The Journal of School Nursing
© The Author(s) 2021
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DOI: 10.1177/10598405211009501
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2022, Vol. 38(3) 311–317
Substance abuse in adolescents has been recognized as a public health problem at the national and global levels. Adolescents are at risk for experimenting with substances. School nurses in secondary schools are well positioned to screen and counsel students on substance use. In this project, school nurses’ self-efficacy levels increased in using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) process posteducation, and SBIRT was integrated into school nurses’ practice. Initiatives aimed at stopping or preventing substance use are beneficial for a healthy society.
SBIRT, school nurses, adolescents, risky behavior, boarding school, prevention programs, high school, substance abuse
Substance abuse in adolescents is a problem that is increasing at national and global levels (Centers for Disease Control and Prevention [CDC], 2018; World Health Organization, 2019). The prevalence of this problem is exemplified in a recent survey conducted by the National Institute of Health (NIH) on substances used by 10th graders. The results of the NIH annual survey found 30.4% of 10th grades used an illicit drug, 40.7% used alcohol and 28% used marijuana (National Institute on Drug Abuse [NIDA], 2020). The evidence in the literature indicates these substances led to a diagnosis of substance use disorder (SUD; Mogro-Wilson et al., 2017). Data from the NIDA is especially concerning due to the decades of clear consistent evidence that SUD in adolescents is associated with reduced academic performance, increased incidence of mortality, and increases in health care costs (Kwon et al., 2020; Mogro-Wilson et al., 2017).
A school-based prevention program to screen for substance use is in the forefront of addressing these challenging statistics. A school nurse research priority is to evaluate school systems infrastructures within the context of outcomes for the school-age population (Bergren, 2020). School nurses must be able to translate research into evidence-based practice and analyze the outcomes of the change (Bergren, 2020). School nurses are vital in preventing SUD.
SUD is defined by Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), as a collective of disorders ranging from mild to severe that are related to habituated substance use/abuse despite the occurrence of detractors (DSM-5; American Psychiatric Association, 2013). NIDA has identified the high incidence of experimentation of substance use of senior high school students. Approximately 70% percent of high school seniors have experimented with alcohol, 40% of adolescents have experimented with cigarettes, 36% have tried at least one illegal drug, and over 20% of adolescents have used prescription drugs not prescribed to them (NIDA, 2014). These statistics reflect an impact on health care costs of US$600 billion a year (Patestos et al., 2014). While the financial costs due to SUD are high, there are also nontangible costs to the health care system and to society at large. The long-term impact of SUD should also be considered. Individuals who begin unhealthy risky behaviors such as substance use in adolescence are prone to carry these behaviors with them into adulthood (Viega et al., 2018). Therefore, screening and implementing interventions warranted for students have begun to experiment with substances.
To compound and complicate matters, substance use prevention messages and programs have declined in schools. A survey conducted by the National Survey on Drug Use and Health identifies that substance prevention programs have declined since 2002 (Lipari, 2017). Barriers to disseminating SUD messages are the lack of education by school administration on how to develop and provide a prevention program in their schools (Haug et al., 2018). An additional challenge is the resources needed to support a SUD program, including funding, personnel, and time (Haug et al., 2018).
It is well understood that adolescents lack personal development and life experiences that can serve to circumvent SUD. They do not have the capacity to fully understand the power and implications of addiction. The frontal lobe of the brain is not fully developed until a person is in their early 20s, which can interfere with judgment, problem-solving, and coping skills (Ernst et al., 2006; Galvan et al., 2006; Willoughby et al., 2014). Additional challenges during adolescence such as rebellion against parents and other authoritative figures can also contribute to SUD. Adolescence is an optimal time to implement prevention strategies against SUD and deterrent strategies against the initial use of a substance (Waller et al., 2017). Evidence exists that a key “window of prevention” is open in early adolescence, where the impact by peer pressure and experimentation is shown to be diminished (Waller et al., 2017). Therefore, the secondary school years are the ideal time to assess for substance use (Waller et al., 2017, p. 2).
The American Academy of Pediatrics encourages screening for adolescent substance use during routine medical visits (Levy et al., 2014). Several assessment processes have been applied to assess substance use in the high school student population, including the Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescents (Levey, 2015). The American Academy of Pediatrics has endorsed the use of the SBIRT process as a method to screen (S) for individuals at risk in developing SUD and, if warranted, initiate a brief intervention (BI) which may include referral to treatment (RT) with a mental health provider or the initiation of a substance rehabilitation plan (Stanhope et al., 2018).
SBIRT is an evidence-based process used to screen for substance use. The screening to brief intervention tool, or S2BI is a brief screening instrument funded by NIDA and validated to screen substance use in adolescents (American Academy of Pediatrics, 2021; Falvo & Schmid, 2018; Levey, 2015). The S2BI guides providers algorithmically through a client’s responses to the questions “In the past year, how many times have you used: Tobacco? Alcohol? Marijuana?” If found to be at risk of SUD, a brief intervention plan is developed in collaboration with the client. A brief intervention may vary from educational material and follow-up visits to the health care provider to a referral to a substance abuse treatment facility or mental health provider. If the S2BI instrument was negative for a risk of SUD, no further action would be needed except to encourage the client to continue making healthy choices and offer to discuss any concerns.
The school nurse has become a pivotal professional health care leader in developing public health initiatives in school communities. Because school nurses are perceived by students as caring health care professionals with whom they feel safe, they are uniquely positioned to conduct SUD screening (Hardin et al., 2018; Pavletic et al., 2016). Students have reported feeling more open to discuss their concerns regarding substance use when they feel connected to an adult within their school community, and the adult most students feel connected when it comes to their health is the school nurse (Beck & Reilly, 2017). In families with school-age children who have limited access to health care professionals, the school nurse is their health care resource including preventive health screening.
The National Association of School Nurses (2019) has recognized that SUD is a priority, and they recognize the role and importance of school nurses in student SUD prevention and education. In a National Longitudinal Study of Adolescent Health conducted by the CDC (2009), students who reported a connection to school experienced increased academic success and decreased incidence of SUD (CDC, 2009).
Evidence also supports other benefits of school nurse assessment for substance use (Patetos et al., 2014). A school clinic visit is an opportune time to both screen for substance use and to educate the adolescent on SUD as a first step in prevention. With school nurses viewed as caring and safe, they should have the training and tools to carry out SUD screening and prevention during the time that the window of prevention is open.
Self-efficacy theory supports understanding the schoolbased nurses’ knowledge, confidence, and the ability to perform a SUD assessment and the integration of the SBRIT instrument into practice (Polit & Beck, 2017). Self-efficacy is defined as a person’s belief to change their own behaviors and attain performance that is expected (Polit & Beck, 2017). School nurse self-efficacy is enhanced through evidenced-based SUD screening and prevention knowledge and skill acquisition and subsequently increases the likelihood of a practice change.
While the role school nurses in educating students on healthy behaviors has been found to be vital, the literature lacks evidence on school nurse use of SUD assessment instruments in practice (Hardin et al., 2018). Therefore, this quality improvement (QI) project was not hypothesis driven but was designed to begin filling the gap in the translation of evidence on SUD screening to practice through (1) training school-based nurses to utilize the SBIRT assessment instrument process in assessing students for risk of SUD as well as to (2) assess the integration of S2BI instrument in the school nurses’ daily practice.
This QI project was designed to educate school nurses in utilizing the SBIRT screening assessment process and the S2BI instrument and then evaluate their self-efficacy in using the instrument at two time points (posteducation and at the end of the 6-week project implementation period). The overarching goal of the project was to provide the nurses with foundational knowledge and an opportunity to employ the SBIRT screening assessment process and the S2BI instrument in daily practice with each student they assessed at the health care center.
This project was conducted at a residential boarding school located in the northeastern United States. The students at the school are all male and between the ages of 14 and 20 years. At the time of the project implementation, there were 404 students from 26 states and 24 countries. The health care center at the school is available to all students 24 hr, 7 days a week. The school nurses and physician see students in the school-based residential health center during the day shift. The school nurses work in two shifts, which are classified as days and evenings. Day shift runs from 7 a.m. to 3 p.m., and evening shift runs from 3 p.m. to 7 p.m. Any students who require evaluation or interventions after 7:00 p.m. are seen by the on-call nurse. The nurses would see students on the weekends as well, but those hours are limited.
All nurses (n = 6) employed by the school participated in the project. Each school nurse lives within a 20-min driving distance to the school, which is a requirement established by the school administration designed to meet the on-call needs of students residing at the school.
The only students who were screened using the SBIRT process were students who requested care at the health center. The students had the option to refuse the SBIRT process utilizing the S2BI instrument by not answering screening questions.
At the time the project was initiated, there were no policies or practice guidelines for SUD screening for the school nurses to follow at the school’s residential health center. Historically, the nurses had not assessed for SUD, nor did they report having knowledge on the use of a SUD screening instrument.
This QI project was a collaborative effort between the school administration and authors. The project was approved both by the school and the Sacred Heart University Institutional Review Board.
The school nurses were invited to attend an education session on adolescent substance abuse, the SBIRT process, the S2BI instrument, and the SBIRT Daily Tally Worksheet (Supplemental Figure S1). The education session was 2 hr long and conducted at a venue located away from the school and the health center. A private conference room was equipped with a power point presentation capabilities, comfortable seating, and ample room for the attendees to make notes. Individual folders included the day’s agenda, all forms the nurses would use during the QI project, a notepad, a pen, and the author’s contact information.
The content of the education session included a discussion on the school nurses’ current knowledge on school, state, national, and global substance use and their knowledge on utilizing a screening instrument for SUD and motivational interviewing. A presentation on the substance abuse in the state, nationally, and globally was provided with current statistics. Content on normal development of the human brain and its effect on risky behaviors was reviewed, and research on preventing substance abuse in the adolescent population was presented. The importance of the school nurse’s role in a substance abuse prevention program was also discussed in detail. A discussion also occurred on the increasing medical and societal changes that have influenced the need for school nurses to lead health care systems in schools to meet the increased needs of students.
The school nurses were educated on the SBIRT process. A case study and role-playing demonstration were provided to rehearse conversations that may occur with students during the SBIRT process utilizing the S2BI instrument. The five principles of motivation interviewing were provided to use as a reference when assessing students. The school nurses were also educated on the data collection process and timeline, including the use of the S2BI screening instrument, the SBIRT Daily Tally Worksheet, the collection of the data, a secure location for the collected data, and the presentation of the results.
The school nurses self-reported levels of self-efficacy using a 5-point Likert-type scale at baseline (or pre-education session), after the SUD and SBIRT training, and at the end of the project which reflected the level of knowledge assimilation and translation of knowledge into daily practice (Elisa, 2020). The 5-point Likert-type scale included 10 questions indicating knowledge of SUD as a global, national, state problem, use of the SBIRT instrument, use of the SBIRT resource binder, the interview process, and their ability to embed the SBIRT into their practice (Supplemental Figure S2). The questions reflected the didactic content presented at the educational session. With the education session completed, the school nurses then started administering the SBIRT instrument during each student visit to the residential health center for 6 weeks.
A Daily Tally Worksheet was used to collect the school nurses’ use of the SBIRT process and the S2BI instrument, including the day of the week, shift, the number of students seen, and whether the SBIRT instrument was used with each student they saw during their shift. To assess the feasibility and acceptability of the SBIRT process and the S2BI instrument, data were collected on the use of both forms by the school nurse during their shift. If the SBIRT process and the S2BI instrument were not used, the nurse was asked to indicate the reason on the SBIRT Daily Tally Worksheet. The school nurses completed this Daily Tally Worksheet at the end of each shift and then placed it in a designated secure location for project staff retrieval.
An Excel spreadsheet was used to organize data for import into the IBM Statistical Package for the Social Sciences (SPSS) Version 25. SPSS was employed for the descriptive and inferential analysis of the data in this project. Descriptive statistics were utilized to describe the sample and data characteristics. The SBIRT Daily Tally Worksheets were analyzed using frequency distributions to examine feasibility and acceptability metrics as well as trends in the use of the SBIRT in this student population by the school nurses. Descriptive statistics were utilized to depict the sample characteristics in terms of the shifts and days of the week worked. Paired sample t tests and repeated measures ANOVA (RMANOVA) were utilized to compare changes in self-efficacy between time periods and over time.
Six school nurses participated in the project. All were bachelor of science in nursing–prepared registered nurses with 2 or more years of nursing experience and current Basic Life Support certification. One nurse was master’s degree prepared, and another nurse had completed two baccalaureate degrees. The school nurses were all Caucasian, ranging in age from 30 to 50 years. About half of the school nurses solely worked the day shift. The majority of the school nurses worked on weekdays rather than weekends. Half, or 52.3% (n = 34), of the SBIRT Daily Worksheets were completed during the day shift (Supplemental Figure S3). A majority, or 90.8% (n = 59), of the SBIRT Daily Worksheets were completed on weekdays (Supplemental Figure S4).
The most frequently reported reason (n = 33) the nurses did not complete the SBIRT process and the S2BI instrument on all the students/patients they saw during their shift was that the students had already been assessed. Additional reasons the school nurses did not complete the SBIRT process and the S2BI instrument during all student visits, ranked in order of frequency reported, included time constraint (n = 13), the nurse forgot (n = 3), and lack of availability of a clinical room (n = 3). One nurse reported a student refused to complete the SBIRT process (n = 1); this same nurse also indicated time constraint was a barrier during the encounter. No school nurses indicated that they were not comfortable using the SBIRT process or the S2BI instrument.
RMANOVA with Greenhouse–Geisser correction demonstrated that mean nurse self-efficacy differed between time points, F(1.134, 13.55) = 42.43, p = .001. Post hoc tests using the Bonferroni correction reveal that nurse selfefficacy on a scale 1–5 increased by an average of 1.73 from baseline to posteducation (p = .005), and 2.13 points from baseline to terminal (p = .000) as noted in Supplemental Table S2, with Supplemental Table S3 noting the byquestion changes for the time period of baseline to posteducation.
Supplemental Table S4 reflects the change in selfefficacy by-question between posteducation and terminal (the end of the project data collection). The lack of significant change during this time period seems to reflect that the educational component was largely effective overall posteducation but after putting the SBIRT process into practice development of self-efficacy slowed or stagnated. During this time period, Question 6, or “I am comfortable with the knowledge of the current problem of substance use in the adolescent population globally,” was the one item that showed a decrease in self-efficacy.
The largest and most significant change in self-efficacy was appreciated between pre-education and terminal (Supplemental Table S5); while self-efficacy grew most due to the education, it is clear that self-efficacy development continued over time across the items through the end of the project.
Limitations of this project include that this was a QI project and not a formal hypothesis-driven research study. Nonetheless, the findings are important and worthy of dissemination, given the magnitude and growing trend for SUD in adolescents.
Additional limitations include that the nurses in this private school had a much smaller caseload than the typical public school nurse (Willgerodt et al., 2018). Because only one school nurse is scheduled for each shift, the nurse on duty at the health center was responsible to conduct the full visit (e.g., admit each student, clinically assess the student, then document the visit) in addition to conducting the additional SBIRT screening.
Because public school nurses have higher caseloads and at times provide nursing care at multiple schools, time constraints would likely be a stronger deterrent to the adoption of the SBIRT model employed in this project (Willgerodt et al., 2018). An additional limitation for the public school nurses is access to administrative staff to support the nurse the ability and time to conduct the SBIRT screening and education (Willgerodt et al., 2018).
It should be noted that an additional limitation existed around the lack of diversity among the school nurses who were working with a boarding school student body from diverse communities across the United States and globally. Because unintentional bias could have occurred but was not captured in the project as designed, this is a gap future work should address.
A final limitation was that the project was only run for a relatively short period of time. Collection information on self-efficacy for a longer period of time may have provided important information on growth in self-efficacy overall and in the area of knowledge about SUD on a global level.
A national milestone set for the Institute for Healthcare Improvement (IHI) includes providing patient-centered preventive care, improving the health of a population, and reducing the cost of health care by decreasing the adverse effects of unhealthy practices that can impact the physical health, mental health, and mortality of a population (IHI, 2021). This QI project contributed to the IHI milestone. This QI project was an interprofessional initiative to develop a sustainable method for the nurses to assess students for SUD. Anecdotally, the school nurses discussed how this QI project improved their practice in the care of students at the health care center. An anecdotal finding during the education session was the school nurses verbalized willingness to integrate the SBIRT process and S2BI assessment instrument into their daily practice.
The majority of students across this nation attend public schools, and this project took place at a boarding school. While this could be viewed as a limitation, the student body at the school is quite diverse with students coming from across the nation and world. Future work in this area would benefit from replication in public school settings in order to ascertain differences between the two setting types.
While nurse knowledge on SUD in the context of a global, national, and state problem increased, the analysis showed Question 6 (e.g., “I am comfortable with the knowledge of the current problem of substance use in the adolescent population globally”) had a decrease in self-efficacy from the posteducation to terminal measure. Question 6 focused on nursing global knowledge regarding substance use in adolescents. This finding may be due to the nurses becoming more acutely aware of their personal knowledge gaps, which became more apparent to them over time as they learned about the topic and realized to a greater degree what they did not know about this topic on a global scale. Understanding school nurses’ awareness of the global issue of SUD and the impact of individual cultural influence on a student’s engagement in a SUD prevention program is important when developing a SUD prevention program (Gewin & Hoffman, 2016). Incorporating cultural awareness education and information on local social determinants of health that can influence student propensity toward SUD is vitally important (Gewin & Hoffman, 2016). The school nurse’s knowledge of cultures and SUD issues beyond national borders are important concepts, and competencies to address these concepts should become threads within 21st-century nursing practice. Integrating these concepts is congruent with standards of practice set by the American Nurses Association (Marion et al., 2017). Providing a website for the nurses which is focused on the global impact of adolescent substance use may enhance their knowledge about the global problem of SUD within the context of culture. This would be especially beneficial at the project school since there are 24 countries represented in the current student body.
Because the participants in the project were the nurses and not the students, the data on racial/ethnic breakdown of the student body were not collected. In hindsight, the data on racial/ethnic breakdown of the student body may have been valuable in examining the decrease in self-efficacy in Question 6 and whether that decrease could be attributed to a broader knowledge of cultural/global nuances within the student body or to some other factor.
The data from this project demonstrated that the school nurses who participated “bought-in” to the project were comfortable using the SBIRT process and the S2BI instrument by the end of the project. While the educational intervention worked well for this population of nurses, the data demonstrated a gap in the education around the Question 6 content or the knowledge of the current problem of substance use in the adolescent population globally. Future educational initiatives may want to consider this finding as they develop their own school-based SUD screening programs. Adding a follow-up meeting 2 weeks after implementation to address any issues or concerns on using the SBIRT process and S2BI instrument and to reinforce the original education could be of benefit.
The most frequently reported reasons that nurses did not complete the SBIRT process and the S2BI instrument was that the student had already been assessed, followed by time constraint, that the nurse forgot, and the lack of availability of a clinical room. These all seem to be issues that could be further examined and addressed at the systems level.
The QI project enhanced the assessment practice for schoolbased nurses at the clinical site to identify students at risk of SUD. School nurses reported increased self-efficacy in the utilization of the SBIRT process and the S2BI instrument. The clinical implications based on project findings include that nurses who receive education and support to implement the SBIRT process and the S2BI instrument have potential to gain comfort in the use of the instrument, which supports sustainability of use. Through this, school nurses can become integral partners in the prevention, identification, and referring to the treatment of the adolescent patient population who seek care and counseling for SUD at the health center. Facilities wishing to replicate the project may contact the primary author for details of the education used in this project.
The findings from this project are important and begin to fill the gap that exists in translation science on screening for SUD by school nurses in adolescent populations. The project also informs school nurse practice by providing an exemplar for school nurses on initiating SUD screening, including some of the barriers that may be encountered.
The SBIRT process, S2BI assessment instrument, and this QI model to educate school nurses can be easily replicated. Interventions to change substance use/abuse behaviors in the adolescent population are important in addressing this global and national problem. States like Massachusetts have moved to passing legislation regarding screening for substance use/abuse in their public schools. Legislation was passed on March 2016 in the public schools of Massachusetts to screen for substance using SBIRT process (MASBIRT, 2019). A study by Mitchell et al. (2012) had 629 adolescents in their study, at 13 different high schools that received the SBIRT process, using a SUD assessment instrument and intervention, found there was a decrease in the incidence of drinking alcohol and drug use in the participants after 6 months. Mitchell et al. (2012) found SBIRT inherently bridges the gap between prevention and treatment. Mitchell et al. (2012) affirm that SBIRT is a significant process to prevent, identify, and treat adolescents who are at risk for chronic substance use.
Future work should include replication of the project in other private school settings, as well as K–12 school systems (i.e., public schools), and in school systems servicing diverse populations. Prevention programs to stop or prevent the initiation of substance use are beneficial for a healthy society.
Thank-you Dr. Donna Faye McHaney for all your guidance, support, and encouragement. Without the support of Dean Doyle and Ms. Callaghan, this project could not have been completed.
A.B., L.E. contributed to the development of the project, to the analysis of the results and to the writing/editing the manuscript. A.B. conducted the onsite implementation and data collection for the project.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by 2020 Dr. Sandra L. Wise/Dr. Pamela Fuller Founder’s Scholarship awarded by the Omicron Delta Chapter of Sigma Theta Tau International. The Founder’s Scholarship recognizes researchers for their dedication to academic excellence, professional development, and leadership potential for promoting healthier communities and efforts demonstrating evidence-based research and practice.
Anna Bourgault, DNP, MSN, RN, CCRC https://orcid.org/0000-0003-4034-1566
The supplemental material for this article is available online.
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Anna Bourgault, DNP, RN, CCRC, is a Clinical Assistant Professor in the School of Nursing at the University of Connecticut.
LuAnn Etcher, PhD, RN, is a Clincial Associate Professor in the Dr. Susan L. Davis, R.N. and Richard J. Henley Colleg of Nursing at Sacred Heart University.
1 University of Connecticut, Storrs, CT, USA
2 Sacred Heart University, Fairfield, CT, USA
Corresponding Author:Anna Bourgault, DNP, MSN, RN, CCRC, University of Connecticut, 231 Glenbrook Road, Storrs, CT 06269, USA.Email: anna.bourgault@uconn.edu
