opening pandora’s box professional attitudinal barriers to implementing practice nurse-led sbirt...
TRANSCRIPT
Opening Pandora’s BoxProfessional attitudinal barriers to implementing practice nurse-led SBIRT in general practice
Jock MackenzieProject Officer
Reducing Risky Drinking ProjectSouthcity Clinic
Bayside Medicare Local
Reducing Risky Drinking Project
· Southcity Clinic - Bayside Medicare Local - July 2012
· Substance dependent and DD clients w complex needs
· Training, consultancy and support services
· Reducing Risky Drinking Project RRDP
· Practice nurse-led SBIRT in general practice
· Barriers and Facilitators Report & Recommendations
· Professional attitudinal barriers
· Research questions
Opening Pandora’s Box
Design and Methods
· Exploration of reasons for low rates of SBIRT
· Literature review on barriers to SBIRT
· Focus group with practice nurses and nurse mentor
· Key informant survey of steering group members
· Delphi technique
· Quantitative screening outcomes data
NICS Barriers Tool
· the innovation itself (and its implementation)
· the health professional level
· the patient level
· the organizational context
· the economic and political context
NICS (2006) Identifying Barriers to Evidence Uptake. National Institute of
Clinical Studies http://www.nhmrc.gov.au/nics
Some Interesting Findings
· Poor acceptance of NHMRC Alcohol Guidelines
· Influence of clinician’s personal drinking habits
· Lack of confidence in managing patient resistance
· Over-estimation and over-generalization of patient
resistance
· Differential patient resistance by level of risk
Addressing Risky Drinking in General Practice
Addressing harms in General Practice
· Harms well known & occur to drinkers and others
· Most harms avoidable and SBIRT effective response
· GP and PN well placed to detect and treat
· Most risky drinkers won’t seek help or consider an issue
· Risky drinking goes unrecognized & unaddressed
· Unless obvious or client raises as an issue
· Many reasons but PRIMARY reason is clinicians avoid
What is SBIRT?
· Screening, BI and Referral to Treatment (& follow ups)
· Non-treatment seeking risky drinkers in primary care
· Aim to encourage and initiate behaviour change
· Different evidentiary support, resources barriers and
enablers
· Very important stage precedes - Engagement
· Failure to engage is the KEY barrier to SBIRT
Evidence for SBIRT
· Short term evidence strong (Babor et al., 2007)
· Long-term population health simulation models promising
· Collins & Lapsley (2008) reduce risky drinking by 50%, avoid
2,000 early deaths and directly save $6 billion
· SIPS Study UK - just attempting screening beneficial
· Brief feedback has same impact as more extended BIs
· Simply raising question initiates dialogue - active ingredient
· Follow the latest research! tinyurl.com/findingsSBIRT
Ashton, M. (2012) Alcohol screening and brief interventions in primary health care. Drug Findings http://findings.org.uk/
Barriers to SBIRT in General Practice
· Lack of time, awareness, training, funding & access to AOD
· Competing priorities, scepticism, confusion re guidelines,
lack of role security
· Fear of offending and losing rapport
· Most patients not seeking help for drinking
· Challenging risky drinking taboo in many cultures
· More a clinician drinks, the less they engage patients
· Professional anxiety is THE main barrier to SBIRT
Perceptions of Resistance
· Clinicians overstate and overgeneralise patient resistance
· Patients consider appropriate, important, not embarrassed
· While some do object and a few may not come back
· Worried patients appreciate a chance to discuss and those
not worried are usually open to information and advice
· Resistance does happen and confidence to manage is KEY
Johnson, et al (2010). Barriers and enablers to implementing SBIRT: Systematic review of qualitative evidence J Public Health (2011) 33(3): 412-421
Perception of Resistance
Tips and Tricks for Engaging
· Engaging not easy when no obvious link w presentation· Non-routine clinical context health checks or registration· Many different strategies for creating opportunity · Includes screening in ‘Patient Information Update Form’ · Take the focus off patient, refocus on the process itself· Framing screening as health promotion campaign· Link presentation e.g. diabetes/ anxiety/insomnia to drinking · Appeal to pride in managing good health· Acknowledge questions may seem odd which may defuse
refusal· Be creative! · All of these are contained in the Clinical Protocol
Products from the Project
· Web resource at bml.org.au search for SBIRT
· This will contain:
· The Barriers and Enablers Report “Opening Pandora’s Box”
· Newletter articles about the project
· The Clinical Protocol
· Training materials
· Online E3 Learning Module with APNA March 2013
Further research ideas
· Compare self-reported resistance of patients vs perceived
resistance
· Attitudes of patients to engagement
· By demographics, by CALD, by risk level, by Stage of
Change
· Perceived resistance as outcome measure
· Is there a compliant middle ground
· Differential effectiveness of components of SBIRT in
initiating and maintaining therapeutic conversations
References
Please visit http://www.bml.org.au and search for SBIRT or [email protected]