellin, & O'Connor, 2005). Students were taught the following components: asking permission to raise the subject of substance use, providing feedback about the patient's behavior to facilitate the patient's ambivalence regarding implementation of a behavioral change, enhancing motivation by assessing readiness to change, summarizing, and negotiating a plan (D'Onofrio et al., 2005). Thereafter, students viewed demonstrations of the steps and techniques. Although the students did not practice these skills in this course, they were reintroduced to motivational interviewing the following semester in the Health Promotion course.
Theoretical Foundations. The transtheoretical model of behavioral change (Prochaska & DiClemente, 1983) was introduced in the Theoretical Foundations course as a model to conceptualize the process of intentional behavior change. The model is described in further detail with a focus on the stages of change in the Health Promotion course.
Health Promotion. In the Health Promotion course, stages of change and motivational interviewing were integrated into lectures on substance use disorders and other Healthy People 2020 (Office of Disease Prevention and Health Promotion, 2014) topic areas, such as overweight and obesity, physical activity, tobacco use, injury and violence, mental health, oral health, and occupational health. Students learned motivational interviewing as part of health promotion counseling. They practiced the BNI skills learned in Health Assessment using role-play with open-ended questions, affirmation, reflection, and summarizing (OARS). The students paired off and exchanged the roles of patient and NP. The students received information for each of their assigned roles and practiced in 20-minute role-playing sessions. Students were instructed to apply each step of the BNI process when serving in the role of NP.
Faculty observed the role-playing and offered suggestions and encouragement. Following completion of the role-playing sessions, faculty and students discussed the students' reactions, and faculty presented additional information to overcome barriers encountered by students during the role-plays. In addition, students completed essay test questions about the application of motivational interviewing.
Adolescent Primary Care Seminar. In the Adolescent Primary Care Seminar course, stages of change and motivational interviewing were discussed again in relation to weight management, substance use, and risky behaviors typical of adolescents. The core components of SBIRT also were reviewed.
Primary Care of Adults I. In the Primary Care of Adults I course, students viewed three tutorials that reviewed motivational interviewing skills and strategies. They also reviewed the use of motivational interviewing in relation to alcohol, drug, and tobacco use, as well as weight management, exercise, and other health behaviors relevant to adults.
Primary Care of Adults II. In the Primary Care of Adults II course, students viewed two tutorials that reviewed the elements of the BNI and referral of patients to treatment. Students were introduced to various referral resources such as local inpatient and outpatient treatment services, rehabilitation centers, and support groups. Students were directed to training videos on treatment of substance use disorders from a variety of sources available in the public domain. Students were taught that selection of a referral source was dependent on additional patient factors such as comorbid conditions, patient preferences, family support, transportation, health insurance, primary language, disabilities, and other characteristics.
Referrals were completed in accordance with established clinical protocols and referral networks— for example, referring patients to a counselor who would contact local resources and schedule patients for follow-up, calling local substance abuse treatment services or providers and scheduling an appointment, or providing names of the services and providers to patients. Students also were taught how to seek referral services through the SAMHSA Behavioral Health Treatment Services Locator ( https://findtreatment.samhsa.gov).
In a substance use disorder module, students studied peer-reviewed journal articles and tutorials that explored all three SBIRT core components. Moreover, the students were provided with information on current procedural terminology codes assigned for screening and brief intervention, state laws regarding legal alcohol limits and age restrictions, and state laws regarding insurance companies' practices for reimbursement for SBIRT performance. Students were required to complete a U.S. Food and Drug Administration (USFDA) online Risk Evaluation and Mitigation Strategy (REMS) training (D'Arcy & Hudspeth, 2017; USFDA, 2017), and they practiced applying SBIRT concepts to substance use disorder case scenarios via faculty-guided case study analyses.
Pharmacology. In the Pharmacology course, students reviewed the mechanisms of action, recommended dosing, potential side effects, and clinical applications of controlled substances including pain, behavioral, and mental health medications. The five Drug Enforcement Agency controlled substance schedules were reviewed. Prescribing responsibility and the issues surrounding patients with drug-seeking behaviors were discussed.
Clinical Courses. In the clinical courses (NP Practicum I, II, and III) and the courses with precepted clinical components (Primary Care of Adults I and II), students were encouraged to use the SBIRT approach in their precepted clinical settings. Because students might encounter barriers to using SBIRT, implementation of SBIRT in the clinical setting was not a requirement. To supplement clinical experiences, particularly in settings that posed significant barriers to practicing SBIRT, simulated case scenarios were created. The simulation laboratory provided students with additional opportunities to practice SBIRT and enabled faculty to directly evaluate students' implementation of SBIRT.
Students documented all SBIRT clinical encounters using the Typhon Group's NPST Student Tracking System Software. This system is configured to allow students to document when they screen a patient for substance use, perform a brief intervention, or refer a patient for treatment.