Attachment 5 Practitioner Survey

Form Approved

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Attachment 5:
Practitioner Survey

SBIRT Cross-Site Evaluation
Practitioner Survey—DRAFT

This survey is part of a national evaluation effort to describe the implementation of seven SBIRT programs throughout the country. The following questions ask about your experiences with the [WASBIRT, etc.] program that was implemented in this [ED, practice, school, agency, clinic, department, etc.] on [date]. The first set of questions is designed to gather background information about you, your working environment and the SBIRT services you provide.

Today’s Date: |___|___||___|___||___|___|
MO DAY YR

Provider Organization Identification Number |___|___|___|___|

___________________________________________________

Public reporting burden for this collection of information is estimated to average 24 minutes per response; including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to SAMHSA Reports Clearance Officer, Room 7-1045, 1 Choke Cherry Road, Rockville, MD 20857. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The control number for this project is 0930-XXXX.

Section A
Demographics

A1. Are you: Male Female

A2. Your Birth Year: 19 |___|___|

A3. Are you Hispanic or Latino?

Yes

No

A4. What is your race? (Please select one or more)

Alaska Native

American Indian

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White

A5. What is the highest grade or year of school that you completed?

Never attended school

1st grade completed

2nd grade completed

3rd grade completed

4th grade completed

5th grade completed

6th grade completed

7th grade completed

8th grade completed

9th grade completed

10th grade completed

11th grade completed

12th grade completed/high school diploma/equivalent

Voc/tech program after high school but no voc/tech diploma

Voc/tech diploma after high school

College or university/1st year completed

College or university/2nd year completed/Associate’s degree (AA, AS)

College or university/3rd year completed

Bachelor’s degree (BA, BS) or higher

Master’s degree

Doctoral degree or equivalent

Medical degree or equivalent

A6. What is the name of the organization that employs you?

A7. Who is your immediate supervisor?

A8. Are you clinical staff (e.g., physician, nurse)?

Yes (Please go to question A10)

No

A9. Which of the following best describes you?

Administration (Please go to Section D)

Office Support Staff (receptionist, clerk, billing) (Please go to Section D)

Medical records technician (Please go to Section D)

A10. Which of the following best describes you? (Check as many as apply)

MD

DO

APRN

PA

RN

LPN

RD

Medical Assistant (CMA/MA)

Health Educator

A11. Current Discipline/Professional Focus: [Check ALL THAT APPLY]

Medicine: Family Practice

Medicine: Internal Medicine

Medicine: Emergency

Medicine: OBGYN

Medicine: Pediatrics

Medicine: Diet/Nutrition

Medicine: General Health Education

Medicine: Behavioral Health

Medicine: Psychiatry

Medicine: Other, describe

Social Work/Human Services

Addictions Counseling

Other Counseling, specify

Education

Vocational Rehabilitation

Criminal Justice

Psychology

None, unemployed

None, student

Other (specify)

A12. Certification Status in Addictions, Medicine, Nursing Fields (if applicable): [MARK ONE]

Not certified or licensed in addiction treatment

Previously certified or licensed, not now

Currently certified or licensed

Intern

No license or certification available in your field

A13. How many years of experience did you have in substance use counseling prior to the initiation of the SBIRT activities at your site?

None

0–5 months

6–11 months

1 to 2 years

3 to 4 years

5 or more years

A14. How long have you been in your present job?

0–5 months

6–11 months

1 to 2 years

3 to 4 years

5 or more years

A15. On an average day, to how many SBIRT patients or clients do you provide screening or other services?

1–10

11–20

21–30

31–40

41–50

51–60

>60

A16. In total, to how many total patients or clients are you currently providing services?

1–10

11–20

21–30

31–40

41–50

51–60

>60

A17. Do you perform Screening (i.e., identify at-risk substance users using standardized screening instruments)?

Yes

No (Please go to question A19)

A18. In addition to Screening do you also perform Brief Feedback (i.e., provide educational materials or feedback to patients/clients who screen negative)?

Yes

No

A19. Do you perform Brief Intervention (i.e., provide short motivational counseling sessions to patients/clients who screen positive)?

Yes

No

A20. Do you perform Brief Treatment (i.e., provide 2–6 counseling sessions of manual-guided therapy to higher-risk individuals)?

Yes

No

A21. Do you provide Referrals to Treatment (i.e., provide treatment referrals to severe clients/patients who need more intensive services outside of the scope of the SBIRT services)?

Yes

No

A22. How long have you been in your current position, delivering SBIRT services?

None

0–5 months

6–11 months

1 to 2 years

3 to 4 years

5 or more years

Section B
Training and Self Efficacy

The next set of questions asks about the training you received and how prepared you feel in conducting SBIRT services.

B1. When conducting behavioral counseling services in general, how prepared do you feel when talking with patients about each of the behavior areas listed below?
Babor, T., J. Higgins-Biddle, D. Dauser, P. Higgins, and J. Burleson. 2005. “Alcohol Screening and Brief Intervention in Primary Care Settings: Implementation Models and Predictors.” Journal of Studies on Alcohol 66(3):361-368.

Behavior Area	Very prepared	Somewhat prepared	Somewhat unprepared	Very unprepared
Not smoking tobacco
Exercising regularly
Reducing alcohol consumption
Avoiding excess calories
Reducing illicit drug use

B2. How effective do you feel you are in helping patients achieve change in each of the following behavior areas?

Behavior Area	Very effective	Somewhat effective	Somewhat ineffective	Very ineffective
Not smoking tobacco
Exercising regularly
Reducing alcohol consumption
Avoiding excess calories
Reducing illicit drug use

B3. About how many hours of SBIRT-related training (related to alcohol and illicit drug use) have you received since the beginning of the SBIRT initiative?

None

Less than 4 hours

4 – 10 hours

11 – 40 hours

More than 40 hours

B4. How would you rate staff in your [facility ED, practice, school, agency, clinic, department, etc] in terms of their need for staff development on issues related to SBIRT services for at-risk substance use? (Check one)

Significant need for staff development in these areas

Staff is reasonably competent in these areas. Some could benefit from staff development if offered.

No need for staff development. All staff have sufficient knowledge to perform competently in their own capacities.

Section C
Use of Screening and Brief Intervention with At-risk Substance Users

The next set of questions concerns the use of screening and brief intervention with at-risk substance users (alcohol and other drug use).

Please circle the number that indicates how strongly you agree or disagree with each of the statements.
Rollnick, S., N. Heather, R. Gold, and W. Hall. 1992. “Development of a Short ‘Readiness to Change’ Questionnaire for Use in Brief, Opportunistic Interventions among Excessive Drinkers.” British Journal of Addiction 87(5):743-754

	Strongly Agree	Agree	Unsure	Disagree	Strongly Disagree
1. I don’t regularly use screening and brief intervention to manage my patients’/clients’ substance use.	1	2	3	4	5
2. I am making concrete efforts to use substance use screening and brief intervention in my organization.	1	2	3	4	5
3. I agree with using screening and brief intervention, but I don’t always do it.	1	2	3	4	5
4. Sometimes I think I should use screening and brief intervention more in my practice.	1	2	3	4	5
5. It’s a waste of time to conduct substance use screening and brief intervention on my patients/clients.	1	2	3	4	5
6. I have just recently started to use screening and brief intervention on my patients/clients.	1	2	3	4	5
7. Many people talk about conducting screening and brief intervention with their patients/clients, but I am actually doing it.	1	2	3	4	5
8. I am at the stage where I should think about using screening and brief intervention on my patients/clients.	1	2	3	4	5
9. Conducting screening and brief intervention is sometimes a problem.	1	2	3	4	5
10. There is no need for me to use screening and brief intervention for substance use in my practice.	1	2	3	4	5
11. I am actually using screening and brief intervention in my practice right now.	1	2	3	4	5
12. Conducting screening and brief intervention for substance use with my patients/clients would be pointless for me.	1	2	3	4	5

Section D
Work Environment

The next set of questions asks about your work environment. Please be reminded that individual respondents will not be identified by name in any analyses or reports. Responses will be aggregated and reported as summary statistics only.

Ohman-Strickland et al. In press. “Measuring Organizational Attributes of Primary Care Practices: Development of a New Instrument, A Study in the New Jersey Family Physicians Research Network.” HSR.

Circle the number that best describes how much you agree or disagree with the following statements about this practice (office, department, agency, etc)	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
1. The practice defines success as teamwork and concern for people.	1	2	3	4	5
2. Our practice has changed how everyone relates.	1	2	3	4	5
3. The staff members of this practice very frequently feel overwhelmed by the work demands.	1	2	3	4	5
4. Our staff has constructive work relationships.	1	2	3	4	5
5. Practice leadership discourages nursing staff from taking initiative.	1	2	3	4	5
6. This practice is almost always in chaos.	1	2	3	4	5
7. Leadership in this practice is available for consultation on problems.	1	2	3	4	5
8. This practice encourages nursing and front office staff input for making changes and improvements.	1	2	3	4	5
9. There is often tension among people in this practice.	1	2	3	4	5
10. All staff members participate in important decisions about clinical operations.	1	2	3	4	5
11. The staff and clinicians in this practice operate as a real team.	1	2	3	4	5
12. Staff members are involved in developing plans for improving quality.	1	2	3	4	5
13. It’s hard to make any changes in this practice because we’re so busy seeing patients.	1	2	3	4	5
14. Our practice has changed how it does business.	1	2	3	4	5
15. This practice encourages staff input for making changes and improvements.	1	2	3	4	5
16. The clinicians in this practice very frequently feel overwhelmed by the work demands.	1	2	3	4	5
17. When there is a conflict in this practice, the people involved usually talk it out and resolve the problem successfully.	1	2	3	4	5
18. This practice is experienced as “stressful.”	1	2	3	4	5
19. This is a very hierarchical organization; the decisions are made at the top with little input from those doing the work.	1	2	3	4	5
20. Things have been changing so fast in our practice that it is hard to keep up with what is going on.	1	2	3	4	5
21. Our practice has changed how it takes initiative to improve patient care.	1	2	3	4	5
22. The people who work in this practice talk with each other about their lives or families.	1	2	3	4	5

Section E
Implementation Feedback

Please read each statement carefully and check the numbered circle that indicates the extent to which each factor affected the implementation of SBIRT activities in your practice.

Babor, T., J. Higgins-Biddle, D. Dauser, P. Higgins, and J. Burleson. 2005. “Alcohol Screening and Brief Intervention in Primary Care Settings: Implementation Models and Predictors.” Journal of Studies on Alcohol 66(3):361-368.

To what extent were the following factors barriers to implementing the SBIRT Program in your practice (office, dept. etc)?	To a very little extent		To some extent		To a very great extent
Clinical staff turnover.	1	2	3	4	5
Support staff (RN’s, MA’s) turnover.	1	2	3	4	5
Administrative office staff turnover.	1	2	3	4	5
SBIRT screening staff turnover.	1	2	3	4	5
Competing priorities at this site.	1	2	3	4	5
Lack of available treatment slots for referrals.	1	2	3	4	5
Clinicians’ lack of time.	1	2	3	4	5
Support staff’s lack of time.	1	2	3	4	5
Administrative staff’s lack of time.	1	2	3	4	5
SBIRT screening staff’s’ lack of time.	1	2	3	4	5
Treatment counselors’ lack of time.	1	2	3	4	5
To what extent did the following factors facilitate the implementation of the SBIRT Program in your clinic?	To a very little extent		To some extent		To a very great extent
Your site’s SBIRT coordinator.	1	2	3	4	5
Involving practice staff in the initial decision to participate in the program.	1	2	3	4	5
A champion in your department.	1	2	3	4	5
Making organizational changes within the practice to facilitate increased screening and intervention activities.	1	2	3	4	5
Having assistance available from SBIRT training staff at _______	1	2	3	4	5

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