Nurse Educator

Nurse Educator Vol. 39, No. 5, pp. 252-255 Copyright * 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Tobacco Cessation Education for Advanced Practice Nurses Diane Whitehead, PhD, DNP, RN & Steven B. Zucker, DMD, MEd & Jennifer Stone, DNP, APRN The predicted shortfall of primary care physicians and the millions of newly insured beginning in 2014 call for an increase in the number of advanced practice nurses (APRNs). Advanced practice nurses can significantly improve their clients’ quality of life and increase their life expectancy through tobacco cessation education. The purpose of this study was to educate APRN students on smoking information and techniques to assist clients with quitting smoking in the primary care setting. Keywords: advanced practice nursing; advanced practice nursing education; tobacco cessation; tobacco education

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ccording to the Centers for Disease Control (2013),1 cigarette tobacco causes 1 in 5 deaths each year in the United States. Along with approximately 443,000 deaths annually in the United States and 5 million deaths worldwide, tobacco use is the leading cause of disability. More than $193 billion annually in healthcare expenses and loss of work productivity is caused by tobacco use. In addition to the individual who actually uses tobacco is the person who suffers from exposure to secondhand smoke.2-4 The Surgeon General makes it clear that ‘‘there is no risk-free level of exposure to tobacco smoke, and there is no safe tobacco product.’’4 Unfortunately, the Healthy People (HP) 2010 goal of reducing the percentage of smokers older than 18 years to 12% was not met, extending this 12% target for the HP 2020 goal. Currently, 19.0% of adults still smoke.1 Forty percent to 60% of smokers attempt to quit annually. Without assistance by healthcare providers, only 3% to 5% are successful with quitting. Smokers assisted by healthcare providers are 1.7 to 2.2 times more likely to remain a nonsmoker after 5 months.5,6 The US Department of Health and Human Services Clinical Practice Guidelines recommends that every clinician consistently identifies and documents tobacco use at each patient encounter. This guideline recommends that every tobacco user be treated at each patient encounter.7 The Institute of Medicine recommends that a mandatory tobacco assessment and cessation referral be a condition of reimbursement for all standard medical procedures.8,9 Author Affiliations: Professor (Dr Whitehead), College of Nursing; Associate Dean (Dr Zucker), Director Area Health Education Center, College of Osteopathic Medicine; Assistant Professor (Dr Stone), College of Nursing, Nova Southeastern University, Fort Lauderdale, Florida. The authors declare no conflicts of interest. Correspondence: Dr Whitehead, Nova Southeastern University, 3200 South University Dr, Fort Lauderdale, FL 33328 ([email protected]). Accepted for publication: April 5, 2014 Published ahead of print date: May 23, 2014 DOI: 10.1097/NNE.0000000000000056

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The predicted shortfall of primary care physicians and the millions of newly insured beginning in 2014 call for an increase in the number of advanced practice nurses (APRNs).10 Advanced practice nurses can significantly improve their clients’ quality of life and increase their life expectancy through tobacco cessation education. Research supports that nurse practitioners believe that they should have a role in tobacco cessation education with their clients and that further education in this area is needed. However, nurses still report reasons for not providing tobacco cessation support, including lack of reimbursement, motivation, busy competing health priorities, lack of confidence in approaching this topic, a feeling that pushing clients to quit might force them to find another provider, respect for privacy, and a belief that most smokers do not want to quit.11-14 The purpose of this educational intervention was to educate nurse practitioner students on smoking information and techniques to assist clients with quitting smoking in the primary care setting. The research question was: Will the education program based on the Rx for Change curriculum increase APRN students’ knowledge, skills, and confidence in providing tobacco cessation training?

Evidence-Based Literature The US Department of Health and Human Services began publishing guidelines for treating tobacco use in 2000. The current update reflects a systematic review of more than 8,700 research articles and collaboration among 8 governmental and nonprofit organizations. Based on this systematic review, the 2008 Quick Reference Guide for Clinicians 2008 Update: Treating Tobacco Use and Dependence recommends the following actions: (a) tobacco should be considered a chronic disease, (b) tobacco use should be documented and addressed at every clinician encounter, (c) tobacco dependence treatment can be brief and still be effective, (d) a variety of counseling methods have been Nurse Educator

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shown to be effective, (e) 7 first-line medications have been demonstrated to increase smoking abstinence rates, (f ) a combination of counseling and medication is more effective together than alone, and ( g) telephone quit lines are effective.7 A 2014 review of the Cochrane Database of Systematic Reviews identified 92 systematic reviews on topics related to tobacco. One of these reviews, completed in 2012, assessed the effectiveness of training healthcare professions to deliver smoking cessation interventions. This review included 17 randomized controlled trials (RCTs) using interventions for tobacco cessation with healthcare professionals. All RCTs included in the review had maintained data collection for a minimum of 6 months after intervention. The authors of the review concluded that training health professionals in tobacco cessation interventions had a significant difference in the point prevalence of smoking and continuous abstinence.15 Additional reviews of evidence-based literature for the past 5 years related to tobacco cessation education with health professionals revealed 13 cohort studies, 1 systematic review qualitative study, 5 descriptive studies, and 4 reports from experts.16

Methods This research project was pretest-posttest design. The intervention was an online education program on tobacco cessation and motivational interviewing. Five online PowerPoint modules using the RX for Change program information and the Florida Area Health Education Centers (AHEC) Tobacco Cessation and Training17,18 were used for this education intervention: (a) introduction and epidemiology of tobacco use, (b) nicotine pharmacology and principles of addiction, (c) drug interactions with smoking, (d) assisting clients with quitting using a transtheoretical model, and (e) aids for cessation.17,18 The tobacco cessation training was incorporated into the second-term graduate advanced health assessment APRN course. The outcomes for this educational intervention were (a) increased knowledge on smoking information and cessation and (b) perceived confidence to provide smoking cessation information.

Participants Participants (n = 36) for this project were a nonprobability convenience sample of APRN students enrolled in an MSN Family Nurse Practitioner Program in south Florida. Age, race, smoking status, and experience in nursing and tobacco cessation education were assessed using a researcherdeveloped demographic survey. Students were advised in the online training course that although the completion of the education on tobacco cessation was a required part of the advanced health assessment course, completion of the demographic survey was optional. All 36 students elected to complete the demographic survey. Only 3 students responded yes to the question, ‘‘have you ever discussed smoking cessation with your patients’’? These students also indicated that they had assessed current smoking status with patients. However, only 1 of the 33 respondents indicated that smoking cessation information or supportive materials had been provided to patients. None of the students had ever attended any training on providing smoking cessation to patients. Twenty-five of the 36 students had never Nurse Educator

smoked. One student was a current smoker, and 10 students indicated a previous history of smoking. Of these 10 students, 7 had smoked from 1 to 10 years, and 4 had smoked 11 to 20 years. Approval from the institutional review board was obtained prior to implementation of the research.

Instruments A 20-question survey of knowledge related to tobacco use and cessation and a 15-question Skills and Confidence for Smoking Cessation Tool were completed by the APRN students before and after completing the online educational program. The Skills and Confidence for Smoking Cessation Tool was initially used in the study of Matten et al19 of an evaluation of tobacco cessation classes with hospital staff nurses. Approval to use this tool was received from the developer. The first 6 questions measured participants’ skills in dealing with smoking cessation. The next 9 questions measured participants’ confidence in providing smoking cessation education. The Likert-scale responses on the Skills and Confidence for Smoking Cessation tool were coded as follows: 1 (none), 2 (poor), 3 (good), 4 (very good), and 5 (excellent). The highest score on the skills section was 30, and the confidence section 45. Matten et al19 reported internal consistency for the 6-question skill portion of the tool at Cronbach’s ! = .81, and the confidence portion at Cronbach’s ! = .93.19 A knowledge-based preassessment and postassessment tool was developed by the researcher. The knowledge assessment tool was reviewed by the director of the university AHEC Tobacco Cessation and Training program. No changes were recommended. The knowledge survey consisted of 20 multiple-choice questions with the highest score of 20.

Procedures The Skills and Confidence for Smoking Cessation Tool and the knowledge survey were placed in an online noncredit section of the Blackboard course management tool used by the university. Students enrolled in the fall 2013 term of advanced health assessment in the Family Nurse Practitioner Program were uploaded into the tobacco education course by the registrar’s office. The faculty of record and the researcher met with the students in September 2013. Students were introduced to the State of Florida tobacco education funding provided through Florida AHEC programs and the activities currently in place at the university. Students were informed of the training modules within their health assessment course and the requirements for completion in the course. Students were advised about the 6-week schedule to complete a pre and post knowledge survey as well as a skills and confidence survey after reviewing the modules. Students were advised that the aggregate scores for these surveys would be used to improve the tobacco cessation training modules in the future.

Data Analysis Paired-sample t tests were conducted to analyze the pretest and posttest results of the survey on knowledge related to tobacco use and cessation and the Skills and Confidence for Smoking Cessation Tool. Separate paired-sample t tests were Volume 39 & Number 5 & September/October 2014

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completed on the 6 questions related to skills and 9 questions related to knowledge. SPSS Statistics Student Version 18 (IBM, Inc, Armonk, New York) was used for analyzing the data. The level of significance was set at .05.

Results The mean on the knowledge presurvey was 9.77 (SD, 2.02). The mean on the knowledge postsurvey was 17.47 (SD, 2.26). The mean on the presurvey for the 6 skills questions was 14.61 (SD, 4.06), and the mean on the postsurvey was 25.75 (SD, 3.99). The mean on the presurvey for the 9 confidence questions was 16.41 (SD, 6.46), and the mean on the postsurvey was 39.36 (SD, 5.01). There was a statistically significant increase in the APRN students’ perceptions of their knowledge, skills, and confidence for assisting clients with smoking cessation after completing the education intervention (P G .001) (Table 1).

Discussion There was a significant difference in the scores on the knowledge survey and on the questions related to skills and confidence before and after the APRN students’ completion of the online education intervention. These findings are consistent with the literature, including conclusions of the Cochrane systematic reviews supporting increased knowledge, skills, and confidence of nurses after education on smoking cessation.14,15,19,20 As the largest group of healthcare providers in the United States, nurses have the potential to reach a significant number of tobacco users. Despite the focus on treating tobacco dependence, including The Joint Commission core measures requirement that all hospitalized patients be screened for tobacco use,21 tobacco cessation education is not a part of most nursing curricula.22 Information related to health benefits of cessation, nicotine addiction and withdrawal, and treatment options should be discussed in all levels of nursing education. Although any content on tobacco cessation is useful, an integrated approach across nursing curriculum that could address the unique needs of special populations such as women, adolescents, and patients with mental health needs may provide a more effective foundation for practicing interventions while in the clinical setting. In graduate programs, nurse practitioners and clinical nurse specialist students not only should be taught tobacco cessation content but should also understand how to provide leadership in clinical and community settings for tobacco cessation programs. Nursing education students should explore effective ways of integrating and evaluating tobacco cessation education into curriculum. Faculty can explore materials already developed for tobacco cessation education. The Rx for Change5 standardized curriculum is based on the Clinical Table 1. Presurvey-Postsurvey Scores (n = 36) Test Knowledge Skills Confidence

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Pre

Post

9.77 (SD, 2.02) 14.61 (SD, 4.06) 16.41 (SD, 6.46)

17.47 (SD, 2.26) 25.74 (SD, 3.99) 39.36 (SD, 5.01)

t j17.427 j10.990 j16.090

P .001 .001 .001

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Practice Guideline for Treating Tobacco Use and Dependence.7 This program provides readings, lecture with animated PowerPoint slides, and video case scenarios in both a 6- and 2-hour format. All materials are continuously updated to reflect current practice guidelines. This program offers a foundation of tobacco cessation content that faculty can then make more relevant to their individual curriculum. Students also need opportunities to practice tobacco cessation treatment messages in the clinical area. Beginning with observing the video scenarios from the Rx for Change program,5 role play and simulation case studies can also provide opportunities for practice and evaluation of tobacco cessation interventions. At the graduate level, the use of standardized patients can be used. These experiences can be tailored to interventions for special populations such as different race, ethnicity, age, and medical conditions. If available, collaboration with multidisciplinary groups of students should be considered. Regardless of the practice setting, students should be provided timely feedback with suggestions for improvement.23 Barriers to including tobacco cessation curriculum in nursing programs include lack of time within the course materials, competing priorities of course content, lack of resources, lack of trained faculty, and lack of institutional support.24 One recommendation is to identify early adopters who will take on the ‘‘train-the-trainer’’ approach and assist other faculty.25 Several current studies revealed that after participating in tobacco cessation education courses, the percentage of faculty who spent at least 3 hours of a course devoted to tobacco cessation significantly increased.23,24

Strengths The major strength of this study was providing knowledge and skills to APRN students on tobacco cessation education that they can use to support their clients in primary care. Apparent success of the intervention was noted through a significant difference in pretest and posttest scores. The use of online modules that could be reviewed on the students’ own time over a period of several weeks appeared to be helpful to the busy APRN students.

Limitations The small sample size (n = 36) was a significant limitation. Although the education intervention was a requirement of the APRN health assessment course, there was no penalty for nonparticipation or grade or participation. Forty students were enrolled in the course. Three students failed at midterm and did not complete the education intervention. One student completed the health assessment course but did not participate in any of the tobacco cessation education.

Recommendations The tobacco cessation education should be a mandatory requirement for APRN education. Although the online modules demonstrated significant differences between presurvey and postsurvey, the inclusion of a face-to-face education component might provide more opportunities for dialogue and shared experiences among APRN students. Data on APRN students’ experience with tobacco cessation education in their primary care clinical rotations should be collected. Nurse Educator

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Tobacco cessation education also should be included in associate degree and baccalaureate nursing programs. The use of already developed quality materials such as those provided through the Rx for Change program5 should be considered as a starting point for inclusion into the curriculum. Faculty showing an interest in tobacco cessation education should be provided opportunities for further education and certification to develop expertise in supporting other faculty. Preparing students to participate in the prevention of tobacco-related illnesses is an important part of all levels of nursing education. Further research is needed to identify effective educational strategies in tobacco cessation education. Data on the effectiveness of students’ tobacco cessation interventions with patients in the clinical settings also should be explored.

References 1. Centers for Disease Control and Prevention. Morb Mortal Wkly Rep. 2012;61(44):889-905. 2. Chaney S, Sheriff S. Evidence-based treatments for smoking cessation. Nurse Pract. 2012;37(4):24-31. 3. US Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking Attributable Disease. Rockville, MD: Public Health Service; 2020. 4. Centers for Disease Control and Prevention. Smoking and Tobacco Use. CDC Web site. Updated 2013. http://www.cdc.gov/tobacco/ index.htm. Accessed August 16, 2013. 5. Regents of the University of California. Rx for Change: Clinician Assisted Tobacco Cessation. RX for Change Web site. http://rxfor change.ucsf.edu/curricula/teaching_materials.php. Accessed August 16, 2013. 6. Sheffer CE, Barone CP, Anders ME. Training health care providers in the treatment of tobacco use and dependence: pre-and post-training results. J Eval Clin Pract. 2011;15(4):607-613. 7. US Department of Health and Human Services. Quick Reference Guide for Clinicians 2008 Update: Treating Tobacco Use and Dependence. Rockville, MD: Public Health Service; 2008. 8. Whitehead D. Smoking Cessation for Advance Practice Nurses [Paper presented in partial fulfillment of doctor of Nursing Practice Degree]. Minneapolis, MN: Walden University; 2013. 9. Balough E, Patlak M, Nass S. Reducing Tobacco-Related Cancer Incidence and Mortality: Workshop Summary. Washington, DC: National Academies Press; 2012. 10. Levin P, Bateman R. Organizing and investing to expand primary care availability with nurse practitioners. J Community Health. 2012;37(2):265-269.

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11. Schroeder S. An update about tobacco and cancer: what clinicians should know. J Cancer Educ. 2012:27(1):5-10. 12. Patelarou E, Vardavas C, Ntzilepi P, et al. Nursing education and beliefs towards tobacco cessation and control: a cross-sectional national survey (GHPSS) among nursing students in Greece. Tob Induc Dis. 2011;9(4):1-6. 13. Studts J, Flynn S, Dill T, et al. Nurse practitioners’ knowledge, attitudes, and clinical practices regarding treatment of tobacco use and dependence. J Nurse Pract. 2010;6(3):212-219. 14. McIvor A, Kayser J, Assaad J, et al. Best practices for tobacco cessation interventions in primary care. Can Respir J. 2009;16(4): 129-134. 15. Carson K, Verbiest M, Crone M, et al. Training health professionals in tobacco cessation. Cochrane Database Syst Rev. 2012;5:1-144. 16. Melynk B, Fineout-Overholt E. Evidence-Based Practice in Nursing and Health Care. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 17. Regents of the University of California. Rx for Change: clinician assisted tobacco cessation. Rx for Change Web site. http://rxfor change.ucsf.edu/curricula/teaching_materials.phd. Accessed July 12, 2013. 18. Keys AHEC Tobacco Dependence—Health Care Professional. Florida Keys AHEC Web site. http://www.aheceducation.com/ ELearning/CourseCatalog.aspx. Accessed July 13, 2013. 19. Matten P, Morrison V, Rutledge D, Chen T, Chung E, Wong S. Evaluation of tobacco cessation classes aimed at hospital staff nurses. Oncol Nurs Forum. 2011;38(1):67-73. 20. Ubina E, van Sell S, Arnold C, Woods S. Best practice guidelines for nurse practitioners regarding smoking cessation in American Indian and Alaskan Native youth. J Community Health. 2011; 34(3):266-274. 21. The Joint Commission. Specifications Manual for National Hospital Inpatient Quality Measures. 2014. Updated 2014. Joint Commission Web site. http://www.jointcommission.org/specifications_ manual_for_national_hospital_inpatient_quality_measures.aspx. Accessed March 23, 2014. 22. Sarna L, Bialous S, Rice V, Weavers E. Promoting tobacco dependence treatment in nursing education. Drug Alcohol Rev. 2009; 28(5):507-516. 23. Heath J, Inglett S, Young S, et al. The impact of the Georgia Health Sciences University nursing faculty practice on tobacco cessation rates. Nurs Clin North Am. 2012;47(1):1-12. 24. Heath J, Crowell N. Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty. J Prof Nurs. 2007;23(4):189-200. 25. Prochaska J, Fromont S, Hudmon K, Cataldo J. Designing for dissemination: development of an evidence-based tobacco treatment curriculum for psychiatry training programs. J Am Psychiatr Nurses Assoc. 2009:15(1):24-31.

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Tobacco cessation education for advanced practice nurses.

The predicted shortfall of primary care physicians and the millions of newly insured beginning in 2014 call for an increase in the number of advanced ...
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