Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
Linda P. Sarna, PhD, RN, FAAN Stella Aguinaga Bialous, RN, DrPH, FAAN Eva Kra´lı´kova´, MD, PhD Alexandra Kmetova, MD Vladislava Felbrova´, RN Stanislava Kulovana´, RN Katerina Mala´, RN Eva Roubı´ˇckova´, RN Marjorie J. Wells, PhD, RN Jenny K. Brook, MS
Tobacco Cessation Practices and Attitudes Among Nurses in the Czech Republic K E Y
W O R D S
Background: Tobacco is the leading cause of cancer in the Czech Republic. More
Continuing education
than one-third of the population older than 15 years smokes, including many nurses.
Czech Republic
Most smokers want to quit, but the extent of nurses’ involvement in tobacco cessation
Eastern Europe
is unknown. Objective: The purposes of this study are to describe the frequency of
Nurses
nurses’ interventions in helping smokers quit, examine their attitudes and skills, and
Smoking cessation
explore the relationship of nurses’ smoking status to level of intervention. Methods: A convenience sample of nurses in the Czech Republic completed a survey about their frequency of interventions according to the 5As for tobacco dependence treatment (ie, ask, advise, assess, assist, arrange), their attitudes and perceived skills, and their smoking status (never, former, current). Results: A total of 157 nurses completed the survey; 26% ‘‘always’’ or ‘‘usually’’ assisted patients with smoking cessation. Few (22%) reported that nurses could play an important role in helping patients quit, and 65% rated their ability to help smokers quit as ‘‘fair/poor.’’ Nurse who smoked (30%) were less likely to consistently assess smoking status or arrange for follow-up support. Conclusion: Few nurses in the Czech Republic consistently provide smoking cessation support to patients, have the skills to do so, or view this
Author Affiliations: School of Nursing, (Drs Sarna and Wells), David Geffen School of Medicine (Ms Brook), University of California, Los Angeles; Tobacco Policy International, San Francisco, California (Dr Bialous); Institute of Hygiene and Epidemiology (Drs Kra´lı´kova´ and Kmetova) and Military University Hospital (Ms Mala´), First Faculty of Medicine, Charles University in Prague; the General University Hospital (Drs Kra´lı´kova´ and Kmetova); Centre for TobaccoDependent of the Third Medical Department (Drs Kra´lı´kova´ and Kmetova and Mss Felbrova´ and Kulovana´); and Radiotheraputic and Oncology Clinic, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic (Ms Roubı´cˇkova´).
This study was supported by a grant to the International Society of Nurses in Cancer Care from Bristol Meyers Squibb Foundation, Bridging Cancer Care, and Sarna’s Lulu Wolf Hassenplug Endowed Chair Fund, School of Nursing, University of California, Los Angeles. The authors have no conflicts of interest to disclose. Correspondence: Linda P. Sarna, PhD, RN, FAAN, University of California, Los Angeles, School of Nursing, 700 Tiverton Ave, Los Angeles, CA 90095-6918 ([email protected]). Accepted for publication October 28, 2014. DOI: 10.1097/NCC.0000000000000222
E22 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
role as an important part of their role. Implications for Practice: To reduce tobacco-related cancers in the Czech Republic, capacity-building efforts are needed to enhance nurses’ skills and confidence in providing smoking cessation interventions. Support is also need to help nurses who smoke quit.
D
espite overwhelming scientific evidence of the link between smoking and cancer, smoking remains common in Central and Eastern Europe.1 Smoking is a major contributor of all-cause mortality in the European Union and accounted for 25% of all cancer-related deaths, with lung cancer, a largely preventable cancer, as the major component.2 In Europe, lung cancer deaths are projected to overtake breast cancer deaths among women by 2015.3 However, few countries in Europe have tobacco dependence treatment support in place.4 In addition to preventing the uptake of new users, supporting quit efforts is an important part of reducing the risk for cancer as well as improving overall health. The involvement of nurses in the delivery of smoking cessation interventions to patients in hospital settings in the Czech Republic is unknown.
n
Background
Tobacco use is the main cause of preventable disease and death worldwide2 and in the Czech Republic. It is estimated that approximately 16 000 deaths attributed to tobacco use, including 7000 deaths from cancer, occur every year in this country.2 Approximately 36% of the population aged 15 to 64 years use tobacco (41% of men and 32% of women) and approximately 25% of the population older than 15 years are daily smokers.1 Smoking among youth, aged 13 to 15 years, is of great concern as 40% currently use tobacco and 31% smoke cigarettes (higher among girls, 33%, than among boys, 30%).5 Approximately 100 000 Czech nurses,5 the largest group of healthcare providers, if adequately educated about brief cessation interventions, could make a significant difference in helping smokers quit and in reducing the risk for cancer. Most smokers in the Czech Republic (60%) express a desire to quit.6 Evidence supports the efficacy of nurses in effectively helping patients to quit smoking.7 Czech nurses have a professional guideline that supports their role and responsibility in smoking cessation.8 The evidence-based intervention for tobacco dependence treatment includes the provision of pharmacotherapy and support, including skills training. Interventions for treating tobacco dependence are summarized as the 5As (ie, ask about tobacco use, advise smokers to quit, assess readiness to quit, assist with a quit attempt, and arrange for follow-up to prevent relapse).9,10 However, only 7% of Czech nurses received education about tobacco dependence treatment in school.11,12 Recognizing this need, the Centre for Tobacco-Dependent of the Third Medical Department, Prague, developed a program for healthcare professionals, including nurses, to become tobacco dependence treatment specialists.8,10 Some of these nurse specialists provide care to smokers in their quit efforts in the over 40 cessation centers throughout the country. However, to receive this support, smokers must travel to these locations. It is
Czech Nurses and Tobacco Cessation
unknown if nurses working in hospitals have the knowledge and skills to support smokers in their quit efforts. Although the Czech Republic is 1 of the 178 countries that are a Party to the World Health Organization (WHO) Framework Convention on Tobacco Control (http://www.who.int/fctc/signatories_ parties/en/), comprehensive tobacco control policies in the country are yet to be fully implemented.1 One of the components of the WHO Framework Convention on Tobacco Control includes providing support for tobacco cessation; however, equipping healthcare professionals with knowledge and skills is a necessary prerequisite. Existing resources to support quit efforts in the Czech Republic do exist but are underused, including a national telephone quitline and Web sites (Stop-koureni [Stop smoking], www.stop-koureni.cz, and Odvykanikoureni [Quitting smoking], www.odvykanikoureni.cz). If nurses were knowledgeable about resources, they could support patients’ quit efforts. Nonsmoking role modeling and increasing tobacco control content in healthcare curricula are 1 of the strategic policy recommendations in the Fourth Edition of the Tobacco Atlas13 and the WHO’s recommendations to combat noncommunicable diseases.14 Smoking among healthcare providers can be a barrier to interventions by increasing negative attitudes and decreasing involvement to help patients who smoke quit.15 This is a concern in the Czech Republic because among healthcare professional students (physicians, dentists, pharmacists, and nurses), female nursing students have the highest rates of smoking, 32.2%.11,12 Data from an unpublished study report smoking among practicing nurses to be as high as 40% (Eva Kralikova, personal communication, June 23, 2011, regarding unpublished data from Kralikova et al). Because the focus of this study was the assessment of an evidencebased intervention for smoking cessation interventions for nurses, we used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) translational research model.15,16 This allowed us to determine the level of involvement of nurses in smoking cessation before we began and evaluated the impact of an educational workshop on improving outcomes in the long and short-term. Based on previous studies,17Y21 nurses’ educational and clinical background, as well as personal characteristics, including age, sex, and smoking status, may influence their knowledge, attitudes, and involvement in smoking cessation interventions. The purpose of this article is to describe the frequency of hospitalbased Czech nurses’ delivery of smoking cessation interventions and examine their attitudes and skills about smoking cessation. Given the reported high prevalence of smoking among nurses in the Czech Republic, we also examined the relationship of nurses’ smoking status to their delivery of tobacco interventions. The results of a train-thetrainer program to increase tobacco dependence interventions, including 62% of respondents in this sample, are published elsewhere.18 Ethical approval was obtained from the University of California, Los Angeles (UCLA), Institutional Review Board and from the Charles University Hospital in Prague. Data were collected in October to December 2012. Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E23
n
Methods
Sampling Design This study includes a descriptive survey of a convenience sample of nurses recruited from 6 hospitals in the Czech Republic. These nurses were recruited from those attending an educational program on the nurses’ role in smoking cessation.
Instrument The instrument used to assess the frequency of nursing intervention in tobacco dependence treatment was based on a previously developed and validated questionnaire.19 The 19-item Czech Republic Helping Smokers Quit instrument was translated by native speakers and reevaluated with test-retest for reliability (93% of the . values were in the acceptable range, ie, 90.7). Nurses’ frequency (‘‘always,’’ ‘‘usually,’’ ‘‘sometimes,’’ ‘‘rarely,’’ or ‘‘never’’) of self-reported delivery of smoking cessation interventions using the 5As, in addition to items about referring to a telephone quitline for cessation support, recommending tobacco cessation medications, reviewing barriers to quitting, and recommending the importance of a smoke-free home, was assessed. In addition, nurses’ attitudes about involvement in helping patients to stop smoking and their opinion about need for additional skills/training (rated on a 5-point scale from ‘‘strongly agree’’ to ‘‘strongly disagree’’) were assessed.22,23 A 13item subscale assessed nurse confidence in her/his skills to help patients quit smoking (responses on a 5-point scale ranged from ‘‘strongly disagree’’ to ‘‘strongly agree’’), and a 6-item subscale evaluated beliefs about confidence in delivering an intervention (responses on a 5-item Likert scale ranged from ‘‘poor’’ to ‘‘excellent’’).22,23 Other survey items included demographic information (sex, age), self-reported smoking status (current, former, never) and previous quit attempts, and professional characteristics, including clinical setting.
Data Collection Procedure This collaborative project involved the International Society of Nurses in Cancer Care; the School of Nursing, UCLA; and the Centre for Tobacco-Dependent of the 3rd Medical Department, General University Hospital, Charles University, Prague, Czech Republic. Nurses from 6 hospitals in the Czech Republic who participated in an educational program about tobacco cessation18 were invited to complete a survey describing the frequency of their delivery of tobacco cessation interventions in clinical practice and their attitudes and perceived skills in helping smokers quit before the beginning of the educational program. A nurse faculty was responsible for distributing and collecting the surveys. All responses were confidential and anonymous. Surveys from each hospital were mailed to the Czech team, and these were posted by mail to UCLA for data entry and analysis.
Statistical Analyses Data entry was performed at UCLA. All analyses were done using SAS 9.2. Descriptive statistics were used to characterize study variables. The percentage of nurses delivering tobacco dependence
treatment interventions(ie, ‘‘always’’, ‘‘usually’’, ‘‘sometimes’’, ‘‘rarely’’, and ‘‘never’’) was described for each component of the intervention (ask, advise, assess, assist, arrange, recommend the quitline, refer to community resources, recommend cessation medications, review barriers to quitting, and creating a smoke-free environment). The percentages of nurses who ‘‘strongly disagree,’’ ‘‘disagree,’’ were ‘‘neutral,’’ ‘‘agree,’’ or ‘‘strongly agree’’ were calculated for each of the 13 statements involving attitudes about intervening with patients who smoke. In addition, the percentages of nurses rating their confidence level in smoking cessation as ‘‘poor,’’ ‘‘fair,’’ ‘‘good,’’ ‘‘very good,’’ and ‘‘excellent’’ were presented. Differences in the consistent delivery (ie, ‘‘always’’ and ‘‘usually’’) of each of the cessation interventions were examined by the nurses’ smoking status (never, former, current smoker) using analysis of variance. n
Results
Sample Characteristics The survey was completed by 157 nurses. Demographic characteristics, including information about the nurses’ smoking status, and information about their clinical practice setting are displayed in Table 1. All were women, mean age was 44 years, and most worked in medical-surgical or oncology settings. Most never smoked. Among the 43 current smokers, 29 (67.44%) had not made any quit attempts in the past year; 5 made 1 quit attempt, 5 had made 3 to 5 quit attempts, and 1 nurse reported 12 quit attempts. Of those who were former smokers, 2 quit in the past 12 months.
Frequency of Nurses’ Delivery of Tobacco Dependence Interventions The frequency of self-reported tobacco dependence interventions is displayed in Table 2. Whereas 63% of nurses consistently (ie,
Table 1 & Demographics Characteristics Sex Female Clinical practice setting Medical- surgical Oncology Intensive care Outpatient/urgent care Psychiatric Obstetrics Smoking status Never smokers Former smokers Current smokers
Age, y Years since graduated from nursing school
E24 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
%
157
100
55 45 20 25 8 3
35.03 28.66 12.50 16.03 5.13 1.97
83 28 46
52.56 17.95 29.49
Mean
SD
44 24.11
14.2 11.62
Sarna et al
Table 2 & Frequency of Czech Nurses’ Delivery of Tobacco Dependence Treatment Interventions (N = 157)
Delivery of 5As and Other Interventions
n
Ask about smoking/tobacco use Always 76 Usually 23 Sometimes 33 Rarely 15 Never 10 Advise patients to quit smoking Always 30 Usually 41 Sometimes 50 Rarely 26 Never 8 Assess readiness to quit smoking Always 19 Usually 42 Sometimes 48 Rarely 27 Never 21 Assist with smoking cessation Always 17 Usually 23 Sometimes 37 Rarely 37 Never 40 Arrange smoking cessation follow-up Always 12 Usually 6 Sometimes 12 Rarely 20 Never 103 Recommend the telephone quitline Always 11 Usually 15 Sometimes 35 Rarely 28 Never 64 Refer to community cessation resources Always 22 Usually 19 Sometimes 34 Rarely 34 Never 47 Recommend tobacco cessation medications Always 7 Usually 17 Sometimes 34 Rarely 31 Never 64 Review barriers to quitting Always 14 Usually 24 Sometimes 43 Rarely 37 Never 37 Recommend creating a smoke-free home environment Always 20 Usually 24 Sometimes 33 Rarely 34 Never 44
Czech Nurses and Tobacco Cessation
% 48.41 14.65 21.02 9.55 6.37 19.35 26.45 32.36 16.77 5.16 12.10 26.75 30.57 17.20 13.38 11.04 14.94 24.03 24.03 25.97 7.84 3.92 7.84 13.07 67.32 7.19 9.80 22.88 18.30 41.83 14.10 12.18 21.79 21.79 30.13 4.58 11.11 22.22 20.26 41.83 9.03 15.48 27.74 23.87 23.87 12.90 15.48 21.29 21.94 28.39
‘‘always/usually’’) asked patients about their smoking status, fewer (46%) consistently provided advice to quit, assessed readiness to quit (38.9%), assisted with a smoking cessation plan (26%), or arranged for follow-up (11%). Only 17% ‘‘always/ usually’’ referred smokers to a quitline. Few (26.3%) routinely referred patients to community resources, recommended medications (16%), reviewed barriers to quit (24.5%), or recommended a smoke-free environment (28%).
Attitudes About Tobacco Dependence Treatment As displayed in Table 3, few Czech nurses (19%) ‘‘strongly agreed/ agreed’’ that asking smokers about smoking would increase their likelihood of quitting. More than a quarter (28%) ‘‘strongly agreed/ agreed’’ that it was difficult for them to get patients to quit smoking and that counseling for cessation was not an efficient use of their time (30%). Some nurses ‘‘strongly agreed/agreed’’ that patients appreciated receiving advice about quitting smoking (35%) or that discussing this topic would improve their relationship with patients (28%). Over 1 of 5 nurses (22%) ‘‘strongly agreed/agreed’’ that they felt uncomfortable asking patients if they smoke. Only a minority (22%) ‘‘strongly agreed/agreed’’ that nurses could play an important role in helping patients quit. Almost half (47%) ‘‘strongly agreed/agreed’’ that they needed more training to help patients quit. Most (58%) ‘‘strongly agreed/agreed’’ that they had insufficient time to intervene. More than one-third (38%) ‘‘strongly agreed/agreed’’ that they should take a more active role in helping patients quit smoking. Twenty-two percent ‘‘strongly agreed/ agreed’’ that patients would be offended if they enquired about their smoking status. However, most (73%) ‘‘strongly agreed/ agreed’’ that providing cessation was important and that they had an obligation to advise patients about the health risk associated with tobacco (55%). Most nurses believed that they did not have the necessary skills to help smokers quit, with 63% rating their overall ability to help patients quit in the ‘‘poor/fair’’ range (Table 4). This perception of inadequate skills was higher when additional intervention was required such as arranging for follow-up counseling (73%). When comparing the consistent delivery of tobacco dependence interventions to help smokers quit, nurses’ smoking status made a significant difference in some components (Table 5). Nurses who smoked had the lowest frequency of assessing readiness to quit, arranging for follow-up, referring to a quitline, or recommending a smoke-free environment.
n
Discussion
The 50-year anniversary of the US Surgeon General report on smoking and health provided a time for reflection on the death and devastation caused by tobacco use, changes in smoking prevalence, as well as a call to do much more to end the epidemic of tobacco-induced diseases.24 Even after a diagnosis of a cancer, some cancer patients and family members have difficulty quitting and continue to smoke.25 However, based on emerging evidence, Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E25
Table 3 & Czech Nurses’ Attitudes About Helping Patients to Quit Smoking (N = 157)
Opinion Questions
n
A. Asking patients about smoking increases the likelihood that they will quit. Strongly disagree Disagree Neutral Agree Strongly agree B. It is difficult for me to get people to quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree C. Counseling patients about quitting is not an efficient use of my time. Strongly disagree Disagree Neutral Agree Strongly agree D. Patients appreciate it when I provide advice about quitting smoking. Strongly disagree Disagree Neutral Agree Strongly agree E. Discussing smoking cessation improves my relationship with patients. Strongly disagree Disagree Neutral Agree Strongly agree F. I feel uncomfortable asking patients whether they smoke. Strongly disagree Disagree Neutral Agree Strongly agree G. As a nurse, I can play an important role in helping patients quit. Strongly disagree Disagree Neutral Agree Strongly agree H. I need more training to help patients quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree
%
Table 3 & Czech Nurses’ Attitudes About Helping Patients to Quit Smoking (N = 157), Continued
Opinion Questions 28 54 45 16 14
17.83 34.39 28.66 10.19 8.92
22 40 50 33 10
14.19 25.81 32.36 21.29 6.45
27 46 34 29 16
17.76 30.26 22.37 19.08 10.53
9 22 55 54 14
5.84 14.29 35.71 35.06 0.09
15 33 65 39 4
9.62 21.15 41.67 25.00 2.56
39 50 31 24 10
25.32 32.47 20.13 15.58 6.49
34 48 40 25 9
21.79 30.77 25.64 16.03 5.77
10 29 43 56 18
6.41 18.59 27.56 35.90 11.54 (continues)
I.I have insufficient time to counsel patients about quitting smoking. Strongly disagree Disagree Neutral Agree Strongly agree J. I should take a more active role in helping patients to quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree K. Patients will be offended if I inquire about their smoking status. Strongly disagree Disagree Neutral Agree Strongly agree L. Providing tobacco cessation counseling is important to our hospital even if only a few patients quit. Strongly disagree Disagree Neutral Agree Strongly agree M. I have an obligation to advise patients on the health risks associated with tobacco use. Strongly disagree Disagree Neutral Agree Strongly agree
n
%
5 20 41 61 30
3.18 12.74 26.11 38.85 19.11
6 30 58 47 11
3.95 19.74 38.16 30.92 7.24
20 60 42 29 6
12.74 38.22 26.75 18.47 3.82
4 10 29 55 59
2.55 6.37 18.47 35.03 37.58
10 24 36 50 36
6.41 15.38 23.08 32.05 23.08
the importance of smoking cessation after a cancer diagnosis can make a difference in morbidity and mortality.24 As tobacco continues to be heavily promoted, with youth continuing to take up tobacco use and few smokers being supported in their quit efforts, cancer-related deaths are expected to escalate in many parts of the world, including countries in Eastern Europe.1
Nurses’ Delivery of Tobacco Dependence Interventions According to these data, despite a professional guideline supporting nursing intervention,8 few nurses in the Czech Republic consistently supported smokers with their quit efforts. Although most identified patients’ smoking status, few actually helped with a cessation intervention, including referral to resources such as the evidence-based quitline. This low level of nursing involvement has been reported in other countries as well.12,14
E26 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
Table 4 & Czech Nurses’ Confidence in Skills to Help Smokers Quit (N = 157)
Confidence Questions
n
A. Overall ability to help patients quit using tobacco Poor Fair Good Very good Excellent B. Asking patients whether they use tobacco Poor Fair Good Very good Excellent C. Advising patients to quit tobacco Poor Fair Good Very good Excellent D. Assessing patients’ readiness to quit tobacco Poor Fair Good Very good Excellent E. Assisting patients with quitting tobacco Poor Fair Good Very good Excellent F. Arranging follow-up counseling for tobacco Poor Fair Good Very good Excellent
%
58 37.42 39 25.16 52 33.55 6 3.87 0 0 29 33 54 23 17
18.59 21.15 34.62 14.74 10.90
33 42 58 16 7
21.15 26.92 37.18 10.26 4.49
63 33 42 16 0
40.91 21.43 27.27 10.39 0
66 42.58 34 21.94 42 27.10 11 7.10 2 1.29 94 60.65 19 12.26 28 18.06 6 3.87 8 5.16
Nurses’ Attitudes and Skills Although nurses have the potential to significantly decrease the burden of tobacco-related disease, these respondents undervalued the importance of their role and questioned the importance of their involvement in helping smokers quit. Clearly, some nurses were conflicted. On one hand, many nurses valued helping smokers quit and wanted to take a more active role; on the other hand, some were uncomfortable discussing the topic and had concerns about offending patients. Others were not sure if engaging smokers would increase their quit efforts. These concerns, including the concern about lack of time have, been expressed by nurses in other countries as well.22 There are many competing priorities in clinical practice, but tobacco dependence treatment is 1 of the most cost-effective clinical interventions.9 The importance of a therapeutic nurse-patient relationship is stressed as an essential part of a nurse-led tobacco cessation program in Sweden.27 Even brief interventions can be effective.9 Most Czech nurses agreed that they needed additional training, especially in providing the support needed and referral to resources. This is not surprising, as the lack of training of healthcare professionals in tobacco dependence treatment has been reported by many others.4,7,12,13
Nurses’ Smoking Status and Interventions With Patients Smoking among nurses was a barrier to the provision of interventions to smokers. Nurses who smoked were less likely to assess patients’ readiness to quit, arrange for follow-up, refer patients to a quitline, or recommend creating a smoke-free home environment. As reported in our study describing the results of a train-thetrainer program, nurses who smoked were less likely to benefit from the educational program to help smokers quit.18 Support for nurses’ quit efforts is an important component of addressing smoking in clinical practice. Most of the nurses who were current smokers in this study had not made a quit attempt in the past year. Some described multiple attempts. In Spain, a comprehensive workbased smoking cessation program was conducted in 33 hospitals.
Table 5 & Differences in Consistent (Always/Usually) Delivery of 5As to Help Patients Quit by Nurses’ Smoking Status (N = 157)
Smoking Status Never
Former
Current
5As
n
%
n
%
n
%
P
Ask Advise Assess Assist Arrange Quitline Refer to resources Recommend medications Review barriers to quitting Recommend smoke-free home
55 41 34 16 11 11 25 16 21 29
67.07 50.00 41.46 20.25 13.92 13.92 30.86 20.51 25.93 35.80
20 15 15 11 6 10 8 4 9 10
71.43 58.57 53.57 39.29 22.22 37.04 28.57 14.29 33.33 37.04
23 14 11 12 1 5 8 4 8 5
50.00 31.82 23.91 26.09 2.17 10.87 17.39 8.70 17.39 10.87
.09 .09 .03 .14 .03 .009 .24 .21 .29 .007
Czech Nurses and Tobacco Cessation
Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E27
The program, which included free pharmacotherapy for 930 hospital workers, 28% of them nurses, was successful in achieving 50% abstinence rates at 6 months.28 With the high smoking prevalence among nurses in the Czech Republic, future capacity building efforts also must address this important issue by providing resources for quitting and enhancing the culture of nurses as smoke-free role models.
Nurses in the Czech Republic recognize the need for more education about how to help smokers quit. Smoking among nurses is similar to rates in the general public. Support for nurses’ quit efforts should be included as part of any educational program to help smokers quit. Nurses, as the most numerous group of Czech health professionals (100 000 nurses compared with 40 000 physicians), could make a substantial impact on improving quit efforts.
Limitations This survey was completed by a relatively small convenience sample size of nurses in the Czech Republic who elected to come to an educational program. Thus, these nurses may be more likely to engage in tobacco cessation interventions than those who did not attend. However, the sample demographics reflected those of nurses in the Czech Republic.5 As these data are self-reported frequency of nurses’ intervention, the results may not be an accurate assessment of their actual behavior in clinical practice. The involvement of other members of the healthcare team, especially involvement of physicians, is important in addressing smoking cessation.9 This survey did not include information about the level of involvement of other healthcare professionals and how that might influence nurses’ perceptions of their own responsibilities in this area. Tobacco use of the nurses was self-reported and not biochemically verified. Thus, there may be a higher prevalence of smokers among the sample. There may have been other factors influencing the nurses’ frequency of intervention that were not included in questionnaire such as the institutional value given nurses involvement in tobacco control. In addition, the relatively small sample size did not allow for subgroup analyses. n
Conclusions
Tobacco control is central to reducing cancer incidence, mortality, and suffering in any country. As such, this is a vital issue for oncology nursing. These data demonstrate that consistent nursing intervention to help patients quit smoking in the Czech Republic is relatively rare, with some nurses expressing a reluctance to intervene with patients on this topic. This is important information to consider as capacity-building programs to improve nurses’ knowledge and skills in tobacco control are created to address this critical health concern. Enhancing nursing education about smoking cessation at the prelicensure level is also pivotal.22 Although this sample includes only nurses in the Czech Republic, these findings may be similar for practicing nurses in other countries throughout Eastern Europe where smoking rates are very high and intervening with smokers is not part of routine clinical practice. n
Lessons for Practice
Tobacco use is the leading cause of preventable death in the Czech Republic, and efforts are needed to engage all healthcare providers in helping patients stop smoking. Few nurses in the Czech Republic actively intervened with hospitalized smokers.
References 1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2013. http://www.who.int/tobacco/global_report/2013/en/index.html. Accessed December 12, 2013. 2. Peto R, Lopez AD, Boreham J, et al. Mortality from smoking in developed countries 1950Y2000 or later. Updated March 2012. www.ctsu.ox.ac.uk/~tobacco/. Accessed December 12, 2013. 3. Malvezzi M, Bertuccio P, Levi F, La Vecchia C, Negri E. European cancer mortality predictions for the year 2013. Ann Oncol. 2013;24(3):792Y800. 4. Pine´-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction. 2013;108(8):1476Y1484. doi:10.1111/add.12172. 5. Czech Nurses Association, 2013. http://www.cnna.cz/en/about-the-company. Accessed December 12, 2013. 6. Sovinova H, Sadilek P, Csemy L. Smoking prevalence in the Czech adult population of the Czech Republic and opinions and attitudes to smoking in the population (1997Y2011). National Institute of Public Health. 2012. http://www.szu.cz/tema/podpora-zdravi/studie-kuractvi?highlightWords= koureni. Accessed May 14, 2014. 7. Rice VH, Hartmann-Boyce J, Stead LF. Does support and intervention from nurses help people to stop smoking? Cochrane Database Syst Rev. 2013;8:CD001188. doi:10.1002/14651858.CD001188.pub4. 8. Mala´ K, Felbrova´ V, Kulovana´ S, Kra´lı´kova´ E, Sˇteˇpa´nkova´ L. Smoking cessation guidelines for nurses. The Society for Treatment of Tobacco Dependence. 2010. http://www.slzt.cz/odborna-doporuceni. Accessed December 12, 2013. 9. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2008. 10. Kralikova E, Bonevski B, Stepankova L, et al. Postgraduate medical education on tobacco and smoking cessation in Europe. Drug Alcohol Rev. 2009;4: 474Y483. doi:10.1111/j.1465-3362.2009.00104.x. 11. Sovinova H. Czech Republic 2011 country report: Global Health Professions Student Survey (GHPSS) 1Y17. http://www.szu.cz/uploads/documents/ czzp/zavislosti/koureni/2013/GHPSS_Country_Report_CR.pdf. Accessed December 12, 2013. 12. Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and training on cessation counseling among nursing students: cross-country data from the Global Health Professions Student Survey (GHPSS), 2005Y2009. Int J Environ Res Public Health. 2009;6(10):2534Y2549. doi:10.3390/ijerph6102534. 13. Eriksen M, Mackay J, Ross H. The Tobacco Atlas. 4th ed. Atlanta, GA: American Cancer Society; 2012. www.TobaccoAtlas.org. Accessed December 12, 2013. 14. World Health Organization. Enhancing nursing and midwifery capacity to contribute to the prevention, treatment and management if noncommunicable diseases. Human Resources for Health Observer No. 12. Geneva, Switzerland: World Health Organization; 2012. http://www.who.int/hrh/resources/observer12 .pdf. Accessed December 12, 2013. 15. Dzewaltowski DA, Glasgow RE, Klesges LM, et al. RE-AIM: evidencebased standards and a Web resource to improve translation of research into practice. Ann Behav Med. 2004;28(2):75Y80. doi:10.1207/s1532479abm2802_1. 16. Glasgow RE, Klesges LM, Dzewaltowski DA, et al. The future of health behavior change research: what is needed to improve translation of research into health promotion practice? Ann Behav Med. 2004;27(1):3Y12. doi:10 .1207/s15324796abm2701_2. 17. Lenz BK. Beliefs, knowledge, and self-efficacy of nursing students regarding
E28 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
18.
19.
20.
21.
22. 23.
tobacco cessation. Am J Prev Med. 2008;35(suppl):S494YS500. doi:10.1016/j .amepre.2008.09.004. Sarna LP, Bialous SA, Kralikova E, et al. Impact of a smoking cessation educational program on nurses’ interventions. J Nurs Scholarsh. 2014;46(5):1Y8. doi:10.1111/jnu.12086. Sarna L, Bialous S, Ong M, Wells M, Kotlerman J. Nurses’ treatment of tobacco dependence in hospitalized smokers in three states. Res Nurs Health. 2012;35(3):250Y64. doi:10.1002/nur.21476. Sarna LP, Brown JK, Lillington L, Rose M, Wewers ME, Brecht ML. Tobacco interventions by oncology nurses in clinical practice. Cancer. 2000;89:881Y889. doi:10.1002/1097-0142(20000815)89:4G881. Sarna L, Bialous SA, Ong MK, Wells M, Kotlerman J. Increasing nursing referral to telephone quitlines for smoking cessation using a web-based program. Nurs Res. 2012;61:433Y40. doi:10.1097/NNR.0b013e3182707237. Corelli RL, Kroon LA, Chung EP, et al. Statewide evaluation of a tobacco cessation curriculum for pharmacy students. Prev Med. 2005;40:888Y895. Hudmon KS, Corelli RL, Chung E, et al. Development and implementation of a tobacco cessation training program for students in the health professions. J Cancer Educ. 2003;18(3):142Y149.
Czech Nurses and Tobacco Cessation
24. US Department of Health and Human Services. The Health Consequences of SmokingV50 years of Progress. A report of the surgeon general. Rockville, MD: US Department of Health and Human Services; 2014. http://www .surgeongeneral.gov/library/reports/50-years-of-progress/#fullreport. Accessed January 17, 2014. 25. Cooley ME, Finn KT, Wang Q, et al. Heath behaviors, readiness to change, and interest in health promotion programs among smokers with lung cancer and their family members: a pilot study. Cancer Nurs. 2013;36(2):145Y154. doi:10.1097/NCC.0b013e31825e4359. 26. Sarna L, Bialous SA, Rice VH, Wewers ME. Promoting tobacco dependence treatment in nursing education. Drug Alcohol Rev. 2009;28:507Y516. doi:10.1111/j.1465-3362.2009.00107.x. 27. Sharp L, Tishelman C. Smoking cessation for patients with head and neck cancer: a qualitative study of patients’ and nurses’ experiences in a nurse-led intervention. Cancer Nurs. 2005;28(3):226Y235. 28. Martinez C, Martinez-Sanchez JM, Balbe M, et al. Smoking cessation in hospital workers: effectiveness of a coordinated program in 33 hospitals in Catalonia (Spain). Cancer Nurs. 2012;35(5):327Y336. doi:10.1097/NCC .0b013e3182321389.
Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E29
Linda P. Sarna, PhD, RN, FAAN Stella Aguinaga Bialous, RN, DrPH, FAAN Eva Kra´lı´kova´, MD, PhD Alexandra Kmetova, MD Vladislava Felbrova´, RN Stanislava Kulovana´, RN Katerina Mala´, RN Eva Roubı´ˇckova´, RN Marjorie J. Wells, PhD, RN Jenny K. Brook, MS
Tobacco Cessation Practices and Attitudes Among Nurses in the Czech Republic K E Y
W O R D S
Background: Tobacco is the leading cause of cancer in the Czech Republic. More
Continuing education
than one-third of the population older than 15 years smokes, including many nurses.
Czech Republic
Most smokers want to quit, but the extent of nurses’ involvement in tobacco cessation
Eastern Europe
is unknown. Objective: The purposes of this study are to describe the frequency of
Nurses
nurses’ interventions in helping smokers quit, examine their attitudes and skills, and
Smoking cessation
explore the relationship of nurses’ smoking status to level of intervention. Methods: A convenience sample of nurses in the Czech Republic completed a survey about their frequency of interventions according to the 5As for tobacco dependence treatment (ie, ask, advise, assess, assist, arrange), their attitudes and perceived skills, and their smoking status (never, former, current). Results: A total of 157 nurses completed the survey; 26% ‘‘always’’ or ‘‘usually’’ assisted patients with smoking cessation. Few (22%) reported that nurses could play an important role in helping patients quit, and 65% rated their ability to help smokers quit as ‘‘fair/poor.’’ Nurse who smoked (30%) were less likely to consistently assess smoking status or arrange for follow-up support. Conclusion: Few nurses in the Czech Republic consistently provide smoking cessation support to patients, have the skills to do so, or view this
Author Affiliations: School of Nursing, (Drs Sarna and Wells), David Geffen School of Medicine (Ms Brook), University of California, Los Angeles; Tobacco Policy International, San Francisco, California (Dr Bialous); Institute of Hygiene and Epidemiology (Drs Kra´lı´kova´ and Kmetova) and Military University Hospital (Ms Mala´), First Faculty of Medicine, Charles University in Prague; the General University Hospital (Drs Kra´lı´kova´ and Kmetova); Centre for TobaccoDependent of the Third Medical Department (Drs Kra´lı´kova´ and Kmetova and Mss Felbrova´ and Kulovana´); and Radiotheraputic and Oncology Clinic, Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic (Ms Roubı´cˇkova´).
This study was supported by a grant to the International Society of Nurses in Cancer Care from Bristol Meyers Squibb Foundation, Bridging Cancer Care, and Sarna’s Lulu Wolf Hassenplug Endowed Chair Fund, School of Nursing, University of California, Los Angeles. The authors have no conflicts of interest to disclose. Correspondence: Linda P. Sarna, PhD, RN, FAAN, University of California, Los Angeles, School of Nursing, 700 Tiverton Ave, Los Angeles, CA 90095-6918 ([email protected]). Accepted for publication October 28, 2014. DOI: 10.1097/NCC.0000000000000222
E22 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
role as an important part of their role. Implications for Practice: To reduce tobacco-related cancers in the Czech Republic, capacity-building efforts are needed to enhance nurses’ skills and confidence in providing smoking cessation interventions. Support is also need to help nurses who smoke quit.
D
espite overwhelming scientific evidence of the link between smoking and cancer, smoking remains common in Central and Eastern Europe.1 Smoking is a major contributor of all-cause mortality in the European Union and accounted for 25% of all cancer-related deaths, with lung cancer, a largely preventable cancer, as the major component.2 In Europe, lung cancer deaths are projected to overtake breast cancer deaths among women by 2015.3 However, few countries in Europe have tobacco dependence treatment support in place.4 In addition to preventing the uptake of new users, supporting quit efforts is an important part of reducing the risk for cancer as well as improving overall health. The involvement of nurses in the delivery of smoking cessation interventions to patients in hospital settings in the Czech Republic is unknown.
n
Background
Tobacco use is the main cause of preventable disease and death worldwide2 and in the Czech Republic. It is estimated that approximately 16 000 deaths attributed to tobacco use, including 7000 deaths from cancer, occur every year in this country.2 Approximately 36% of the population aged 15 to 64 years use tobacco (41% of men and 32% of women) and approximately 25% of the population older than 15 years are daily smokers.1 Smoking among youth, aged 13 to 15 years, is of great concern as 40% currently use tobacco and 31% smoke cigarettes (higher among girls, 33%, than among boys, 30%).5 Approximately 100 000 Czech nurses,5 the largest group of healthcare providers, if adequately educated about brief cessation interventions, could make a significant difference in helping smokers quit and in reducing the risk for cancer. Most smokers in the Czech Republic (60%) express a desire to quit.6 Evidence supports the efficacy of nurses in effectively helping patients to quit smoking.7 Czech nurses have a professional guideline that supports their role and responsibility in smoking cessation.8 The evidence-based intervention for tobacco dependence treatment includes the provision of pharmacotherapy and support, including skills training. Interventions for treating tobacco dependence are summarized as the 5As (ie, ask about tobacco use, advise smokers to quit, assess readiness to quit, assist with a quit attempt, and arrange for follow-up to prevent relapse).9,10 However, only 7% of Czech nurses received education about tobacco dependence treatment in school.11,12 Recognizing this need, the Centre for Tobacco-Dependent of the Third Medical Department, Prague, developed a program for healthcare professionals, including nurses, to become tobacco dependence treatment specialists.8,10 Some of these nurse specialists provide care to smokers in their quit efforts in the over 40 cessation centers throughout the country. However, to receive this support, smokers must travel to these locations. It is
Czech Nurses and Tobacco Cessation
unknown if nurses working in hospitals have the knowledge and skills to support smokers in their quit efforts. Although the Czech Republic is 1 of the 178 countries that are a Party to the World Health Organization (WHO) Framework Convention on Tobacco Control (http://www.who.int/fctc/signatories_ parties/en/), comprehensive tobacco control policies in the country are yet to be fully implemented.1 One of the components of the WHO Framework Convention on Tobacco Control includes providing support for tobacco cessation; however, equipping healthcare professionals with knowledge and skills is a necessary prerequisite. Existing resources to support quit efforts in the Czech Republic do exist but are underused, including a national telephone quitline and Web sites (Stop-koureni [Stop smoking], www.stop-koureni.cz, and Odvykanikoureni [Quitting smoking], www.odvykanikoureni.cz). If nurses were knowledgeable about resources, they could support patients’ quit efforts. Nonsmoking role modeling and increasing tobacco control content in healthcare curricula are 1 of the strategic policy recommendations in the Fourth Edition of the Tobacco Atlas13 and the WHO’s recommendations to combat noncommunicable diseases.14 Smoking among healthcare providers can be a barrier to interventions by increasing negative attitudes and decreasing involvement to help patients who smoke quit.15 This is a concern in the Czech Republic because among healthcare professional students (physicians, dentists, pharmacists, and nurses), female nursing students have the highest rates of smoking, 32.2%.11,12 Data from an unpublished study report smoking among practicing nurses to be as high as 40% (Eva Kralikova, personal communication, June 23, 2011, regarding unpublished data from Kralikova et al). Because the focus of this study was the assessment of an evidencebased intervention for smoking cessation interventions for nurses, we used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) translational research model.15,16 This allowed us to determine the level of involvement of nurses in smoking cessation before we began and evaluated the impact of an educational workshop on improving outcomes in the long and short-term. Based on previous studies,17Y21 nurses’ educational and clinical background, as well as personal characteristics, including age, sex, and smoking status, may influence their knowledge, attitudes, and involvement in smoking cessation interventions. The purpose of this article is to describe the frequency of hospitalbased Czech nurses’ delivery of smoking cessation interventions and examine their attitudes and skills about smoking cessation. Given the reported high prevalence of smoking among nurses in the Czech Republic, we also examined the relationship of nurses’ smoking status to their delivery of tobacco interventions. The results of a train-thetrainer program to increase tobacco dependence interventions, including 62% of respondents in this sample, are published elsewhere.18 Ethical approval was obtained from the University of California, Los Angeles (UCLA), Institutional Review Board and from the Charles University Hospital in Prague. Data were collected in October to December 2012. Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E23
n
Methods
Sampling Design This study includes a descriptive survey of a convenience sample of nurses recruited from 6 hospitals in the Czech Republic. These nurses were recruited from those attending an educational program on the nurses’ role in smoking cessation.
Instrument The instrument used to assess the frequency of nursing intervention in tobacco dependence treatment was based on a previously developed and validated questionnaire.19 The 19-item Czech Republic Helping Smokers Quit instrument was translated by native speakers and reevaluated with test-retest for reliability (93% of the . values were in the acceptable range, ie, 90.7). Nurses’ frequency (‘‘always,’’ ‘‘usually,’’ ‘‘sometimes,’’ ‘‘rarely,’’ or ‘‘never’’) of self-reported delivery of smoking cessation interventions using the 5As, in addition to items about referring to a telephone quitline for cessation support, recommending tobacco cessation medications, reviewing barriers to quitting, and recommending the importance of a smoke-free home, was assessed. In addition, nurses’ attitudes about involvement in helping patients to stop smoking and their opinion about need for additional skills/training (rated on a 5-point scale from ‘‘strongly agree’’ to ‘‘strongly disagree’’) were assessed.22,23 A 13item subscale assessed nurse confidence in her/his skills to help patients quit smoking (responses on a 5-point scale ranged from ‘‘strongly disagree’’ to ‘‘strongly agree’’), and a 6-item subscale evaluated beliefs about confidence in delivering an intervention (responses on a 5-item Likert scale ranged from ‘‘poor’’ to ‘‘excellent’’).22,23 Other survey items included demographic information (sex, age), self-reported smoking status (current, former, never) and previous quit attempts, and professional characteristics, including clinical setting.
Data Collection Procedure This collaborative project involved the International Society of Nurses in Cancer Care; the School of Nursing, UCLA; and the Centre for Tobacco-Dependent of the 3rd Medical Department, General University Hospital, Charles University, Prague, Czech Republic. Nurses from 6 hospitals in the Czech Republic who participated in an educational program about tobacco cessation18 were invited to complete a survey describing the frequency of their delivery of tobacco cessation interventions in clinical practice and their attitudes and perceived skills in helping smokers quit before the beginning of the educational program. A nurse faculty was responsible for distributing and collecting the surveys. All responses were confidential and anonymous. Surveys from each hospital were mailed to the Czech team, and these were posted by mail to UCLA for data entry and analysis.
Statistical Analyses Data entry was performed at UCLA. All analyses were done using SAS 9.2. Descriptive statistics were used to characterize study variables. The percentage of nurses delivering tobacco dependence
treatment interventions(ie, ‘‘always’’, ‘‘usually’’, ‘‘sometimes’’, ‘‘rarely’’, and ‘‘never’’) was described for each component of the intervention (ask, advise, assess, assist, arrange, recommend the quitline, refer to community resources, recommend cessation medications, review barriers to quitting, and creating a smoke-free environment). The percentages of nurses who ‘‘strongly disagree,’’ ‘‘disagree,’’ were ‘‘neutral,’’ ‘‘agree,’’ or ‘‘strongly agree’’ were calculated for each of the 13 statements involving attitudes about intervening with patients who smoke. In addition, the percentages of nurses rating their confidence level in smoking cessation as ‘‘poor,’’ ‘‘fair,’’ ‘‘good,’’ ‘‘very good,’’ and ‘‘excellent’’ were presented. Differences in the consistent delivery (ie, ‘‘always’’ and ‘‘usually’’) of each of the cessation interventions were examined by the nurses’ smoking status (never, former, current smoker) using analysis of variance. n
Results
Sample Characteristics The survey was completed by 157 nurses. Demographic characteristics, including information about the nurses’ smoking status, and information about their clinical practice setting are displayed in Table 1. All were women, mean age was 44 years, and most worked in medical-surgical or oncology settings. Most never smoked. Among the 43 current smokers, 29 (67.44%) had not made any quit attempts in the past year; 5 made 1 quit attempt, 5 had made 3 to 5 quit attempts, and 1 nurse reported 12 quit attempts. Of those who were former smokers, 2 quit in the past 12 months.
Frequency of Nurses’ Delivery of Tobacco Dependence Interventions The frequency of self-reported tobacco dependence interventions is displayed in Table 2. Whereas 63% of nurses consistently (ie,
Table 1 & Demographics Characteristics Sex Female Clinical practice setting Medical- surgical Oncology Intensive care Outpatient/urgent care Psychiatric Obstetrics Smoking status Never smokers Former smokers Current smokers
Age, y Years since graduated from nursing school
E24 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
%
157
100
55 45 20 25 8 3
35.03 28.66 12.50 16.03 5.13 1.97
83 28 46
52.56 17.95 29.49
Mean
SD
44 24.11
14.2 11.62
Sarna et al
Table 2 & Frequency of Czech Nurses’ Delivery of Tobacco Dependence Treatment Interventions (N = 157)
Delivery of 5As and Other Interventions
n
Ask about smoking/tobacco use Always 76 Usually 23 Sometimes 33 Rarely 15 Never 10 Advise patients to quit smoking Always 30 Usually 41 Sometimes 50 Rarely 26 Never 8 Assess readiness to quit smoking Always 19 Usually 42 Sometimes 48 Rarely 27 Never 21 Assist with smoking cessation Always 17 Usually 23 Sometimes 37 Rarely 37 Never 40 Arrange smoking cessation follow-up Always 12 Usually 6 Sometimes 12 Rarely 20 Never 103 Recommend the telephone quitline Always 11 Usually 15 Sometimes 35 Rarely 28 Never 64 Refer to community cessation resources Always 22 Usually 19 Sometimes 34 Rarely 34 Never 47 Recommend tobacco cessation medications Always 7 Usually 17 Sometimes 34 Rarely 31 Never 64 Review barriers to quitting Always 14 Usually 24 Sometimes 43 Rarely 37 Never 37 Recommend creating a smoke-free home environment Always 20 Usually 24 Sometimes 33 Rarely 34 Never 44
Czech Nurses and Tobacco Cessation
% 48.41 14.65 21.02 9.55 6.37 19.35 26.45 32.36 16.77 5.16 12.10 26.75 30.57 17.20 13.38 11.04 14.94 24.03 24.03 25.97 7.84 3.92 7.84 13.07 67.32 7.19 9.80 22.88 18.30 41.83 14.10 12.18 21.79 21.79 30.13 4.58 11.11 22.22 20.26 41.83 9.03 15.48 27.74 23.87 23.87 12.90 15.48 21.29 21.94 28.39
‘‘always/usually’’) asked patients about their smoking status, fewer (46%) consistently provided advice to quit, assessed readiness to quit (38.9%), assisted with a smoking cessation plan (26%), or arranged for follow-up (11%). Only 17% ‘‘always/ usually’’ referred smokers to a quitline. Few (26.3%) routinely referred patients to community resources, recommended medications (16%), reviewed barriers to quit (24.5%), or recommended a smoke-free environment (28%).
Attitudes About Tobacco Dependence Treatment As displayed in Table 3, few Czech nurses (19%) ‘‘strongly agreed/ agreed’’ that asking smokers about smoking would increase their likelihood of quitting. More than a quarter (28%) ‘‘strongly agreed/ agreed’’ that it was difficult for them to get patients to quit smoking and that counseling for cessation was not an efficient use of their time (30%). Some nurses ‘‘strongly agreed/agreed’’ that patients appreciated receiving advice about quitting smoking (35%) or that discussing this topic would improve their relationship with patients (28%). Over 1 of 5 nurses (22%) ‘‘strongly agreed/agreed’’ that they felt uncomfortable asking patients if they smoke. Only a minority (22%) ‘‘strongly agreed/agreed’’ that nurses could play an important role in helping patients quit. Almost half (47%) ‘‘strongly agreed/agreed’’ that they needed more training to help patients quit. Most (58%) ‘‘strongly agreed/agreed’’ that they had insufficient time to intervene. More than one-third (38%) ‘‘strongly agreed/agreed’’ that they should take a more active role in helping patients quit smoking. Twenty-two percent ‘‘strongly agreed/ agreed’’ that patients would be offended if they enquired about their smoking status. However, most (73%) ‘‘strongly agreed/ agreed’’ that providing cessation was important and that they had an obligation to advise patients about the health risk associated with tobacco (55%). Most nurses believed that they did not have the necessary skills to help smokers quit, with 63% rating their overall ability to help patients quit in the ‘‘poor/fair’’ range (Table 4). This perception of inadequate skills was higher when additional intervention was required such as arranging for follow-up counseling (73%). When comparing the consistent delivery of tobacco dependence interventions to help smokers quit, nurses’ smoking status made a significant difference in some components (Table 5). Nurses who smoked had the lowest frequency of assessing readiness to quit, arranging for follow-up, referring to a quitline, or recommending a smoke-free environment.
n
Discussion
The 50-year anniversary of the US Surgeon General report on smoking and health provided a time for reflection on the death and devastation caused by tobacco use, changes in smoking prevalence, as well as a call to do much more to end the epidemic of tobacco-induced diseases.24 Even after a diagnosis of a cancer, some cancer patients and family members have difficulty quitting and continue to smoke.25 However, based on emerging evidence, Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E25
Table 3 & Czech Nurses’ Attitudes About Helping Patients to Quit Smoking (N = 157)
Opinion Questions
n
A. Asking patients about smoking increases the likelihood that they will quit. Strongly disagree Disagree Neutral Agree Strongly agree B. It is difficult for me to get people to quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree C. Counseling patients about quitting is not an efficient use of my time. Strongly disagree Disagree Neutral Agree Strongly agree D. Patients appreciate it when I provide advice about quitting smoking. Strongly disagree Disagree Neutral Agree Strongly agree E. Discussing smoking cessation improves my relationship with patients. Strongly disagree Disagree Neutral Agree Strongly agree F. I feel uncomfortable asking patients whether they smoke. Strongly disagree Disagree Neutral Agree Strongly agree G. As a nurse, I can play an important role in helping patients quit. Strongly disagree Disagree Neutral Agree Strongly agree H. I need more training to help patients quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree
%
Table 3 & Czech Nurses’ Attitudes About Helping Patients to Quit Smoking (N = 157), Continued
Opinion Questions 28 54 45 16 14
17.83 34.39 28.66 10.19 8.92
22 40 50 33 10
14.19 25.81 32.36 21.29 6.45
27 46 34 29 16
17.76 30.26 22.37 19.08 10.53
9 22 55 54 14
5.84 14.29 35.71 35.06 0.09
15 33 65 39 4
9.62 21.15 41.67 25.00 2.56
39 50 31 24 10
25.32 32.47 20.13 15.58 6.49
34 48 40 25 9
21.79 30.77 25.64 16.03 5.77
10 29 43 56 18
6.41 18.59 27.56 35.90 11.54 (continues)
I.I have insufficient time to counsel patients about quitting smoking. Strongly disagree Disagree Neutral Agree Strongly agree J. I should take a more active role in helping patients to quit smoking. Strongly disagree Disagree Neutral Agree Strongly agree K. Patients will be offended if I inquire about their smoking status. Strongly disagree Disagree Neutral Agree Strongly agree L. Providing tobacco cessation counseling is important to our hospital even if only a few patients quit. Strongly disagree Disagree Neutral Agree Strongly agree M. I have an obligation to advise patients on the health risks associated with tobacco use. Strongly disagree Disagree Neutral Agree Strongly agree
n
%
5 20 41 61 30
3.18 12.74 26.11 38.85 19.11
6 30 58 47 11
3.95 19.74 38.16 30.92 7.24
20 60 42 29 6
12.74 38.22 26.75 18.47 3.82
4 10 29 55 59
2.55 6.37 18.47 35.03 37.58
10 24 36 50 36
6.41 15.38 23.08 32.05 23.08
the importance of smoking cessation after a cancer diagnosis can make a difference in morbidity and mortality.24 As tobacco continues to be heavily promoted, with youth continuing to take up tobacco use and few smokers being supported in their quit efforts, cancer-related deaths are expected to escalate in many parts of the world, including countries in Eastern Europe.1
Nurses’ Delivery of Tobacco Dependence Interventions According to these data, despite a professional guideline supporting nursing intervention,8 few nurses in the Czech Republic consistently supported smokers with their quit efforts. Although most identified patients’ smoking status, few actually helped with a cessation intervention, including referral to resources such as the evidence-based quitline. This low level of nursing involvement has been reported in other countries as well.12,14
E26 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
Table 4 & Czech Nurses’ Confidence in Skills to Help Smokers Quit (N = 157)
Confidence Questions
n
A. Overall ability to help patients quit using tobacco Poor Fair Good Very good Excellent B. Asking patients whether they use tobacco Poor Fair Good Very good Excellent C. Advising patients to quit tobacco Poor Fair Good Very good Excellent D. Assessing patients’ readiness to quit tobacco Poor Fair Good Very good Excellent E. Assisting patients with quitting tobacco Poor Fair Good Very good Excellent F. Arranging follow-up counseling for tobacco Poor Fair Good Very good Excellent
%
58 37.42 39 25.16 52 33.55 6 3.87 0 0 29 33 54 23 17
18.59 21.15 34.62 14.74 10.90
33 42 58 16 7
21.15 26.92 37.18 10.26 4.49
63 33 42 16 0
40.91 21.43 27.27 10.39 0
66 42.58 34 21.94 42 27.10 11 7.10 2 1.29 94 60.65 19 12.26 28 18.06 6 3.87 8 5.16
Nurses’ Attitudes and Skills Although nurses have the potential to significantly decrease the burden of tobacco-related disease, these respondents undervalued the importance of their role and questioned the importance of their involvement in helping smokers quit. Clearly, some nurses were conflicted. On one hand, many nurses valued helping smokers quit and wanted to take a more active role; on the other hand, some were uncomfortable discussing the topic and had concerns about offending patients. Others were not sure if engaging smokers would increase their quit efforts. These concerns, including the concern about lack of time have, been expressed by nurses in other countries as well.22 There are many competing priorities in clinical practice, but tobacco dependence treatment is 1 of the most cost-effective clinical interventions.9 The importance of a therapeutic nurse-patient relationship is stressed as an essential part of a nurse-led tobacco cessation program in Sweden.27 Even brief interventions can be effective.9 Most Czech nurses agreed that they needed additional training, especially in providing the support needed and referral to resources. This is not surprising, as the lack of training of healthcare professionals in tobacco dependence treatment has been reported by many others.4,7,12,13
Nurses’ Smoking Status and Interventions With Patients Smoking among nurses was a barrier to the provision of interventions to smokers. Nurses who smoked were less likely to assess patients’ readiness to quit, arrange for follow-up, refer patients to a quitline, or recommend creating a smoke-free home environment. As reported in our study describing the results of a train-thetrainer program, nurses who smoked were less likely to benefit from the educational program to help smokers quit.18 Support for nurses’ quit efforts is an important component of addressing smoking in clinical practice. Most of the nurses who were current smokers in this study had not made a quit attempt in the past year. Some described multiple attempts. In Spain, a comprehensive workbased smoking cessation program was conducted in 33 hospitals.
Table 5 & Differences in Consistent (Always/Usually) Delivery of 5As to Help Patients Quit by Nurses’ Smoking Status (N = 157)
Smoking Status Never
Former
Current
5As
n
%
n
%
n
%
P
Ask Advise Assess Assist Arrange Quitline Refer to resources Recommend medications Review barriers to quitting Recommend smoke-free home
55 41 34 16 11 11 25 16 21 29
67.07 50.00 41.46 20.25 13.92 13.92 30.86 20.51 25.93 35.80
20 15 15 11 6 10 8 4 9 10
71.43 58.57 53.57 39.29 22.22 37.04 28.57 14.29 33.33 37.04
23 14 11 12 1 5 8 4 8 5
50.00 31.82 23.91 26.09 2.17 10.87 17.39 8.70 17.39 10.87
.09 .09 .03 .14 .03 .009 .24 .21 .29 .007
Czech Nurses and Tobacco Cessation
Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E27
The program, which included free pharmacotherapy for 930 hospital workers, 28% of them nurses, was successful in achieving 50% abstinence rates at 6 months.28 With the high smoking prevalence among nurses in the Czech Republic, future capacity building efforts also must address this important issue by providing resources for quitting and enhancing the culture of nurses as smoke-free role models.
Nurses in the Czech Republic recognize the need for more education about how to help smokers quit. Smoking among nurses is similar to rates in the general public. Support for nurses’ quit efforts should be included as part of any educational program to help smokers quit. Nurses, as the most numerous group of Czech health professionals (100 000 nurses compared with 40 000 physicians), could make a substantial impact on improving quit efforts.
Limitations This survey was completed by a relatively small convenience sample size of nurses in the Czech Republic who elected to come to an educational program. Thus, these nurses may be more likely to engage in tobacco cessation interventions than those who did not attend. However, the sample demographics reflected those of nurses in the Czech Republic.5 As these data are self-reported frequency of nurses’ intervention, the results may not be an accurate assessment of their actual behavior in clinical practice. The involvement of other members of the healthcare team, especially involvement of physicians, is important in addressing smoking cessation.9 This survey did not include information about the level of involvement of other healthcare professionals and how that might influence nurses’ perceptions of their own responsibilities in this area. Tobacco use of the nurses was self-reported and not biochemically verified. Thus, there may be a higher prevalence of smokers among the sample. There may have been other factors influencing the nurses’ frequency of intervention that were not included in questionnaire such as the institutional value given nurses involvement in tobacco control. In addition, the relatively small sample size did not allow for subgroup analyses. n
Conclusions
Tobacco control is central to reducing cancer incidence, mortality, and suffering in any country. As such, this is a vital issue for oncology nursing. These data demonstrate that consistent nursing intervention to help patients quit smoking in the Czech Republic is relatively rare, with some nurses expressing a reluctance to intervene with patients on this topic. This is important information to consider as capacity-building programs to improve nurses’ knowledge and skills in tobacco control are created to address this critical health concern. Enhancing nursing education about smoking cessation at the prelicensure level is also pivotal.22 Although this sample includes only nurses in the Czech Republic, these findings may be similar for practicing nurses in other countries throughout Eastern Europe where smoking rates are very high and intervening with smokers is not part of routine clinical practice. n
Lessons for Practice
Tobacco use is the leading cause of preventable death in the Czech Republic, and efforts are needed to engage all healthcare providers in helping patients stop smoking. Few nurses in the Czech Republic actively intervened with hospitalized smokers.
References 1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2013. http://www.who.int/tobacco/global_report/2013/en/index.html. Accessed December 12, 2013. 2. Peto R, Lopez AD, Boreham J, et al. Mortality from smoking in developed countries 1950Y2000 or later. Updated March 2012. www.ctsu.ox.ac.uk/~tobacco/. Accessed December 12, 2013. 3. Malvezzi M, Bertuccio P, Levi F, La Vecchia C, Negri E. European cancer mortality predictions for the year 2013. Ann Oncol. 2013;24(3):792Y800. 4. Pine´-Abata H, McNeill A, Murray R, Bitton A, Rigotti N, Raw M. A survey of tobacco dependence treatment services in 121 countries. Addiction. 2013;108(8):1476Y1484. doi:10.1111/add.12172. 5. Czech Nurses Association, 2013. http://www.cnna.cz/en/about-the-company. Accessed December 12, 2013. 6. Sovinova H, Sadilek P, Csemy L. Smoking prevalence in the Czech adult population of the Czech Republic and opinions and attitudes to smoking in the population (1997Y2011). National Institute of Public Health. 2012. http://www.szu.cz/tema/podpora-zdravi/studie-kuractvi?highlightWords= koureni. Accessed May 14, 2014. 7. Rice VH, Hartmann-Boyce J, Stead LF. Does support and intervention from nurses help people to stop smoking? Cochrane Database Syst Rev. 2013;8:CD001188. doi:10.1002/14651858.CD001188.pub4. 8. Mala´ K, Felbrova´ V, Kulovana´ S, Kra´lı´kova´ E, Sˇteˇpa´nkova´ L. Smoking cessation guidelines for nurses. The Society for Treatment of Tobacco Dependence. 2010. http://www.slzt.cz/odborna-doporuceni. Accessed December 12, 2013. 9. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services, Public Health Service; 2008. 10. Kralikova E, Bonevski B, Stepankova L, et al. Postgraduate medical education on tobacco and smoking cessation in Europe. Drug Alcohol Rev. 2009;4: 474Y483. doi:10.1111/j.1465-3362.2009.00104.x. 11. Sovinova H. Czech Republic 2011 country report: Global Health Professions Student Survey (GHPSS) 1Y17. http://www.szu.cz/uploads/documents/ czzp/zavislosti/koureni/2013/GHPSS_Country_Report_CR.pdf. Accessed December 12, 2013. 12. Warren CW, Sinha DN, Lee J, Lea V, Jones NR. Tobacco use, exposure to secondhand smoke, and training on cessation counseling among nursing students: cross-country data from the Global Health Professions Student Survey (GHPSS), 2005Y2009. Int J Environ Res Public Health. 2009;6(10):2534Y2549. doi:10.3390/ijerph6102534. 13. Eriksen M, Mackay J, Ross H. The Tobacco Atlas. 4th ed. Atlanta, GA: American Cancer Society; 2012. www.TobaccoAtlas.org. Accessed December 12, 2013. 14. World Health Organization. Enhancing nursing and midwifery capacity to contribute to the prevention, treatment and management if noncommunicable diseases. Human Resources for Health Observer No. 12. Geneva, Switzerland: World Health Organization; 2012. http://www.who.int/hrh/resources/observer12 .pdf. Accessed December 12, 2013. 15. Dzewaltowski DA, Glasgow RE, Klesges LM, et al. RE-AIM: evidencebased standards and a Web resource to improve translation of research into practice. Ann Behav Med. 2004;28(2):75Y80. doi:10.1207/s1532479abm2802_1. 16. Glasgow RE, Klesges LM, Dzewaltowski DA, et al. The future of health behavior change research: what is needed to improve translation of research into health promotion practice? Ann Behav Med. 2004;27(1):3Y12. doi:10 .1207/s15324796abm2701_2. 17. Lenz BK. Beliefs, knowledge, and self-efficacy of nursing students regarding
E28 n Cancer NursingTM, Vol. 38, No. 6, 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Sarna et al
18.
19.
20.
21.
22. 23.
tobacco cessation. Am J Prev Med. 2008;35(suppl):S494YS500. doi:10.1016/j .amepre.2008.09.004. Sarna LP, Bialous SA, Kralikova E, et al. Impact of a smoking cessation educational program on nurses’ interventions. J Nurs Scholarsh. 2014;46(5):1Y8. doi:10.1111/jnu.12086. Sarna L, Bialous S, Ong M, Wells M, Kotlerman J. Nurses’ treatment of tobacco dependence in hospitalized smokers in three states. Res Nurs Health. 2012;35(3):250Y64. doi:10.1002/nur.21476. Sarna LP, Brown JK, Lillington L, Rose M, Wewers ME, Brecht ML. Tobacco interventions by oncology nurses in clinical practice. Cancer. 2000;89:881Y889. doi:10.1002/1097-0142(20000815)89:4G881. Sarna L, Bialous SA, Ong MK, Wells M, Kotlerman J. Increasing nursing referral to telephone quitlines for smoking cessation using a web-based program. Nurs Res. 2012;61:433Y40. doi:10.1097/NNR.0b013e3182707237. Corelli RL, Kroon LA, Chung EP, et al. Statewide evaluation of a tobacco cessation curriculum for pharmacy students. Prev Med. 2005;40:888Y895. Hudmon KS, Corelli RL, Chung E, et al. Development and implementation of a tobacco cessation training program for students in the health professions. J Cancer Educ. 2003;18(3):142Y149.
Czech Nurses and Tobacco Cessation
24. US Department of Health and Human Services. The Health Consequences of SmokingV50 years of Progress. A report of the surgeon general. Rockville, MD: US Department of Health and Human Services; 2014. http://www .surgeongeneral.gov/library/reports/50-years-of-progress/#fullreport. Accessed January 17, 2014. 25. Cooley ME, Finn KT, Wang Q, et al. Heath behaviors, readiness to change, and interest in health promotion programs among smokers with lung cancer and their family members: a pilot study. Cancer Nurs. 2013;36(2):145Y154. doi:10.1097/NCC.0b013e31825e4359. 26. Sarna L, Bialous SA, Rice VH, Wewers ME. Promoting tobacco dependence treatment in nursing education. Drug Alcohol Rev. 2009;28:507Y516. doi:10.1111/j.1465-3362.2009.00107.x. 27. Sharp L, Tishelman C. Smoking cessation for patients with head and neck cancer: a qualitative study of patients’ and nurses’ experiences in a nurse-led intervention. Cancer Nurs. 2005;28(3):226Y235. 28. Martinez C, Martinez-Sanchez JM, Balbe M, et al. Smoking cessation in hospital workers: effectiveness of a coordinated program in 33 hospitals in Catalonia (Spain). Cancer Nurs. 2012;35(5):327Y336. doi:10.1097/NCC .0b013e3182321389.
Cancer NursingTM, Vol. 38, No. 6, 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
n
E29
