SBAR: Sample Paper

SBAR: Situation-Background-Assessment-Recommendation: Analysis of Internship Placement 2019–2020

S: Situation

a) Maryland Salem Children’s Trust was founded and functions on Christian principles and aims to “provide a home, therapy, and educational services to children who have been abused or neglected, or have educational or behaviors needs that require a residential or day school placement” (mdsalem.com, 2021). Their website goes on: “The Maryland Salem Children’s Trust is an organization committed to comprehensive health and wellness, and we strive to provide, facilitate, and encourage physical activity and wellness for our residents and our staff. Regarding residents, Salem seeks to involve and support 80% of its resident children/teens in regular physical activity including horseback riding, sports, and organized recreational outings and events. We also seek to provide all residents with dietary knowledge and serve a well balanced healthy individualized diet. Salem participates in the National School Lunch Program, and the Summer Food Service Program. These programs insure that proper nutrition practices are being followed and that the meals served are of proper nutrition value and portions.”

b) The agency serves youths, between the ages of six and 18, who have been referred through DJS (Department of Juvenile Services) or DSS (Department of Social Services) for residential placement.

c) The team with whom I work and collaborate with on a regular basis includes one part-time school counselor, one full-time social work clinician (my supervisor), one clinical/residential director, one residential assistant, and two residential specialists. This team meets once a week to discuss youths’ progress in clinical and residential settings and via email as needed. Additionally, there are all-staff meetings once a month that incorporate team building exercises and administrative check-ins.

d) My role is primarily to work as a part-time clinician with a caseload of 3–5 youths and my responsibilities include meeting with my assigned clients a minimum of three times each month for individual sessions, maintaining client records and progress notes, and occasionally accompanying youth to court cases and psychiatry appointments. I also shadow family and individual sessions with my supervisor, attend all-staff meetings and weekly service team meetings, as well as participate in Service Plan meetings.

B: Background

a) There is a variety of common social determinants of health, risk and protective factors related to our target population of adolescents. Developmental factors related to puberty and brain development correlate with structural factors such as national wealth, income inequality, and access to education, as well as the presence or absence of safe, supportive families and schools and positive, supportive peers to predict health and wellness outcomes in adulthood (Viner, 2012). Protective factors for young people include communication with caregivers and familial support and positive peer relations that support forming one’s identity, developing social skills and self-esteem, and working toward autonomy, as well as living in communities with high levels of social capital (Currie et al., 2012). Risk factors include hyperactivity, poor academic performance, peer delinquency, and availability of drugs in the community, as well as the presence of mental health disorders, genetic predispositions to illnesses, and familial stressors (Bilsen, 2018; Herrenkohl et al., 2000).

b) Patients are referred to the agency via DJS or DSS, and each referral is reviewed by the Residential Referral team, which includes clinicians, residential directors, the nurse practitioner, and the executive director, on a weekly basis. The information provided about patients in advance includes basic demographic information, reason(s) for the referral, current medical and psychiatric information (diagnoses, medications), and a brief on the youth’s experience(s) with previous institutions and the legal system from the perspective of the youth’s prior clinician(s) and attorney(s).

c) My understanding of how the team decides if or when to refer patients to other services is limited. During my time at Salem, there was only one instance wherein a youth went through the process of emergency discharge, which can only be initiated by the clinician. From what I understand, the team reviews the youth’s progress with residential and clinical goals and discusses their level of need and safety risk to determine if a more supportive, structured environment would better serve the youth.

d) While there are a variety of assessments and information-gathering tools utilized and administered by the clinical and residential team (initial intake assessment, MD CANS, OMS, social history), the only screening instrument I am aware that we use is the suicide screening tool and this can only be administered by a licensed clinician. The tool we use is labeled Screening of Suicide Risk Factors/Outpatient Services.

A: Assessment

a) Screening for suicide is a vital tool to use with the adolescent population (Ham & Allen, 2012). However, the specific screening tool used by this organization may not be the best evidence-based tool available. SPRC (2014) recommends choosing a tool that has documented evidence of effectiveness, as well as one that is cost effective and age appropriate. Based on the copy of the screening tool I was provided, I have no idea where this screening tool is from, when it was developed, or who developed it, which is concerning. It includes a rating scale for level of suicidal ideation (acute/moderate, moderate/high) and check boxes for risk factors and protective factors. Unfortunately, because there is limited information about this particular suicide screening tool and it fails to incorporate direct questions about suicidal ideation, it does not seem to be adequate.

b) Additionally, research shows that it is also important to screen adolescents for depression and risky behaviors, including poor diet/low physical activity, sexual activity, substance abuse, eating disorders, and unintentional injury, as these correlate with health and wellness outcomes later in life (Cotton, Ball, & Robinson, 2003; Ham & Allen, 2012; Stice et al., 2017).

c) There are a variety of areas in which screening can help by allowing prevention or early intervention of risky behaviors so that teens have better wellness outcomes but administering a myriad of screening tools in a single sitting could be overwhelming for patients. Additionally, because Salem Children’s Trust is a Christian-faith-based organization, it may be against values to screen for sexual activity.

R: Recommendations

a) The population served at this organization should be screened for mental illnesses, suicidality, and risky behaviors, including poor diet/low physical activity, sexual activity, substance abuse, eating disorders, and unintentional injury (Cotton, Ball, & Robinson, 2003; Ham & Allen, 2012; Stice et al., 2017).

b) Based on the mission statement of Salem Children’s Trust (2021) to “provide, facilitate, and encourage physical activity and wellness,” it would make sense to incorporate screenings for diet/low activity and substance abuse, as well as suicidal ideation and unintentional injury. Often the youth have already been diagnosed with mental illness(es) by the time of referral and regular appointments with a psychiatrist are built into the program, so screening for depression and eating disorders would not be a duty of the agency but rather the youth’s psychiatrist.

c) Based on the small staff (one nurse practitioner, one clinical social worker) and our agency’s mission, the agency is most likely able to screen for diet/low activity, substance abuse, and suicidal ideation.

d) The agency should use tools that are evidence based and age appropriate (SPRC, 2014). The S2BI (Screening to Brief Intervention) is evidence-based, geared toward youth, and can be used to screen for tobacco, alcohol, marijuana, and other/illicit drug use (AAP, 2015). Ask Suicide-Screening Questions (ASQ) is a validated tool for youth that should be used to screen for suicide (NIMH, 2020). It is my recommendation for the agency to implement screenings with S2BI and ASQ specifically.

e) The ‘clinical pathway’ for screening:

1. The screenings for substance abuse and suicidal ideation should be administered by the clinical social worker according to their discretion. A screening on poor diet/low physical activity should be chosen and administered by the nurse practitioner when the patient is first admitted, halfway through their stay, and before discharge to monitor progress.
2. The clinical social worker and residential lead will be informed of the results during one of the weekly team meetings. Depending on the results of the screening, actions will be taken to support the youth. For instance, positive results on the suicide screening would lead to an increased “watch” level to ensure the youth’s safety and noted in their clinical file. If a youth indicates difficulties with maintaining physical activity or poor diet, their residential lead could work that into the youth’s personal goals. Positive results on the S2BI would lead to clinical intervention facilitated by the clinical social worker. The current screening for suicidal ideation should be replaced with ASQ in order to improve the agency’s screening procedure.
3. Positive suicidal ideation will be relayed to the teaching parents in the youth’s house in order to ensure safety. This information is relayed via phone call to the teaching parents currently working in the house, documented in the youth’s files, and progress is revisited during weekly residential staff meetings called Switch meetings. Likewise, information regarding goals around physical health would be relayed to teaching parents and noted in the youth’s file in their house. If the screening indicates that a youth needs to be monitored for “cheeking” medication or hiding tobacco/substances in their room, that would also be relayed to the teaching parents in their house. I think the current process for relaying screening information is comprehensive and appropriate.

Conclusion

If I were to present these findings to the agency, I would ask to have time for a presentation during one of the weekly meetings with the team (residential specialists, clinicians, nurse practitioner, and executive director). I would create a printout in SBAR format to handout and then present on the situation, background, assessment, and recommendations to the team. I would particularly focus on the specific recommended screenings that are feasible for our agency in order to avoid overwhelming the audience with every screening that is recommended for adolescents. If the team agrees with one or all of the recommended screening changes, I would then ask to present at the next all-staff meeting in order to inform all the staff of the incoming changes and give them time to become familiar with the new screening tools. This would also allow for opportunities for questions and adjustments to the screening process and information dissemination as needed.

References

American Academy of Pediatrics. (2015). Substance Use Screening and Brief Intervention for Youth. Retrieved from https://www.aap.org/en-us/advocacy-and-policy/aap-healthinitiatives/Pages/Substance-Use-Screening.aspx

Bilsen, J. (2018). Suicide and Youth: Risk Factors. Frontiers in Psychiatry, 9, 540. DOI=10.3389/fpsyt.2018.00540

Cotton, M., Ball, C., & Robinson, P. (2003). Four simple questions can help screen for eating disorders. JGM, 18, 53–56. Retrieved from
https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1525-1497.2003.20374.x

Currie, C., [eds.] (2012). Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen, WHO Regional Office for Europe, 2012 (Health Policy for Children and Adolescents, №6). Retrieved from
https://www.academia.edu/download/39900069/Social_determinants_of_health_and_well-b20151111–27604-w42wjb.pdf

Ham, P. & Allen, C. (2012). Adolescent Health Screening and Counseling. Am Fam Physician, 86(12), 1109–1116. Retrieved from https://www.aafp.org/afp/2012/1215/p1109.html

Herrenkohl, T.I., Maguin, E., Hill, K.G., Hawkins, J.D., Abbott, R.D., Catalano, R.F. (2000). Developmental risk factors for youth violence. Journal of Adolescent Health, 26(3), 176-196. https://doi.org/10.1016/S1054-139X(99)00065-8

Maryland Salem Children’s Trust (2021). Home page. Retrieved from https://mdsalem.com/ and https://mdsalem.org/about.html

National Institute of Mental Health (2020). Ask Suicide-Screening Questions (ASQ) Toolkit. Retrieved from https://www.nimh.nih.gov/research/research-conducted-at-nimh/asqtoolkit-materials/index.shtml

Suicide Prevention Resource Center. (2014, September). Suicide Screening and Assessment. Waltham, MA: Education Development Center, Inc.

Stice, E., Gau, J. M., Rohde, P., & Shaw, H. (2017). Risk factors that predict future onset of each DSM-5 eating disorder: Predictive specificity in high-risk adolescent females. Journal of Abnormal Psychology, 126(1), 38–51. https://doi.org/10.1037/abn0000219

Viner, R.M., Ozer, E.M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., Currie, C. (2012). Adolescence and the social determinants of health. The Lancelot, 379, 1641–52. DOI:10.1016/S0140- 6736(12)60149–4