A review of the screening and brief intervention model
The National Institute on Alcohol Abuse and Alcoholism reports that excessive drinking is responsible for 140,000 deaths and over $249 billion in economic costs per year, with three quarters of that cost attributed to binge drinking. Overconsumption of alcohol can result in injury and death from motor-vehicle accidents, falls, violence, and drownings as well as adverse health conditions such as liver disease, cardiovascular disease, stroke, GI bleeding, mental health disorders, and cancer. Alcohol misuse also contributes to fetal alcohol spectrum disorders, domestic and child abuse and neglect, and improper use of household resources.
The incidence of unhealthy alcohol use continues to rise. In 2023, the National Institute on Drug Abuse (NIDA) reported that binge drinking among adults between the ages of 35 and 50 years reached an all-time high in 2022, representing a significant 5- and 10-year increase. The Drug Abuse Warning Network, a public health surveillance system, estimates that over 8.5 million alcohol-related emergency department visits occurred from January 2021 through September 2023, with alcohol as the most prevalent source of all substance-related emergency department visits. Moreover, many workplace violence incidents are associated with alcohol-use disorder. The U. S. Bureau of Labor and Statistics reports that from 2021 through 2022, healthcare and social assistance workers experienced the highest rates of workplace violence injuries, with the highest rate of injury occurring in substance abuse and psychiatric hospital settings.
These data raise concerns, not only for the increase in alcohol-related disease and injury but for the burden on our healthcare resources and the impact of violent patient interactions in the workplace. To address this issue, the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) advocate for the use of screening and brief intervention (SBI) tools in healthcare settings as an effective method for reducing excessive alcohol use. (SAMHSA adds “referral to treatment” to this model, creating the acronym SBIRT.)
SBI described
The SBI model contains two parts: a validated screening questionnaire to evaluate for alcohol overuse and a short conversation (brief intervention) for patients identified as at-risk for unhealthy alcohol use. The intervention isn’t limited to individuals with alcohol dependency. In fact, the intervention has the most impact before a person becomes dependent.
Screening
Nurses conduct the screening with a standardized, validated tool to aid identification of patients who exhibit risky drinking behavior. NIDA recommends the Alcohol Use Disorders Identification Test – Concise (AUDIT-C). This brief but effective survey includes three questions that address quantity and frequency of alcohol use. Accurate screening requires an understanding of what a “standard” drink is and what constitutes risky behavior. (See Defining a standard drink.)
Defining a standard drink
To ensure consistency in screening and reporting, the Centers for Disease Control and Prevention has established guidelines for what constitutes a standard drink. Rather than simply documenting that a patient typically drinks one bottle of wine on a single occasion, the nurse should note that a bottle of wine equals five standard drinks, which qualifies as risky drinking behavior that requires a brief intervention.
1 pint of craft beer or malt liquor = ~2 SDs
1 fifth (750 mL) of hard alcohol = 17 SDs
ABV = alcohol by volume
Risky drinking behavior includes both the frequent use of alcohol as well as binge drinking. The CDC defines binge drinking as consuming four to five or more standard drinks on a single occasion based on gender and age. After the screening, patients who score positive for risky drinking behavior should receive the brief intervention.
Brief intervention
The brief intervention involves a short conversation with the goal of creating awareness of the patient’s alcohol misuse and guiding a behavioral change in drinking habits. Typical components of this conversation include the following:
- Review of the patient’s alcohol use. Comparing the standards for risky drinking to the patient’s answers can prove eye-opening. Patients may not think that they’re overusing alcohol until they see what amount constitutes risky drinking behavior.
- Education on health-related harms. Discuss the detrimental health effects of excessive alcohol use. Include the role of alcohol in the patient’s specific health problems such as hypertension or heart disease.
- Incentives/benefits to change drinking behavior. Discuss what, if anything, they’d like to change. Allow the patient to discuss positive outcomes to a change in their behavior and suggest other positive benefits to a reduction in drinking habits.
- Introduce a plan to reduce drinking. Offer options such as reducing the number of drinks per day, reducing the number of drinking days per week, or stopping for a specific time frame (for example, abstaining from drinking for a week or volunteering to act as the designated driver when going out). Provide printed materials to reinforce discussion topics and offer resources for continued support.
SBI program framework
The literature demonstrates the effectiveness of SBI as a tool to reduce harmful drinking behaviors, including its implementation in acute-care settings. However, lack of SBI support and training for nursing staff, low confidence in the process, and negative perceptions about its effectiveness lead to underuse in nursing. The CDC and SAMHSA offer free informational guides for a variety of healthcare settings. In addition, many scholarly articles identify successful application strategies as well as common barriers and facilitators. A prevailing theme presented in the literature involves creating a conceptual framework for the implementation of an SBI program, including institutional support, system readiness, training and education, and program feedback.
Institutional support
Institutional support (a collaborative effort that includes administration, management, and other leadership personnel) requires leader confidence in the success of the program, the creation of a sufficient plan for implementation, and provision of necessary resources. This support might include champions and interdisciplinary teams working together to design and execute the program.
All leaders and team members play an important role in motivating nurses to understand the effectiveness of the program and its value to patient care. The champion roles provide an opportunity for interested nurses to take on leadership responsibilities or complete clinical-ladder projects.
System readiness
System readiness involves incorporating the necessary tools (such as the screening questionnaire) into the electronic health record (EHR), the ability to make referrals if necessary, and simple documentation of completed SBIs. For example, the screening questionnaire should be brief, user-friendly, and readily accessible. Nurses will more likely complete the screening if they don’t find it too time-consuming and if it’s built into an existing assessment.
The EHR can calculate risk scores and prompt the nurse to complete the brief intervention for patients whose scores indicate risky drinking behavior. The system also should, if necessary, prompt a referral or consultation for further intervention and treatment.
Documentation that’s easy to complete and refer to supports continuation of care among healthcare providers within the hospital and for internal and external audits. Internal audits provide feedback on SBI use and success. The Joint Commission now includes audits of SBI completion and documentation in its National Quality Measures (v2024A).
Training and education
Successful SBI programs require training and education. The perception by staff that they don’t have the knowledge or skills to complete SBI screening or deliver the brief intervention remains one of the biggest barriers to program implementation. Appropriate training can help address these concerns. Depending on available resources, organizations can provide in-person classes or online modules before program implementation for each new hire and as part of annual competencies.
Training in the accurate use of the screening tool will help ensure that opportunities for intervention aren’t missed. In addition, training should emphasize that screening isn’t only for patients with alcohol-related admissions; everyone should receive screening. (See Therapeutic and empathetic conversations.)
Therapeutic and empathetic conversations
To conduct the brief intervention, nurses must have tools and strategies to approach this discussion. Training should include conversational techniques designed to decrease patient and nurse resistance to the intervention.
- To help reduce the stigma of “alcoholism,” emphasize that the National Institutes of Health considers alcohol-use disorder a medical condition; individuals with the disorder have an impaired ability to control their alcohol use despite adverse consequences.
- Provide examples of methods for implementing the brief intervention, including therapeutic communication, an empathetic approach, and de-stigmatizing language.
- Using therapeutic communication techniques helps to establish trust between the patient and the nurse, which can lead to honest and productive conversations.
- An empathetic approach involves nonjudgmental language combined with compassion and an understanding of the patient’s perspective.
- To avoid stigmatizing language, focus on the disorder rather than the individual. Refrain from using words and phrases like “alcoholic” and “alcohol abuse,” which label the patient. Instead, use phrases like “alcohol-use disorder” when referring to risky drinking behavior.
- Provide nurses with additional tools, such as conversational guides and printed informational resources.
To overcome the perception that SBI will significantly add to the nurse’s workload, reinforce its brevity. Nurses should refer patients who require lengthy discussions for further intervention, such as to social work for additional resources or alcohol treatment programs.
Program feedback
Providing feedback on the program’s progress and success as well as areas for improvement aid sustainment. Reports and data that bolster the use of SBI help to maintain institutional and nursing support. In addition, celebrating the program’s success can prove motivational for nurses and encourage its use.
Implications for nursing practice
Patients interact with nurses more than any other healthcare professionals, which aids in establishing trust. That trust makes nurses particularly well-suited to conduct SBI assessments. Nurses can build the rapport necessary to elicit honest responses to the screening and inspire participation in the brief intervention.
Working to reduce risky drinking behavior results in fewer alcohol-related admissions, which tend to squander nursing resources and potentially cause harm due to violent workplace interactions. Implementing SBI also offers an effective way to expand the caregiver role of nurses and improve the safety and quality of nursing care.
Improving safety, enhancing care
The SBI model, when properly implemented into the acute healthcare setting, serves as an effective tool to help nurses reduce the prevalence of unhealthy alcohol consumption. Nurses can effectively deliver SBI within an appropriate framework when they have the support, tools, training, and motivation needed for success. Ultimately, a successful SBI program improves patient and nurse safety and enhances care quality.
Christina Montalva is a critical care float RN at Kona Community Hospital in Kealakekua, Hawaii.
American Nurse Journal. 2025; 20(7). Doi: 10.51256/ANJ072538
References
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Drug Abuse Warning Network. Short report—Alcohol-related ED visits. samhsa.gov/data/sites/default/files/reports/rpt44498/DAWN-TargetReport-Alcohol-508.pdf
The Joint Commission. Specifications Manual for Joint Commission National Quality Measures (v2024A). Substance use measures. manual.jointcommission.org/releases/TJC2024A
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National Institute on Alcohol Abuse and Alcoholism. Alcohol facts and statistics. June 2024. niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics
National Institute on Drug Abuse. Form: AUDIT-C questionnaire. August 31, 2015. cde.nlm.nih.gov/formView?tinyId=myWNfJaZwe
National Institute on Drug Abuse. Marijuana and hallucinogen use, binge drinking reached historic highs among adults 35 to 50. August 17, 2023. nida.nih.gov/news-events/news-releases/2023/08/marijuana-and-hallucinogen-use-binge-drinking-reached-historic-highs-among-adults-35-to-50
Rosário F, Santos MI, Angus K, Pas L, Ribeiro C, Fitzgerald N. Factors influencing the implementation of screening and brief interventions for alcohol use in primary care practices: A systematic review using the COM-B system and Theoretical Domains Framework. Implement Sci. 2021;16(1):6. doi:10.1186/s13012-020-01073-0
Substance Abuse and Mental Health Services Administration. TAP 33: Systems-level implementation of screening, brief intervention, and referral to treatment. May 2013. library.samhsa.gov/product/tap-33-systems-level-implementation-screening-brief-intervention-and-referral-treatment
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U.S. Bureau of Labor Statistics. Workplace violence 2021-2022. bls.gov/iif/factsheets/workplace-violence-2021-2022.htm
