Fit and Feasibility: Adapting a Standardized Curriculum to Prepare Future Health Professionals to Address Alcohol Misuse

Abstract

Standardized screening, brief intervention, and referral to treatment (SBIRT) is effective when used by health care professionals to assess, educate, and intervene to address risky alcohol use. To accelerate SBIRT training within academic settings, the Substance Abuse and Mental Health Services Administration funded implementation of its SBIRT curriculum to promote its use by future health care professionals. We report on how SBIRT content was implemented within nursing, social work, psychology, and family medicine residency programs at a state university. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) evaluation framework was used to compare delivery of SBIRT curriculum across health professions. Survey data measured changes in student knowledge, confidence, and responsibility to use SBIRT for alcohol and drugs, pre- and post-SBIRT training. Twelve months postgraduation follow-up surveys examined maintenance of outcomes and SBIRT use in practice. Observational data explored fidelity and adaptations made to curriculum content and delivery logistics. Results indicated that instructor adoption, fidelity, and format varied across health professional training programs, with adaptations made to improve fit, role alignment, and cultural relevance. Despite variation in curriculum delivery, students demonstrated significant gains in knowledge and confidence, (p < .001). Key implementation and maintenance challenges included time constraints, instructor buy-in, competing accreditation requirements, and costs for using the university simulation laboratory to practice SBIRT. Strengths supporting maintenance included flexibility to adapt curriculum, department champions, and electronic resources to support curriculum delivery. Results suggest that adaptations maximizing the feasibility and fit of SBIRT within existing courses enhanced its adoption and maintenance potential without sacrificing effectiveness.

Keywords

adaptation evidence-based practice clinical education sustainability

The U.S. Preventive Services Task Force (2013) recommends that clinicians screen all their adult patients and conduct brief behavioral counseling for those misusing alcohol, yet few health professional training programs prepare students to do so (Babor et al., 2007). Improving the quality of health care delivery to promote practical, preventive, integrated services is a key component of health care reform and Medicaid expansion, which requires changes to the training curricula for health professionals (Wilkes, Cassel, & Klau, 2018). In 2013, the Substance Abuse and Mental Health Services Administration (SAMHSA) funded health professional training programs at 14 universities to adopt a standardized training curriculum for an evidence-based preventive practice known as SBIRT (i.e., Screening, Brief Intervention, and Referral to Treatment; SAMHSA, 2013). Grantees were encouraged to adapt the curriculum, which was developed for medical residents, and embed it within nursing, social work, and counseling programs. SBIRT is an effective but underused preventive service that health care professionals can use to systematically identify patients who are drinking more than they should and help them reduce their drinking. Professionals are trained to administer a standardized screening tool to identify patients whose frequency, quantity and/or patterns of alcohol consumption exceed limits recommended for their age, sex, or specific health condition (Babor et al., 2007). Following screening the health care professional provides reinforcement, education and/or a brief behavioral counseling intervention to prevent misuse and promote overall health (Babor et al., 2007). Research that 9 in 10 adults who drink too much alcohol are not alcohol dependent provides further support for widespread adoption of SBIRT in primary care, public health, and other community settings, to identify and intervene with this frequently overlooked risk population (Esser et al., 2014). SAMHSA’s goals were to further the acceptance of SBIRT as standard practice by preparing diverse health care professionals entering the workforce to use this evidence-based approach to prevent or reduce risky use of alcohol and other substances, and promote population health.

Standardized educational curriculum across the health care professions is a means to disseminate evidence-based interventions with fidelity, and avoid program drift, that is, deviation from standardized protocols that reduce intervention effectiveness (Chambers, Glasgow, & Stange, 2013). However, theories of health behavior and health education emphasize that tailoring education to meet the needs of the target population may enhance learning and its transferability to real-world contexts (Glanz, Rimer, & Viswanath, 2008). Similarly, lessons from implementation and dissemination research emphasize that closing the gap between research and practice requires a willingness to adapt interventions in a way that optimizes the fit between the intervention and the context; that is, to successfully adopt and sustain changes, implementation strategies must consider organizational environments and constraints, as well as the needs and limitations of the professionals expected to deliver them (Castro, Barrera, & Martinez, 2004; Chambers et al., 2013; Chambers & Norton, 2016; Devieux et al., 2005; Gibbs, Krieger, Cutbush, Clinton-Sherrod, & Miller, 2016; Hawe, Shiell, & Riley, 2004; Satre, Manuel, Larios, Steiger, & Satterfield, 2015; Stirman, Miller, Toder, & Calloway, 2013). Studies of SBIRT implementation within health care settings have identified numerous obstacles at the organizational and provider levels, including time limitations, competing priorities, lack of confidence, and threats to sustainability such as funding for staff training (Broyles, Kraemer, Kengor, & Gordon, 2013; Murphy, 2009; Rahm et al., 2015). Implementing the SBIRT curriculum within professional training programs may help address some of these obstacles (e.g., enhanced confidence and skills of professionals entering the workforce). However, changing or adding curriculum within university programs requires overcoming many of the same obstacles cited by providers, to reach, and be effective for, students (Breitbach et al., 2013; Graybeal, Long, Scalise-Smith, & Zeibig, 2010).

This article describes the authors’ use of mixed methods and the theoretically informed RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework (Glasgow, Vogt, & Boles, 1999) to evaluate and compare the adaptation and implementation of the SBIRT curriculum within four professional training programs at a state university. RE-AIM’s Reach and Effectiveness domains are reported for students across select health care professions. Adoption, Implementation, and Maintenance are described, emphasizing profession-specific adaptations and challenges related to integrating the SBIRT curriculum within existing courses so that it will be delivered, with fidelity, over time.

Method

Setting and Participants

The University of Alaska Anchorage (UAA), located in the state of Alaska, within the United States, is Alaska’s largest postsecondary university and the academic hub for the health professions. Health professional training programs selected for SBIRT implementation included nursing, social work, psychology, and the Alaska Family Medicine Residency. Brief descriptions of participating programs follow.

UAA’s School of Nursing offers AAS, BS, MS, and DNP programs. AAS and BS graduates are often employed in hospitals and larger health systems, and MS graduates (FNPs) in primary care, public health nursing, and administrative roles. UAA’s School of Social Work prepares generalist social workers at the BSW and MSW levels. Social work graduates practice in family services, community health, school districts, social services, and behavioral health centers. Psychology offers BA/BS, MS, and PhD degrees; however, since bachelor’s-level professionals are not credentialed to practice in clinical settings in Alaska, the SBIRT training curriculum was only taught to MS and PhD students.

The 3-year Anchorage-based Alaska Family Medicine Residency is affiliated with the University of Washington School of Medicine’s Family Medicine Residency Network and the collaborative medical education program known as WWAMI (for its member states Washington, Wyoming, Alaska, Montana, Idaho). Residents include both MDs and DOs, and come from all areas of the USA. On graduation, residents work in diverse settings including community health centers, tribal health systems, and small rural medical practices.

The SBIRT curriculum contains five topics and seven modules, each with learning resources and materials (Pringle, Kearney, Rickard-Aasen, Campopiano, & Gordon, 2017). The five topics include (1) What is SBIRT (describe its purpose and the evidence base), (2) Screening (describe the rationale for universal alcohol/substance use screening in primary care and hospital settings, and practice using standardized alcohol and drug screeners), (3) Motivational Interviewing ([MI]; a three-module lesson covering MI principles, core MI skills, and practice applying MI to enhance motivation to change behavior), (4) Brief Negotiated Interview ([BNI]; apply MI principles, learn BNI steps, and practice conducting a brief behavioral counseling intervention to reduce risky drinking or drug use), and (5) referring patients to treatment (review techniques for identifying appropriate treatment or supportive programs, and use MI and BNI skills to make a successful referral). The curriculum is designed to be modified to fit the needs of the instructor and amount of classroom time available. Delivery of the entire content, including videos and interactive classroom activities, takes approximately 7 hours, with individual modules taking about 60 minutes. Alternatively, instructors could choose to have students access SAMHSA’s online, self-directed, 4-hour course, which was designed for medical residents. For all students, providing classroom time for skills practice (e.g., role-play) was encouraged. The project team prepared faculty for delivering SBIRT by offering instructor training, and the SAMHSA curriculum PowerPoints (PPTs) for their use. In addition to the PPTs or online course, instructors were given access to resources that were organized by topic, including journal articles, skills demonstration videos, character vignettes for in-class role-plays, standardized patient simulation scenarios, observation checklists for critiquing student role-plays and simulations, and knowledge quizzes. All materials and updates were made available to faculty through UAA’s virtual learning and course management platform, Blackboard Learn (http://www.blackboard.com/learning-management-system/blackboard-learn.aspx).

Faculty were encouraged to provide opportunities for skills practice through in-class role-playing and, where feasible, through UAA’s Interprofessional Health Sciences Simulation Center (i.e., SIM Center). The SIM Center is an on-campus facility that provides students in health care programs opportunities to practice their skills using standardized patients (actors) and computerized simulation. Sessions may be recorded, and faculty are able to observe students to provide feedback. The standardized patients also provide feedback from a patient perspective.

Program Evaluation Framework

The RE-AIM framework (Glasgow et al., 1999) was used to evaluate and compare the four participating health professional training programs. Data collection tools included program and course enrollment data, paper and electronic self-report surveys, from fall semester 2014 through spring semester 2016 (five terms). During the first year the research team performed classroom observations and faculty debriefings, to inform resource and technical assistance needs. RE-AIM domains were evaluated as follows:

Reach was estimated based on the total number of unique students enrolled in courses providing SBIRT divided by the total unique students enrolled in each discipline, which was calculated from course rosters and a list of graduates per year.

Effectiveness was measured at the student level using a repeated-measures design to test changes in knowledge and perceptions of confidence and responsibility from pre- to post-SBIRT training. The survey was developed based on instruments used in prior studies, but specific items were tailored to the SBIRT curriculum. The survey included SBIRT knowledge questions (19 items), confidence in executing all elements of SBIRT (i.e., screening, brief intervention, referral to treatment; 12 items), and perceived responsibility to implement and execute SBIRT tasks (12 items). Responses were multiple choice for knowledge items and on 5-point Likert-type scales for confidence and responsibility. Postgraduation maintenance of SBIRT training effects was measured 12 months following graduation (i.e., postgraduation) and included 13 items on SBIRT use after graduation plus the confidence and perceived responsibility items.

Adoption by faculty members was calculated using the number of faculty members who taught the courses selected for SBIRT curriculum implementation. The total number of faculty agreeing to deliver SBIRT was divided by the number of faculty offered the curriculum.

Implementation was evaluated based on the extent that faculty delivered the seven curriculum modules and any adaptations made to improve feasibility and/or relevance of the material to the target population (i.e., students or medical residents). Fidelity was determined by classroom and SIM Center observations that were conducted during the first year of implementation. Research assistants used fidelity checklists to document whether learning objectives for each of the seven modules were 2 = fully met, 1 = partially met, or 0 = not met, with a total possible score of 14. End-of-semester debriefs were conducted with instructors to gather additional information about implementation, including procedures for delivering SBIRT, successes and challenges in the classroom or SIM Center, and needs for additional support.

Maintenance at the program level was assessed qualitatively using the domains from the Program Sustainability Assessment Tool (PSAT; Luke, Calhoun, Robichaux, Elliott, & Moreland-Russell, 2014) to understand each program’s potential to sustain SBIRT after the grant ended. The PSAT was selected based on its utility and relevance to evaluating systems-level implementation of public health programming (Calhoun et al., 2014; Proctor et al., 2015). The project team and key SBIRT stakeholders, including department heads and instructors, reviewed the eight PSAT domains (i.e., environmental support; funding stability; partnerships; organizational capacity; program adaptation; program evaluation, communication, and strategic planning) during a meeting near the end of the project. The framework helped focus the discussion on sustainability-related strengths and threats and provided a guide for developing strategies and a strategic plan for maintaining SBIRT.

All activities were approved by the UAA IRB prior to data collection. Free and informed consent was obtained from all participants.

Data Analysis

Surveys

Data from the student surveys were analyzed using IBM SPSS Statistics, Version 24 (IBM Corp., 2016). All data were cleaned, checked for outliers, and tested for assumptions of normality. Changes in student outcomes were evaluated using 4 × 2 discipline (nursing, social work, psychology, medical residency) by time (pre-, post-SBIRT training) repeated-measures multivariate analysis of variance (MANOVA) with dependent measures of SBIRT knowledge, confidence to use SBIRT for alcohol, confidence to use SBIRT for drugs, responsibility to use SBIRT for alcohol, and responsibility to SBIRT for drugs. Follow-up univariate tests were performed to compare pre–post differences in knowledge, confidence, and responsibility outcomes within each discipline. Effect sizes for all univariate comparisons were measured using partial η² and interpreted as .01 ≈ small, .06 ≈ medium, and .14 ≈ large (Cohen, 1988). Postgraduation maintenance of confidence and responsibility outcomes was evaluated using a separate 2 × 3 discipline (nursing, social work) by time (pre-, post-SBIRT training, and after graduation) repeated-measures MANOVA. Given the small numbers of graduates for some programs (e.g., most psychology students enrolled during the study period had not yet graduated by the end of the project), compounded by a high loss to follow-up among students once they entered the workforce, only nursing and social work graduates were included in the postgraduation analyses.

Observational Data

Implementation fidelity and adaptation data were analyzed via review of fidelity checklists, observation, and debriefing notes. Adaptations were identified, labelled using adaptation categories described in the literature (Chambers & Norton, 2016; Moore, Bumbarger, & Cooper, 2013), and compiled in a Microsoft Excel (2016) spreadsheet by course and adaptation category to enhance review and comparison. Adaptation categories were procedures (e.g., delivery mode, location), dosage (i.e., number or length of sessions), content (i.e., adding, removing core components), participants (i.e., changing the material to fit disciplines and student levels), and cultural relevance (i.e., modifications relevant to delivering health services to geographically and demographically diverse Alaskans). Notes were made whether the adaptations were made for philosophical reasons, such as the instructor decided to eliminate or change content based on its believed relevance to their students discipline or level; or logistical reasons, such as the materials were adapted based on course, instructor, or departmental constraints such as time, resources, delivery modality, and confidence in delivering the material (Moore et al., 2013). Results were reviewed and discussed with the project team to reach consensus on categorization.

Results

Reach among students varied across disciplines, ranging from 55.2% for social work students to 100.0% for medical residents (see Table 1). Adoption of the SBIRT curriculum varied among instructors within departments and between disciplines. For example, the five nursing courses selected for SBIRT incorporation were delivered by eight instructors, yet only six included the SBIRT curriculum in their courses (i.e., 75.0% adoption rate). Laboratory sessions required for AAS nursing and graduate-level social work students provided opportunities for skills-based practice; however, these sections were led by different instructors than the primary didactic class. Among lab instructors, adoption was lower: 10.0% of nursing and 50.0% of social work instructors.

Table 1.

Reach and Adoption by Discipline.

Discipline	Nursing	Social work	Psychology	Family medicine residency
Reach	Reach of SBIRT trainings from Spring 2014—Spring 2017
Percent enrolled students trained in SBIRT (number trained (unduplicated)/number enrolled (estimated)^a	69.9 (511/731)	55.2 (112/203)	80.3 (53/66)	100.0 (33/33)
Adoption	Percentage of faculty for selected courses who included SBIRT curriculum
Faculty teaching courses selected for SBIRT	n = 8	n = 5	n = 5	n = 2
Percent faculty delivering SBIRT curriculum in courses selected for SBIRT	75.0	80.0	60.0	100
Required courses^b	4	4	4	1
Elective courses	0	2	0	0

Note. SBIRT = standardized screening, brief intervention, and referral to treatment.

Number of students enrolled was estimated from course rosters and a list of graduates per year. ^bRequired and elective course numbers correspond to the number of distinct courses selected for SBIRT inclusion. Each of these courses may be offered multiple times and taught by multiple instructors.

Implementation varied across disciplines with regard to fidelity and format (see Table 2). Variation in format included customization (standardized online SBIRT course versus condensed PPT presentations with supplementary readings, videos, or other materials); dosage (1-5 hours); and modality (in-person, distance, or hybrid learning). Inclusion of role-playing and/or use of the SIM Center also varied by discipline and degree levels.

Table 2.

Implementation Fidelity and Adaptations in Observed Classes.

Discipline	Nursing	Social work	Psychology	Family medicine residency
Implementation	Extent to which core SBIRT curriculum components were delivered
Number of classroom/SIM observations	7	4	3	1
Average fidelity score (Range: 1-14)^a	8.1 (4-14)	6.8 (6-9)	12.3 (9-14)	14^b
Adaptations made to improve logistical fit
Procedures	Classroom delivery in-person or distance; role-play or SIM	Classroom delivery in-person or distance; role-play or SIM	Classroom delivery with role-play; independent review of SBIRT materials or online course with PSC experience	Independent completion of online course; SIM
Dosage (hours)	1.5	1.5	1-4	5
Cultural relevance	Role-play/simulation scenarios and videos	Role-play/simulation scenarios and videos	Role-play/simulation scenarios and videos	Simulation scenarios
Adaptations made to improve philosophical fit
Content	Screening and MI emphasized	MI omitted (taught in other courses)	BNI emphasized	No changes

Note. PSC = Psychological Services Center; MI = motivational interviewing; BNI = Brief Negotiated Interview; SBIRT = standardized screening, brief intervention, and referral to treatment; SIM = UAA’s Interprofessional Health Sciences Simulation Center.

Average fidelity score reflects the extent that learning objectives for each of the seven: modules were fully met (=2); partially met (=1); or not met (=0), with a total possible score of 14. ^bAll medical residents complete an online SBIRT curriculum that included all Substance Abuse and Mental Health Services Administration modules.

Adaptations made to content were primarily related to participant considerations (e.g., emphasizing some components over others to align with instructors’ assumptions about their discipline’s role within practice settings). Nursing courses emphasized administration of the standardized Alcohol Use Disorders Identification Test (AUDIT; Babor et al., 2007), to screen for unhealthy consumption and patterns of alcohol use, the Drug Abuse Screening Test (DAST; Skinner, 1982), to screen for drug use, and principles of MI, with associate-level nursing courses focused solely on screening. SBIRT for psychology students was at master’s and PhD levels only and focused on conducting a BNI, which includes assessing client readiness and encouraging behavior change, using MI techniques (Miller & Rollnick, 2012). Social work instructors omitted the MI component of the SBIRT curriculum as they had already covered MI extensively in other courses. Family medicine residents received the full SBIRT curriculum with no adaptations.

Procedural adaptations were observed for instructors in all disciplines. For example, some students were expected to learn SBIRT material independently (i.e., outside class) or with a mixture of independent learning and in-class didactics. Independent learning was supported by narrated PPTs, online videos, empirical articles, and/or online courses. In-class content included lectures, videos, role-play, and standardized simulation in the SIM center. For most disciplines, the dosage (i.e., length of in-class time devoted to SBIRT) was drastically reduced from approximately 4 hours that it took to complete the SAMHSA online curriculum to about 1 hour 30 minutes of classroom time. Cultural adaptations were made across disciplines to assure that role-play vignettes represented diverse cultures, local verbiage, and alcohol use problems prevalent in the state of Alaska.

Effectiveness

Significant main effects were found for discipline, F(15, 842) = 3.76, p < .01; Wilks’s Λ = 0.836, η² = 0.058 and time, F(5, 305) = 55.03, p < .01; Wilks’s Λ = 0.526, η² = 0.474. These main effects were qualified by a significant discipline by time interaction, F(15, 842) = 2.84, p < .01, Wilks’s Λ = 0.873, η² = 0.044. Follow-up univariate tests identified significant increases in SBIRT knowledge and confidence to use SBIRT for alcohol and drugs across all disciplines (see Table 3). Smaller and, in some cases, nonsignificant increases in perceived responsibility to use SBIRT for alcohol and drugs were found across disciplines. Medical residents experienced the largest gains on all outcome measures.

Table 3.

Program Effectiveness Over Time, by Content Area, and by Discipline.

	Pre		Post
Discipline/content area	M	SD	M	SD	F	$η_{p}^{2}$
Nursing (n = 210)
Knowledge	9.03	2.39	10.52	2.61	65.68**	.24
Confidence
Alcohol	3.63	.82	4.20	.66	111.11**	.35
Drugs	3.60	.87	4.19	.67	120.99**	.37
Responsibility
Alcohol	4.42	.58	4.59	.51	31.92**	.13
Drugs	4.44	.58	4.60	.51	23.57**	.10
Social work (n = 52)
Knowledge	8.50	2.06	10.87	2.66	44.15**	.46
Confidence
Alcohol	3.31	1.03	4.23	.67	59.74**	.54
Drugs	3.27	1.04	4.21	.69	60.22**	.54
Responsibility
Alcohol	4.22	.89	4.50	.82	6.57*	.11
Drugs	4.31	.86	4.49	.82	2.64	.05
Psychology (n = 38)
Knowledge	9.82	2.34	12.18	2.72	25.21**	.41
Confidence
Alcohol	3.57	.77	4.48	.56	60.42**	.62
Drugs	3.50	.73	4.52	.56	88.35**	.71
Responsibility
Alcohol	4.43	.43	4.57	.46	3.52	.09
Drugs	4.44	.38	4.61	.45	6.04*	.14
Family medicine residency (n = 13)
Knowledge	11.69	2.43	15.00	2.00	101.78**	.90
Confidence
Alcohol	3.29	.56	4.50	.54	26.80**	.69
Drugs	3.15	.63	4.50	.54	40.24**	.77
Responsibility
Alcohol	4.63	.40	4.91	.16	8.16*	.41
Drugs	4.71	.34	4.93	.16	6.94*	.37

Note. Knowledge scores are from a maximum of 19; confidence and responsibility scores range from 1 to 5, with 5 reflecting greater levels. Boldface entries indicate statistical significance.

p < .05. **p < .01.

Maintenance of effectiveness at the student level was measured through postgraduation surveys, completed by a small number of graduates from nursing (n = 44) and social work (n = 17). Among nursing graduates, 27.6% reported that SBIRT is encouraged or available and 25.0% reported using SBIRT as standard practice. Among social work graduates employed in their field, 41.7% reported that SBIRT is encouraged or available for use at their workplace but none reported using SBIRT as standard practice. With regard to maintaining confidence and responsibility to use SBIRT for alcohol and drugs after graduation, a significant multivariate effect of time was found, F(8, 148) = 8.37, p < .001; Wilk’s Λ = 0.46, partial η² = 0.32. Follow-up pairwise comparisons identified significant posttraining and postgraduation increases in confidence to use SBIRT for drugs and alcohol, compared with pretraining levels. Significant decreases in perceived responsibility to use SBIRT for drugs and alcohol were found at postgraduation, compared with both pre- and posttraining levels (see Figure 1).

Figure 1.

Confidence and responsibility to use standardized screening, brief intervention, and referral to treatment (SBIRT) after graduation.

Maintenance at the program level was defined as the potential for continuing the SBIRT curriculum for all target disciplines beyond the funded period, using the PSAT domains as a framework for interpreting meeting notes derived during a facilitated discussion with stakeholders. Strengths that favored maintenance included program adaptation (i.e., the flexibility to customize the logistical and discipline-specific fit of the curriculum within existing courses), a supportive internal climate in the form of program champions that included department heads and instructors who recognize the need for SBIRT, and a favorable external climate due to statewide priorities to reduce alcohol and drug use as a leading health indicator (State of Alaska, 2017). Evidence of organizational capacity included widespread access to all SBIRT resources through Blackboard Learn and continued access to the SIM Center which agreed to make the standardized patient scenarios available to programs. Potential threats to sustaining SBIRT included a lack of funding sources for some programs to handle the cost of standardized patients required by the SIM Center (e.g., the Family Medicine Residency and Psychology programs identified funding sources, but not nursing or social work) and uncertain organizational capacity to train new faculty or to require practicum settings to provide supervised opportunities for students to practice SBIRT in the field. Finally, the lack of internal and/or external requirements to teach SBIRT from an accreditation or licensing perspective threaten its continuance in the face of competing priorities or other constraints.

Discussion

Health professional training programs that prepare future providers to deliver evidence-based preventive services have potential to improve their adoption within practice. However, colleges and universities face constraints similar to clinical settings, that is, competing demands, time, training, logistics (Breitbach et al., 2013), when attempting to add or change curriculum, thereby requiring flexible delivery approaches and adaptations that enhance feasibility without diluting the learning objectives that promote student knowledge, attitudes, and behavior change (Moore et al., 2013). Too much variation in fidelity to curriculum content may have weakened the potential knowledge gains for disciplines where student experience is highly variable (e.g., associate vs. master’s level), and behavioral interventions are new territory. For example, for social work, where MI was already taught in a number of courses, it was removed from the SBIRT lessons, resulting in a lower fidelity rating (i.e., 6.8 out of a possible 14 points), but did not appear to negatively affect the effect of the training on student knowledge ( $η_{p}^{2}$ = 0.46). For nursing, associate-level courses focused solely on screening, and the higher level courses that included MI varied greatly with regard to offering students opportunities to practice these brand new skills (i.e., fidelity scores ranged from 4 to 14). Overall knowledge effect sizes were more modest ( $η_{p}^{2}$ = 0.24), suggesting a need for greater fidelity to curriculum content across instructors, with more opportunities for all nursing students to practice screening and MI in the SIM center. This interpretation is supported by the high effect sizes for knowledge gains by the Family Medicine residents ( $η_{p}^{2}$ = 0.90), who received the combination of the original online curriculum, SIM practice with standardized patients, and feedback (Moore et al., 2013). The concept of maximizing fit within complex, multilevel contexts may seem daunting, and even risky, given the goal of assuring that health care professionals are well prepared to deliver evidence-based interventions. On the other hand, ill-fitting protocols that do not match provider roles or real-world conditions are not likely to be useful or relevant to students entering the workforce (Chambers et al., 2013). This study used the RE-AIM framework to evaluate and compare how four health professional training programs adapted a standardized SBIRT curriculum so that it fit within existing courses and could be delivered by diverse faculty to students in various degree programs. Procedural, dosage, content, and cultural adaptations were made; however, students across all programs demonstrated increased knowledge, confidence, and perceived responsibility for intervening to prevent alcohol and drug misuse following training. It was notable that a high proportion of faculty delivered the curriculum in the identified courses, despite time constraints and competing priorities. Maximizing SBIRT’s fit and relevance within courses is likely more important than strict adherence to the original material (Hawe et al., 2004). Consistent with the literature, providing classroom reinforcement and supervised skills practice that focused on fidelity to screening and brief intervention protocols was likely important to promote confidence in conducting effective brief interventions (Alanazi, Nicholson, & Thomas, 2017; Sawyer, Eppich, Brett-Fleegler, Grant, & Cheng, 2016). On the other hand, postgraduation declines in perceived responsibility to deliver SBIRT reinforces the importance of engaging, and potentially educating, employers, professional associations, and other stakeholders, on the relevance of the proposed curriculum to the roles and responsibilities of the specific professions, whether they are performed individually, or within an interprofessional team (Finnell, 2012; Gambescia & Early, 2017).

Limitations

Our inability to confirm whether students completing surveys reviewed online curricula or completed outside readings, limited our ability to understand the relative impact of in-class versus independent learning. Future studies designed to rigorously compare effectiveness of different implementation strategies (e.g., online vs. in-person instruction; in-class role-play vs. SIM Center experiences) are needed. Similarly, our ability to perform subgroup analyses to further understand the potential effect of specific curricula adaptations on knowledge and other outcomes were limited by our inability to verify individual student attendance or exposure to classroom activities. Also, because this was a 3-year grant, only a small student sample was available to be surveyed postgraduation, limiting the representativeness of the postgraduation data. Still, the finding that graduates sustained confidence to use SBIRT but felt less responsible for implementing it may reflect workplace realities. The continued research-to-practice gap related to low SBIRT adoption within health care may threaten its maintenance in health professional training programs, if perceived as neither relevant nor required for accreditation or licensing (Finnell, 2012).

Setting-level maintenance for this study was evaluated based on observation and meeting notes from discussions with program stakeholders, including department heads and faculty. The PSAT was effectively used retrospectively during a facilitated discussion on sustaining SBIRT at UAA, and helped identify areas for strategic planning and capacity building. A recommendation for universities integrating SBIRT training is to discuss the PSAT domains while planning implementation so that threats can be identified early and strategies, such as funding for SIM experiences, instructor training, expectations for practicum sites, and its inclusion in course and practicum evaluations, could be implemented to assure curriculum sustainability.

Conclusions

Health care reform and Medicaid expansion provide opportunities for disseminating evidence-based, health education and health promotion services, such as SBIRT (SAMHSA, 2013), to prevent more serious and costly health conditions. More research that studies how health professional training may be adapted to foster translation of evidence-based health promotion services into practice, and the delicate balance between content fidelity and adaptation, are needed. The success of sustaining curricula that prepare future health care professionals to deliver effective, prevention, and health promotion services may require changes to program accreditation requirements for the health care professions, as well as alignment with expectations of employers, the public, professional associations, professional preparation programs, and certifying boards (Gambescia & Early, 2017; Green & Glasgow, 2006). Such alignment, however, may be insufficient without the flexibility to adapt content and logistics in a way that maximizes fit and feasibility for both educators and learners (Chambers et al., 2013).

Footnotes

Authors’ Note

All authors listed in this article played a significant role in designing and conducting the work described in this article, and have fully participated in writing, reading, and reviewing the submitted article. The contents of this article have not been previously presented elsewhere. The contents of this article are solely the responsibility of the authors and do not necessarily reflect the official views of SAMHSA.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Support for this study was provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) Grant No. 5U79TI025385.

ORCID iD

Diane K. King

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