Form Practitioner Surve Practitioner Surve Practitioner Survey

Form Approved

OMB No. 0930-XXXX

Expiration Date XX/XX/XXXX

Attachment 2:

SBIRT CROSS-SITE EVALUATION
PRACTITIONER SURVEY—DRAFT

This survey is part of a national evaluation effort to describe the implementation of SBIRT programs throughout the country. The following questions ask about your experiences with the [MOSBIRT, etc.] program that was implemented in this [emergency department, practice, school, agency, clinic, department, etc.] on [date]. The questions are 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 18 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? (Check ALL that apply.)

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

11th grade or lower

12th grade completed/high school diploma/equivalent

Vocational/technical 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 (PhD, PsyD, DrPH, etc.)

Medical degree or equivalent (MD, DO, DDS, etc.)

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

A7. What is your job title?

A8. 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

A9. On average, how many hours per week do you work at this job? _______

A10. Do you perform any SBIRT services for at-risk substance use (Pre-Screening, Screening, Brief Feedback, Brief Intervention, Brief Treatment, or Referrals to Treatment) as part of your duties?

Yes

No (Please go to Section C.)

A11. Do you perform Pre-Screening services (ask patients a small number of questions about their substance use to determine if a more detailed screening assessment is needed)?

Yes

No

If Yes, how many patients or clients do you pre-screen on an average day?

1–5

6–10

11–15

16–20

21–25

> 25

A12. Do you perform Screening services (identify at-risk substance users using a standardized screening instrument)?

Yes

No (Please go to Question A14.)

If Yes, how many patients or clients do you typically screen on an average day?

1–5

6–10

11–15

16–20

21–25

> 25

A13. In addition to Screening, do you also perform Brief Feedback services (provide educational materials or feedback to patients/clients who screen negative)?

Yes

No

If Yes, then on an average day, to how many SBIRT patients or clients do you provide Brief Feedback?

1–5

6–10

11–15

16–20

21–25

> 25

A14. Do you perform Brief Intervention services (i.e., provide short motivational counseling and feedback sessions to patients/clients who screen positive)?

Yes

No

If Yes, then on an average day, to how many patients or clients do you provide Brief Intervention?

1–5

6–10

11–15

16–20

21–25

> 25

A15. Do you perform Brief Treatment (i.e., provide 2 to 20 counseling sessions of therapy to higher-risk individuals)?

Yes

No

If Yes, then on an average day, to how many patients or clients do you provide Brief Treatment?

1

2

3

4

5

> 5

A16. Do you provide Referrals to Treatment (i.e., provide treatment referrals by linking substance-dependent patients to more intensive services that are outside of the scope of the SBIRT)?

Yes

No

If Yes, then on an average day, to how many SBIRT patients or clients do you provide Referrals to Treatment?

1

2

3

4

5

> 5

A17. How long have you been in your current position, delivering SBIRT services?

0–5 months

6–11 months

1 to 2 years

3 to 4 years

5 or more years

A18. What percentage of your time is spent performing SBIRT-related activities? _______%

A19. Which of the following best describes you? (Check ALL that apply.)

MD

DO

APRN

PA

RN

LPN

RD

Medical Assistant (CMA/MA)

PhD, PsyD

MSW

MS or MA

CDP, CDC

Health Educator

Other (specify)

A20. Current Discipline/Professional Focus: (Check ALL that apply.)

Medicine: Family Practice

Medicine: Internal Medicine

Medicine: Emergency/Trauma

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

Volunteer

None, student

Other (specify)

A21. Certification Status in Addictions, Medicine, Nursing Fields (if applicable): (Check ALL that apply.)

Not certified or licensed in addiction treatment

Previously certified or licensed in addiction treatment, but not now

Currently certified or licensed in medical or counseling fields

Intern

No license or certification available in your field

Other (specify)

A22. How much 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

A23. In the absence of the SBIRT grant and its funding, do you see value in continuing to provide SBIRT services?

Yes

No

A24. Would you be willing to advocate for sustaining SBIRT services at your organization?

Yes

No

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? Please circle the number that indicates how prepared you feel to talk with patients about each behavior.

Behavior Area	Very prepared	Somewhat prepared	Somewhat unprepared	Very unprepared
Not smoking tobacco	1	2	3	4
Exercising regularly	1	2	3	4
Reducing alcohol consumption	1	2	3	4
Avoiding excess calories	1	2	3	4
Reducing illicit drug use	1	2	3	4

B2. How effective do you feel you are in helping patients achieve change in each of the following behavior areas? Please circle the number that indicates how effective you feel you are in helping patients achieve change in each behavior.

Behavior Area	Very effective	Somewhat effective	Somewhat ineffective	Very ineffective
Not smoking tobacco	1	2	3	4
Exercising regularly	1	2	3	4
Reducing alcohol consumption	1	2	3	4
Avoiding excess calories	1	2	3	4
Reducing illicit drug use	1	2	3	4

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. About how many hours of ongoing clinical supervision (e.g., case reviews, “shadowing”) do you receive each month?

None

Less than 1 hour

1–2 hours

3–4 hours

5–6 hours

7–8 hours

More than 8 hours

B5. How would you rate staff in your facility (emergency department, 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? (Please select one.)

Significant need for staff development in these areas

Staff are 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
SBIRT Implementation

Please read each statement carefully and circle the number that indicates the extent to which you agree with the following factors influencing your decision to adopt SBIRT practices. Note that some questions may appear repetitive, but please answer each question.

To what extent do you disagree or agree with the following statements:	Strongly disagree	Disagree	Disagree somewhat	Neutral	Agree somewhat	Agree	Strongly agree
a. This organization was well-informed about SBIRT.	1	2	3	4	5	6	7
b. This organization had the resources necessary to support the implementation of SBIRT.	1	2	3	4	5	6	7
c. We can deal with the ‘bumps in the road’ that are involved with implementing SBIRT.	1	2	3	4	5	6	7
d. In this organization, a high priority is placed on learning and experimenting with new ideas.	1	2	3	4	5	6	7
e. This organization has a limited capacity to absorb negative consequences that may occur as a result of implementing SBIRT.	1	2	3	4	5	6	7
f. SBIRT is compatible with my professional training.	1	2	3	4	5	6	7
g. There is considerable scientific evidence indicating that SBIRT is effective.	1	2	3	4	5	6	7
h. Implementing SBIRT improves service quality at this organization.	1	2	3	4	5	6	7
i. Implementing SBIRT represents little risk to this organization.	1	2	3	4	5	6	7
j. Implementing SBIRT involves more drawbacks than benefits for this organization.	1	2	3	4	5	6	7
k. This organization has a history of experimenting with new services and technologies.	1	2	3	4	5	6	7
l. There is strong scientific evidence supporting the effectiveness of SBIRT.	1	2	3	4	5	6	7
m. Benefits outweigh costs when it comes to implementing SBIRT at this organization.	1	2	3	4	5	6	7
n. Management at this organization believes trying new services and technologies is risky.	1	2	3	4	5	6	7
o. Management at this organization believes that it’s difficult to predict whether change will be beneficial.	1	2	3	4	5	6	7
p. Implementing SBIRT represents a great risk to this organization.	1	2	3	4	5	6	7
q. There is only a limited amount of scientific evidence supporting the effectiveness of SBIRT.	1	2	3	4	5	6	7
r. Staff from this organization talked with staff from similar organizations about implementing SBIRT.	1	2	3	4	5	6	7
s. From a technical standpoint, it is complicated to implement SBIRT correctly.	1	2	3	4	5	6	7
t. Management places a high value on taking risks even if there are occasional mistakes.	1	2	3	4	5	6	7
u. Other organizations that have implemented SBIRT question its effectiveness.	1	2	3	4	5	6	7
v. It would be a serious blight on a person’s record at this organization if they were to try something new and fail.	1	2	3	4	5	6	7
w. Management at this organization believes that change usually creates more problems than it solves.	1	2	3	4	5	6	7
x. There was healthy discussion at this organization about implementing SBIRT.	1	2	3	4	5	6	7
y. This organization prefers to take a wait-and-see approach when it comes to adopting new services and technologies.	1	2	3	4	5	6	7
z. The scientific evidence supporting the effectiveness of SBIRT is weak.	1	2	3	4	5	6	7
aa. SBIRT is compatible with the professional training of most treatment staff in this organization.	1	2	3	4	5	6	7
bb. This organization had the manpower necessary to support the implementation of SBIRT.	1	2	3	4	5	6	7
cc. Overall, implementing SBIRT is advantageous to this organization.	1	2	3	4	5	6	7
dd. This organization’s resilience allows us to deal with difficulties that may arise in the course of implementing SBIRT.	1	2	3	4	5	6	7
ee. The disadvantages of implementing SBIRT far outweigh the advantages.	1	2	3	4	5	6	7
ff. The experience of other organizations implementing SBIRT convinces me that it’s an effective approach.	1	2	3	4	5	6	7
gg. This organization tends to be among the early adopters of new services and technologies.	1	2	3	4	5	6	7
hh. This organization tends to be on the leading edge when it comes to trying new things.	1	2	3	4	5	6	7
ii. Implementing SBIRT enhances the effectiveness of this organization.	1	2	3	4	5	6	7
jj. Organizations that have implemented SBIRT have evidence that it’s an effective approach.	1	2	3	4	5	6	7
kk. This organization can manage the risks associated with implementing SBIRT.	1	2	3	4	5	6	7
ll. From a technical standpoint, it is easy to implement SBIRT correctly on a consistent basis.	1	2	3	4	5	6	7
mm. It is easy to train staff to perform the tasks necessary to implement SBIRT.	1	2	3	4	5	6	7
nn. SBIRT is compatible with my beliefs about treatment.	1	2	3	4	5	6	7
oo. We do not have the resources necessary to implement SBIRT on a long-term basis.	1	2	3	4	5	6	7
pp. It is difficult for staff to implement SBIRT.	1	2	3	4	5	6	7
qq. Staff from this organization has been in contact with professionals who were implementing SBIRT at other organizations.	1	2	3	4	5	6	7
rr. This organization can deal with any negative fallout that may occur in the course of implementing SBIRT.	1	2	3	4	5	6	7
ss. Management at this organization believes that change involves a lot of uncertainty.	1	2	3	4	5	6	7
tt. SBIRT is compatible with the treatment philosophy of this organization.	1	2	3	4	5	6	7
uu. History shows that this organization is averse to taking risks.	1	2	3	4	5	6	7
vv. Organizations that have implemented SBIRT cannot present evidence that it’s effective.	1	2	3	4	5	6	7

Section D
Implementation Feedback

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

To what extent were the following factors barriers to implementing the SBIRT Program in your practice (office, department, 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, MA) 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