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Substance Abuse

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

Julie Lunstead, Elissa R. Weitzman, Dylan Kaye & Sharon Levy

To cite this article: Julie Lunstead, Elissa R. Weitzman, Dylan Kaye & Sharon Levy (2017)Screening and brief intervention in high schools: School nurses' practices and attitudes inMassachusetts, Substance Abuse, 38:3, 257-260, DOI: 10.1080/08897077.2016.1275926

To link to this article: https://doi.org/10.1080/08897077.2016.1275926

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Accepted author version posted online: 27Dec 2016.Published online: 20 Mar 2017.

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BRIEF REPORT

Screening and brief intervention in high schools: School nurses’ practicesand attitudes in Massachusetts

Julie Lunstead, MPHa, Elissa R. Weitzman, ScD, MScb,c, Dylan Kaye, BAa, and Sharon Levy, MD, MPHa,b

aAdolescent Substance Abuse Program, Division of Developmental Behavioral Pediatrics, Boston Children’s Hospital, Boston, Massachusetts, USA;bDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA; cDivision of Adolescent/Young Adult Medicine, Boston Children’sHospital, Boston, Massachusetts, USA

ABSTRACTBackground: Screening, brief intervention, and referral to treatment (SBIRT) is recommended as a strategyto prevent or reduce adolescent substance use. Offering SBIRT in schools may provide an opportunity toreach adolescents not accessing primary care. The objective is to assess school nurses’ attitudes andpractices regarding adolescent SBIRT. Methods: The authors administered electronically and in person aquestionnaire including 29 items on SBIRT attitudes and practices to school nurses registered for theNortheastern University’s School Health Institute Summer Program in Massachusetts (N D 168). Surveyquestions were adapted from a questionnaire originally developed by the American Academy ofPediatrics. 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 inschools. 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 alcoholuse. 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 respondentsreported including the following recommended clinical strategies: asking about problems related toalcohol use (56.3%), explaining the harms of alcohol use (70.1%), and advising abstinence (73.6%). Onaverage, respondents spend 5 to 10 minutes discussing alcohol use with their students. Conclusion: Surveyrespondents were supportive of universal alcohol screening in school, although few were doing so at thetime. When respondents identified students using alcohol, their interventions were closely aligned withclinical recommendations for brief intervention. Implementation of SBIRT that focuses on standardized,annual screening has the potential to deliver high-quality care in this setting.

KEYWORDSAlcohol; brief intervention;school health; school nurses;screening; substance use

Introduction

Alcohol use during adolescence accounts for a large propor-tion of life-years lost due to disease, disability, and prema-ture death,1 results in an array of chronic problems,2 and isarguably the most important modifiable health behavior forthis age group. Brief interventions delivered by medical pro-fessionals may delay initiation and reduce alcohol use byteens.3–6

Screening, brief intervention, and referral to treatment(SBIRT) is recommended as part of routine health care,7

although adolescents have the lowest primary care utiliza-tion rates of any age group.8 In March 2016, Massachu-setts passed House Bill 4056, titled “An Act relative tosubstance use treatment, education, and prevention,”which requires all schools in the state to utilize a verbalscreening tool annually at 2 different grade points, asapproved by the Department of Public Health.9 The Mas-sachusetts Department of Public Health has deemedSBIRT as the approved screening practice, in an attemptto increase the number of teens who have the opportunity

for a private conversation about substance use with ahealth care professional.9 Effective implementation ofSBIRT in schools is contingent upon the readiness and thecapacity of the workforce to undertake this practicechange. The objective of this report is to describe findingsof a survey measuring SBIRT attitudes and screening andbrief intervention practices among school nurses practic-ing in Massachusetts prior to the legislation requiringschools to screen all students.

Methods

Survey development

In July 2014, we administered a survey on SBIRT practices andattitudes to Massachusetts school nurses prior to their partici-pation in a 3-day professional development summer programthat concluded with 4 hours of SBIRT training. The survey wasbased on a questionnaire originally administered to pediatri-cians nationally and subsequently in Massachusetts.10 Ques-tions about SBIRT practices represented the common

CONTACT Julie Lunstead, MPH julie.lunstead@childrens.harvard.edu Boston Children’s Hospital, 1295 Boylston Street, Suite 100, Boston, MA 02115, USA.Supplemental data for this article can be accessed at www.tandfonline.com/wsub.

© 2017 Taylor & Francis Group, LLC

SUBSTANCE ABUSE2017, VOL. 38, NO. 3, 257–260https://doi.org/10.1080/08897077.2016.1275926

components taken from a compilation of published recommen-dations (Supplemental Table 1).

The brief survey was anonymous and was exempted by theBoston Children’s Hospital Internal Review Board.

Participants

The School Health Institute at Northeastern Universitye-mailed a survey link to all nurses registered for an August2014 training session (N D 168); nurses also had the opportu-nity to complete a paper survey in person prior to the training.

Analyses

Responses were entered into REDCap (Research ElectronicData Capture), cleaned in Microsoft Excel 2010, and analyzedusing SPSS (version 19; IBM, Armonk, NY).

Response frequencies were computed for all variables.Respondents who answered the question “Do you screen stu-dents for alcohol use?” as “Yes, when I do physicals” or “Yes,when I suspect a child has used alcohol or has an alcohol prob-lem” were recorded as positive for having screened. For ques-tions that assessed frequency, responses were dichotomized asNever/Sometimes and Often/Always.

Results

Sample characteristics

Eighty-eight electronic and 56 paper surveys were received for atotal of 144 completed surveys from 168 eligible participants(response rate D 85.7%). Data from 87 respondents whoworked in middle and high school or only high school settingsare included in this report. There were no significant differen-ces between participants who saw middle and high school stu-dents (n D 67) compared with participants who only saw highschool students (n D 20). Respondents were mostly female(87.4%), median range of nursing experience was 11 to 15 years,most (71.3%) worked in only 1 school, and 69.0% saw morethan 60 students per week.

Screening attitudes and practices

Most respondents (77.0%) answered “yes” to the question “Doyou support universal alcohol screening in schools?”More thanhalf (64.4%) reported screening for alcohol use; however, noneindicated routine screening during physicals. Nearly allrespondents (98.4%) used a clinical interview to screen; 17.9%used a validated screening tool. A majority of respondents(79.3%) indicated that they had not received training on SBIRTin the past 3 years (Table 1).

Brief intervention practices

The median time spent discussing alcohol use was 5 to 10 minutes.Respondents endorsed having used the following interventionstrategies: asking about alcohol-related problems (56.3%), explain-ing harms (70.1%), advising students to stop drinking (73.6%),referring to a counselor (67.8%), notifying parents (42.5%), andnotifying primary care providers (19.5%) (Table 1).

Barriers to SBIRT

The most commonly cited barriers were unfamiliarity withscreening tools (35.6%), insufficient time to administer a screen(31.0%) or respond to screen results (23.0%), concerns that stu-dents will not be receptive (23.0%) or respond honestly (27.6%),and concerns about parental support (18.4%) (Table 2).

Discussion

A majority of this sample of Massachusetts school nurses weresupportive of universal alcohol screening. Despite high levels ofsupport, routine screening was not being employed; typicalpractice involved assessing and counseling students who wereidentified as having alcohol problems. Offering annual SBIRTin schools would present an opportunity to counsel studentswith alcohol problems not identified by school staff, those whohave not had alcohol problems, and even those who have notused alcohol.

A large proportion of school nurse respondents endorseduse of brief intervention strategies when discussing alcohol usewith students. This finding may reflect significant experience ofschool nurses in managing students with alcohol problems andsuggests that the workforce could be readily trained to respondto students identified with substance use problems when SBIRTprograms are implemented. On average, respondents spent 5 to10 minutes discussing alcohol use. Many respondents reportedinadequate time to respond to screen results, consistent with

Table 1. Screening practices among a sample of Massachusetts school nurses.

Item n (%) (N D 87)

Do you screen students for alcohol use?Yes, when I do physicals 0 (0.0)Yes, when I suspect a child has used alcohol 56 (64.4)Almost never or never 31 (35.6)

If a student does report alcohol use, how oftendo you do each of the following? (Often/Always)a

Advise stopping 64 (73.6)Explain harms of alcohol use 61 (70.1)Refer to a counselor or social worker 59 (67.8)Ask if alcohol has ever caused a problem 49 (56.3)Tell parents 37 (42.5)Tell primary care provider 17 (19.5)

n (%) (N D 56)Use a valid screening toolb,c 10 (17.9)

Method of administration (Select all that apply)b

Face-to-face interviews 55 (98.2)Paper/pencil questionnaire 3 (5.4)Electronic 2 (2.6)

Time spent discussing alcohol useb

0 minutes 1 (1.8)<5 minutes 13 (23.2)5–10 minutes 14 (25.0)>10 minutes 27 (48.2)

aResponses were dichotomized so that individuals who reported often or alwaysemploying a brief intervention component were categorized as affirmativewhereas those who reported never or sometimes employing a component werenegative.

bOnly individuals who reported screening for alcohol use received this question.c Individuals who reported using the Alcohol Use Disorders Identification Test(AUDIT)/Abbreviated AUDIT (AUDIT-C), CRAFFT (Car, Relax, Alone, Forget,Friends, Trouble), or the National Institute on Alcohol Abuse and Alcoholism(NIAAA) Youth Screening Guide/Tool were classified as having used a validscreening tool.

258 J. LUNSTEAD ET AL.

previous reports.11 This barrier may increase if more studentsin need of an intervention are identified through universalscreening. With the high volume of students seen by nurses,school districts may need to assess their workforce to insureadequate capacity to effectively deliver brief interventions aspart of a school-based SBIRT program.

Lack of familiarity with validated screens was another bar-rier identified. In medical settings, clinical instincts are insensi-tive for identifying substance use problems. 12 Implementationof a validated screening tool that efficiently identifies riskgroups could minimize the chance that early problems goundetected by clinical interview. Self-administered electronicscreens are efficient and effective.13 Use of these instrumentscould reduce staff time and insure fidelity and are preferred byadolescents, who may be willing to disclose more substance usein this format,14 addressing a concern expressed byrespondents.

A number of limitations to this project should be noted. Thesurvey response rate among nurses participating in a summereducational conference was high. Nevertheless, nurses whoattended the summer program may not have been representa-tive of all school nurses in the state. It is possible that attendees’SBIRT practices and attitudes were systematically differentfrom those of their colleagues, although we believe this isunlikely, as the conference content was wide-ranging and didnot focus exclusively on SBIRT. We used a self-report surveythat asked respondents to report on whether they used recom-mended procedures for screening and brief intervention. Thetool has been not been formally validated, although it has beenused previously in other settings.10 SBIRT recommendationsthat were used to form the questions were culled from guide-lines designed for primary care providers rather than schoolnurses, as we were not aware of guidelines specifically preparedfor this group. The self-report format has intrinsic limitations,including desirability bias, and it is possible that participants’responses do not correlate with their actual practices. The sam-ple was limited to nurses practicing in the state of Massachu-setts and generalizability to other states is unknown. Despitethese limitations, the findings from this report provide impor-tant considerations for the implementation of SBIRT programswithin the Massachusetts Public School System.

Offering SBIRT in schools appears to have broad supportamong Massachusetts school nurses, although less than half of

the sample reported actually conducting screening. Moreover,when screening was done, nearly all used a clinical interviewrather than a validated screening tool. Use of self-administeredscreening tools could overcome a number of barriers identifiedby this group.

Acknowledgments

We would like to acknowledge Mary Ann Gapinski at the MassachusettsDepartment of Public Health for helping prepare the survey instrumentand for providing feedback on this manuscript. We would also like toacknowledge, Kathy Hassey, from Northeastern University, for assistingwith survey administration and support. The authors declare they have noconflicts of interest.

Funding

This study was supported by grant 5U79-TI025389 from the SubstanceAbuse and Mental Health Services Administration. The funding organiza-tion had no role in the design and conduct of the study; collection, man-agement, analysis, and interpretation of the data; preparation, review, orapproval of the manuscript; and decision to submit the manuscript forpublication. This study was also funded by Conrad N. Hilton Foundation(CNHF20140273) and the National Institute on Alcohol Abuse and Alco-holism (R01AA021913).

Author contributions

J.L., E.R.W., and S.L. designed and conducted the study. D.K. manageddata collection. All authors contributed in the analysis and interpretationof the data. All authors drafted, revised, and approved the final manuscript.

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Table 2. Barriers to screening among a sample of Massachusetts school nurses.

Item n (%)

How often do you encounter the following barriers asreasons not to screen for alcohol use? (Often/Always)a

Unfamiliar with screening tools 31 (35.6)Insufficient time to administer 27 (31.0)Students won’t be honest 24 (27.6)Insufficient time to respond 20 (23.0)Students won’t be receptive 20 (23.0)Don’t know how to respond 16 (18.4)Parents won’t support 16 (18.4)Lack of support services 15 (17.2)Administration won’t support 9 (10.3)Not clinical responsibility 8 (9.2)

aResponses were dichotomized so that individuals who reported often or alwaysencountering a barrier where categorized as affirmative whereas those whoreported never or sometimes were negative.

SUBSTANCE ABUSE 259

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