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 emailjmackenize@southcityclinic.org.au