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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: Pediatr Emerg Care. 2011 Sep;27(9):812–825. doi: 10.1097/PEC.0b013e31822c1343

Beliefs and Practices of Pediatric Emergency Physicians and Nurses Regarding Counseling Alcohol Using Adolescents - Can Counseling Practice Be Predicted?

Thomas H Chun 1, Anthony Spirito 2, Gail D’Onofrio 3, Robert H Woolard 4
PMCID: PMC9715011  NIHMSID: NIHMS1849552  PMID: 21878829

Abstract

Objectives:

The objectives of the study were to investigate the attitudes and practices of pediatric emergency department (PED) physicians (MDs), MD extenders (MD’s assistants [PAs], nurse practitioners [NPs]), and nurses (RNs) regarding their counseling of alcohol using adolescent PED patients and to determine which, if any, PED clinician characteristics predict current counseling practice.

Methods:

An Internet based survey of PED clinicians (MDs, PAs, NPs, and RNs) from 11 academic US PEDs was conducted. Respondents were asked about their counseling training, current counseling practices, confidence in their counseling skills, importance of counseling, attitudes and beliefs about counseling, and demographic information. Univariate and multivariate analyses were performed to determine the relationship between clinician characteristics and counseling practice.

Results:

Counseling practice was strongly associated with one’s profession; PED MDs/PAs/NPs reported significantly higher rates of counseling alcohol using adolescents than PED RNs. These 2 groups differed significantly in terms of counseling training and experience. Counseling training and experience remained significant predictors of counseling practice, even after controlling for profession and other covariates. Both groups had similar views on the importance of counseling, confidence in their ability to counsel, and counseling substance using adolescent PED patients.

Conclusions:

Pediatric ED MDs/PAs/NPs differ significantly from PED RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

Keywords: alcohol, adolescent, counseling

1. Introduction

Alcohol use is a significant cause of adolescent mortality and morbidity in the United States. 1,2 The emergency department (ED) is well suited for adolescent alcohol interventions in that large numbers of adolescent ED visits are related to alcohol use.3 An advantage of the ED setting is that high risk and other wise difficult-to-reach populations are frequently seen in the ED.4,5 In addition, adolescents may have increased motivation to change their alcohol use after an acute alcohol related event.6,7

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an alcohol treatment model that has been endorsed by numerous medical and government organizations including the Society for Academic Emergency Medicine,8,9 the American College of Surgeons Committee on Trauma,10 the Substance Abuse Mental Health Services Administration,11 and the Centers for Disease Control,12 as a method of improving the care of alcohol using patients. Although several ED based trials of SBIRT for adults with problematic alcohol use have shown that SBIRT can be successfully administered in the ED setting and have a positive impact on patients’ drinking and alcohol related behaviors,13,14 little is known about ED based SBIRT for adolescents who use alcohol.

Among the many unresolved questions is who is willing and best able to deliver SBIRT in the ED. Previous adult ED studies have used a variety of SBIRT providers, including physicians (MDs), nurses (RNs), MD’s assistants (PAs), nurse practitioners (NPs), social workers,13 and other alcohol interventionists.14,15 Several studies have investigated ED MDs training in, attitudes toward, and practice of counseling their alcohol using patients.16-18 These studies have found that although a large majority ED MDs report favorable attitudes and beliefs toward alcohol disorders as treatable conditions and ED based brief interventions (BIs), most have little training in such BIs. Lack of sufficient time was commonly cited as the biggest impediment to performing such interventions in the ED. Among primary care providers, lack of training, lack of confidence in their intervention skills, negative past experiences treating alcohol problems, and lack of reinforcement or incentives to administer alcohol interventions were identified as additional barriers to performing alcohol BIs.19

Less is known about the training in, belief and attitudes toward, and practice of ED RNs in counseling their alcohol using patients. Kelleher and Cotter20 found that whereas ED RNs in Ireland have optimistic attitudes about alcohol as a treatable disorder, most reported little or no training in alcohol counseling and had large knowledge deficits about alcohol interventions. In a study of RN SBIRT in a UK ED,21 half the RNs found that screening was “easy” or “OK when I’m not busy,” the remainder found screening “difficult,” “annoying (to patients),” “too judgmental,” and “not something appropriate for (the ED).”

Primary care RNs have been better studied.22,23 Although neither primary care RNs nor MDs reported poor attitudes toward or unwillingness to administer BIs, RNs were less likely to feel confident about their counseling abilities and felt less competent to administer BIs.22,24,25 Lack of training and confidence in administering BIs and lack of support in the workplace for administering BIs have also been identified as barriers to RN administered BIs.23 In addition, some RNs fear that discussing alcohol use may harm their relationships with their patients.25

A limited number of studies have directly compared ED RNs and MDs. Studies of the RN managers and MD clinical directors of EDs in Scotland and England yielded conflicting results. Waller et al26 found that RN managers generally had more optimistic attitudes about the ED treatment of alcohol using patients than MD clinical directors, whereas Anderson et al27 found little difference between the 2 groups.

In a study of 2 Australian ED staffs, Indig et al28 surveyed MDs and RNs about alcohol related ED visits. The majority of survey respondents had less than 3 years of experience. Physicians reported much higher rates of asking patients about their alcohol use, as well as greater confidence in asking about alcohol use. Nearly 60% of RNs reported lack of knowledge and skills as barriers to ED alcohol treatment, twice the rate of MDs. In this study, more RNs endorsed favorable beliefs about ED treatment of alcohol using patients, whereas more MDs endorsed negative beliefs about such patients. Unadjusted bivariate analyses found that asking about alcohol use and confidence in asking about alcohol use were significantly associated with being an MD.

The purpose of this study was to investigate the training in, beliefs about, attitudes toward, perceived barriers to, and current practice of pediatric emergency department (PED) MDs and RNs regarding alcohol BIs for their alcohol using adolescent patients. It was hypothesized that PED MDs and RNs would have positive attitudes toward adolescent alcohol BIs, that MDs will report greater confidence in administering such BIs than RNs, and that both groups would endorse multiple barriers to administering BIs in the PED setting.

2. Methods

Study Setting and Population

The survey was administered to 1 subgroup of participants (Rhode Island [RI]) as part of a larger trial testing the efficacy of an educational intervention to teach PED MDs and RNs an adolescent alcohol BI. For comparison, and to increase the statistical power of this study, additional respondents were recruited from 10 academic US PEDs with an active fellowship training program as of 2005.29 A random number generator was used to assign a number to the PEDs. Starting with the PED assigned no. 1, PEDs were sequentially contacted until 10 PEDs had been enrolled.

The medical directors of the external PEDs were contacted, to determine if they or one of their designees were willing to collaborate in the survey. Survey site collaborators distributed a total of 4 recruitment notices, each 1 week apart, to all the PED MDs (attending MDs and fellows), staff RNs, NPs, and PAs. The first 2 recruitment notices were via e-mail, with a hyperlink to the survey Web site embedded in the e-mail. The second 2 recruitment notices were paper copies of the e-mail notice, distributed to the PED staff’s usual mailbox. Survey site coordinators were reimbursed $200 to defray the cost of their recruitment activities.

All study protocols were approved by the overseeing institutional review board. Written, informed consent was obtained from all RI respondents, as part of their participation in the larger study. For external PED respondents, written informed consent was waived by the overseeing institutional review board.

Questionnaire Development and Administration

The survey tool used in this study was a modified version of the questionnaire (Appendix) used in the study by D’Onofrio et al.16 All study participants were “blind” to the survey’s purpose, i.e. all were told that it was a survey about adolescent health counseling in the ED. The survey questionnaire asked about a variety of types of adolescent counseling topics, including other substance use, sexual activity, diet, and other risky behaviors.

An electronic version of the survey was created and posted on the Internet by the information services department of one of the study’s sponsoring organizations. The survey questionnaire was accessible to potential respondents between April 2006 and December 2006. If a respondent completed the survey and provided an e-mail address, they were remunerated with a $20 electronic gift certificate, redeemable at a popular Internet retailer. It was possible for a respondent to complete the survey without providing an e-mail address. Study personnel were kept blinded to respondent e-mail addresses. A secretary not connected with the study, but with access to the e-mail addresses, sent the electronic gift certificates via e-mail.

Demographics

Collected respondent data included age, sex, race/ethnicity, profession, and year of professional school graduation.

Question Order Bias

To assess for question order bias, 3 versions of the survey were created, each with a different sequence of counseling questions. Respondents, as they visited the survey Web site, were randomly assigned a survey version.

Counseling Practice, Training, Importance, and Confidence

Identical wording was used for all similar subsets of questions. Subsets of questions about counseling had the following format: (1) ask about (the) risky behavior(s); (2) ask about the quantity and frequency of (the) risky behavior(s); (3) advise about (the) risky behavior(s); and (4) refer to treatment for (the) risky behavior(s). For example, for the category of adolescent alcohol use, all questions began with: “What percentage of your adolescent patients do you ask about their alcohol use; ask about the quantity of frequency of their use; discuss with or advise to change their alcohol use; and make any kind of referral (including to their pediatrician) for alcohol treatment?”

Counseling practice possible responses were in the form of a 5-point rating scale and ranged from 0%, 1% to 25%, 26% to 50%, 51% to 75%, and 76% to 100% of patients. Possible responses for the confidence in and importance of counseling adolescent PED patients questions were in the form of a 4 point rating scale, with responses ranging from “not at all” (confident/ important) to “very” (confident/important). All questions had a “decline to answer” response option.

Counseling training questions asked respondents about the number of didactic hours on adolescent counseling they had during their professional schooling and in the past year, as well as the number of didactic hours on any kind of counseling they had during their professional schooling. Possible responses were categorized into 0, 1 to 10, 11 to 25, and greater than 25 hours of training during their professional schooling, and 0, 1 to 2, 3 to 5, and greater than 5 hours of training in the past year. Counseling experience was assessed with a 5-point rating scale. Possible responses were “I have: (1) little or no experience, (2) a small amount of experience, (3) a moderate amount of experience, (4) a large amount of experience, and (5) a very extensive amount of experience.”

Counseling Beliefs and Attitudes

Questions about counseling substance using ED patients included questions about both positive and negative attitudes and beliefs, as well as 2 questions about barriers to screening and BI. The attitude and belief questions about substance abuse were derived from the Substance Abuse Attitude Scale (SAAS).30 The SAAS is a well validated instrument for measuring MD attitudes toward substance abusing patients. Response options for the substance abuse and substance abuse counseling beliefs questions were in the form of “agree” or “disagree.”

To derive the most conservative estimates of the survey results, all “declined to answer” results were coded as the least socially desirable response. Response categories with no responses were collapsed into the next contiguous response category. Univariate analyses included Pearson χ2 for categorical variables and t tests for continuous variables. Linear regression models were used to investigate the relationship between counseling predictor variables and reported counseling practices. All statistical analyses were performed using Stata (version 10.0; StataCorp, College Station, TX).

3. Results

Survey Development and Administration

Twelve PEDs were contacted; 2 declined to participate, yielding 10 external participating PEDs. A total of 188 PED clinicians, 21.2% of possible respondents, completed the survey. Response rate by institution varied from 5% to 69%.

Demographics

A total of 10 PAs and 10 NPs completed the survey. Because of the small number of NP and PA responses, and to make meaningful statistical comparisons, NPs and PAs were compared with RNs and MDs. Nurse practitioners and PAs were similar to MDs, both in terms of demographics and survey responses, and dissimilar to RNs (data not shown). Respondent NPs and PAs were thus included with MDs in the data analyses. Response rates for RNs ranged from 0% to 53%, whereas the response rates for MDs/PAs/NPs ranged from 7% to 96%. Excluding responses from RI which had a high response rate, the upper range of response for other institutions was 41%. For RNs, the upper range of response rates was 31%. The upper range of response rates for MDs/PAs/NPs was 54%.

Because 27% of respondents were from 1 site (RI), an analysis was performed to determine if these respondents were significantly different from non-RI respondents. Rhode Island and non-RI respondents were not significantly different in terms of age, profession, sex, race, or ethnicity. Non-RI respondents did report more professional experience than RI respondents (13.0 vs 9.5 years, t = 2.24, P = 0.03). With regard to individual survey items, RI respondents significantly differed from those from the other sites on 5 items. Compared with non-RI respondents, RI respondents reported greater confidence (χ2 = 8.70, P = 0.03) and placed greater importance on asking adolescents about the quantity and frequency of risky behaviors (χ2 = 8.43, P = 0.02); placed greater importance on referring adolescents to treatment for their risky behaviors (χ2 = 7.89, P = 0.02); expressed a stronger belief that advising teens can result in early, successful intervention (100% vs 92%, χ2 = 3.83, P = 0.05); and expressed a stronger belief that ED clinicians can effectively counsel and treat risky adolescent behaviors (76% vs 52%, χ2 = 8.58, P = 0.00). Because of these minimal differences, the RI respondents were included in all subsequent analyses.

Nurse respondents were significantly more likely to be female (92% vs 54%) and white (94% vs 83%) than were MD/PA/ NP respondents. The 2 groups were similar on other demographic variables.

Question Order Bias

To determine if question order bias was present, respondent results were compared by the 3 versions of the survey that had been administered. There were no significant differences among any survey items by survey version (data not shown).

Counseling Practice, Training, Importance, and Confidence

The results of the questionnaire are presented in Table 1. Physicians and MD extenders (PAs and NPs) reported significantly more training in counseling during their professional schooling (both counseling in general and specifically counseling adolescents), more training in adolescent counseling in the past year, and more experience counseling adolescents over the course of their careers. On every dimension of screening for alcohol use (i.e., asking about alcohol use and quantity and frequency of use) and counseling (i.e., advising about alcohol use and referring to treatment), MDs/PAs/NPs reported higher rates of alcohol screening and counseling in their current clinical practice, as well as being more confident about their screening and counseling abilities than RN respondents. Both groups were similar, however, in terms of the importance of alcohol screening and counseling and overall substance abuse beliefs and attitudes.

TABLE 1.

Survey Responses by Profession

RNs, n (%) MDs/NPs/PAs, n
(%)		 Pearson χ2
Counseling training and experience
 Hours of training in teen counseling during schooling 0 23 (26.4) 7 (6.9) Pearson χ2= 22.67, P = 0.00
1-10 60 (69.0) 70 (69.3)
>11 4 (4.6) 24 (23.8)
 Hours of training in any kind of counseling during schooling 0 15 (17.2) 3 (3.0) Pearson χ2= 26.76, P = 0.00
1-10 60 (69.0) 53 (52.5)
11-25 8 (9.2) 27 (26.7)
>25 4 (4.6) 18 (17.8)
 Hours of training in teen counseling in the past year 0 68 (78.2) 54 (53.5) Pearson χ2= 12.51, P = 0.00
>1 19 (21.8) 47 (46.5)
 Career experience counseling adolescents Little 28 (32.2) 6 (5.9) Pearson χ2= 35.47, P = 0.00
Small 38 (43.7) 32 (31.7)
Mod 19 (21.8) 52 (51.5)
Large/exten 2 (2.3) 11 (10.9)
Current counseling practice
 Percentage of adolescents asked about alcohol use 0% 16 (18.4) 2 (2.0) Pearson χ2= 40.20, P = 0.00
1%-25% 48 (55.2) 34 (33.7)
26%-50% 14 (16.1) 16 (15.8)
51%-75% 4 (4.6) 20 (19.8)
76%-100% 5 (5.8) 29 (28.7)
 Percentage of adolescents asked about quantity and frequency of alcohol use 0% 27 (31.0) 4 (4.0) Pearson χ2= 29.67, P = 0.00
1%-25% 25 (28.7) 24 (23.8)
26%-50% 9 (10.3) 17 (16.8)
51%-75% 7 (8.1) 14 (13.9)
76%-100% 19 (21.8) 42 (41.6)
 Percentage of adolescents advised about alcohol use 0% 32 (36.8) 5 (5.0) Pearson χ2= 34.08, P = 0.00
1%-25% 23 (26.4) 28 (27.7)
26%-50% 11 (12.6) 15 (14.9)
51%-75% 7 (8.1) 14 (13.9)
76%-100% 14 (16.1) 39 (38.6)
 Percentage of adolescents referred to alcohol treatment 0% 48 (55.2) 12 (11.9) Pearson χ2= 41.76, P = 0.00
1%-25% 19 (21.8) 4 52 (51.5)
26%-50% (4.6) 10 (9.9)
51%-75% 9 (10.3) 13 (12.9)
76%-100% 7 (8.1) 14 (13.9)
Counseling confidence and importance
 Confidence in asking adolescents about their alcohol use Not at all 14 (16.1) 1 (1.0) Pearson χ2= 45.05, P = 0.00
Some 37 (42.5) 12 (11.9)
Mod 18 (20.7) 43 (42.6)
Very 18 (20.7) 45 (44.6)
 Confidence in asking adolescents about the quantity and frequency of their alcohol use Not at all 19 (21.8) 3 (3.0) Pearson χ2= 31.33, P = 0.00
Some 27 (31.0) 13 (12.9)
Mod 23 (26.4) 43 (42.6)
Very 18 (20.7) 42 (41.6)
 Confidence in advising adolescents about their alcohol use Not at all 29 (33.3) 11 (10.9) Pearson χ2= 15.77, P = 0.00
Some 26 (29.9) 31 (30.7)
Mod 18 (20.7) 36 (35.6)
Very 14 (16.1) 23 (22.8)
 Confidence in referring adolescents to treatment for their alcohol use Not at all 32 (36.8) 14 (13.9) Pearson χ2= 20.08, P = 0.00
Some 34 (39.1) 36 (35.6)
Mod 11 (12.6) 35 (34.7)
Very 10 (11.5) 16 (15.8)
 Importance of asking adolescents about their alcohol use Not/some 21 (24.1) 15 (14.9) Pearson χ2= 2.97, P = 0.23
Mod 27 (31.0) 31 (30.7)
Very 39 (44.8) 55 (54.5)
 Importance of asking adolescents about the quantity and frequency of their alcohol use Not/some 25 (28.7) 22 (21.8) Pearson χ2= 1.34, P = 0.51
Mod 31 (35.6) 37 (36.6)
Very 31 (35.6) 42 (41.6)
 Importance of advising adolescents about their alcohol use Not/some 22 (25.3) 20 (19.8) Pearson χ2= 1.92, P = 0.38
Mod 28 (32.2) 42 (41.6)
Very 37 (42.5) 39 (38.6)
 Importance of referring adolescents to treatment for their alcohol use Not/some 23 (26.4) 28 (27.7) Pearson χ2= 4.25, P = 0.12
Mod 23 (26.4) 39 (38.6)
Very 41 (47.1) 34 (33.7)
Counseling beliefs and attitudes
 Counseling adolescents makes me feel like a responsible clinician Agree 80 (92.0) 97 (96.0) Pearson χ2= 1.42, P = 0.23
Disagree 7 (8.1) 4 (4.0)
 Counseling adolescents takes too much time from other ED duties Agree 40 (46.0) 49 (48.5) Pearson χ2= 0.12, P = 0.73
Disagree 47 (54.0) 52 (51.5)
 Smoking marijuana leads to hard drug use Agree 52 (59.8) 54 (53 5) Pearson χ2= 0.76, P = 0.39
Disagree 35 (40.2) 47 (46.5)
 Adolescent risky behaviors should be treated only by specialists Agree 23 (26.4) 15 (14.9) Pearson χ2= 3.89, P = 0.05
Disagree 64 (73.6) 86 (85.2)
 It’s hard to find good referrals for adolescent risky behaviors Agree 64 (73.6) 84 (83.2) Pearson χ2= 2.57, P = 0.11
Disagree 23 (26.4) 17 (16.8)
 Advising adolescents can lead to early, successful interventions Agree 83 (95.4) 95 (94.1) Pearson χ2= 0.17, P = 0.68
Disagree 4 (4.6) 6 (5.9)
 I have not had many role models for adolescent counseling in the ED Agree 76 (87.4) 63 (62.4) Pearson χ2= 15.13, P = 0.00
Disagree 11 (12.6) 38 (37.6)
 Marijuana use can be a healthy experiment Agree 14 (16.1) 22 (21.8) Pearson χ2= 0.98, P = 0.32
Disagree 73 (83.9) 79 (78.2)
 Adolescents will get angry if I ask about their risky behaviors Agree 31 (35.6) 11 (10.9) Pearson χ2= 16.49, P = 0.00
Disagree 56 (64.4) 90 (89.1)
 Adolescents with risky behaviors use too much ED time and resources Agree 43 (49.4) 65 (64.4) Pearson χ2= 4.26, P = 0.04
Disagree 44 (50.6) 36 (35.6)
 Adolescents can stop their risky behaviors if they want to Agree 56 (64.4) 71 (70.3) Pearson χ2= 0.75, P = 0.39
Disagree 31 (35.6) 30 (29.7)
 Treatment doesn’t work for adolescent risky behaviors Agree 4 (4.6) 8 (7.9) Pearson χ2= 0.86, P = 0.35
Disagree 83 (95.4) 93 (92.1)
 Past referrals for adolescent risky behaviors haven’t worked Agree 22 (25.3) 37 (36.6) Pearson χ2= 2.79, P = 0.10
Disagree 65 (74.7) 64 (63.4)
 ED clinicians can effectively counsel and treat adolescent risky behaviors Agree 54 (62.1) 56 (55.5) Pearson χ2= 0.84, P = 0.36
Disagree 33 (37.9) 5 (44.6)
 Complete abstinence is necessary to reduce harm from drugs Agree 52 (59.8) 42 (41.6) Pearson χ2= 6.18, P = 0.01
Disagree 35 (40.2) 59 (58.4)
 Coercive tactics are effective in treating resistant adolescents Agree 7 (8.1) 21 (20.8) Pearson χ2= 5.99, P = 0.01
Disagree 80 (92.0) 80 (79.2)
 My counseling of adolescents in the ED can help change their risky behaviors Agree 64 (73.6) 83 (82.2) Pearson χ2= 2.03, P = 0.15
Disagree 23 (26.4) 18 (17.8)
 Adolescents won’t answer me if I ask about risky behaviors Agree 23 (26.4) 8 (7.9) Pearson χ2= 11.64, P = 0.00
Disagree 64 (73.6) 93 (92.1)
Open in a new tab

Entries in bold face indicate P < 0.05.

Counseling Beliefs and Attitudes

To determine if respondents with more favorable beliefs and attitudes toward counseling adolescent patients in the ED setting were different from respondents with less favorable beliefs and attitudes, a belief/attitude summary score was developed, using the counseling related questions of the SAAS. Answers favorable to counseling were coded as one. Less favorable answers were coded as zero. To render the most conservative estimate of whether a respondent had a favorable view of ED adolescent counseling, questions answered with “decline to answer” were recoded as less favorable responses.

A belief summary score was calculated by the sum of the respondents SAAS questions. The range of possible summary scores was 0 to 18. The higher the score, the greater the number of positive beliefs endorsed by the respondent about adolescent counseling in the ED. The observed range of scores was 1 to 12. The median score was 5. Forty-one (21.8%) of the respondents scored between 1 and 3, 108 respondents (57.4%) scored between 4 and 7, and 39 (20.7%) of the respondents scored between 8 and 12. Using these cut points, respondents were divided into 3 groups, a group less favorable toward ED adolescent counseling, a middle/intermediate group, and a group more favorable toward ED adolescent counseling. The 3 groups were not significantly different in terms of sex, ethnicity or race, age, years of clinical experience, or profession (RNs vs MDs/PAs/NPs).

The results of the comparison between respondents with more favorable and less favorable scores are presented in Table 2. Compared with respondents with less favorable attitudes, respondents with more favorable attitudes toward adolescent ED counseling reported significantly more training in counseling during their professional schooling, more training in counseling the past year, and more career experience counseling adolescents. These respondents asked more of their adolescent patients about their alcohol use and about the quantity and frequency of their alcohol use. Favorable respondents were more confident about their ability to ask about alcohol use, quantity and frequency of alcohol consumption, and advising and referring adolescents to treatment for their alcohol use.

TABLE 2.

Survey Responses by Beliefs About ED Counseling

More
Favorable,
n (%)		 Neutral,
n (%)		 Less
Favorable,
n (%)		 Pearson χ2
Counseling training and experience
 Hours of training in teen counseling during schooling 0-10 31 (75.6) 94 (87.0) 35 (89.7) Pearson χ2= 3.90, P = 0.14
>11 10 (24.4) 14 (13.0) 4 (10.3)
 Hours of training in any kind of counseling during schooling 0-10 21 (51.2) 79 (73.2) 31 (79.5) Pearson χ2= 9.51, P = 0.05
11-25 12 (29.3) 19 (17.6) 4 (10.3)
>25 8 (19.5) 10 (9.3) 4 (10.3)
 Hours of training in teen counseling in the past year 0 19 (46.3) 70 (64.8) 33 (84.6) Pearson χ2= 12.85, P = 0.00
>1 22 (53.7) 38 (35.2) 6 (15.4)
 Career experience counseling adolescents Little/no 5 (12.2) 17 (15.7) 12 (30.8) Pearson χ2= 16.79, P = 0.01
Small 10 (24.4) 47 (43.5) 13 (33.3)
Mod 19 (46.3) 39 (36.1) 13 (33.3)
Large/ext 7 (17.1) 5 (4.6) 1 (2.6)
Current counseling practice
 Percentage of adolescents asked about alcohol use 0% 1 (2.4) 9 (8.3) 53 8 (20.5) Pearson χ2= 22.23, P = 0.01
1%-25% 15 (36.6) (49.1) 18 14 (35.9)
26%-50% 7 (17.1) (16.7) 13 5 (12.8)
51%-75% 3 (7.3) (12.0) 15 8 (20.5)
76%-100% 15 (36.6) (13.9) 4 (10.3)
 Percentage of adolescents asked about quantity and frequency of alcohol use 0% 5 (12.2) 16 (14.8) 10 (25.6) Pearson χ2= 17.19, P = 0.03
1%-25% 7 (17.1) 30 (27.8) 12 (30.8)
26%-50% 4 (9.8) 18 (16.7) 4 (10.3)
51%-75% 2 (4.9) 15 (13.9) 4 (10.3)
76%-100% 23 (56.1) 29 (26.9) 9 (23.1)
 Percentage of adolescents advised about alcohol use 0% 6 (14.6) 16 (14.8) 15 (38.5) Pearson χ2= 17.61, P = 0.02
1%-25% 9 (22.0) 33 (30.6) 9 (23.1)
26%-50% 3 (7.3) 18 (16.7) 5 (12.8)
51%-75% 5 (12.2) 13 (12.0) 3 (7.7)
76%-100% 18 (43.9) 28 (25.9) 7 (18.0)
 Percentage of adolescents referred to alcohol treatment 0% 9 (22.0) 32 (29.6) 19 (48.7) Pearson χ2= 13.29, P = 0.10
1%-25% 13 (31.7) 47 (43.5) 11 (28.2)
26%-50% 4 (9.8) 8 (7.41) 2 (5.1)
51%-75% 7 (17.1) 10 (9.3) 5 (12.8)
76%-100% 8 (19.5) 11 (10.19) 2 (5.1)
Counseling confidence and importance
 Confidence in asking adolescents about their alcohol use Not at all 1 (2.4) 9 (8.3) 5 (12.8) Pearson χ2= 16.46, P = 0.01
Some 7 (17.1) 26 (24.1) 16 (41.0)
Mod 12 (29.3) 42 (38.9) 7 (18.0)
Very 21 (51.2) 31 (28.7) 11 (28.2)
 Confidence in asking adolescents about the quantity and frequency of their alcohol use Not at all 2 (4.9) 12 (11.1) 8 (20.5) Pearson χ2= 17.45, P = 0.01
Some 6 (14.6) 22 (20.4) 12 (30.8)
Mod 12 (29.3) 46 (42.6) 8 (20.5)
Very 21 (51.2) 28 (25.9) 11 (28.2)
 Confidence in advising adolescents about their alcohol use Not at all 3 (7.3) 18 (16.7) 19 (48.7) Pearson χ2= 25.45, P = 0.00
Some 12 (29.3) 36 (33.3) 9 (23.1)
Mod 14 (34.2) 33 (30.6) 7 (18.0)
Very 12 (29.3) 21 (19.4) 4 (10.3)
 Confidence in referring adolescents to treatment for their alcohol use Not at all 5 (12.2) 26 (24.1) 15 (38.5) Pearson χ2= 15.85, P = 0.02
Some 12 (29.3) 46 (42.6) 12 (30.8)
Mod 13 (31.7) 26 (24.1) 7 (18.0)
Very 11 (26.8) 10 (9.3) 5 (12.8)
 Importance of asking adolescents about their alcohol use Not/some 3 (7.3) 20 (18.5) 13 (33.3) Pearson χ2= 11.96, P = 0.02
Mod 12 (29.3) 32 (29.6) 14 (35.9)
Very 26 (63.4) 56 (51.9) 12 (30.8)
 Importance of asking adolescents about the quantity and frequency of their alcohol use Not/some 5 (12.2) 25 (23.2) 17 (43.6) Pearson χ2= 14.02, P = 0.01
Mod 14 (34.2) 40 (37.0) 14 (35.9)
Very 22 (53.7) 43 (39.8) 8 (20.5)
 Importance of advising adolescents about their alcohol use Not/some 6 (14.6) 19 (17.6) 17 (43.6) Pearson χ2= 14.17, P = 0.01
Mod 15 (36.6) 42 (38.9) 13 (33.3)
Very 20 (48.8) 47 (43.5) 9 (23.1)
 Importance of referring adolescents to treatment for their alcohol use Not/some 11 (26.8) 24 (22.2) 16 (41.0) Pearson χ2= 9.26, P = 0.06
Mod 9 (22.0) 43 (39.8) 10 (25.6)
Very 21 (51.2) 41 (38.0) 13 (33.3)
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Entries in bold face indicate P < 0.05.

Predictors of Counseling Practice

To further elucidate the relationship between adolescent counseling practices and potential predictor variables (i.e., profession, sex, training in counseling, years of PED clinical experience, and counseling experience), a multivariate regression model was constructed. To estimate a respondent’s current practice of counseling PED adolescent patients about their alcohol use, a counseling practice summary score was calculated by the sum of the respondent’s answers to the alcohol counseling questions. The range of possible summary scores was 0 to 16. The higher the score, the greater the number of patients the respondent counseled about their alcohol use while in the PED. The observed range of the self reported counseling practice variable was 0 to 16 (maximum possible score, 20), with an interquartile range of 4 to 10. The median score was 7.

Table 3 presents the univariate relationship between predictor variables and self reported counseling practice. With the exceptions of sex and years of PED clinical experience, the relationship between the other 5 predictor variables and counseling practice was statistically significant.

TABLE 3.

Univariate Analysis of Predictor Variables and Self-Reported Counseling Practices

Variable Parameter
Estimate* 		SE t P 95% Confidence Interval
Profession 4.04 0.62 6.51 0.00 2.82 to 5.27
Sex 1.37 0.73 1.87 0.06 −0.07 to 2.81
Training in adolescent counseling during professional schooling 2.15 0.48 4.50 0.00 1.20 to 3.09
Training in any counseling during professional schooling 2.18 0.40 5.51 0.00 1.40 to 2.96
Training in counseling in the past year 1.83 0.56 3.27 0.00 0.73 to 2.94
Clinical experience (years) 0.03 0.04 0.27 0.47 −0.05 to 0.10
Counseling experience (5-point scale) 2.36 0.34 6.86 0.00 1.68 to 3.04
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*

Parameter estimates are unstandardized ß weights.

Entries in bold face indicate P > 0.05.

A multivariate model including all 7 predictor variables was then constructed. Sex and years of PED clinical experience were included in the model in case these variables mediated the effects of other variables and to yield the most conservative estimate of the predictor variables relationships with reported counseling practices. The results are presented in Table 4. After adjusting for covariates, a respondent’s profession, training in counseling during their professional schooling, and their career counseling experience were significant predictors of their counseling practice.

TABLE 4.

Multivariate Analysis of Predictor Variables and Self-Reported Counseling Practices

Variable Parameter
Estimate* 		SE t P 95% Confidence Interval
Profession 2.61 0.75 3.48 0.00 1.13 to 4.09
Sex −1.6 0.75 −1.42 0.16 −2.54 to 0.41
Training in adolescent counseling during professional schooling 0.00 0.61 0.00 1.00 −1.21 to 1.20
Training in any counseling during professional schooling 1.01 0.53 2.06 0.04 0.05 to 2.15
Training in counseling in the past year −0.06 0.54 −0.11 0.91 −1.13 to 1.01
Clinical experience (years) 0.05 0.03 1.42 0.16 −0.02 to 0.11
Counseling experience (5-point scale) 1.51 0.42 3.58 0.00 0.68 to 2.36
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F7,174 = 11.21; P = 0.00; R2 = 0.31.

*

Parameter estimates are unstandardized ß weights.

Entries in bold face indicate P > 0.05.

4. Discussion

To the best of our knowledge, this is the largest survey of PED nurse, MD, and MD extender alcohol counseling beliefs and practice. The results of this survey suggest that a PED clinician’s profession, counseling training, and counseling experience are significant predictors of their current counseling practice in the PED setting. Although MDs/PAs/NPs in general reported more counseling training during their professional schooling, counseling training during professional schooling remained a significant predictor, after controlling for profession. However, profession and training alone do not appear to account for all the differences. It also appears that the more experience a PED clinician garners in his/her clinical career, the more likely he/she is to counsel his/her alcohol using adolescent patients.

These finding have important implications for future studies as well as the education and clinical careers of PED clinicians. Increasing counseling training during one’s professional schooling appears to be important for both RNs and MDs and MD extenders. For RNs in particular, such training may be critical in improving their confidence in their counseling ability. Studies have shown that even brief alcohol and drug educational training improves nursing students’ knowledge of and confidence in their intervention skills.31,32 Continuing to utilize counseling skills once training is completed also appears to be an important predictor of counseling practice. There are many ways this might be accomplished. Ongoing education, training, supervision, and feedback in counseling are a possibility. Previous studies have shown that educational interventions can improve MD16 and RN33,34 knowledge, skills, and confidence in treating alcohol using patients. Simply instituting routine alcohol screening may improve ED RN attitudes toward alcohol interventions,35 although the authors also note that this change in attitude did not translate into increased intervention. Aalto et al36 found that both primary care MDs’ and RNs’ alcohol BI knowledge, attitude, and skills improved after BI training, but that the RNs in particular had larger gains. Lock et al23 found that support from supervisors and administrators may also be important. Finally, changing the culture/belief that “counseling is not part of my job” may play a critical role in improving ED clinician counseling practices.

The median score of 5 (of a maximum possible score of 17) on the belief summary score suggests that despite the majority of respondents endorsing the importance of adolescent alcohol counseling, a large majority of respondents have negative beliefs and attitudes toward counseling alcohol using adolescents in the PED. The range of scores among respondents with a “favorable” view of adolescent alcohol counseling was 8 to 12. This indicates that even among respondents with a positive view of adolescent alcohol counseling, this group still harbors a number of reservations. These data, taken as a whole, suggest that belief in adolescent alcohol counseling alone may not be sufficient to change alcohol counseling practices.

There are many other interesting findings from this survey. Profession was not associated with the importance respondents assigned to adolescent counseling, nor was it associated with a respondent’s attitude or beliefs about counseling in the PED or substance abuse. Both RNs and MDs/PAs/NPs believe counseling alcohol using adolescents is important, and both report favorable attitudes toward such counseling. Similar to other studies, both MDs and RNs believe that counseling their patients is an important part of their clinical practice.16-18,22,23 Profession similarly did not distinguish respondents with more favorable versus less favorable attitudes and beliefs.

Rhode Island respondents differed from non-RI respondents on 1 of 10 demographic variables (years of PED clinical experience) and 5 of 30 survey items. Although years of PED clinical experience achieved statistical significance, it is debatable whether the difference (9.5 vs 13 years, respectively) represents a significant clinical difference. Of the 5 differing survey items, there is no consistent “theme” to or obvious relationship between the 5 items.

The fact that RI respondents were not significantly different from non-RI respondents is interesting, given that alcohol BI studies had been performed in the RI PED before the administration of this survey. In these studies, RI PED clinicians were informed about the nature of the studies and the interventions. They were encouraged to identify and refer alcohol using adolescents to the intervention study and to treat, advise, and counsel these patients as they normally would do. These clinicians, however, were not involved in administering the BI, nor did they receive any special training in alcohol screening or interventions. This finding suggests that workplace exposure to alcohol intervention researchers and research projects alone does not significantly influence PED clinician practice of or attitudes toward alcohol counseling.

Limitations of this study include the low overall response rate from non-RI sites. Without data on survey nonresponders, it is unclear whether survey respondents are representative of academic PED clinicians in the United States. Although RI respondents do not appear to be significantly different than non-RI respondents, if in fact there are true differences, this study’s findings would be subject to type II error. Given these limitations, the generalizability of this survey’s findings is unknown and could be biased in any number of ways.

One possible explanation for the similarity between RI and non-RI respondents is that all respondents may have shared a high motivation to complete the survey and/or interest in the survey topic, thus explaining their comparable responses. All survey responses were self report. Reports of training, experience, and counseling practices were not independently verified. Despite the anonymity of the survey, respondents may still have felt biased toward selecting more socially desirable responses.

Future research is needed to determine if the findings of this study accurately represent PED clinician practice of and beliefs about PED adolescent alcohol counseling. To success fully administer ED based adolescent alcohol BIs, it will be important to further understand the BI training needs of PED clinicians and optimal educational curricula, as well as elucidate the barriers to performing PED BIs. Larger studies with improved response rates are needed to address these questions.

CONCLUSIONS

Pediatric ED MDs/PAs/NPs differ significantly from RNs in their counseling training, experience, and practice. These findings have important implications for the training and support necessary to successfully implement PED counseling. Specifically, formal training in counseling during professional schooling and garnering counseling experience after completing training may be critical factors in promoting PED counseling.

ACKNOWLEDGMENTS

The authors thank the survey site collaborators for their invaluable assistance. Without their assistance in recruiting survey participants, this study would not have been possible. The authors gratefully recognize Marvin Culbertson, MD (Dallas, Texas); Laura Fitzmaurice, MD, and Theodore Barnett, MD (Kansas City, Missouri); William Hawk, MD (Oakland, California); Jeffrey Louie, MD (Minneapolis, Minnesota); Charles Macias, MD, MPH (Houston, Texas); Sandra Nairn, DO (Camden, New Jersey); Rick Place, MD (Fairfax, Virginia); Theodore Putnam, MD (Buffalo, New York); Anthony Woodward, MD, MBA (Seattle, Washington); and Robert Wright, MD, MPH (Boston, Massachusetts). The authors also thank Robert Norigian (Lifespan Corporation, Information Services Department, Providence, RI) for his assistance in creating and maintaining the Web based survey.

Funding Support:

NIAAA Grant# AA014934

Appendix A. PED ADOLESCENT COUNSELING SURVEY

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Contributor Information

Thomas H. Chun, Departments of Emergency Medicine and Pediatrics, The Alpert Medical School of Brown University, Providence, RI, USA.

Anthony Spirito, Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies, The Alpert Medical School of Brown University, Providence, RI, USA.

Gail D’Onofrio, Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA.

Robert H. Woolard, Department of Emergency Medicine, The Alpert Medical School of Brown University, Providence, RI, USA.

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