Adolescent substance use is a national priority issueAdolescent substance use is a national priority issue. In addition, tobacco use was reported in 2017 as just over 70% in high school students (grades 9-12). Rates of other substances, such as alcohol (16%) and marijuana (36%), have remained steady since 2015 (Centers for Disease Control and Prevention [CDC], 2018). Efforts to prevent substance use disorder (SUD) begin with screening at the earliest possible point in both schools and in primary care. Evidence-based strategies, such as screening, brief intervention and referral to treatment (SBIRT), have promise to reduce risky substance use, yet only a small percentage of providers have incorporated this screening into practice (Babor et al., 2017).

Efforts to prevent substance use disorder (SUD) begin with screening at the earliest possible point in both schools and in primary careThis article describes the work of two senior nursing students who studied the experience of SBIRT training among their peers in clinical practice. The University of Massachusetts Amherst (UMA) College of Nursing received a three-year grant from the Substance Abuse and Mental Health Services Association (SAMHSA) to train nursing students and faculty in SBIRT, which included providing practice and feedback in pediatric and adult psychiatric mental health (PMH) clinical settings.

Background

Over the past five decades SAMHSA has provided funding mechanisms to train first line health providers with education and training to identify and intervene in populations at risk for SUD, as well as to incorporate this screening into any and every patient encounter. The strategies of screening and motivational interviewing are key components of this tool. Most recently, efforts to incorporate universal screening into primary adult and adolescent care are underway (Hargraves et al., 2017), yet sustained screening remains an ongoing challenge.

SBIRT interventions vary across clinical settings...Data on screening is uneven and not standardized. In a nationwide study of emergency departments, only 20% of clients were being screened in 2010 compared to 15% in 1999 (Broderick et al., 2015). SBIRT interventions vary across clinical settings, with only 15.4% of providers consistently screening patients, and in many cases, it is not done (Hirschtritt et al., 2018, Muench et al., 2015; Rehm et al., 2016, Rizer & Lusk, 2017). Despite recommendations by the United States Preventive Health Task Force [USPSTF] (2018) to use SBIRT in primary care, there is limited evidence that these funded demonstration projects have made a change in day-to-day primary care office practice. In addition, there is little evidence that without funding support, beginning SBIRT screening in practices has happened (Hargraves, 2017).

A comparative effectiveness study conducted by the Agency for Healthcare Research and Quality (AHRQ) concluded that brief, multi-contact behavioral interventions were found to be most effective to improve behavioral outcomes for adults with risky/hazardous drinking (Jonas et al., 2012). After 10 years of studying the impacts of using SBIRT in Colorado, several lessons learned point to the fact that administrative buy in and attention to workflow are essential for successful execution and maintenance of this strategy (Nunes et al., 2017).

SBIRT in the Clinical Setting

Purpose of Projects
This article describes two exemplars that illustrate the lack of knowledge and practice of SBIRT in clinical settings. Two focus groups, conducted independently by two honors nursing students (first and second authors) are offered as exemplars to illustrate the need for further training and implementation of this type of screening. The overall aim of both projects (hereafter referred to as Focus Group 1 and Focus Group 2) was to discover students’ experiences using SBIRT training in the clinical area, although each focus group considered a unique perspective. These two students were part of the UMA SAMHSA study and participated in the education, training, and clinical practice components. They also participated in pre- and post-training research that measured changes in knowledge, attitudes, skills and stigma. Following review of the literature, focus group 1 was completed in 2018 and focus group 2 in 2019.

Review of Literature
Focus Group 1: Experiences of Student Nurses. Author 1 (JB) searched the PubMed, CINAHL, and OVID Nursing databases using the search terms “SBIRT”, “SBIRT and peers”, “SBIRT and nursing students”, and “SBIRT and nurses.” The subjects studied were college students, nurses, and nursing students. The purpose of the review was to search for experiences of students and nurses using SBIRT in the clinical setting.

The purpose of the review was to search for experiences of students and nurses using SBIRT in the clinical settingEleven studies focused on experiences of students and nurses performing SBIRT in the clinical setting. In particular, it was found that nurses are a valuable facilitator for SBIRT. Through trust, communication, and time, nurse implemented SBIRT is more widely accepted (Broyles et al., 2012). Similarly, this was seen through the use of SBIRT with peers. Student nurses were able to connect with peer-patients at a closer level than other healthcare professions because of closeness in their ages (Bergen-Cico, 2000).

Focus Group 2: Barriers and Supports. Author 2 (WS) reviewed the CINAHL and PsycINFO databases, using the search terms “SBIRT or Screening, Brief Intervention, and Referral to Treatment”, “Nursing students or student nurses or undergraduate student nurses”, “Training, or development, or education, or learning, “Nursing role” and “Substance Use Disorder or alcohol abuse or drug abuse.” The purpose of this review was to examine studies that focused on barriers and supports of nurse and students trained in SBIRT.

...several barriers existed for student nurses practicing SBIRTTen articles were identified that focused on the supports and barriers of student nurses who used the SBIRT approach. One finding of the review was that SBIRT training improved nurses’ confidence to identify and treat individuals with SUD (Mitchell et al., 2013). Conversely, several barriers existed for student nurses practicing SBIRT. These included lack of knowledge, attitude, and skills to perform screening by preceptors and faculty (Cook et al., 2018). In another study, SBIRT training and use of SBIRT in the clinical setting led to decreased negative attitudes toward people who use substances (Mahmoud et al., 2018).

SBIRT Student Nurse Training and Implementation
Trainings featured materials approved by CDC and SAMHSA, delivered by an expert trainerJunior and senior nursing students participated in focus groups within the College of Nursing at the University of Massachusetts Amherst. Students received specific training about SBIRT and were able to practice this approach during their clinical rotations. Trainings featured materials approved by CDC and SAMHSA, delivered by an expert trainer. Training sessions ranged from 2 to 4 hours. Major components of the sessions were role-play and group practices. To balance the training, which is primarily aimed for adults, simulation software (Kognito® for Adolescents) was used as an adjunct to classroom teaching and learning. We also provided extra clinical training scenarios to enhance trainee confidence.

Knowledge and Practice Gap
When attending clinical, students who were trained in SBIRT discovered a gap in knowledge and practice on the part of their clinical preceptors and faculty. The combined training experiences and clinical informed these focus groups to further explore this gap. In this section, we discuss each of the independent focus groups to consider how SBIRT trainings are applied and maintained in clinical practice.

Focus Group Methods

Sample Recruitment and Setting
Focus Group 1 (n = 10) was conducted to explore the experiences of nursing students utilizing SBIRT in clinical settings. Focus Group 2 (n = 5) considered supports and barriers of student nurse use of SBIRT in the clinical area. Each student received approval from the UMA Institutional Review Board. Focus group participants gave verbal and written consent.

Nursing student participants were recruited and provided information about the location, time, and topic of the focus group using a class Facebook page, senior email listserv, and flyers posted within the college. An announcement was made in the research class, by the professor, about the study and she referred those interested to respond to the contact information in the flyer in the associated course. She insured that no undue influence was put on potential participants.

Focus Group Process
Each student who conducted a focus group established ground rules (e.g., Participants agreed to maintaining confidentiality during and after the conclusion of the focus group) and convened a one-hour discussion. Focus group leaders followed an interview script and timeline. Each participant had an opportunity to respond to each question. The students were supported in implementing their projects by weekly honors research seminars and mentoring from a faculty advisor (Author 3, DZ). Both focus groups were conducted using the methods outlined by Krueger and Casey (2015).

Research Questions. The research question that guided Focus Group 1 asked, “What are your experiences with using SBIRT in clinical settings?” The research question for Focus Group 2 was, “What are the supports and barriers to using SBIRT in your clinical settings?” Discussions were recorded and transcribed digitally using the campus translation service. Emerging themes were captured from data analysis using the scissor and sort method (Stewart & Shamdasani, 2014).

Data Analysis. First, we reviewed the transcript and read from beginning to end three times. During the fourth reading, sections of dialogue that related to the research question were placed in brackets. After major sections were identified, specific topics were highlighted with new colors for each separate topic. Finally, the highlighted sentences, phrases, and paragraphs that fell under the same topic and color were cut out and grouped together. From these groups, the emerging themes were summarized and used to describe the findings. As is best practice in qualitative research, we made intentional efforts to reduce bias. Seminar lessons about bracketing and efforts to increase trustworthiness of the data included discussion with and review by faculty advisors; keeping accurate step-by-step records; and member checks.

Findings

Findings of both focus groups are described in detail here, and a comparative summary can be found in the Table.

Table. Comparative Summary of Focus Group Findings

Focus Group 1: Experiences of Student Nurses
Three major themes emerged that described the experiences of student nurses utilizing SBIRT in the clinical setting. The three themes considered the SBIRT approach as an effective guide; in the right situation; and with the right training.

A Useful Guide. Nursing students stated that SBIRT was an effective way to have a conversation with patients and motivate change. Several of their comments included:

• “It gives us that tool of how to approach a difficult topic in a nonjudgmental way that’s beneficial for the patient.”
• “We can empower change in our patients.”
• “I didn’t use the whole thing, but I definitely used the questions that were like on the scale of one to ten how likely are you to change and what are some of the good things about using the substance and what are some of the bad things.”

Situationally Appropriate. An ideal situation for SBIRT use was described as having enough time, a patient with the appropriate level of care and needs, and a nurse preceptor with prior SBIRT knowledge. One student described the challenge of finding enough time this way, asking: “As a nurse you’re so busy. How are you supposed to find time to ask and have this honest conversation that you’re truly listening to them?” The final component of the ideal situation for use of the SBIRT approach among nursing students seem to cause the most stress for students. There was great concern about having a nurse preceptor with prior knowledge of SBIRT.

With the Right Training. Students felt that the training was too long. However, an engaging and interactive instructor was the key to promoting SBIRT education and future use. Two students stated:

• “I thought it was this big, long thing but then the more I understood about SBIRT, the more I realized it’s really just having a conversation with your patient and not being judgmental about it.”
• “She was a really good engaging teacher so we should get her involved when she teaches because it’s hard not to pay attention to her.”

Focus Group 2: Barriers and Supports
Five themes emerged from Focus Group 2; these described barriers and supports of student use of SBIRT in the clinical area. These included the influences of age barriers; the significance of individual instructors; the impact of using Kognito^® simulation software; the effect of specific clinical site; and the consequences of personal experiences with SBIRT.

Age Barriers. A common theme included the idea that age was a factor in the student nurses’ comfort in their ability to effectively use SBIRT. The focus group participants claimed it was much easier to approach the topic of substance use with children and adolescents, as compared to older adults, noting:

• “I felt I was more qualified, like, I’m older [than them] so they might see me as experienced [high school setting]”
• “I felt like [Kognito] made a difference in our clinical because [our clinical site] was practically all older adults”

The Significance of Individual Instructors. The influence that each individual instructor had on the students’ use of SBIRT was repeatedly mentioned throughout the focus group discussions. Students felt that instructors played a key role in their success and use of SBIRT in the clinical setting, stating:

• “It was her support and confidence in us to be independent that made it easier to use something like SBIRT”
• If I didn’t have an instructor who was behind me and knew I could be independent I would be more hesitant to do anything.”

Some students had instructors who did not maintain a physical presence on the clinical unit, making it difficult for them to have the confidence they needed to carry out SBIRT. For example, one student explained, “She was never on the floor with us to reinforce something” [when discussing her instructor’s role in her personal use of SBIRT].

The Impact of using Kognito^®. The students stated that the Kognito^® simulation software was helpful and allowed them to understand each part of the SBIRT technique within the various simulated conversations. One student offered, “I think [Kognito^®] really helped make connections for what the more positive things to say are, and it gave you explanations as to why some answers were better than others.”

The students brought up some limitations to the Kognito^® program as well. One student mentioned the limited population of the program’s simulated conversations, and how it narrowed thinking about the uses of SBIRT. The student stated, “It limited my thinking to, you know, young adults or young children,” in reference to the limited range of populations that the Kognito^® simulation addressed.

Effect of Specific Clinical Site. Each student’s particular clinical site offered varied opportunities for enhanced learning and practice with SBIRT. On one unit, the nurses were told it was the student’s role to ask the patients questions about their behavior and perform the safety checks. One student noted that this seem to facilitate the process, stating, “I think with our [in-patient PMH] clinical site it was easier to use SBIRT because that was our job for the day, we had to accomplish that.”

Conversely, another student discussed her experiences during her clinical hours at the substance use treatment center. The nurses on the unit asked the student not to discuss risky behaviors with her patients, completely eliminating the opportunity to practice SBIRT from that experience.

Consequences of Personal Experiences with SBIRT. Many students had encountered a healthcare provider who they felt asked questions with judgment or made assumptions by the way they phrased questions. This made it hard for the students to be honest about their health and risk-taking behaviors, and impacted their approach. A student stated, “Knowing how I felt when people have asked questions in that way, it made me more apt to want to use SBIRT-style questioning.”

Discussion

The findings confirm what is known in the literature...there remains a gap in clinical practice with inconsistent or no use of SBIRTThese two focus groups uncovered experiences of senior nursing students following training and clinical practice using SBIRT. The findings confirm what is known in the literature, that after 40 plus years of SBIRT training and education there remains a gap in clinical practice with inconsistent or no use of SBIRT (Hargraves et al., 2017; Hirschtritt et al., 2018; Muench et al., 2015; Rehm et al., 2016, Rizer & Lusk, 2017)

Respondents reported they needed time and skilled clinical preceptors to have confidence in using these new skillsFocus Group 1 findings reflected the first year that SBIRT trainings were offered. The participants concluded SBIRT is a valuable clinical tool that is particularly effective when talking about substance abuse. However, students agreed they were not satisfied with the training, reporting that the training they received was lengthy and too daunting. Respondents reported they needed time and skilled clinical preceptors to have confidence in using these new skills.

Focus Group 2 responses came from students who were trained during the second year of the grant, after some changes were incorporated based on the feedback from the prior year (e.g., After the first year, we offered the trainings earlier in the semester and offered a short booster training prior to graduation). In considering the barriers and facilitators of using SBIRT in clinical sites, they stated that supportive faculty and preceptors informed their experiences talking to patients. These students also felt that younger clients were more receptive to their conversations. A barrier was the lack of opportunities to practice in their clinical rotations. Participants stated that clinical instructors who failed to support the use of SBIRT throughout the semester, whether at clinical or during simulations, had a significant impact on the students’ ability to practice this approach.

Limitations included only one focus group was convened per project. This was most likely due to the end of semester and difficulty in gathering peers in one place at one time. This was the first time that the students had attempted to study a question using qualitative methods and reflected their novice approach to qualitative research, methods, and analysis. As such, the application of focus group methodology was not elaborate, but did follow an established guideline for descriptive research and narrative analysis.

Most students who participated in the focus groups reported that they felt the clinical area has very few SBIRT trained role models...A strength was their identification of a clinical problem and a strategy to explore this gap. Although the training and focus groups were conducted a year apart, there were some similarities experienced by both groups. Both identified the need for shortened and repeated trainings using an enthusiastic and engaging trainer. Kognito^® simulation software, as an adjunct to training, was very good but also limited to a specific age group (adolescents). Most students who participated in the focus groups reported that they felt the clinical area has very few SBIRT trained role models; thus they were inhibited to use these new skills where not supported.

Implications for Education and Practice

... both groups noted the lack of faculty comfort with SBIRT toolsThe findings from these focus groups are important for clinical practice and can inform efforts to close the gap found by the students as they compared classroom training and clinical experiences. Preceptors and faculty must engage with student nurses in both classroom SBIRT training as well as during clinical experiences. Factors of importance to the successful rollout of SBIRT training included faculty and student training and buy-in by everyone. Depending on the clinical site, both groups noted the lack of faculty comfort with SBIRT tools. Moreover, nurse preceptors in clinical sites had varied knowledge and comfort with using SBIRT, and this represents an important area for improvement. As simulation is an essential adjunct to skills training, SBIRT content can easily be incorporated into any scenario both in the academic and clinical settings.

Conclusion

...a successful SBIRT approach requires sufficient knowledge and competence in this skill by both nursing faculty and preceptors in practice...Findings from these focus groups represent a snapshot in time of current practice and provide considerations to improve future practice. The two focus group exemplars illustrate that SBIRT trainings were generally well received by students. However, the lack of application in practice noted by the students is of concern. Focus group data and feedback was extremely helpful to inform recommendations for future change to nursing education and clinical practice. In sum, a successful SBIRT approach requires sufficient knowledge and competence in this skill by both nursing faculty and preceptors in practice, and a commitment to use this established best practice. 

Authors

Jacklyn Beynor, BS, RN
Email: Jacklynb14@gmail.com

Jacklyn is a registered nurse presently residing in Massachusetts. Jacklyn received her education and training at the University of Massachusetts Amherst. She graduated in May of 2018 and received her nursing license in July of 2018. Currently Jacklyn works at Cape Cod Hospital on a medical surgical unit. Her floor, Mugar 5, specializes in surgical, hemodialysis, continuous ambulatory peritoneal dialysis, and ventilators. During her time spent at UMass Amherst, she was trained on how to use Screening, Brief Intervention, and Referral to treatment (SBIRT). Jacklyn then used the skills and information she obtained from SBIRT training to conduct her own research for her senior thesis. In April of 2018, Jacklyn presented her research, “Experience of nursing students implementing Screening, Brief Intervention, and Referral to Treatment”, in a clinical setting [poster presentation], at the Eastern Nursing Research Society 30^th Annual Scientific Sessions in Newark, New Jersey.

Waverley Stanfield, BS, RN
Email: waverleystanfield@gmail.com

Waverley is a recent graduate from the University of Massachusetts Amherst College of Nursing and is currently working as a registered nurse in the Trauma and Neurosciences Surgical Intensive Care Unit at Boston Medical Center. Waverley focused her undergraduate research study on evaluating student nurses’ experiences with “Screening Brief Intervention, and Referral to Treatment” (SBIRT) in the clinical setting after participating in the Substance Abuse and Mental Health Services Administration (SAMSHA) grant. Waverley served as a member on the College of Nursing SBIRT Student Advisory Board as well as conducted a focus group among senior nursing students evaluating their use of the SBIRT training and likelihood of utilizing SBIRT in their own practice upon graduation.

Donna M. Zucker, RN, PhD, FAAN
Email: donna@acad.umass.edu

Dr. Zucker is recognized as an expert in behavioral treatment for stress in incarcerated persons both in the United States and abroad, particularly those incarcerated for substance misuse disorder. She is currently co-chair of the Eastern Nursing Research Society Research Interest Group on Criminal Justice, Violence and Trauma, a member of the board of the Academic Consortium on Criminal Justice Health, and member of the University of Connecticut Center for Correctional Health Networks. Dr. Zucker was the Principal Investigator on a Substance Abuse and Mental Health Services Administration (SAMHSA) grant (2016-2019) that trained over 700 student nurses, faculty and community members in Screening, Brief Intervention and Referral to Treatment.