A Mindful Approach to Diabetes Self-Management Education and Support for Veterans.

Purpose The purpose of this study is to determine feasibility, satisfaction, and preliminary effects of Mindful Stress Reduction in Diabetes Education (Mind-STRIDE), a mindfulness-based intervention for veterans. Methods The study used a single-group pretest-posttest repeated-measures design. The 90-minute Mind-STRIDE training, adapted from Mindfulness Based Stress Reduction (MBSR), was provided as the final component of a half-day diabetes self-management education class at a Veterans Affairs (VA) outpatient diabetes clinic. Following initial training, participants were asked to practice mindfulness at home for 10 minutes each day during the 3-month study. Study recruitment and retention were calculated as rates. Veteran and diabetes educator satisfaction were assessed by rating scales and open-ended comments. Psychosocial-behavioral and metabolic outcomes were assessed at baseline and 3 months after initial training. Bivariate correlations were performed to describe relationships between mindfulness and other outcome variables. Gain scores and Wilcoxon matched-pair signed rank tests were used to assess pre to post changes; Cohen's d was applied to estimate the magnitude of effects. Results Twenty-eight of 49 eligible veterans (57%) enrolled in the study. Of those, 11 veterans (39%) demonstrated participation in home practice, and 20 veterans (71%) completed the study. Overall, participants and diabetes educators were highly satisfied with the Mind-STRIDE intervention. Significant improvements were found in diabetes distress, diabetes self-efficacy, diabetes self-management behaviors, mindful-describing, and A1C. Conclusion Results suggest feasibility, satisfaction, and positive preliminary effects. Efficacy testing by randomized controlled trial with analysis of covariance structures is warranted.

Intimate partner violence, unhealthy alcohol use, and housing instability among women veterans in the Veterans Health Administration.

Women U.S. military veterans face particularly high rates of homelessness, which may be associated with psychosocial experiences including unhealthy alcohol use and experience of intimate partner violence (IPV). In this study, we examined clinical social health screening data to assess the association between housing instability and (a) experience of past-year IPV victimization, and (b) unhealthy alcohol use among 554 women receiving primary care from the Veterans Health Administration. Approximately 12% of patients screened reported housing instability. Experience of past-year IPV was associated with increased risk of housing instability (OR = 2.10, 95% CI [1.16, 3.81]), with 1 in 5 women screening positive for IPV also reporting housing concern. There was no statistically significant association between current unhealthy alcohol use and housing instability. Findings hold implications for addressing potential housing concerns among women VA patients. (PsycINFO Database Record

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

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

Hazardous alcohol use and cultural adjustment among U.S. college students abroad in Italy: Findings and recommendations for study abroad staff and researchers.

BACKGROUND: Italy is a top destination for U.S. college students studying abroad. Both international and local Italian media outlets, such as city newspapers, have cited the discordance between Italian cultural norms and U.S. college students' drinking behaviors. Hazardous alcohol consumption abroad, such as binge drinking, can result in individual- (e.g., physical injury) and social- (e.g., promotion of negative stereotypes) level adverse consequences. METHODS: We assessed the prevalence of hazardous alcohol use and recent binge drinking in a sample of U.S. college students studying abroad in Italy (n = 111). We evaluated associations among drinking and cultural adjustment and determined which sociocultural factors predicted binge drinking for students abroad. RESULTS: Forty-six percent of students were classified as hazardous drinkers and 63% reported recent binge drinking. Socializing with American peers was a significant predictor for binge drinking abroad. CONCLUSIONS: Binge drinking was quite prevalent in our sample of students studying abroad in Italy. Study abroad advisors, instructors, and staff should consider diverse strategies to screen, educate, prevent, and/or intervene on alcohol misuse with their students. These strategies should be personalized to both the student as well as the host culture's norms.

Alcohol brief intervention for hospitalized veterans with hazardous drinking: protocol for a 3-arm randomized controlled efficacy trial.

BACKGROUND: Various hospital accreditation and quality assurance entities in the United States have approved and endorsed performance measures promoting alcohol brief intervention (BI) for hospitalized individuals who screen positive for unhealthy alcohol use, the spectrum of use ranging from hazardous use to alcohol use disorders. These performance measures have been controversial due to the limited and equivocal evidence for the efficacy of BI among hospitalized individuals. The few BI trials conducted with hospital inpatients vary widely in methodological quality. While the majority of these studies indicate limited to no effects of BI in this population, none have been designed to account for the most pervasive methodological issue in BI studies presumed to drive study findings towards the null: assessment reactivity (AR). METHODS/DESIGN: This is a three-arm, single-site, randomized controlled trial of BI for hospitalized patients at a large academic medical center affiliated with the U.S. Department of Veterans Affairs who use alcohol at hazardous levels but do not have an alcohol use disorder. Participants are randomized to one of three study conditions. Study Arm 1 receives a three-part alcohol BI. Study Arm 2 receives attention control. To account for potential AR, Study Arm 3 receives AC with limited assessment. Primary outcomes will include the number of standard drinks/week and binge drinking episodes reported in the 30-day period prior to a final measurement visit obtained 6 months after hospital discharge. Additional outcomes will include readiness to change drinking behavior and number of adverse consequences of alcohol use. To assess differences in primary outcomes across the three arms, we will use mixed-effects regression models that account for a patient's repeated measures over the timepoints and clustering within medical units. Intervention implementation will be assessed by: a) review of intervention audio recordings to characterize barriers to intervention fidelity; and b) feasibility of participant recruitment, enrollment, and follow-up. DISCUSSION: The results of this methodologically rigorous trial will provide greater justification for or against the use of BI performance measures in the inpatient setting and inform organizational responses to BI-related hospital accreditation and performance measures. TRIAL REGISTRATION: NCT01602172.

Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response.

Appropriate use of language in the field of addiction is important. Inappropriate use of language can negatively impact the way society perceives substance use and the people who are affected by it. Language frames what the public thinks about substance use and recovery, and it can also affect how individuals think about themselves and their own ability to change. But most importantly, language intentionally and unintentionally propagates stigma: the mark of dishonor, disgrace, and difference that depersonalizes people, depriving them of individual or personal qualities and personal identity. Stigma is harmful, distressing, and marginalizing to the individuals, groups, and populations who bear it. For these reasons, the Editorial Team of Substance Abuse seeks to formally operationalize respect for personhood in our mission, our public relations, and our instructions to authors. We ask authors, reviewers, and readers to carefully and intentionally consider the language used to describe alcohol and other drug use and disorders, the individuals affected by these conditions, and their related behaviors, comorbidities, treatment, and recovery in our publication. Specifically, we make an appeal for the use of language that (1) respects the worth and dignity of all persons ("people-first language"); (2) focuses on the medical nature of substance use disorders and treatment; (3) promotes the recovery process; and (4) avoids perpetuating negative stereotypes and biases through the use of slang and idioms. In this paper, we provide a brief overview of each of the above principles, along with examples, as well as some of the nuances and tensions that inherently arise as we give greater attention to the issue of how we talk and write about substance use and addiction.

A tailored curriculum of alcohol screening, brief intervention, and referral to treatment (SBIRT) for nurses in inpatient settings.

A package of clinical strategies known as alcohol screening, brief intervention, and referral to treatment (SBIRT) is increasingly recommended for reducing unhealthy alcohol use, the spectrum of alcohol consumption from at-risk drinking (defined as consumption above recommended guidelines) to alcohol abuse and alcohol dependence. The United States' Joint Commission issued new SBIRT-related hospital accreditation measures for alcohol. Ongoing initiatives aim to promote, support, and sustain SBIRT implementation in hospital settings. In hospital settings, nurse-delivered SBIRT may be a particularly viable and efficient model for SBIRT implementation. However, like physicians, most nurses have not been trained in how to perform SBIRT, and few authors have described alcohol-related curricula specifically for nurses. In addition, historical differences in nurse and physician professional scopes of practice, role perceptions, and patterns of care delivery suggest the need for effective SBIRT initial and continuing education and training that are tailored to the nursing profession and inpatient environments. In this article, we provide an in-depth description of the registered nurse SBIRT curriculum and describe its development and contents as well as various nurse- and setting-specific adaptations. In addition, we describe how we engaged nursing stakeholders in the development and implementation of the curriculum and discuss potential implications for future SBIRT training and delivery by nurses. SBIRT continuing education and training for nurses represents one of the first steps in expanded SBIRT implementation. Comprehensive workforce and organizational development of inpatient and nurse-delivered SBIRT may provide the means to address the entire spectrum of unhealthy alcohol use across healthcare settings.

Expanded roles and responsibilities for nurses in screening, brief intervention, and referral to treatment (SBIRT) for alcohol use.

It is the position of the International Nurses Society on Addictions and the Emergency Nurses Association that nurses in all practice settings be prepared to deliver screening, brief intervention, and referral to treatment, or SBIRT, to identify and effectively respond to alcohol use and related disorders across the lifespan.

A scoping review of interdisciplinary collaboration in addictions education and training.

Developing a workforce of multidisciplinary healthcare professionals equipped with the knowledge and skills to collaboratively address the public health crisis of alcohol and other drug (AOD) use is critical for effectively identifying, preventing, and managing AOD conditions and their sequelae. Despite general enthusiasm for interdisciplinary education and training, little is known overall about the nature and outcomes of interdisciplinary collaboration in addictions education and training. We conducted a five-stage scoping review of the literature to provide an eight domain overview of the state of interdisciplinary collaboration in addictions education (ICAE). In our final review of 30 articles, we identified a lack of conceptual and terminological clarity around ICAE but a wide range of learners and professional collaborators in ICAE initiatives, which focused on a variety of AOD topics and used a constellation of didactic, interactive, and service-learning teaching strategies and formats. Although we found limited substantive educational or practice-oriented outcomes available for ICAE initiatives, learner and faculty feedback reflected high enthusiasm for ICAE and widespread perceptions of benefit for improved clinical care. Facilitators and barriers to the implementation of ICAE initiatives occurred at the level of the individual and the institution and ranged from pragmatic to conceptual. Emerging trends in ICAE initiatives included increased application of learning and implementation theory and extension of ICAE into research training. We conclude with recommendations to support ICAE as a new paradigm for addictions education for all health professionals.

Evaluation of a pilot training program in alcohol screening, brief intervention, and referral to treatment for nurses in inpatient settings.

Alcohol screening, brief intervention, and referral to treatment (SBIRT) is a set of clinical strategies for reducing the burden of alcohol-related injury, disease, and disability. SBIRT is typically considered a physician responsibility but calls for interdisciplinary involvement requiring basic SBIRT knowledge and skills training for all healthcare disciplines. The purpose of this pilot study was to design, implement, and evaluate a theory-driven SBIRT training program for nurses in inpatient settings (RN-SBIRT) that was developed through an interdisciplinary collaboration of nursing, medical, and public health professionals and tailored for registered nurses in the inpatient setting. In this three-phase study, we evaluated (1) RN-SBIRT's effectiveness for changing nurses' alcohol-related knowledge, clinical practice, and attitudes and (2) the feasibility of implementing the inpatient curriculum. In a quasi-experimental design, two general medical units at our facility were randomized to receive RN-SBIRT or a self-directed Web site on alcohol-related care. We performed a formative evaluation of RN-SBIRT, guided by the RE-AIM implementation framework. After training, nurses in the experimental condition had significant increases in Role Adequacy for working with drinkers and reported increased performance and increased competence for a greater number of SBIRT care tasks. Despite some scheduling challenges for the nurses to attend RN-SBIRT, nurse stakeholders were highly satisfied with RN-SBIRT. Results suggest that with adequate training and ongoing role support, nurses in inpatient settings could play active roles in interdisciplinary initiatives to address unhealthy alcohol use among hospitalized patients.

A qualitative study of anticipated barriers and facilitators to the implementation of nurse-delivered alcohol screening, brief intervention, and referral to treatment for hospitalized patients in a Veterans Affairs medical center.

BACKGROUND: Unhealthy alcohol use includes the spectrum of alcohol consumption from risky drinking to alcohol use disorders. Routine alcohol screening, brief intervention (BI) and referral to treatment (RT) are commonly endorsed for improving the identification and management of unhealthy alcohol use in outpatient settings. However, factors which might impact screening, BI, and RT implementation in inpatient settings, particularly if delivered by nurses, are unknown, and must be identified to effectively plan randomized controlled trials (RCTs) of nurse-delivered BI. The purpose of this study was to identify the potential barriers and facilitators associated with nurse-delivered alcohol screening, BI and RT for hospitalized patients. METHODS: We conducted audio-recorded focus groups with nurses from three medical-surgical units at a large urban Veterans Affairs Medical Center. Transcripts were analyzed using modified grounded theory techniques to identify key themes regarding anticipated barriers and facilitators to nurse-delivered screening, BI and RT in the inpatient setting. RESULTS: A total of 33 medical-surgical nurses (97% female, 83% white) participated in one of seven focus groups. Nurses consistently anticipated the following barriers to nurse-delivered screening, BI, and RT for hospitalized patients: (1) lack of alcohol-related knowledge and skills; (2) limited interdisciplinary collaboration and communication around alcohol-related care; (3) inadequate alcohol assessment protocols and poor integration with the electronic medical record; (4) concerns about negative patient reaction and limited patient motivation to address alcohol use; (5) questionable compatibility of screening, BI and RT with the acute care paradigm and nursing role; and (6) logistical issues (e.g., lack of time/privacy). Suggested facilitators of nurse-delivered screening, BI, and RT focused on provider- and system-level factors related to: (1) improved provider knowledge, skills, communication, and collaboration; (2) expanded processes of care and nursing roles; and (3) enhanced electronic medical record features. CONCLUSIONS: RCTs of nurse-delivered alcohol BI for hospitalized patients should include consideration of the following elements: comprehensive provider education on alcohol screening, BI and RT; record-keeping systems which efficiently document and plan alcohol-related care; a hybrid model of implementation featuring active roles for interdisciplinary generalists and specialists; and ongoing partnerships to facilitate generation of additional evidence for BI efficacy in hospitalized patients.

Teaching the teachers: faculty preparedness and evaluation of a retreat in screening, brief intervention, and referral to treatment.

Effective clinical faculty are essential for disseminating substance abuse screening, brief intervention, and referral to treatment (SBIRT). The authors developed an 8-hour SBIRT training for internal medicine faculty preceptors. Trainers conducted SBIRT lectures and small-group communication practice sessions. The authors assessed participants' (n = 27) knowledge, skills, and attitudes using an enhanced Alcohol and Alcohol Problems Perceptions Questionnaire (AAPPQ). Participants self-assessed their changes in SBIRT competence and comfort. Faculty trainees did not feel competent in SBIRT, particularly in intervention and referral to treatment. AAPPQ subscale scores were highest in Role Legitimacy and Motivation and lowest in Role Adequacy and Satisfaction. After training, faculty members reported greater likelihood of performing and teaching SBIRT. In some topic areas, faculty attending an SBIRT training reported limited knowledge and competence for treating drinkers; however, their interest and motivation for doing so was high. Ongoing faculty and organizational development efforts may help close these gaps.

Use of augmentative and alternative communication strategies by family members in the intensive care unit.

BACKGROUND: Little is known about communication between patients and their family members during critical illness and mechanical ventilation in the intensive care unit, including use of augmentative and alternative communication tools and strategies. OBJECTIVES: To identify (1) which augmentative and alternative communication tools families use with nonspeaking intensive care patients and how they are used, and (2) what families and nurses say about communication of family members with nonspeaking intensive care patients. METHODS: A qualitative secondary analysis was conducted of existing data from a clinical trial testing interventions to improve communication between nurses and intensive care patients. Narrative study data (field notes, intervention logs, nurses' interviews) from 127 critically ill adults were reviewed for evidence of family involvement with augmentative and alternative communication tools. Qualitative content analysis was applied for thematic description of family members' and nurses' accounts of patient-family communication. RESULTS: Family involvement with augmentative and alternative communication tools was evident in 44% of the 93 patients who completed the parent study protocol. Spouses or significant others communicated with patients most often. Main themes describing patient-family communication included (1) families being unprepared and unaware, (2) families' perceptions of communication effectiveness, (3) nurses deferring to or guiding patient-family communication, (4) patients' communication characteristics, and (5) families' experience with and interest in augmentative and alternative communication tools. CONCLUSIONS: Assessment by skilled bedside clinicians can reveal patients' communication potential and facilitate useful augmentative and alternative communication tools and strategies for patients and their families.

Hospitalized patients' acceptability of nurse-delivered screening, brief intervention, and referral to treatment.

BACKGROUND: Inpatient healthcare providers in the United States may soon be required to offer alcohol screening, brief intervention, and referral to treatment (SBIRT) for hospital accreditation, but little is known about inpatient acceptability for SBIRT, particularly when performed by nonphysician providers such as nurses. The purpose of this study was to assess patient acceptability for and comfort with nurse-delivered SBIRT care among hospitalized patients and to identify factors associated with SBIRT acceptability. METHODS: We conducted a cross-sectional survey of 370 hospitalized medical-surgical patients at a large university-affiliated medical center, which is part of the U.S. Department of Veterans Affairs. RESULTS: Patient acceptability for 8 of 10 individual nurse-delivered SBIRT tasks was >84%. Patients were more accepting of SBIRT tasks if they felt able to determine their alcohol risk, able to reduce alcohol-related health risks, and expressed some degree of concern about their own use of alcohol. Approximately 20% of patients reported some degree of personal discomfort with alcohol-related discussions. Patients who were less comfortable with these discussions had lower perceived ability to reduce alcohol-related health risk, were >60 years old, had a positive AUDIT-C screening, and were of nonblack race. CONCLUSIONS: Among hospitalized patients, patient acceptability for nurse-delivered SBIRT is high, and alcohol-related risk perceptions appear to be important factors associated with acceptability for SBIRT tasks. Providers can proceed with greater confidence in SBIRT-related discussions with most hospitalized patients but may need particular sensitivity and skill addressing alcohol with patient subgroups such as older patients and those with positive alcohol screenings.

Do words matter? Incongruent responses to inconsistently worded AUDIT-C alcohol screening instruments.

The first 3 questions of the Alcohol Use Disorders Identification Test (AUDIT-C) are often used as a brief alcohol screening instrument. However, the implications of common modifications made to the original AUDIT questions and response options have not been considered. The authors examined existing data from a randomized controlled trial of 310 persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) that was testing the efficacy of 2 antiretroviral medication adherence interventions. Logistic regression was used to model the probability of participants having inconsistent AUDIT-C item responses. Three patterns of conflicting responses to the AUDIT-C items were identified. Common item modifications resulted in 14% (n = 48) of the parent study sample reporting conflicting responses across related AUDIT-C items. The odds of having conflicting data were 3 times greater in opioid users (odds ratio [OR] = 3.139, 95% confidence interval [CI] = 1.267-7.777, P = .01) and greater in persons with higher levels of conscientiousness (OR = 1.053, 95% CI = 1.006-1.103, P = .03). Inconsistent question format and response options may impede proper scoring and interpretation of the AUDIT-C. Further discussion and consensus building are needed on the psychometrically ideal version of the AUDIT-C.

Predictive Utility of Brief Alcohol Use Disorders Identification Test (AUDIT) for human immunodeficiency virus antiretroviral medication nonadherence.

Alcohol use negatively affects adherence to antiretroviral therapy (ART), thus human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care providers need accurate, efficient assessments of alcohol use. Using existing data from an efficacy trial of 2 cognitive-behavioral ART adherence interventions, the authors sought to determine if results on 2 common alcohol screening tests (Alcohol Use Disorders Identification Test--Consumption [AUDIT-C] and its binge-related question [AUDIT-3]) predict ART nonadherence. Twenty-seven percent of the sample (n = 308) were positive on the AUDIT-C and 34% were positive on the AUDIT-3. In multivariate analyses, AUDIT-C-positive status predicted ART nonadherence after controlling for race, age, conscientiousness, and self-efficacy (P = .036). Although AUDIT-3-positive status was associated with ART nonadherence in unadjusted analyses, this relationship was not maintained in the final multivariate model. The AUDIT-C shows potential as an indirect screening tool for both at-risk drinking and ART nonadherence, underscoring the relationship between alcohol and chronic disease management.

Overcoming barriers to the recruitment of nurses as participants in health care research.

Adequate participant recruitment is critical for the successful execution of research studies involving human subjects. Participant recruitment can be particularly challenging when the intended study participants are health care providers as opposed to patients. Discussions of the challenges and successful strategies associated with provider recruitment are limited, particularly regarding providers other than physicians and settings outside of primary care. Using a case study format, we present our experiences recruiting inpatient nurses into a study which involved focus group methodology at a United States Veterans Health Administration facility. We describe the initial logistical and ethical issues involved, various challenges we encountered, and five successful action strategies used during a second recruitment wave addressing logistical issues; on-site recruitment; increased scheduling flexibility and peer-to-peer recruitment; attention to the sensitive nature of the research topic; and increased involvement of stakeholders. In conclusion, we advocate for multimodal recruitment strategies that facilitate ongoing investigator-clinician partnerships.