Journal of Nursing Education

Major Article 

Screening, Brief Intervention, and Referral to Treatment: Nurses Helping Colorado Training Program

Paul F. Cook, PhD; Laurra Aagaard, MS, MA; Fara Bowler, MS, APRN, ANP-C, CHSE; Laura Rosenthal, DNP, ACNP, FAANP; Lisa Krug Avery, MSW; Mary Weber, PhD, PMHNP-BC, FAANP, FAAN

Abstract

Background:

Nurses Helping Colorado was a Substance Abuse and Mental Health Administration–funded program to train nurses on Screening, Brief Intervention, and Referral to Treatment (SBIRT), a research-based strategy for preventing substance use disorders.

Method:

Trainees were 678 undergraduate nursing students and 480 graduate advanced practice nursing students at an academic medical center. Training included classroom lectures, role-play simulation, and supervised practice. The program was evaluated using participant self-reports immediately posttraining, 3 to 12 months later, and postgraduation.

Results:

Trainees reported high satisfaction, increased knowledge, and willingness to use SBIRT. Gains were maintained after training. After students graduated, 52% used screening, 52% offered brief interventions, and 37% used referral to treatment. Results were higher than those for past graduates, and most were higher than community benchmarks.

Conclusion:

When SBIRT training was woven through nursing curricula, students demonstrated learning and used these methods in practice after graduation. SBIRT education is appropriate across the lifespan and across settings in nursing. [J Nurs Educ. 2018;57(8):476–482.]

Abstract

Background:

Nurses Helping Colorado was a Substance Abuse and Mental Health Administration–funded program to train nurses on Screening, Brief Intervention, and Referral to Treatment (SBIRT), a research-based strategy for preventing substance use disorders.

Method:

Trainees were 678 undergraduate nursing students and 480 graduate advanced practice nursing students at an academic medical center. Training included classroom lectures, role-play simulation, and supervised practice. The program was evaluated using participant self-reports immediately posttraining, 3 to 12 months later, and postgraduation.

Results:

Trainees reported high satisfaction, increased knowledge, and willingness to use SBIRT. Gains were maintained after training. After students graduated, 52% used screening, 52% offered brief interventions, and 37% used referral to treatment. Results were higher than those for past graduates, and most were higher than community benchmarks.

Conclusion:

When SBIRT training was woven through nursing curricula, students demonstrated learning and used these methods in practice after graduation. SBIRT education is appropriate across the lifespan and across settings in nursing. [J Nurs Educ. 2018;57(8):476–482.]

Alcohol and substance use disorders are prevalent in the United States, and Colorado ranks 10th highest in the nation for the percentage of people age 12 and older with unmet substance abuse treatment needs (Substance Abuse and Mental Health Services Administration [SAMHSA], 2013). These problems cause significant distress and disability, and the U.S. Preventive Services Task Force (2013) endorsed universal alcohol screening for patients age 18 and older in primary care. Substance use disorders also occur at higher than average rates in primary care (SAMHSA, 2013) and exacerbate the course of common health problems (Robert Wood Johnson Foundation, 2001). Health care settings should therefore screen, treat, and prevent substance use disorders, but such services are not well-integrated into medical care (Kessler et al., 2014).

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based substance abuse prevention approach originally designed for health professionals' use in primary care, with a level of evidence similar to that of colorectal cancer screening (Maciosek et al., 2006). The method relies on an understanding of substance abuse as the extreme manifestation of a continuum ranging from normal to disordered use of substances. Health care providers are most aware of substance use problems in those patients with serious and long-standing impairment, but those individuals represent only approximately 5% of the substance-using population (SAMHSA, 2013).

The SBIRT approach begins with the idea that all health care providers, including bedside nurses as well as advanced practice nurses, should ask each patient about substance use. This screening step is most effective when it is done routinely for all patients and when validated screening tools are used to augment providers' clinical judgment. When patients' use of substances is at a subclinical level for a substance abuse diagnosis but is still above guideline-recommended levels or is causing some degree of problems in their lives, a brief intervention provided directly by the health care provider can often be effective in reducing patients' use. These at-risk patients represent approximately 30% of the substance-using population (SAMHSA, 2013). From a public health perspective, it is important to intervene early when they can benefit most from a brief intervention using motivational interviewing or cognitive-behavioral interventions (Kaner et al., 2009). Furthermore, their substance use behavior is often less ingrained and longstanding than those in the smaller group of patients with disordered use, and therefore more amenable to modification (American Public Health Association, 2008). When screening identifies a patient with a diagnosable substance abuse disorder, providers should refer him or her to established substance abuse treatment services (Saitz, 2010). This requires an understanding of what services might be effective, knowledge of what providers and facilities are available in the area, and relationships with other professionals to facilitate effective referrals (Booth, Crowley, & Zhang, 1996; Collins, Hewson, Munger, & Wade, 2010).

Nurses, as the largest group of health care professionals, have well-established roles in most health care settings and significant contact with patients, and they are trained in a whole-person philosophy of health care that is an excellent fit with the public health approach and brief intervention methods used in SBIRT (Broyles, Rosenberger, Hanusa, Kraemer, & Gordon, 2012). Nurses can provide cost-effective SBIRT services in coordination with other health care providers and within their own scope of practice (Friedel, 2012), and they are highly regarded by the public as ethical, trustworthy, and reliable sources of health information (American Nurses Association, 2017). Further, nurses can be effectively trained to use motivational interviewing techniques as the basis for brief intervention (Cook et al., 2016). Nurses are therefore ideal health care team members to deliver SBIRT in a variety of health care settings.

Unfortunately, SBIRT is not a standard component of most nurses' undergraduate or graduate nursing education, and most do not have the knowledge, attitudes, and skills needed to deliver SBIRT successfully. For instance, SBIRT trainers report that nurses in community settings readily embrace a role educating patients about diabetes or obesity, but they tend to be less comfortable offering SBIRT until they can link substance use and chronic health conditions, gain familiarity with the range of substance abuse treatment options, and have the opportunity to practice discussing substance use as part of routine care (C. Swenson, Peer Assistance Services Inc., personal communication, April 15, 2013). In a 2013 needs assessment of 175 nurses who precept students at eight high-volume practice sites in the Denver, Colorado, area (Cook & Weber, 2013), the current authors found that only 24% had received prior training in SBIRT although 73% said they had received training on substance abuse more generally. Furthermore, only 58% of these community-based nurses said they routinely screen their patients for substance use disorders. Furthermore, only 44% said they ever used brief interventions, and 9% said they routinely offer referrals for substance use treatment. Many of these community-based nurses told us that substance use was a problem to be addressed by social workers or addictions specialists, and therefore not something that they felt was their responsibility, with some arguing that brief interventions were outside the nursing role. Based on these findings, a significant opportunity existed to improve care by preparing and encouraging nurses to use SBIRT.

Study Purpose

The current study was an evaluation of an SBIRT training program for nurses at the University of Colorado College of Nursing (CU CON). CU CON is one of the largest suppliers of new nurses in Colorado and surrounding states, in a predominantly rural area of the United States with few academic medical centers. In a training project from 2013 to 2016, CU CON implemented an SBIRT training program at both the bachelor's (BS) and graduate (advanced practice registered nurse [APRN]) levels. CU CON's APRN programs include master's-prepared nurse practitioners (NPs), nurse midwives, and clinical nurse specialists. SBIRT training was woven throughout these curricula, focusing on substance use as a public health issue, on SBIRT as a primary and secondary prevention intervention, and on improving students' communication techniques and comfort talking about substance use.

Our evaluation question was whether this training program improved nurses' use of SBIRT. To address this question, we examined process data including the number and type of training events and number of students reached; short-term outcomes involving students' satisfaction, knowledge, and willingness to use SBIRT; and long-term outcomes involving students' actual delivery of screening, brief interventions, or referral to treatment in varied health care settings after graduation. To evaluate effects of the training program, we compared postgraduation survey data with those from a comparable group of students prior to implementing the training program and also to baseline rates from a survey of nursing preceptors.

Method

Participants

BS Students. Institutional review board approval was not required for this educational program evaluation. CU CON's undergraduate nursing program graduates approximately 225 students annually, who serve patients in Colorado and surrounding states, with a focus on rural, underserved, high-risk, and veteran populations. Students who graduate with a BS from CU CON go on to practice at the RN level, with a 2015 pass rate of 96% on the NCLEX®. In 2016, 14% of BS students were men and 33% were members of underrepresented minority groups (13% Latino/Latina, 3% African American, 0.5% foreign born, 0.5% Native American, 6% Asian/Pacific Islander, 6% multiple categories, and 6% other or unknown).

APRN Students. CU CON was the birthplace of the NP role in which nurses obtain advanced training for independent practice (American Academy of Nurse Practitioners, 2018). One APRN specialty option educates psychiatric mental health nurse practitioners (PMHNP) in the treatment of all levels of substance use, including SBIRT. However, PMHNP graduates are few in number and after graduation work mainly in specialty behavioral health care settings. Therefore, the current training program focused instead on expanding the behavioral health workforce by training APRN students in other specialties: family NP, adult gerontology primary care NP, pediatric primary care NP, women's health NP, nurse midwifery, and adult/gerontology certified nurse specialist. These programs enroll approximately 125 APRN students per year. Across specialties, 12% of 2016 APRN students were men and 28% were minority group members (10% Latino/Latina, 4% Asian/Pacific Islander, 3% African American, 1% foreign born, 5% multiple groups, and 5% other or unknown). This distribution accurately reflects the limited level of diversity in Colorado and is up from only 11% minority students enrolled in the BS nursing program in 2005.

Patient Populations Served. CU CON places students at practicum sites throughout metropolitan Denver and in rural areas of the state. The college also directly operates nurse-managed primary care clinics where faculty practice and supervise students, including a federally qualified health center (FQHC). After graduation, BS nurses and APRNs work in hospitals and clinics throughout the western United States, with 9% serving patients in rural areas and an additional 4% serving patients in surrounding states including Arizona, New Mexico, Nebraska, Wyoming, Oklahoma, Utah, Montana, and others. CU CON specifically trains students to work with low-income patients, minority group members, rural, medically underserved populations, veterans, and other at-risk groups, and after graduation most CU CON students go on to work with these vulnerable groups.

Procedure

CU CON partnered with the federal statewide SBIRT training grantee, Peer Assistance Services, Inc., for two preliminary steps. First, Peer Assistance helped to train 49 CU CON faculty on essential SBIRT knowledge, attitudes, and skills, including a train-the-trainer session to help CU CON faculty teach SBIRT to others. Next, a core workgroup of these trained nursing faculty, together with collaborators from Peer Assistance, reviewed CU CON's BS and APRN curricula for points where SBIRT content could be integrated. In this process, we identified two faculty champions with particular interest in SBIRT for the BS and APRN programs.

Meetings were held over the first several months of the grant to get faculty input at all levels as to how we might implement SBIRT training. Faculty suggestions for the BS curriculum were to thread and level the content and skills so that BS nursing students could demonstrate all SBIRT competencies by the end of the program. For the APRN curricula, faculty suggested introducing SBIRT skills in the Advanced Assessment course, with reinforcement, more complex content, and more practice completed in later specialty course work. Curriculum modifications were then introduced gradually into identified courses. CU CON maintains curriculum integrity via course proposals approved by the general faculty, which specify learner competencies; however, individual faculty have discretion over learning activities and assignments. Our leveling and threading strategy added SBIRT content and learning activities in ways that did not require course revisions Table A (available in the online version of this article). In general, faculty were very supportive of adding SBIRT content as a way to meet preexisting learner competencies such as holistic patient-centered assessment, communication skills, health promotion and disease prevention, and integration of behavioral health with medical care. Specific learning activities and examples were prepared by project team members as guest lectures, videos, online course modules, or in-class exercises that supplemented and reinforced existing course material on prevention, health promotion, underserved populations, or patient communication. Content on motivational interviewing was particularly in demand because nursing faculty were interested in having their students learn this well-validated counseling method for a variety of health behavior issues. Points of intersection with CU CON's BS and APRN curricula are shown in Table B (available in the online version of this article).

Curriculum Mapping to Core Screening, Brief Intervention, and Referral to Treatment (SBIRT) CompetenciesCurriculum Mapping to Core Screening, Brief Intervention, and Referral to Treatment (SBIRT) Competencies

Table A:

Curriculum Mapping to Core Screening, Brief Intervention, and Referral to Treatment (SBIRT) Competencies

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Content Integrated into Bachelor's (BS) and Advanced Practice Registered Nurse (APRN) CurriculaScreening, Brief Intervention, and Referral to Treatment (SBIRT) Content Integrated into Bachelor's (BS) and Advanced Practice Registered Nurse (APRN) CurriculaScreening, Brief Intervention, and Referral to Treatment (SBIRT) Content Integrated into Bachelor's (BS) and Advanced Practice Registered Nurse (APRN) Curricula

Table B:

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Content Integrated into Bachelor's (BS) and Advanced Practice Registered Nurse (APRN) Curricula

To further support learning, we also worked to include SBIRT in multidisciplinary, collaborative clinical practicum experiences, and to create clinical simulation exercises that students would use to practice SBIRT skills at specific points in training. Simulation exercises for BS students included in-person role-plays on therapeutic communication, screening, brief intervention in multiple settings across the lifespan, and referral to treatment when needed. Exercises included scenarios with alcohol, opiates, and marijuana use, all of which are common in Colorado. For APRN students, simulation activities included online avatar-based simulation with alcohol screening, and face-to-face SBIRT role-plays during coursework-intensive days.

Although we also attempted to provide students with opportunities to practice SBIRT in supervised clinical practice, we had less control over these learning experiences. As described above, many community preceptors did not use SBIRT. To address these gaps, we trained 396 faculty and preceptors over the life of the grant, with positive results (Rosenthal, Barnes, Aagaard, & Weber, in press).

Measures and Analysis Plan

Our overall approach to program evaluation was based on Kirkpatrick's four-level typology of outcomes for professional education activities (Bates, 2004): (1) trainee satisfaction, (2) change in trainees' knowledge about clinical care, (3) change in trainees' clinical behaviors, and (4) change in patient outcomes including access to care. Our plans to collect process data and outcome data, as well as the instruments used, are described below.

Process Measures. Throughout the course of the training program, we recorded the number of training events, course and faculty member for whom training was provided, trainee group (BS students, APRN students, faculty, or preceptors), and number of trainees. We also collected the following trainee demographics: clinical specialty, year in school, age, gender, and race/ethnicity.

Short-Term Outcomes: Center for Substance Abuse Treatment Baseline and Follow-Up Surveys. The SAMHSA Center for Substance Abuse Treatment (CSAT) developed a survey used nationally in all CSAT-funded training activities. This tool includes items on satisfaction (“how satisfied are you with the overall quality of this training”), knowledge change (“the training enhanced my skills in this topic area”), and willingness to provide care (“I expect to use the information gained from this training”). These single-item metrics match levels one through three of Kirkpatrick's typology. The CSAT baseline survey was completed the first time a student received any SBIRT content and was given immediately after training as a paper-and-pencil measure. Surveys were identifiable based on trainee name, but the trainer emphasized that they were unrelated to course grades and would be used only for program evaluation. Baseline surveys were completed by 678 BS students and 480 APRN students.

A CSAT follow-up survey with parallel items was also administered at least 30 days after SBIRT training; this occurred at the end of the individual course for APRN students and at the end of the full sequence of courses on SBIRT for the BS students. CSAT follow-up surveys were administered in-class, when possible, to increase the response rate. Again, students were not required to respond and were told that surveys had no effect on their course grade. All surveys were administered by project staff rather than by course faculty. CSAT follow-up surveys were completed by 557 BS students (an 82% response rate), and by 287 APRN students (60%).

Short-Term Outcomes: Consortium Survey. In year one of the training project, we worked with a consortium of other nursing schools that also received CSAT funding to design a more objective measure of trainees' knowledge, attitudes, and behaviors. This survey was intended to complement the 1-item self-report scales on the CSAT surveys. Knowledge items were drawn from a question bank developed by physician SBIRT residency training programs in a previous CSAT grant cycle (A. Johnson, personal communication, April 29, 2014); item content was linked to National Institute on Alcohol Abuse and Alcoholism (2017) guidelines and had excellent content validity based on prior review by national experts. Attitude items were drawn from the Short-Form Alcohol and Alcohol Problems Questionnaire, a validated survey with internal consistency of α = .75 and good construct validity (Terhorst et al., 2013). Our version was modified slightly to reduce stigma (e.g., “patients who drink alcohol” instead of “drinkers”). Items on behavior were developed by the same physician–resident training group (A. Johnson, personal communication, April 29, 2014), but used a 5-point Likert-type scale to evaluate practice behavior based on a similar approach to measuring health care professionals' self-reported behavior change in other training programs (Cook, Friedman, Lord, & Bradley-Springer, 2009).

Long-Term Outcomes: Survey of Program Graduates. We followed up with BS and APRN program graduates to evaluate their use of SBIRT in actual practice settings postgraduation. The CU CON Academic Programs Office tracks graduation rates and employment postgraduation and collects student contact data for alumni relations. We added questions to CU CON's existing postgraduation survey to capture changes in knowledge, use of SBIRT skills, and practice behavior using quantitative and qualitative items. Survey items addressed nurses' comfort and use of each of 13 SBIRT-related competencies identified by SAMHSA, using a format from Kang-Dufour and Khamarko (2012). Postgraduation data were first collected in May 2014, before graduates had received any SBIRT content; results for the next 3 cohorts were compared with this base year to test for improvement. In addition, students' reported use of SBIRT skills was compared with community preceptor data from a needs assessment in year one of the project. Finally, we used postgraduation surveys to examine how many graduates went to work in rural areas, providing primary care, and working with racial/ethnic minority group members, veterans, or other at-risk groups.

Results

Training Process

We reached our BS program training goals in June 2016, with a total of 712 unique BS students trained. All those students received SBIRT content in multiple classroom courses and also completed clinical simulation exercises involving SBIRT as part of their regular nursing curriculum. We completed our last APRN trainings and CSAT data collection in spring 2016, with a grand total of 480 distinct APRN students trained over 3 years (324% of our original goal). These students had varying exposure to SBIRT content, with some students at the beginning of the 3-year training period receiving only information about screening and others by the end of the training period receiving training on SBIRT in many courses throughout their curriculum. All BS students who received classroom instruction also participated in at least one clinical simulation exercise using SBIRT. During the 3 years of the program, 430 APRN students also completed supervised practice using SBIRT at 283 clinical practicum sites around the state, providing services to a total of 2,314 patients with substance misuse or abuse.

Students' Initial Response to Training

Overall results on the CSAT immediate posttraining survey for BS students over the life of the grant were 61% were satisfied, 61% gained knowledge, 69% intend to use SBIRT. Among APRN students, the results were 65% were satisfied, 65% gained knowledge, 70% intend to use SBIRT. Final consortium survey results were similar: 66% attitude, 80% knowledge test, 66% behavior for BS students, and 67% attitude, 91% knowledge test, 61% behavior among APRN students.

Follow-Up Survey Results

The same surveys were administered several months posttraining, with an overall 65% response rate. Results on the CSAT follow-up survey for BS students over the life of the grant were 67% satisfied, 69% gained knowledge, 69% intend to use SBIRT. Among APRN students, the results were 65% satisfied, 65% knowledge gain, 69% intend to use SBIRT. Final consortium survey results were similar: 69% attitude, 90% knowledge test, 65% behavior for BS students, and 69% attitude, 86% knowledge test, 63% behavior among APRN students.

Postgraduation Practice Settings

We began distributing online follow-up surveys to program graduates in August 2014. The response rate was only 11% in the first year, when few graduates had actually received any SBIRT training due to a gradual roll-out of the training program. However, the response rate was substantially higher in subsequent years: 20% in 2015, 29% in 2016, and 26% in 2017.

Of 193 survey respondents, 170 (88%) said they currently provide direct clinical services to patients. Graduates reported a focus on underserved patient populations, with 38% working at FQHC clinics, rural health centers, or other practices that serve vulnerable or indigent patients. Graduates reported that 55% of their patients received public insurance (e.g., Medicare, Medicaid, Ryan White Program), 23% were uninsured, 51% were low-income clients, and 14% were homeless. On average, survey respondents said that 46% of their patients were racial/ethnic minority group members, 10% were sexual minorities, and 17% were recent immigrants. Their patients were more likely to be older adults (46%) and men (52%) and less likely to be women (48%), children (21%) or adolescents (15%). On average, 16% of patients served by graduates lived in rural areas and 4% were incarcerated or on parole. Respondents said that 23% of their patients had a substance use disorder and that 21% had a serious and persistent mental illness. Overall, these data were consistent with our expectation that CU CON nursing students would go on to serve vulnerable populations after graduation.

Postgraduation Use of SBIRT

The Figure shows students' postgraduation results over time on the three components of SBIRT. Results from the postgraduation survey showed increases in each element of SBIRT compared to the baseline year: Screening increased from 43% at baseline to 52% at the end of year three but this change was not statistically significant, χ2 = 0.69, p = .41, OR = 1.50. Similarly, postgraduation rates of brief intervention rose from 38% at baseline to 52% at the end of year three, χ2 = 1.38, p = .24, OR = 1.79; and referral to treatment rose from 28% at baseline to 37% by the final data collection point, χ2 = 0.37, p =.54, OR = 1.38. Although these differences did not reach conventional levels for statistical significance due to small sample size, all changes were in the predicted direction, were sustained over 3 years as shown in the Figure, and were associated with odds ratios, suggesting clinically meaningful increases in the percentage of nursing graduates who performed SBIRT skills.

Percentage of nursing program graduates (bachelor's-prepared and advanced practice registered nurses combined) who reported using Screening, Brief Intervention, and Referral to Treatment (SBIRT) skills in their first clinical practice role after graduation.

Figure.

Percentage of nursing program graduates (bachelor's-prepared and advanced practice registered nurses combined) who reported using Screening, Brief Intervention, and Referral to Treatment (SBIRT) skills in their first clinical practice role after graduation.

As a further test of the hypothesis that SBIRT skills improved among students who received multicomponent SBIRT training, we compared students' self-reported postgraduation behaviors with those reported by community nurse preceptors at the start of the program. Screening rates reported on the postgraduation survey were similar to the Colorado benchmark rate from our preceptor needs assessment, 52% for trainees versus 58% among community-based nurses, χ2 = 0.76, p = .38, OR = 0.77. However, the percentage of program graduates who reported using brief interventions was slightly but not significantly higher: 52% versus 44% among community-based nurses, χ2 = 1.05, p = .31, OR = 1.36. Finally, CU CON graduates' rate for referral to treatment, 37%, was significantly higher than the benchmark level of 9% among community-based nurses, χ2 = 56.6, p < .001, OR = 8.05. This statistically significant result means that program graduates were eight times more likely to facilitate referrals to substance use treatment than nurses already in practice in the same community. Other findings in this analysis suggest that CU CON program graduates were at least as likely as community-based nursing preceptors to use screening and brief intervention, with the odds ratios suggesting more use of brief intervention but room for improvement in systematically screening for substance use disorders.

Discussion

The purpose of the Nurses Helping Colorado project was to train BS and APRN students in SBIRT skills, so that upon graduation each year, these new nurses would work to integrate behavioral treatment for substance use disorders into primary care and would be able to implement SBIRT as part of an interprofessional health care team. By training a large cohort of BS and APRN nursing students over 3 years, our goal was to increase access and availability of SBIRT and substance treatment services for patients in Colorado and surrounding states. As nursing students graduate, practice, and become local champions for SBIRT, we also hoped that our project would advance the long-term goal of integrating behavioral health services into all of health care to reduce the stigma and consequences of substance use.

Over the course of 3 years, the Nurses Helping Colorado project graduated 678 new BS-level and 480 APRN-level nurses trained to implement SBIRT skills. Students were not selected for the training program; instead, we integrated SBIRT into our regular curricula to train every matriculated BS and APRN student on these skills. Upon graduation, 88% of these students went to work in direct patient care, with a particular emphasis on primary care and settings such as FQHCs that serve rural, medically underserved, minority, veteran and/or medically indigent populations. In addition, 16% of the patients served by CU CON graduates live in rural areas that have a dearth of other behavioral health services in their communities.

An important benefit of training nurses on behavioral health interventions such as SBIRT is that these health care professionals are already well-integrated into medical settings and can provide SBIRT services seamlessly with other medical care. A lack of either real or perceived barriers between the medical and behavioral care systems is crucial in getting at-risk patients to accept behavioral health services, and nurses are therefore ideal champions for SBIRT and providers of brief interventions within a multidisciplinary team. CU CON graduates more often provided all components of SBIRT after the 3-year training program than at the start of the project, and by the end of the 3-year training program CU CON graduates' use of referral to treatment was significantly higher than the rate among community-based RNs.

Limitations and Directions for Future Research

This program evaluation had methodological limitations, with the greatest being the lack of a randomized control group. Because of this, it is impossible to draw firm causal conclusions about the role of the SBIRT training program in producing improved use of SBIRT strategies among CU CON graduates. It is possible that increases in students' use of SBIRT resulted from concurrent changes in the U.S. health care system, such as the full implementation of the Affordable Care Act in 2014 or increased attention to substance use disorders due to the legalization of marijuana in Colorado or the increase in opiate-related deaths in the United States during this period. However, given the low base rate of SBIRT among community-based nurses at the start of the study—particularly the brief intervention and referral to treatment components—these competing explanations for our results are unlikely. In addition, results are dependent on participants' self-report and may represent overestimates of program graduates' true use of SBIRT strategies. Some corroborating evidence is available for BS students, who completed simulation exercises in which they performed SBIRT skills to an observer's satisfaction. Finally, although the 19% to 20% response rates in most years of this study are typical for alumni surveys, it is possible that those students who responded were more likely to use SBIRT skills than those who did not. This critique is particularly applicable to the baseline year, which had a response rate of only 4%, but that year's data also showed the lowest rates of SBIRT use.

Conclusion

Overall, the Nurses Helping Colorado program substantially increased the number of nurses in the state of Colorado trained to use SBIRT, with the 1,158 nursing graduates reached by this program representing an approximate 30% increase over the 3,500 practicing nurses previously trained by Colorado's statewide SBIRT contractor (C. Swenson, Peer Assistance Services Inc., personal communication, May 8, 2013). Based on program results, some of these trainees did in fact use SBIRT skills after graduation, with particularly large increases in the percentage of nurses offering brief interventions and referral to treatment. Contrary to our initial expectations, both faculty and students were enthusiastic about integrating SBIRT into the undergraduate and graduate nursing curricula at CU CON. Students were particularly interested in learning motivational interviewing skills for brief intervention, and faculty were interested in improving substance abuse treatment for underserved and vulnerable populations. After graduation, 87% of CU CON students went on to provide direct clinical care, with the majority working in settings that reach high-risk patient populations. The Nurses Helping Colorado program therefore focused on the right members of the health care team to deliver evidence-based substance abuse prevention services to the right patients. The increased delivery of SBIRT services in turn has significant potential to improve health for the population of Colorado by reducing disease burden related to substance abuse.

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Curriculum Mapping to Core Screening, Brief Intervention, and Referral to Treatment (SBIRT) Competencies

SAMHSA-Identified CompetencyNurses Helping Colorado Program Examples
1. Understanding of the association of medical conditions with substance abuseBS content on how substance use affects medical problems in Med-Surg I, Complex Care, and Older Adults; APRN specialty courses link substance use with specific conditions or populations of interest (chronic disease, pediatrics, women's health, etc.).
2. Using screening tools that identify the full spectrum of risky, problematic substance use, abuse and addictionContent on AUDIT and other screening tools in BS Health Assessment course, APRN Advanced Assessment course.
3. Using brief intervention procedures and summarizing evidence of their effectivenessTwo BS courses provide content and practice using motivational interviewing, with multiple SBIRT-related simulation exercises. Brief interventions introduced in APRN Advanced Assessment, with population-specific practice in APRN specialty courses.
4. Providing “hands-on” screening, identification, brief intervention, and referral for treatment for alcohol, illicit drugs, and prescription drug misuseIn-person simulation exercises for BS students in Complex Care, Community Health, and Mental Health courses. In-person role-play in APRN Health Promotion, plus online scenarios to practice motivational interviewing in specialty courses.
5. Describing detoxification procedures for alcohol and other drugsClassroom content in BS Med-Surg I course, and in APRN mental health specialty courses.
6. Prescribing effective medications to treat craving and prevent relapseReferral discussed in BS Mental Health course. Prescribing practices taught in APRN Acute Care Adult and Psychiatric nurse practitioner specialties.
7. Using appropriate prescribing practices for opioids and medically assisted treatment optionsOpioid risks and guidelines taught in BS Med-Surg I course. Prescribing practices taught in APRN Advanced Pharmacology course, and in specialty course work.
8. Providing ongoing medical management and care coordination for outpatients and other recipients of SBIRT servicesIntegrated care models are discussed in-depth in a graduate-level Integrated Care course and in APRN specialty course work.
9. Linking and communicating with the specialty treatment service system, providers and facilitiesBS Med-Surg I, Older Adult, Pediatrics, OB, Mental Health, and Complex Care courses apply SBIRT to a wide range of patient groups and diagnoses. Advanced Assessment and APRN specialty courses do the same.
10. Contributing to professional behavioral health workforce developmentThe role of SBIRT within broader systems of care is discussed in the BS Mental Health and Community Health courses. Leadership and training roles are discussed in the APRN Integrated Care course, and much more extensively in the college's DNP degree program.
11. Understanding and working with EHR-based screening and assessment systems.BSN students use EHR systems during various practicum rotations, and APRNs use clinic-based EHR systems as well as an online clinical documentation tool to report details on the supervised cases they manage in practicum work.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) Content Integrated into Bachelor's (BS) and Advanced Practice Registered Nurse (APRN) Curricula

CoursePrior Topic AreasSBIRT Content Additions
BS Nursing Courses
Health Assessment

None

Screening for use or misuse

SBIRT method overview and public health framework

Stigma and substance use

Screening tools: AUDIT, DAST

Patient-centered communication (OARS)

Foundations

None

Physical effects of alcohol

Drinking levels/amounts

Brief intervention using motivational interviewing, part 1

SBIRT brief intervention examples

Motivational interviewing reference card

Med-Surg I

Medical support for detox

Interaction of alcohol and drugs with other chronic conditions

Medical support for detox

Simulation involving alcohol withdrawal

SBIRT in inpatient settings

Prescription drugs and opiates

Benzodiazepine withdrawal

Older Adult

Medication safety

Substance use and older adults

Pain medication safety

Simulation involving a primary care patient requesting opiates

Pediatrics

None

Drinking and drug use by teens

Guidance on marijuana post legalization

Simulation involving non-accidental trauma and maternal marijuana use

OB

Fetal alcohol syndrome

Women and alcohol

Fetal alcohol syndrome

Simulation involving alcohol/drug screening during pregnancy

Mental Health

Alcohol use disorders

Cocaine, meth, opiates, and designer drugs

Effects of withdrawal

Community detox treatment

Recovery

Motivational interviewing part 2 – brief intervention examples

Tips for referral to treatment

Substance use and mental health

Substance use and suicide

Substance use and trauma

Substance use across the lifespan

Complex Care

None

Substance use and complex conditions

Simulation involving a patient who tests positive for cocaine

Simulation involving a discussion of lifestyle changes with a cardiac patient

Community Health

None

Complete SBIRT process

Simulation involving screening and brief intervention with a young adult patient

Translational Nursing

None

Substance use by healthcare providers

Non-punitive approach to drug treatment

Simulation involving peer diversion

APRN Core Courses
Advanced Health Assessment

Nursing assessment of patients

Routine public health screenings

Full SBIRT process

Routine alcohol screening using AUDIT

Advanced Pharmacology & Therapeutics

Interactions of prescription drugs, alcohol, recreational drugs

Safe prescribing for opiates

Use of the state prescription drug monitoring program

Health Promotion

Patient communication

Motivational interviewing

Role-play exercises using motivational interviewing for substance use scenarios

APRN Specialty Courses
Acute and Chronic Health Alterations of Women

None

SBIRT for alcohol and marijuana use by women

Specific women's health issues related to substance use

Midwives clinical rotations

None

SBIRT with pregnant women

Prenatal issues related to marijuana and opioid use

Pediatric Chronic Illness and Disability Diagnosis and Management II

Trauma in children and adolescents

Chronic pain

SBIRT for alcohol and marijuana use by children and adolescents

SBIRT with adults who have chronic illnesses

Marijuana and opioid issues in the state of Colorado

Adult Gerontology Acute Care II

Treatment of acute pain in the hospital

Alcohol withdrawal

SBIRT with inpatients

Screening with CIWA, COWS

Safe opiate use in adults and older adults

Chronic pain management

Pediatric Acute Care

Treatment of acute pain in the hospital

Integrated Care

Integrated primary care models

Screening for depression, anxiety, trauma, substances

Full SBIRT process in primary care settings

Authors

Dr. Cook is Associate Professor, Ms. Aagaard is Senior Instructor, Ms. Bowler is Assistant Professor, Dr. Rosenthal is Associate Professor, Ms. Krug Avery is Professional Coordinator, and Dr. Weber is Professor, University of Colorado College of Nursing, Aurora, Colorado.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

This study was funded by a grant from the Center for Substance Abuse Treatment (CSAT) at the Substance Abuse and Mental Health Services Administration (SAMHSA), project # 5U79TI025352-03.

The authors thank the staff of the SBIRT Colorado statewide training program at Peer Assistance, Inc., for their partnership and support.

Address correspondence to Paul F. Cook, PhD, Associate Professor, University of Colorado College of Nursing, Campus Box C288-04, Aurora, CO 80045; e-mail: paul.cook@ucdenver.edu.

Received: September 25, 2017
Accepted: April 04, 2018

10.3928/01484834-20180720-05

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