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Nursing Interventions for smoking cessation

N217 Evidence-Based Practice Presentation
by

Kathy McBane

on 11 April 2011

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Transcript of Nursing Interventions for smoking cessation

Nursing Interventions
for
Smoking Cessation Whyte, R. E., Watson, H. E., & McIntosh, J. (2006). Nurses' opportunistic interventions with patients in relation to smoking. Journal of Advanced Nursing 55 (5), 568-577. Study Purpose
to explore nurses' provision of opportunistic health education on smoking for hospital patients Research design
Qualitative case study Sample characteristics
12 RN's working in acute wards in 3 general hospitals in Scotland
minimun 1 year experience
same educational institution within 2-yr period
40 patients age 18+
smokers: current, recently stopped or ex-smokers
able to understand and respond to verbal
able to give oral and written consent
Data collection methods
prior pilot study at different hospital
one researcher, different times, different locations
patient lifestyle questionnaire
radio-microphone recorded patient-nurse interactions
'recall' interview
non-participant observations
semi-structured interviews
nursing documentation Results
health promotion of smoking cessation was part of nurses' agenda
variable content due to poor communication skills and inadequate knowledge of subject Chouinard, M-C. & Robichaud-Ekstrand, S. (2005). The effectiveness of a nursing inpatient smoking cessation program in individuals with cardiovascular disease. Nursing Research 54 (4), 243-254. Purpose
to measure effectiveness of a nurse-delivered inpatient smoking cessation program based on the Transtheoretical Model Research design
RCT n=168: 3 cohorts
1-hr inpatient counseling with telephone follow-up
1-hr inpatient counseling
usual care
2 intervention nurses
baseline, 2mo, 6mo endpoints
cardio unit in Quebec regional hospital Sample characteristics
18+
hospitalized for CVD: AMI, angina, heart failure or PVD
smoker
French language
local resident
telphone at home
plan of discharge to home
no mental or physical disability Data collection methods
Smoking stages of change (short form)
Fagerstrom Test for Nicotine Dependence
Quebec Health Survey Psychological Distress Index
Self-reports
Biochemical tests (urine and breath) Results
Higher rates (2x) of abstinence in high intensity intervention vs. standard care
HI intervention participants also progressed to ulterior stages of change with greater intent to quit, predicative of ultimate cessation

precontemplation to
contemplation to
preparation to
action to
maintenance Schultz, A. S. H., Bottorff, J. L. & Johnson, J. L. (2006). An ethnographic study of tobacco control in hospital settings. Tobacco Control 15, 317-322. Purpose
to study nurses' hospital workplace culture relevant to tobacco use and control Research design
Qualitative, ethnographic study
part of a mixed-methods research project investigating RN integration of tobacco-related activities in their practice Sample characteristics
2 hospitals in British Columbia, Canada (one in a region where pop smoking prevalence was 31.2%, other was 19.6%)
all adult in-patient wards Data collection methods
Field notes
Documents (admission forms, patient-care forms, referral forms, patient reference materials)
Hand recorded conversations (85 unstructured with nurses)
Photographs Results
Per nurses, 2 key system negatives
high workload
poor relations with admin
Nurses are not comfortable with:
enforcing hospital restrictions
addressing "lifestyle issue"
Don't understand complex nature of addiction


Binary efforts:
tobacco protection

while compliance was variable


tobacco cessation


Clinical Practice Guidelines recommend
availability of cessation materials
documentation system for tobacco status

Jonsdottir, R. & Jonsdottir, H. (2007). The experience of women with advanced chronic obstructive pulmonary disease of repeatedly relapsing to smoking. Scandinavian Journal of Caring Sciences 21, 297-304. Purpose
to illuminate the experience of women with COPD repeatedly relapsing to smoking Research design
Qualitative, interpretive phenomenology (the "lived experience") Sample characteristics
7 women ages 47-65 with COPD
smokers with at least 3 relapses to smoking
with an acute exacerbation of COPD requiring hospitalization Data collection methods
2 1-hr long semi-structured tape-recorded interviews with each participant
1-2 weeks post hospital discharge
in location of client's choosing
the researcher's diary of thoughts r/t interviews Results
5 overlapping themes:
overarching: being caught in a spider web
circumstances of the relapses
shame
the excuse
ambivalence and incomplete attempts to quit Zarling, K. K., Burke, M. V., Gaines, K. A. & Gauvin, T. R. (2008). Registered nurse initiation of a tobacco intervention protocol. Journal of Cardiovascular Nursing 23 (5), 443-448. Borrelli, B., Novak, S., Hecht, J., Emmons, K., Papandonatos, G. & Abrams, D. (2005). Home health care nurses as a new channel for smoking cessation treatment: Outcomes from project CARES (Community-nurse assisted research and education on smoking). Preventive Medicine 41, 815-821. Purpose
to evaluate the effectiveness of enhanced smoking cessation efforts by home health nurses Research design
RTC; 98 nurses randomized to deliver ME (motivational enhancement) or SC (standard care) to patients
278 medically-ill home health care patients randomized to receive ME or SC
all patients in Visiting Nurse Association of Rhode Island Sample characteristics
54.3% female
57.2 years mean age
42% CVD, 38% lung disease, 35% hypertension, 28% diabetes, 12% depression
62% self-report fair or poor health Data collection methods
at baseline:
self-report sociodemographics and smoking history
Fagerstrom Test for Nicotine Dependence
Mini-Mental State Exam
Contemplation Ladder to assess motivation to quit
Confidence Questionnaire to assess self-efficacy
Medical Outcomes Study (MOS) Short-Form General Health Survey for quality of life assessment
at end of treatment, 2mo, 6mo and 12mo post-treatment:
self-report smoking status verified by CO Ecolyzer and informants Results
ME participants were approximately twice as likely to be continuously abstinent than SC participants at all time points.
ME participants more likely to make "quit attempts" than SC participants
Among continuing smokers, ME participants more greatly reduced # cigarettes smoked per day than SC participants PICO
Population is adult smokers 18+, male and female, in any type healthcare setting, in any country
Registered nurses are the intervention providers
Compare to usual care
Outcome is smoking cessation So what?
Tobacco is responsible for 5 million preventable deaths worldwide per year
80% of these deaths are in low to middle-income countries
In the U.S. 20.8% adults, 45 million people smoke
1/5 deaths are related to smoking
Smoking morbidities include COPD, cancers, CVD and stroke
U.S. smoking-related healthcare costs $193 billion per year
Nurses are largest group of healthcare workers worldwide
If 2.5 million U.S. nurses each helped one person quit, nurses would triple the quit rate. Research question
What is the nature of the evidence related to the effectiveness of nursing interventions on patient smoking cessation?
What is the nature of the evidence related to different types of nursing interventions used in different settings and among different populations? Literature strategies
Databases used: PubMed, CINAHL, Cochrane Library and Google/Google Scholar
Key search terms used: smoking, smoking cessation, tobacco dependence, nursing interventions, nurses and smoking advocacy
In MeSH: nursing process, smoking [prevention and control], smoking cessation [methods]
Limits: last 5 years, English, major topics
Websites: CDC,WHO and www.TobaccoFreeNurses.org Key Findings
Countless articles found
Research studies, quality improvement reports
RCT's, mixed methods, descriptive, narrative inquiry, case study, phenomenological, ethnographic, grounded theory
Adult smokers present in all populations and clinical settings: inpatient, outpatient, home health, SES, ethnic groups, mentally and medically ill, rural/urban/suburban


Research problem
70% of U.S. smokers use healthcare services annually
70% report they want to quit
44% attempt to quit
Healthcare providers, including nurses, are not consistently integrating smoking cessation interventions into patient encounters and care plans. Recommendations for clinical practice change
Doing nothing is greatest risk, no longer acceptable and unethical: Level 1 evidence
Document tobacco status on admission and referral forms
Address smoking status on nursing care plans in terms of 5 A's
Advocate for your patient!
Implications for nursing education
Include smoking cessation in curricula
Treat tobacco dependence as an addiction and a chronic disease
Rx for change: Clinician-Assisted Tobacco Cessation
comprehensive, turn-key training program
free of charge
tailored approaches for healthcare subspecialties and populations
interprofessional Summary
Worldwide, nurses have more patient contacts than any other healthcare provider. The costs of smoking in terms of mortality and morbidity are higher than HIV, childbirth, tuberculosis, motor vehicle accidents, suicide and homicide combined. Nurses must assess tobacco dependency as the fifth vital sign. Nurses must implement the 5 A's (ask, advise, assess, assist and arrange) in evidenced-based interventions with all smokers in all healthcare settings. Implications for nursing research
Test interventions based on chronic disease and addiction
Questions?? Case study
At Mayo Clinic Hospital in Rochester, MN

JCAHO and National Quality Forum require
tobacco screening and advice/counseling as mandatory performance measures for CHF, AMI and CAP patients
smoke-free hospitals

Clinical Nurse Specialist led interdisciplinary team to develop "Tobacco Use Protocol" where RN
follows and documents 5 A's (ask, advise, assess, assist, arrange)
includes NRT (nurse can prescribe!)
includes Nicotine Dependence Center consult referral
6,000+ nurses trained on protocol
Results: 50% increase in NDC consults 2004-2006
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