1. Teaching Undergraduate Nursing Students to use
SBIRT in a Culturally Competent
and Relevant Manner
Holly Hagle, PhD, Institute for Research, Education and
Training in Addictions (IRETA)
Dawn Lindsay, PhD, Institute for Research, Education and
Training in Addictions (IRETA)
Ann M. Mitchell, PhD, RN University of Pittsburgh
School of Nursing

2. Project Team
Kathryn Puskar, DrPH, RN, FAAN Project Director
Ann M. Mitchell, PhD, RN, AHN-BC, FAAN Project Coordinator
Holly Hagle, PhD IRETA Trainer
Betty Braxter, PhD, RN Obstetrics Primary Teacher
Marie Fioravanti, MSN, RN Medical Surgical Primary Teacher
Irene Kane, PhD, MSN, RN, CNAA, HFI Psychiatric Nursing Primary Teacher
Gail Ratliff Woomer, MN, RN, IBCLC Community Nursing Clinical Instructor
Martin Houze, PhD Project Statistician
Kimberly Talcott, MPA Project Manager
Heather J. Gotham, PhD Project Evaluator
Helen K. Burns, PhD, RN, FAAN Consultant
Dawn Lindsay, PhD IRETA staff
This 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, Education
and 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 possible
patients with mild risk. This involves a substance abuse or dependence, a
brief discussion to raise patient referral to specialized treatment is
awareness 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 AND
INSTRUCTIONAL METHODS

11. ATN-SBIRT Project
Addictions Training for Nurses (ATN)
Screening, Brief Intervention and
Referral 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 AND
USE 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 Perception
Questionnaire (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 Perceptions
with 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 Perception
Questionnaire (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 Perceptions
with Regard to Drug-Using Patients (n=486)
Significance (pa) Effect Size (rb)
Role Adequacy <.001* .73
Role Legitimacy <.001* .45
Role Support <.001* .25
Motivation .023 .10
Work Satisfaction <.001* .18
Task-specific Self-
<.001* .22
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

27. With Regard to Drug-Using Patients, Following
Training, 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 students
2nd Group: 13 students
3rd Group: 15 students
4th 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 COMPETENT
AND RELEVANT SERVICES

34. Culturally competent and
relevant 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 Competence
Assessment (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-value
Cultural
Awareness & 4.0993 4.3205 -7.071, p=.000
Sensitivity
Subscale
mean score
Cultural
Competence 3.4222 3.7243 -5.869, p=.000
Behavior Subscale
mean score
n=119, Paired-sample t tests

39. Culturally competent and
relevant 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 BE
REPLICATED

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