In the state of Massachusetts, there were 1,501 confirmed opioid-related overdose deaths in 2017. The Department of Public Health estimates that there will be an additional 433-518 deaths in 2018 (Massachusetts Department of Public Health, 2018). Predictive models put that number beyond 2,000 deaths, which peaked in 2016. Efforts to reverse these trends included enhanced law enforcement for drug trafficking, increasing Narcan availability and training, and stricter laws on opioid pain reliever prescribing. Rapid responses by local and state government offices are endeavoring to reverse the trend of mortality from opioid overdose, and our college is poised to address this crisis.

At the University of Massachusetts/Amherst, nursing students have a unique opportunity to firsthand define and actualize both upstream and downstream efforts to address the opioid epidemic that has plagued our nation. Funded by a grant from the Substance Abuse and Mental Health Services Administration, our student nurses learn motivational interviewing (MI) techniques and screening for alcohol and substances misuse and practice their new skills with their patients, peers, and families. Nearly 2 years into this 3-year grant, we have learned from our students: The greatest barrier to substance use disorder (SUD) screening in large and small agencies is stigma.

An essential component of our success has been our student advisory group. Our students, sent out to the community to practice their Screening, Brief Intervention, Referral to Treatment (SBIRT) skills, reported gaps in our intervention plan. Students immediately recommended the need to begin MI techniques on "Day 1" of their education. Second, they spoke of their discomfort in beginning an SBIRT conversation without a planned opportunity to reflect on their own lack of awareness of prejudices and bias and those they encounter within the health care system. As a result, we provided several learning opportunities during their curriculum for students to imagine the best way to unmask the difficulties encountered in talking about an uncomfortable topic such as alcohol and substance use. Equipped with their new skills, they are prepared to practice in the clinical setting; however, in our Advisory Group conversations, we heard multiple reports of a disconnect between what the students were learning and what they witnessed in practice. Students described that their role models in practice were not addressing substance use with their patients.

Stigma can be based on several different stereotypes that exist about people with SUDs. With unexamined biases, people can view people with SUDs as having moral weakness, being blameworthy, unreliable, having a poor work ethic, and that their situation is hopeless and can devalue them altogether. To document the students' experience, our Power of Nursing to Change Health Care evaluation team has now included in the pretraining and posttraining evaluation a battery of questions to gauge how student nurses' stigma in these areas changed over the course of their semester of intensive SBIRT training and practice. Across 239 students who have been trained so far, they show that SBIRT training and practice has increased their sense of value in people who have SUDs. In addition, they show less judgment in the areas of work ethic, unreliability, and moral weakness. Our goal is to try to unmask and promote the visibility of challenges in working with all persons, but particularly individuals with SUDs who are highly stigmatized. Our preliminary data suggest that stigma exists and is currently a barrier to care delivery. We have responded with broadening our approach in teaching and practice. We now start with our freshmen by teaching that MI is a core component of therapeutic communication and a practical approach of conversing about any health care issue. Now, instead of solely engaging in role play activities with fictional clients who may be at a high risk for SUD or who may be having difficulty with smoking cessation, students are practicing using MI when conversing with their peers or superiors in all practice settings. An identified barrier to students using MI is the lack of role models in practice asking these difficult questions and engaging in direct conversations with patients. Our SBIRT grant work to date has been enriched by students participating in shaping this evidence-based interviewing technique resulting in our infusing the nursing curriculum with compassion in nonjudgmental patient encounters. Such best practices are now a key component of the nursing curriculum and have implications beyond screening for substance use, across all caring encounters. We applaud the College of Nursing students for investment in caring for all of their patients and taking the lead in recognizing the curriculum and practice change that is needed.

Donna M Zucker, RN, PhD, FAAN,

Genevieve E. Chandler, RN, PhD

Suzanne Rataj, MPH

Edith Dundon, PhD, RN, CPNP

Dawn Heffernan, MS, RN, CDE

Gloria DiFulvio, PhD, MPH

Diane Fedorchak, M.Ed.

Sally Linowski, Ph.D

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