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Teaching Undergraduate Nursing Students to use SBIRT in a Culturally Competent and Relevant Manner

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  • Program consists of a total of 13 hours of education: during the junior years this includes 6 hours of didactic and experiential instruction via an in-class seminar, 3 hours of practice and supervised feedback during clinical rotations, and 2 hours of practice with culturally diverse scenarios in the simulation lab, and in the senior year students receive 2 hours of didactic and experiential instruction via an in-class booster session.
  • Program consists of a total of 13 hours of education: during the junior years this includes 6 hours of didactic and experiential instruction via a class seminar, 3 hours of practice and supervised feedback during clinical rotations, and 2 hours of practice with culturally diverse scenarios in the simulation lab, and in the senior year students receive 2 hours of didactic and experiential instruction via an in-class booster session.
  • Motivation subscale questions on AAPPQ (5 total): I am interested in the nature of alcohol related problems and the responses that can be made to them. I want to work with drinkers. I feel that the best I can personally offer drinkers is referral to somebody else. I feel that there is little I can do to help drinkers. Pessimism is the most realistic attitude to take toward drinkers.
  • There is only one question on the motivation subscale for DDPPQ: I feel that there is little I can do to help drug users.
  • Transcript

    • 1. Teaching Undergraduate Nursing Students to use SBIRT in a Culturally Competent and Relevant MannerHolly Hagle, PhD, Institute for Research, Education andTraining in Addictions (IRETA)Dawn Lindsay, PhD, Institute for Research, Education andTraining in Addictions (IRETA)Ann M. Mitchell, PhD, RN University of PittsburghSchool of Nursing
    • 2. Project TeamKathryn Puskar, DrPH, RN, FAAN Project DirectorAnn M. Mitchell, PhD, RN, AHN-BC, FAAN Project CoordinatorHolly Hagle, PhD IRETA TrainerBetty Braxter, PhD, RN Obstetrics Primary TeacherMarie Fioravanti, MSN, RN Medical Surgical Primary TeacherIrene Kane, PhD, MSN, RN, CNAA, HFI Psychiatric Nursing Primary TeacherGail Ratliff Woomer, MN, RN, IBCLC Community Nursing Clinical InstructorMartin Houze, PhD Project StatisticianKimberly Talcott, MPA Project ManagerHeather J. Gotham, PhD Project EvaluatorHelen K. Burns, PhD, RN, FAAN ConsultantDawn Lindsay, PhD IRETA staffThis project is supported by funds from the Division of Nursing (DN), Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under Grant D11HP14629 Nurse Education, Practice, and Retention. The information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any official endorsement be inferred by, the DN, BHPr, HRSA, DHHS, or the US Government.
    • 3. Presentation Objectives• Describe the undergraduate nursing school curriculum on SBIRT.• Explain the instructional methods used for curriculum delivery in relation to SBIRT and cultural competency.• Demonstrate that the SBIRT curriculum increased student’s use of an EBP, SBIRT in relation to delivering culturally competent and relevant services.• Identify ways other programs can replicate this curriculum project.
    • 4. School of Nursing• Vision: Advancing Nursing Science, Education and Practice• Educates approximately 600 undergraduate students at any point in time• Academic Programs: BSN (first-degree, second-degree, and RN-BSN) MSN (Nurse Practitioner, Clinical Nurse Specialist, Nurse Anesthesia and Advanced Specialty Roles, RN-MSN) Doctor of Nursing Practice (DNP) PhD (including BSN-PhD) • Ranked 5th in National Institutes of Health (NIH) research dollars • Ranked 7th in U.S. News & World Reports “America’s Best Graduate Schools”
    • 5. Institute for Research, Educationand Training in Addictions (IRETA)• 501c3 Non-profit research and education institute• Mission: To improve the recognition, prevention, treatment, research and policy related to addiction and recovery• Conduct over 60 training events annually training over 2,000 individuals• Conduct a variety of applied research and evaluation activities• Provide a range of professional consulting services such as •Training and technical assistance •Process improvement and performance measurement •Clinical quality improvement programs •Program development •Program evaluation •Strategic planning
    • 6. Background Stigmatization of substance use disorders is a major public health issues IOM, 2011 Alcohol is the leading risk factor for disease burden in the Americas, third leading risk factor worldwide WHO, 2011
    • 7. Background• Of all general hospital admissions, 25% involve complications related to substance use (Hyman,2004)• 20.5 million individuals age 12 and older (approximately 7% of the population) who were identified as needing treatment for alcohol and/or drug problems (SAMHSA, 2011)• 68 million Americans have risky or ‘unhealthy use’ of alcohol and drugs (Humphreys, 2010)
    • 8. What is Evidenced-based Practice?• Key elements:• Screening• Brief Intervention• Referral to Treatment• An evidence-based practice to address risky substance use• Designed for general medical and community settings
    • 9. What is SBIRT? Screening Universal screening identifies patients who may be at risk for problems related to substance use Brief Intervention Referral to Treatment Brief intervention is provided for If screening indicates possiblepatients with mild risk. This involves a substance abuse or dependence, a brief discussion to raise patient referral to specialized treatment isawareness of substance use and its provided. Proactive assistance in consequences and develop accessing care increases the chances of motivation for behavior change. follow through.
    • 10. CURRICULUM ANDINSTRUCTIONAL METHODS
    • 11. ATN-SBIRT ProjectAddictions Training for Nurses (ATN)Screening, Brief Intervention andReferral to Treatment(SBIRT)
    • 12. ATN-SBIRT Project Goals & Objectives• Goal 1: Integrate a sustainable and replicable substance use educational and skill-building component within an undergraduate nursing curriculum – Increase faculty knowledge and competence to train others in SBIRT – Integrate the ATN-SBIRT program within the Pitt SoN – Disseminate information for replication at other nursing schools
    • 13. ATN-SBIRT Project Goals & Objectives• Goal 2: Add 140 nurses annually to the workforce who are able to identify and provide service to patients with substance use, abuse or dependence – Increase student knowledge and awareness of: • The continuum of substance use, abuse and dependence • SBIRT • Culturally appropriate care
    • 14. Partnership Framework
    • 15. ATN- SBIRT 11-Module Curriculum (13 hours)
    • 16. ATN- SBIRT 11-Module Curriculum (13 hours)• Junior class seminar = 6 hours• Practice in clinical rotations = 3 hours• Practice in simulation lab = 2 hours• Senior class review and update session = 2 hours 13 total hours
    • 17. Ring of Knowledge (ROK) Laminated Cards 28 pocket-sized, laminated cards facilitate and prompt use of SBIRT on clinical rotations.
    • 18. RESULTS ANDUSE OF SBIRT
    • 19. Mixed-Method Evaluation Design• Questionnaires • Alcohol and Alcohol Problems Perception Questionnaire (AAPPQ) (pre/post class seminar) • Drug and Drug Problems Perception Questionnaire (DDPPQ) (pre/post class seminar) • Training satisfaction • Focus groups • Cultural Competence Assessment
    • 20. Results• 572 BSN (traditional and 2nd degree) students have been trained• 38 faculty and preceptors have been trained and received continuing education units• 429 have attended the Senior year booster session
    • 21. Student Demographics (N=517*) Percent Gender Female 88% Male 12% Hispanic/Latino 2% Race African American 4% Asian 5% White 91% Other 1% *517 of the 572 students who were trained completed this survey
    • 22. Alcohol and Alcohol Problems PerceptionQuestionnaire (AAPPQ; Shaw et al., 1976):Subscale Sample Items, 30 Total Items• Role Adequacy • I feel I have a working knowledge of alcohol and alcohol related problems. • I feel I know how to counsel drinkers over the long term.• Role Legitimacy • I feel I have a clear idea of my responsibilities in helping drinkers. • I feel I have the right to ask patients questions about their drinking when necessary.• Role Support • If I felt the need when working with drinkers, I could easily find someone who would help me clarify my professional responsibilities. • If I felt the need, I could easily find someone who would be able to help me formulate the best approach to a drinker.
    • 23. Pre- to Post-Seminar Changes in Student Perceptionswith Regard to Alcohol-Using Patients (n=486) Significance (pa) Effect Size (rb) Role Adequacy <.001* .76 Role Legitimacy <.001* .61 Role Support <.001* .29 Motivation .754 -.01 Work Satisfaction <.001* .34 Task-specific Self- <.001* .35 esteem a Wilcoxon Signed Ranks test. Alpha adjusted using Bonferroni correction due to series of analyses; p-values less than .004 considered significant b Cohen, 1988, r > 0.10, small effect; >0.30, medium effect; >0.50 large effect *486 of the 572 students who were trained completed this survey
    • 24. With Regard to Alcohol-Using Patients,Following Training, Students…• Role Adequacy – perceived themselves as more prepared to work with patients who use alcohol• Role Legitimacy – perceived a greater responsibility to deal with alcohol use in their patients• Role Support – felt more support from colleagues in dealing with alcohol use in their patients• Work Satisfaction - felt more work satisfaction related to dealing with alcohol-using patients• Task-specific Self-esteem - felt more confident to deal with alcohol-using patients• *Motivation – no significant change. Need for further practice to increase feelings of confidence and competence
    • 25. Drug and Drug Problems PerceptionQuestionnaire (DDPPQ; Watson et al., 2003):Subscale Sample Items, 22 Total Items• Work Satisfaction • In general, one can get satisfaction from working with drug users. • In general, it is rewarding to work with drug users.• Task Specific Self Esteem • I feel I do not have much to be proud of when working with drug users (reverse scored). • On the whole, I am satisfied with the way I work with drug users.• Motivation • I want to work with drug users. • I feel that there is little I can do to help drug users (reverse scored).
    • 26. Pre- to Post-Seminar Changes in Student Perceptionswith Regard to Drug-Using Patients (n=486) Significance (pa) Effect Size (rb)Role Adequacy <.001* .73Role Legitimacy <.001* .45Role Support <.001* .25Motivation .023 .10Work Satisfaction <.001* .18Task-specific Self- <.001* .22esteema Wilcoxon Signed Ranks test. Alpha adjusted using Bonferroni correction due to series ofanalyses; p-values less than .004 considered significantb Cohen, 1988, r > 0.10, small effect; >0.30, medium effect; >0.50 large effect*486 of the 572 students who were trained completed this survey
    • 27. With Regard to Drug-Using Patients, FollowingTraining, Students…• Role Adequacy – perceived themselves as more prepared to work with patients who use drugs• Role Legitimacy – perceived a greater responsibility to deal with drug use in their patients• Role Support – felt more support from colleagues in dealing with drug use in their patients• Work Satisfaction - felt more work satisfaction related to dealing with drug-using patients• Task-specific Self-esteem - felt more confident to deal with drug-using patients• *Motivation – no significant change. Need for further practice to increase feelings of confidence and competence
    • 28. Training Satisfaction (N=488*) Percent “Very Satisfied’ or How satisfied are you with… “Satisfied”** …the overall quality of this training 88% …the quality of the instruction 94% …quality of the training materials 86% …your training experience 88%*488 of the 544 students who were trained completed this survey**Scored on a 5-point scale where 5 = Very Satisfied and 1 = Very Dissatisfied
    • 29. Training Satisfaction• The most useful aspects of the training were: • Educational tools • Learning how to screen and intervene • Learning how to communicate with patients about substance use
    • 30. Focus Groups (Total=54)1st Group: 11 students2nd Group: 13 students3rd Group: 15 students4th Group: 15 students
    • 31. Focus Group Quotes:• The material was really good because it’s such an awkward subject to bring up• I think it showed me that asking the questions are my responsibility• I feel very comfortable with screening people now for drug and alcohol use, whereas before, I hesitated to ask• I think overall it taught you that…the middle ground of being at-risk provides you an opportunity to give more patient education
    • 32. Focus Group Themes • Students saw the training as linked to their development and role as health educators • SBIRT needs to be mandated hospital-wide or it will not be done • Good to be taught moderation or harm reduction strategies instead of just abstinence
    • 33. CULTURALLY COMPETENTAND RELEVANT SERVICES
    • 34. Culturally competent andrelevant activities• In-class activities – Milton Bennett’s (1993) Developmental Model of Intercultural Sensitivity and examined the cultural competency continuum.• Simulation – The simulation lab was specifically designed for junior level students to have supervised practice delivering SBIRT skills in a culturally competent manner.
    • 35. Simulation Lab• Multiple case scenarios were presented to students during a 7.5 hour day in the simulation lab.• Case scenarios were based on the Scope and Standards of Practice for Psychiatric-Mental Health Nursing (2007) and included: – 1) a middle-aged man with acute pancreatitis and alcohol withdrawal; 2) a young, pregnant woman with bipolar disorder and sporadic cigarette use; 3) an elderly man with congestive heart failure and a history of depression and previous overdose on tricyclic antidepressants; and 4) an elderly woman who was a victim of domestic violence with a dependence on prescription medications.
    • 36. The Cultural CompetenceAssessment (CCA)• Consists of 44 items.• Comprising two subscales: the Cultural Awareness & Sensitivity Subscale and the Cultural Competence Behavior Subscale• Items ask about experience with culturally diverse groups, including self-ratings of cultural competence.
    • 37. Survey Administration• The survey instrument was administered by paper-and-pencil at baseline (beginning of Junior year) and following the end of the simulation lab experience.• Instrument from pre to post simulation experience (n= 119)
    • 38. Results of the CCA subscales Mean Pre-test Mean Post-test t, p-valueCulturalAwareness & 4.0993 4.3205 -7.071, p=.000SensitivitySubscalemean scoreCulturalCompetence 3.4222 3.7243 -5.869, p=.000Behavior Subscalemean score n=119, Paired-sample t tests
    • 39. Culturally competent andrelevant services• Through specific class activities on cultural issues students can become – more culturally aware, – sensitive and – demonstrate competent cultural behavior with practice (simulation). • Short video demonstration of simulation lab
    • 40. HOW CAN THIS BEREPLICATED
    • 41. In other schools• Publications:•Journal of Nursing Education and Practice – published in open access journal Volume 2, Issue 4•Substance Abuse Journal of AMERSA – in press•Develop partnerships•Look for innovative ways to partner
    • 42. GROUP ACTIVITY:“KNOW THY SELF”
    • 43. Draw your culture• May draw pictures of events in your life that have influenced you in your culture• May draw symbols that are particularly meaningful in your culture• Any combination of designs, doodles or lines that have meaning• However may not write or draw any words• Present drawing with explanations of what symbols or drawings mean to the group
    • 44. Contact Information:Holly Hagle – holly@ireta.org Dawn - dawn@ireta.org Ann - ammi@pitt.edu