Baylor Pediatric SBIRT Medical Residency Training Program: Model Description and Evaluation

ABSTRACT. Background: The Baylor College of Medicine SBIRT Medical Residency Training Program is a multilevel project that trains residents and faculty in evidenced-based screening, brief intervention, and referral to treatment methods for alcohol and substance use problems. Methods: This paper describes the training program created for pediatric residents and provides an evaluation of the program. Ninety-five first-year pediatric residents participated in the training program. They were assessed on satisfaction with the program, self-rated skills, observed competency, and implementation into clinical practice. Results: The program was successfully incorporated into the residency curricula in two pediatric residencies. Evaluations indicate a high degree of satisfaction with the program, self-reported improvement in SBIRT skills, observed proficiency in SBIRT skills, and utilization of SBIRT skills in clinical practice. Conclusions: SBIRT skills training can be incorporated into pediatric residency training, and residents are able to learn and implement the skills in clinical practice.     

South Texas Residency Screening,Brief Intervention,and Referral to Treatment (SBIRT) Training: 12-Month Outcomes

Background: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. Methods: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009–2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. Results: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. Conclusions: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.     

Residents' experience of screening,brief intervention,and referral to treatment (SBIRT) as a clinical tool following practical application: A mixed-methods study

ABSTRACT

Background: Screening, brief intervention, and referral to treatment (SBIRT), an evidence-based validated system for providing early detection and brief treatment of substance use disorders, has been widely used in the training of medical residents across specialties at a number of sites. This article investigates the effectiveness of SBIRT training during short-term follow-up at Albany Medical Center, one of the initial Substance Abuse and Mental Health Services Administration (SAMHSA) grantees. Methods: Training outcomes were measured by training satisfaction following opportunities to apply SBIRT skills in clinical work, the rate at which these techniques were applied in clinical work, and the degree to which residents felt that the SBIRT training provided skills that were applicable to their practice. We examined differences in learning experience by postgraduate year and by program, and conducted a qualitative analysis in a convergent parallel mixed-methods design to elucidate barriers encountered by residents upon using SBIRT techniques in clinical practice. Results: Residents remained highly satisfied with the training at 4-month follow-up, with 80.1% reporting that they had used SBIRT skills in their clinical work. Use of SBIRT techniques was high at 6-month follow-up as well, with 85.9% of residents reporting that they regularly screened their patients for substance use, 74.4% reporting that they had applied brief intervention techniques, and 78.2% indicating that SBIRT training had made them overall more effective in helping patients with substance use issues. Differences in application rates and satisfaction were found by specialty. Qualitative analyses indicated that residents encountered patient readiness and specific contextual factors, such as time constraints, externally imposed values, and clinical norms, as barriers to implementation. Conclusions: Despite encountering obstacles such as time constraints and patient readiness, residents utilized many of the skills they had learned during SBIRT training in clinical practice and reported finding these skills useful in their management of patients with substance use issues.     

Addressing Adolescent Substance Use: Teaching Screening,Brief Intervention,and Referral to Treatment (SBIRT) and Motivational Interviewing (MI) to Residents

Background: The American Academy of Pediatrics Committee on Substance Use recommends screening, brief intervention, and referral to treatment (SBIRT) at every adolescent preventive and all appropriate urgent visits. We designed an SBIRT curriculum as part of the adolescent block of a pediatric residency that combined online modules with an in-person workshop, faculty feedback on resident interactions with patients, and resident self-reflection on their motivational interviewing (MI) skills. Methods: To evaluate the curriculum, we measured resident satisfaction and self-reported confidence in using SBIRT and MI with teens using a retrospective pre/post questionnaire. We used qualitative analysis to evaluate the written comments from faculty observations of patient-trainee interactions and comments from resident self-reflection(s) on patient interactions. Results: Thirty-two residents completed the curriculum. Residents reported high satisfaction with the training. Comparing retrospective pre/post scores on the survey of resident self-reported confidence, measures increased significantly in all domains, including for both alcohol and other drug use. Regarding self-reported MI, skillfulness also increased significantly. Analysis of specific faculty feedback to residents revealed subthemes such as normalizing confidentiality and focusing more on the patient's perspectives on substance use. Resident reflections on their own abilities with SBIRT/MI focused on using the ruler tool and on adapting the MI style of shared decision-making. Conclusions: A curriculum that combines online training, small-group practice, clinical observations, and self-reflection is valued by residents and can increase resident self-reported confidence in using SBIRT and MI in adolescent encounters. Future studies should examine to what extent confidence predicts performance using standardized measures of MI skillfulness in patient encounters.     

A statewide screening,brief intervention,and referral to treatment (SBIRT) curriculum for medical residents: Differential implementation strategies in heterogeneous medical residency programs

ABSTRACT

Background: Many screening, brief intervention, and referral to treatment (SBIRT) training curricula have been implemented within graduate medical residency training programs, with varying degrees of success. The authors examined the implementation of a uniform, but adaptable, statewide SBIRT curriculum in 7 diverse residency training programs and whether it could improve resident knowledge, skills, and attitudes regarding SBIRT and unhealthy alcohol and other drug (AOD) use. Methods: The authors assessed the implementation of the Pennsylvania SBIRT Medical and Residency Training (SMaRT) curriculum at 7 residency sites training a variety of disciplines. Faculty could use a variety of training modalities, including (1) Web-based self-directed modules; (2) didactic lectures; (3) small-group sessions; and/or (4) skill-transfer interactions with standardized or real patients in preceptor-led encounters. Acquisition of knowledge, skills, and attitudes regarding SBIRT and unhealthy AOD use–associated patient care were assessed via a pre- and post-survey instrument with 4 domains: Resident Knowledge, Resident Competence, Resident Skills and Attitudes (Alcohol), and Resident Skills and Attitudes (Drug). Responses to the pre- and post-surveys (N = 365) were compared and analyzed with t tests and Wilcoxon signed-rank tests. Results: The diverse modalities allowed each of the residency programs to adapt and implement the SMaRT curriculum based on their needs and environments. Residents' knowledge, skills, and attitudes regarding SBIRT and working with unhealthy AOD use, as assessed by survey, generally improved after completing the SMaRT curriculum, despite the variety of models used. Specifically, Resident Knowledge and Resident Competence domains significantly improved (P < .000). Residents improved the least for survey items within the Resident Skills and Attitudes (Alcohol) domain. Conclusions: Adaptable curricula, such as SMaRT, may be a viable step towards developing a nationwide curriculum.     

Developing and Implementing a Multispecialty Graduate Medical Education Curriculum on Screening,Brief Intervention,and Referral to Treatment (SBIRT)

ABSTRACT

The authors sought to evaluate the feasibility and acceptability of initiating a Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and other drug use curriculum across multiple residency programs. SBIRT project faculty in the internal medicine (traditional, primary care internal medicine, medicine/pediatrics), psychiatry, obstetrics and gynecology, emergency medicine, and pediatrics programs were trained in performing and teaching SBIRT. The SBIRT project faculty trained the residents in their respective disciplines, accommodating discipline-specific implementation issues and developed a SBIRT training Web site. Post-training, residents were observed performing SBIRT with a standardized patient. Measurements included number of residents trained, performance of SBIRT in clinical practice, and training satisfaction. One hundred and ninety-nine residents were trained in SBIRT: 98 internal medicine, 35 psychiatry, 18 obstetrics and gynecology, 21 emergency medicine, and 27 pediatrics residents. To date, 338 self-reported SBIRT clinical encounters have occurred. Of the 196 satisfaction surveys completed, the mean satisfaction score for the training was 1.60 (1 = very satisfied to 5 = very dissatisfied). Standardized patient sessions with SBIRT project faculty supervision were the most positive aspect of the training and length of training was a noted weakness. Implementation of a graduate medical education SBIRT curriculum in a multispecialty format is feasible and acceptable. Future efforts focusing on evaluation of resident SBIRT performance and sustainability of SBIRT are needed.     

Implementing Adolescent Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education in a Pediatric Residency Curriculum

Background: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as part of routine health care for adolescents as well as adults. In an effort to promote universal SBIRT, the Substance Abuse and Mental Health Services Administration awarded funding to residency programs to develop and implement SBIRT education and training. Our project focused on creating scientifically based, developmentally appropriate strategies and teaching materials for the adolescent age range. This paper describes curriculum development and implementation and presents evaluation data. Methods: Pediatric and child psychiatry residents were trained. The training consisted of 4 activities: (1) case-based teaching modules, (2) role-play of motivational interviewing and brief interventions, (3) mock interviews with trained adolescents, and (4) supervised “hands-on” screening and brief interventions. Main outcome measures included trainee satisfaction, and SBIRT knowledge, perceived self-efficacy, and self- and observer report of use of the SBIRT algorithm. Results: Among 150 total participants completing the SBIRT training modules, nearly all (92.3%) were satisfied/very satisfied with the training modules. Knowledge accuracy immediately post training was high, but declined significantly by the end of the first residency year, with little change across subsequent years of residency. Confidence ratings also declined over time. Use of the SBIRT algorithm during the Adolescent Medicine rotation was high according to trainee self- and faculty observer report. Conclusions: We found evidence of training satisfaction, increased confidence in talking to adolescents about substance use, and widespread use of recommended practices immediately following training. Use of a highly structured algorithm to guide practice, and simple, highly structured brief interventions was a successful training approach, as residents self-reported accurate use of the SBIRT algorithm immediately after training. Knowledge and self-confidence declined over time. It is possible that “booster” sessions and ongoing opportunities to review materials could help residents retain knowledge and skills.     

Teaching residents screening,brief intervention,and referral to treatment (SBIRT) skills for alcohol use: Using chart-stimulated recall to assess curricular impact

ABSTRACT

Background: Screening, brief intervention, and referral to treatment (SBIRT) improves identification and intervention for patients at risk for developing an alcohol use disorder (AUD). Residency curriculum is designed to teach SBIRT skills, but resources are needed to promote skill implementation. The electronic health record (EHR) can facilitate implementation through integration of decision-support tools. The authors developed electronic tools to facilitate documentation of alcohol assessment and brief intervention and to reinforce skills from an SBIRT curriculum. This prospective cohort study assessed primary care internal medicine residents' use of SBIRT skills and EHR tools in practice using chart-stimulated recall (CSR). Methods: Postgraduate year 2 and 3 residents received a 5-hour SBIRT curriculum with skills practice and instruction on SBIRT electronic tools. Participants were then given a list of their patients seen in a 1-year period who were drinking at/above the recommended limit. Trainees selected 3 patients to review with a faculty member in a CSR. Faculty used a 24-item chart checklist to assess application of SBIRT skills and electronic tool use and met with residents to complete a CSR interview. CSR interview notes were analyzed qualitatively to understand application of SBIRT skills and EHR tool use. Results: Eighteen of 20 residents participated in the CSR, and 5 faculty reviewed 46 patient charts. Residents documented alcohol use (84.2% of charts) and assessment of quantity/frequency of use (71.0%) but were less likely to document assessment for an AUD (34%), an appropriate plan (50.0%), or follow-up (55%). Few residents used EHR tools. Residents reported barriers in addressing alcohol use, including lack of knowledge, patient barriers, and time constraints. Conclusions: More intensive training in SBIRT with opportunities for practice and feedback may be necessary for residents to consistently apply SBIRT skills in practice. EHR tools need to be better integrated into the clinic workflow in order to be useful.     

‘Asking’ but Not ‘Screening’: Assessing Physicians’ and Nurses’ Substance-Related Clinical Behaviors

Background: Screening, brief intervention, and referral to treatment (SBIRT) is a promising public health approach for problematic substance use. A core component of SBIRT is the use of formal screening tools to categorize a patient's likely level of risk in order to provide an appropriately-matched service. Training in formal screening is included in many SBIRT training programs, but infrequently is emphasized. Objectives: To assess pre-training levels of SBIRT-related clinical behaviors, including screening, this study examined a secondary dataset collected from internal medicine residents and graduate nurse practitioner students. Methods: Learners (n = 117) completed 13 self-report items assessing use of SBIRT-related behaviors. Researchers used exploratory factor analysis to identify underlying concepts in the questionnaire, then used mixed ANOVA to compare mean frequency of utilization of each factor (asking, screening, and intervening) by academic program. Results: Learners reported asking about substance use frequently, intervening some of the time, and infrequently using formal screening tools. Interaction and between-academic-program effects were significant but small. Conclusions: Prior to SBIRT training, most clinical practitioners reported asking patients about substance use, but few reported regularly using formal substance use screening tools. This may have implications for the importance of SBIRT training as part of curricular work, and for the internal content foci of SBIRT curricula.     

Education for the mind and the heart? Changing residents' attitudes about addressing unhealthy alcohol use

Background: Screening and brief intervention counseling for unhealthy alcohol use are among the top 10 recommended clinical preventive services for US adults. Although federally funded training programs in alcohol screening, brief intervention, and referral to treatment (SBIRT) have focused on increasing physicians' professional readiness to address drinking with their patients, programs typically focus on knowledge and skill acquisition, with less attention to attitudinal change. The purpose of this study was to assess the impact of a multicomponent SBIRT training program on changes in internal medical residents' professional readiness for working with patients with unhealthy alcohol use. Methods: Between 2011 and 2013, first-year internal medicine residents (n = 80) at a large academic medical center participated in a 16-hour SBIRT training program, consisting of two 3-hour didactic sessions, online modules, and a half-day clinical experience, during the Ambulatory Care month of the residency training year. Residents completed a modified Alcohol and Problems Perceptions Questionnaire (AAPPQ) at the beginning and end of the residency year to assess changes in professional readiness to work with adults with unhealthy alcohol use across 6 domains: Role Adequacy, Role Legitimacy, Role Support, Motivation, Task-Specific Self-esteem, and Satisfaction. Wilcoxon signed-rank tests were used to evaluate changes in the 6 AAPPQ subscale scores over time. Results: Residents reported significant increases in Role Adequacy (alcohol-related knowledge/skills; pre: 34 and post: 39.5; P < .0001) and Role Support (professional support; pre: 16 and post: 18; P = .005) scores. No significant differences in the remaining AAPPQ subscales were detected. Conclusions: Residents in the SBIRT training program indicated improvements in knowledge, skills, and professional role support but not in motivation, task-specific self-esteem, or satisfaction for working with patients with unhealthy alcohol use. Explicit curricular attention to these domains may be required to facilitate SBIRT skills application and sustained practice change.     

Multispecialty screening,brief intervention,and referral to treatment (SBIRT) training in an academic medical center: Resident training experience across specialties

ABSTRACT

Background: The Substance Abuse and Mental Health Services Administration (SAMHSA) has recently begun to fund programs that train medical residents on how to utilize an evidence-based validated system known as screening, brief intervention, and referral to treatment (SBIRT) for providing early detection and brief treatment of unhealthy substance use. This paper investigates training outcomes of multispecialty SBIRT training at one such program at Albany Medical Center (AMC), one of the initial SAMHSA grantees. Methods: Training outcomes were measured across 3 domains of learning: trainee satisfaction, acquired knowledge, and perceived usefulness. The authors explored differences in learning experience by postgraduate year and by specialty. Results: Overall, residents were highly satisfied with the training, and learning outcomes met objectives. Residents' ratings of usefulness did not vary by program year. However, the results indicate that relative to residents in other programs, residents in psychiatry and pediatrics found the training components significantly more useful, whereas emergency medicine residents found training components to have less utility. Residents who found the training relevant to their daily work were more satisfied and more receptive to SBIRT training overall, which may help explain difference scores by program. Conclusions: Residents were highly satisfied with SBIRT skills training, although ratings of usefulness varied by residency program. Specialization by program and on-site modeling by senior faculty may enhance trainee satisfaction and perceived usefulness.     

Facilitators and Barriers to Implementing Screening,Brief Intervention,and Referral to Treatment (SBIRT) in Primary Care in Integrated Health Care Settings

Background: Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) screening, brief intervention, and referral to treatment (SBIRT) approach in the organization. Methods: Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders: one in English and one in Spanish. Results: All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits; however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. Conclusions: Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening, but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.     

Screening instruments for substance use and brief interventions targeting adolescents in primary care: A literature review

Background

A review of the literature was conducted to examine substance use screening instruments commonly used with adolescents in medical settings, their comparative usefulness, and SBIRT (Screening, Brief Intervention, and Referral to Treatment).

Methods

We screened two databases (Ovid MEDLINE and PsycINFO) targeting journal articles dealing with screening for alcohol and drug use in adolescence as well as adolescent SBIRT.

Results

Adolescents preferred paper forms and computerized questionnaires over interviews with physicians or nurses. The CRAFFT was the best studied instrument for screening for alcohol/drug use and related problems, and is the only tool with data to support its use in medical settings. Other screening instruments require more testing/evaluation in more representative samples of adolescents in primary care settings. Long term follow-up data to establish the efficacy of SBIRT in adolescence are not available. Innovative computerized approaches to screening for substance use in this population have recently been proposed. Although promising, they require further evaluation.

Conclusions

The CRAFFT has the most consistent data to support its use in primary care settings. The effects of SBIRT in adolescence have not been adequately evaluated. Adolescents' opinions and preferences for SBIRT should be studied to improve their acceptance.     

Effects of Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education and Training on Nursing Students’ Attitudes Toward Working With Patients Who Use Alcohol and Drugs

ABSTRACT

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) can reduce alcohol use and negative health outcomes in patients with risky substance use. However, negative attitudes that some health care professionals have toward patients who use substances are a barrier to implementing SBIRT. Methods: The University of Pittsburgh School of Nursing, in partnership with the Institute for Research, Education, and Training in Addictions (IRETA), developed a curriculum to train baccalaureate student nurses to deliver SBIRT. Results: Following SBIRT education and training, students’ perceived attitudes toward patients who use alcohol became more positive. Less robust changes were found for attitudes related to patients who use drugs. Conclusions: Nurses composing the largest group of healthcare workers are in key positions to screen, intervene, and provide education about substance use.     

Communicating about screening,brief intervention,and referral to treatment: Messaging strategies to raise awareness and promote voluntary adoption and implementation among New York school-based health center providers

ABSTRACT

Background: School-based health centers (SBHCs) are satellite primary care clinics conveniently located within high-risk schools. Providing screening, brief intervention, and referral to treatment (SBIRT) in SBHCs has the potential to greatly increase identification and intervention among adolescents with problem substance use. Nevertheless, only 11% of New York State SBHC providers report the use of SBIRT. This study identifies strategies for communicating about SBIRT with the goal of raising awareness and promoting voluntary adoption and implementation among both SBHC program directors and clinicians. Methods: All 162 New York State SBHC program directors and clinicians serving middle and high school students were surveyed between May and June 2013 (40% response rate). Program directors were asked which factors were most important to them in their decision to adopt new practices, and both program directors and clinicians were asked to rank-order statements in 2 categories: (1) Substance use and its effects and (2) SBIRT integration and outcomes. Results: Student need was valued far more than any other factor in program directors’ decisions to adopt new practices. Both program directors and clinicians perceived the association between substance use and risky sexual behavior and the benefits and cost-effectiveness of SBIRT compared with other preventive health screenings as the strongest motivators to adopt and implement SBIRT. Conclusions: Findings from this study suggest that SBIRT awareness-raising strategies present the cost-effectiveness of SBIRT, highlight student need, particularly the connection between substance use and risky sexual behaviors, and should be communicated by state health departments and professional organizations.     

An Evidence-Based Alcohol Screening,Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Emergency Department (ED) Providers Improves Skills and Utilization

SUMMARY

Objective: Emergency Departments (EDs) offer an opportunity to improve the care of patients with at-risk and dependent drinking by teaching staff to screen, perform brief intervention and refer to treatment (SBIRT). We describe here the implementation at 14 Academic EDs of a structured SBIRT curriculum to determine if this learning experience improves provider beliefs and practices.

Methods: ED faculty, residents, nurses, physician extenders, social workers, and Emergency Medical Technicians (EMTs) were surveyed prior to participating in either a two hour interactive workshops with case simulations, or a web-based program (www.ed.bmc.org/sbirt). A pre-post repeated measures design assessed changes in provider beliefs and practices at three and 12 months post-exposure.

Results: Among 402 ED providers, 74% reported <10 hours of prior professional alcohol-related education and 78% had <2 hours exposure in the previous year. At 3-month follow-up, scores for self-reported confidence in ability, responsibility to intervene, and actual utilization of SBIRT skills all improved significantly over baseline. Gains decreased somewhat at 12 months, but remained above baseline. Length of time in practice was positively associated with SBIRT utilization, controlling for gender, race and type of profession. Persistent barriers included time limitations and lack of referral resources.

Conclusions: ED providers respond favorably to SBIRT. Changes in utilization were substantial at three months post-exposure to a standardized curriculum, but less apparent after 12 months. Booster sessions, trained assistants and infrastructure supports may be needed to sustain changes over the longer term.     

Evaluation of a training program to improve clinicians' assessment of patient stability

Introduction and Aims . Public clinics in New South Wales (NSW), Australia play a central role in inducting and stabilising opioid dependent clients onto treatment before transfer to a community pharmacy. Clinical assessment of stability is a vital skill in ensuring that clients are appropriately and effectively transferred. A two‐hour clinical training program was delivered to staff at 31 public clinics, that aimed to improve staff confidence in assessing client stability, and skills in negotiating the transfer of clients to community pharmacies. Design and Methods . Pre‐ and post‐training evaluation was conducted examining self‐ratings of confidence and ability in the assessment of client stability, and the perceived utility of a clinical algorithm to improve assessments. Follow‐up was conducted 3 to 6 months post‐training assessing individual and clinic level changes in clinical practice. Results . 205 staff completed pre‐ and post‐training questionnaires. Staff demonstrated a moderate level of self‐reported baseline knowledge and skills in assessing client stability (mean = 6.5; 1 = poor; 10 = excellent) that improved when re‐assessed following the training (mean = 8.0). 76 staff responded to the follow‐up questionnaire. ≥ 75% reported some level of improvement in their approach to clinical practice regarding stability assessment, and 59% reported being more effective in identifying clients appropriate for community pharmacy transfer. Of 19 public clinics, 14 reported an increased focus on stability assessment. Nine clinics reported barriers to achieving changes in clinical practice. Discussion and Conclusions . This evaluation demonstrates that it is possible to implement a targeted clinical training package to staff that translates into positive changes in clinical practice.[Winstock AR, Lea T. Evaluation of a training program to improve clinicians' assessment of patient stability. Drug Alcohol Rev 2009;28:353–359]     

Screening and brief intervention in high schools: School nurses' practices and attitudes in Massachusetts

Background: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as a strategy to prevent or reduce adolescent substance use. Offering SBIRT in schools may provide an opportunity to reach adolescents not accessing primary care. The objective is to assess school nurses' attitudes and practices regarding adolescent SBIRT. Methods: The authors administered electronically and in person a questionnaire including 29 items on SBIRT attitudes and practices to school nurses registered for the Northeastern University's School Health Institute Summer Program in Massachusetts (N = 168). Survey questions were adapted from a questionnaire originally developed by the American Academy of Pediatrics. Results: One hundred and forty-four nurses completed the survey for a response rate of 85.7%. More than three quarters of the respondents (77.0%) were in favor of universal alcohol screening in schools. None of the respondents reported screening their students on a regular basis. More than half (64.4%) of nurses reported screening students; however, they did so only when they suspected alcohol use. During these instances, only 17.9% used a validated screening tool and almost all (98.2%) used face-to-face clinical interviews. When addressing alcohol use by a student, the large majority of respondents reported including the following recommended clinical strategies: asking about problems related to alcohol use (56.3%), explaining the harms of alcohol use (70.1%), and advising abstinence (73.6%). On average, respondents spend 5 to 10 minutes discussing alcohol use with their students. Conclusion: Survey respondents were supportive of universal alcohol screening in school, although few were doing so at the time. When respondents identified students using alcohol, their interventions were closely aligned with clinical recommendations for brief intervention. Implementation of SBIRT that focuses on standardized, annual screening has the potential to deliver high-quality care in this setting.