Nurses' competence in advising and supporting clients to cease smoking: a survey among Finnish nurses

Australian mental health care practitioners' practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness

Reducing the burden of physical illness among people living with severe mental illnesses (SMI) is a key priority. Smoking is strongly associated with SMIs resulting in excessive smoking related morbidity and mortality in smokers with SMI. Smoking cessation advice and assistance from mental health practitioners would assist with reducing smoking and smoking-related harms in this group. This study examined the attitudes and practices of Australian mental health practitioners towards smoking cessation and tobacco harm reduction for smokers with SMI, including adherence to the 5As (ask, assess, advise, assist and arrange follow up) of smoking cessation. We surveyed 267 Australian mental health practitioners using a cross-sectional, online survey. Most practitioners (77.5%) asked their clients about smoking and provided health education (66.7%) but fewer provided direct assistance (31.1-39.7%). Most believed that tobacco harm reduction strategies are effective for reducing smoking related risks (88.4%) and that abstinence from all nicotine should not be the only goal discussed with smokers with SMI (77.9%). Many respondents were unsure about the safety (56.9%) and efficacy (39.3%) of e-cigarettes. Practitioners trained in smoking cessation were more likely (OR: 2.9, CI: 1.5-5.9) to help their clients to stop smoking. Community mental health practitioners (OR: 0.3, CI: 0.1-0.9) and practitioners who were current smokers (OR: 0.3, CI: 0.1-0.9) were less likely to adhere to the 5As of smoking cessation intervention. The results of this study emphasize the importance and need for providing smoking cessation training to mental health practitioners especially community mental health practitioners.

Do nurses' personal health behaviours impact on their health promotion practice? A systematic review

BACKGROUND

There is a growing expectation in national and international policy and from professional bodies that nurses be role models for healthy behaviours, the rationale being that there is a relationship between nurses' personal health and the adoption of healthier behaviours by patients. This may be from patients being motivated by, and modelling, the visible healthy lifestyle of the nurse or that nurses are more willing to promote the health of their patients by offering public health or health promotion advice and referring the patient to support services.

METHODS

An integrated systematic review was conducted to determine if nurses' personal health behaviour impacted on (1) their health promotion practices, and (2) patient responses to a health promotion message. Medline, CINAHL, SCOPUS, and PsycINFO databases were searched. A narrative synthesis was conducted.

RESULTS

31 studies were included in the review. No consistent associations were noted between nurses' weight, alcohol use, or physical activity level and their health promotion practice, although smoking appeared to negatively impact on the likelihood of discussing and engaging in cessation counselling. Nurses who reported confidence and skills around health promotion practice were more likely to raise lifestyle issues with patients, irrespective of their own personal health behaviours. The two studies included in the review that examined patient responses noted that the perceived credibility of a public health message was not enhanced by being delivered by a nurse who reported adopting healthy behaviours.

CONCLUSIONS

Although it is assumed that nurses' personal health behaviour influences their health promotion practice, there is little evidence to support this. The assertion in health care policy that nurses should be role models for healthy behaviours assumes a causal relationship between their health behaviours and the patient response and adoption of public health messages that is not borne out by the research evidence.

Feasibility and acceptability of a telephone- and face-to-face-delivered counseling intervention for smoking cessation in Dutch patients with coronary heart disease

Intensive behavioral counseling interventions combined with nicotine replacement therapy have increased smoking abstinence rates in cardiac patients, but little is known about their feasibility when initiated upon hospital admission and continued post-discharge. The current study was an evaluation of the use, appreciation, and fidelity of two post-discharge counseling interventions designed for cardiac patients to quit smoking that differed in their delivery mode. In a controlled trial with cross-over randomization at the cardiac unit level, hospitalized smokers in eight cardiac units of eight Dutch hospitals were assigned either telephone counseling (n = 223) or nurse-administered face-to-face counseling (n = 157) using the Ask-Advise-Refer strategy. Eligible patients also received nicotine replacement therapy. Data based on counselors' registration forms and patients' telephone surveys at 6-month follow-up were analyzed. Most patients (>90%) participated in at least one counseling session, and the majority participated in at least five out of a maximum of seven sessions. Higher levels of adherence to either the telephone or face-to-face counseling sessions were associated with higher smoking abstinence rates at the 6-month follow-up, whereas higher nicotine patch use was not associated with abstinence. Patients positively evaluated the content, duration, and number of sessions, and rated the face-to-face counseling significantly better than the telephone counseling for quitting smoking. The counselors largely complied with the intervention protocols. The current intervention offers evidence of feasibility and may improve outpatient continuity of smoking care. Monitoring the use and delivery of such complex interventions is recommended to promote effective dissemination in cardiac practice.

Registered nurses' perception of self-efficacy and competence in smoking cessation after participating in a web-based learning activity

AIMS AND OBJECTIVES

To describe how registered nurses having undergone a web-based learning activity perceive their self-efficacy and competence to support patients with smoking cessation in connection with surgery.

BACKGROUND

Smoking cessation in connection with surgery reduces postoperative complications, and the support patients get from registered nurses may be important in helping them become smoke-free in connection with their surgery. Therefore, registered nurses are in need of enhanced understanding about which kind of counselling is the most effective for smoking cessation. Educating large groups of registered nurses in a digital environment appears to be a flexible and cost-effective way.

DESIGN AND METHODS

A convergent mixed-method design with data collection was done using questionnaires (n = 47) and semistructured interviews (n = 11). Inclusion criteria were registered nurses in surgical wards. The samples were nonprobability and modified nested. Descriptive statistics and content analysis were used for data analysis.

RESULTS

After completing the web-based learning activity, the registered nurses perception was that of good self-efficacy and increased competence in supporting patients with smoking cessation in connection with surgery. They improved their understanding of how to talk about smoking cessation with patients in dialogue using open-ended questions. Nevertheless, the registered nurses requested opportunities for dialogue and interaction with colleagues or topic experts.

CONCLUSIONS

The results indicate that registered nurses can enhance their competence in supporting patients to embrace smoking cessation by learning in a digital environment. Self-efficacy and understanding of the topic seems to motivate registered nurses to counsel patients about smoking cessation.

RELEVANCE TO CLINICAL PRACTICE

Findings from this study will be of particular interest to educators in healthcare settings who can devise further development of web-based learning activities.

An international review of tobacco smoking research in the nursing profession, 1976-2006

Tobacco smoking represents a contentious issue in the nursing profession, and one that has now become an important topic in nursing research. Despite this fact, the epidemiological quality of research varies widely, and it has been difficult to accurately determine the true incidence of smoking among nurses. Given these inconsistencies, we conducted a state-of-the-art review to identify international trends in tobacco usage among nurses, to ascertain how the epidemiological quality of research has improved over the past 30 years, and also to elucidate the directions in which nursing research has evolved. A total of 73 English-language studies that met the inclusion criteria were located and analysed. Overall, our review suggests that, while tobacco smoking among nurses appears to be decreasing in many countries during recent years, the international trend is far from uniform, and some developed nations still report high smoking rates among their nursing staff. From a methodological perspective, the relative epidemiological quality of smoking research has also fluctuated over time, making it difficult to compare the results of one study to the next. Despite these caveats, tobacco smoking remains a key topic in nursing research, as well as a critically important occupational-health issue for the entire nursing profession. In order to make the next generation of tobacco research data as comparable as possible, future scholars should consider devising and implementing a standardised format for conducting international tobacco smoking research within the nursing profession.

[Effectiveness of a multicomponent smoking cessation intervention in primary care]

OBJECTIVE

To evaluate the effectiveness of a multicomponent program applied by nurses in primary care.

METHOD

A non-experimental pre-post study was carried out in 145 smokers from Area V of Asturias (Spain). The intervention consisted of a multicomponent group treatment program, applied for 7 weeks by primary care nurses.

RESULTS

The mean age was 52 years. Men accounted for 39.73% of the study population. The abstinence rate at post-treatment was 51.1% (95% CI: 42.4 to 59.6). At 12 months, the abstinence rate was 41.1% (95% CI: 32.6 to 49.6). The change between the end of the intervention and follow-up at 6 and 12 months was statistically significant at both time points (p = 0.035 and p = 0.013, respectively). Among participants who had stopped smoking, there was a statistically significant decline in daily cigarette consumption. Factors that were statistically significantly associated with continued smoking at 12 months were heavier smoking before the intervention, higher scores on the Fagerström test, and a lower number of sessions attended.

CONCLUSIONS

The multicomponent treatment program was highly effective. The results suggest the desirability of specific training for health professionals to implement this type of intervention in primary care as an alternative to medical advice for smokers who need it.

Smoking cessation treatment practices: recommendations for improved adoption on cardiology wards

BACKGROUND AND OBJECTIVES

Smoking cessation treatment practices described by the 5 A's (ask, advise, assess, assist, arrange) are not well applied at cardiology wards because of various reasons, such as a lack of time and appropriate skills of the nursing staff. Therefore, a simplified guideline proposing an ask-advise-refer (AAR) strategy was introduced in Dutch cardiac wards. This study aimed to identify factors that determine the intentions of cardiac ward heads in adopting the simplified AAR guideline, as ward heads are key decision makers in the adoption of new guidelines. Ward heads' perceptions of current smoking cessation practices at the cardiac ward were also investigated.

METHODS

A cross-sectional survey with written questionnaires was conducted among heads of cardiology wards throughout the Netherlands, of whom 117 (64%) responded.

RESULTS

According to the heads of cardiac wards, smoking cessation practices by cardiologists and nurses were mostly limited to brief practices that are easy to conduct. Only a minority offered intensive counseling or arranged follow-up contact. Heads with strong intentions of adopting the AAR guideline differed significantly on motivational and organizational attributes and perceived more smoking cessation assistance by other health professionals than did heads with weak intentions of adopting. Positive attitudes, social support toward adoption, and perception of much assistance at the ward were significantly associated with increased intentions to adopt the AAR guideline.

CONCLUSIONS

Brief smoking cessation practices are adequately performed at cardiac wards, but the most effective practices, offering assistance and arranging for follow-up, are less than optimal. The AAR guideline offers a more feasible approach for busy cardiology wards. To ensure successful adoption of this guideline, the heads of cardiac wards should be convinced of its advantages and be encouraged by a supportive work environment. Policies may also facilitate the adoption of the AAR guideline.

An exploration of how clinician attitudes and beliefs influence the implementation of lifestyle risk factor management in primary healthcare: a grounded theory study

Background

Despite the effectiveness of brief lifestyle intervention delivered in primary healthcare (PHC), implementation in routine practice remains suboptimal. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about the process by which clinicians' perceptions shape implementation. This study aims to describe a theoretical model to understand how clinicians' perceptions shape the implementation of lifestyle risk factor management in routine practice. The implications of the model for enhancing practices will also be discussed.

Methods

The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in New South Wales (NSW), Australia. This included journal notes kept through the implementation of the project, and interviews with 48 participants comprising 23 clinicians (including community nurses, allied health practitioners and an Aboriginal health worker), five managers, and two project officers. Data were analysed using grounded theory principles of open, focused, and theoretical coding and constant comparative techniques to construct a model grounded in the data.

Results

The model suggests that implementation reflects both clinician beliefs about whether they should (commitment) and can (capacity) address lifestyle issues. Commitment represents the priority placed on risk factor management and reflects beliefs about role responsibility congruence, client receptiveness, and the likely impact of intervening. Clinician beliefs about their capacity for risk factor management reflect their views about self-efficacy, role support, and the fit between risk factor management ways of working. The model suggests that clinicians formulate different expectations and intentions about how they will intervene based on these beliefs about commitment and capacity and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians' appraisal of the overall benefits versus costs of addressing lifestyle issues acts to positively or negatively reinforce their commitment to implementing these practices.

Conclusion

The model extends previous research by outlining a process by which clinicians' perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

Building an integrated model of tobacco control education in the nursing curriculum: findings of a students' survey

This study examined the outcome of a 2-hour introductory lecture on tobacco and health in improving the knowledge and attitudes of nursing students toward smoking and tobacco control. A group of 78 first-year undergraduate nursing students of a major university in Hong Kong were invited to complete a self-administered questionnaire before and after the lecture. The findings indicated a significant improvement in knowledge of and attitudes about tobacco control. The study suggests that education about smoking and tobacco control should be introduced into the nursing curriculum at an early stage so appropriate knowledge, attitudes, and skills can be subsequently strengthened to prepare students to lead an effective role in delivering tobacco control nursing interventions. Finally, a model of integrating tobacco control content in the undergraduate nursing curriculum was recommended.

"Should I and can I?" A mixed methods study of clinician beliefs and attitudes in the management of lifestyle risk factors in primary health care

Background

Primary health care (PHC) clinicians have an important role to play in addressing lifestyle risk factors for chronic diseases. However they intervene only rarely, despite the opportunities that arise within their routine clinical practice. Beliefs and attitudes have been shown to be associated with risk factor management practices, but little is known about this for PHC clinicians working outside general practice. The aim of this study was to explore the beliefs and attitudes of PHC clinicians about incorporating lifestyle risk factor management into their routine care and to examine whether these varied according to their self reported level of risk factor management.

Methods

A cross sectional survey was undertaken with PHC clinicians (n = 59) in three community health teams. Clinicians' beliefs and attitudes were also explored through qualitative interviews with a purposeful sample of 22 clinicians from the teams. Mixed methods analysis was used to compare beliefs and attitudes for those with high and low levels of self reported risk factor management.

Results

Role congruence, perceived client acceptability, beliefs about capabilities, perceived effectiveness and clinicians' own lifestyle were key themes related to risk factor management practices. Those reporting high levels of risk factor screening and intervention had different beliefs and attitudes to those PHC clinicians who reported lower levels.

Conclusion

PHC clinicians' level of involvement in risk factor management reflects their beliefs and attitudes about it. This provides insights into ways of intervening to improve the integration of behavioural risk factor management into routine practice.

Factors influencing intentions to integrate tobacco education among advanced practice nursing faculty

We report on the findings of a national survey that examined factors that influence faculty's intentions to integrate tobacco education in their advanced practice nursing curricula. The addiction component of tobacco use is taking its toll on the health of 48 million smokers in the United States. Several national health authorities recommend and/or mandate that tobacco prevention and tobacco cessation be addressed at every point of entry in the health care delivery system. However, there is increasing evidence that health care providers may not be adequately prepared to meet national goals and/or standards. One hundred sixty-one advanced practice nursing faculty in the United States completed an 88-item survey regarding external factors (e.g., personal history of tobacco use, clinical practice, and current tobacco topics taught) and components of the Theory of Reasoned Action model (including perceived self-efficacy, behavioral beliefs, subjective norms, and control beliefs related to tobacco education). Descriptive statistics, chi(2) analysis, Pearson correlation, and linear regression were used to analyze the data. The findings revealed that sex (chi(2) = 7.949, P = .024), level of education (chi(2) = 26.853, P = .0005), years of academic teaching (chi(2) = 19.418, P = .013), and combined clinical and course responsibility (chi(2) = 10.430, P = .0236) were significant external (demographic) factors and that behavioral beliefs (attitude about tobacco education) demonstrated the strongest relationship with intention scores (r = 0.876, P < .0005). Overall, 62.7% of nurse practitioners reported high scores (>or=5, on a scale of 1-7) for intentions to integrate tobacco education, as compared with 37.5% of nurse midwives, 30.3% of clinical nurse specialists, and 8.7% of nurse anesthetists. This study adds to the growing body of evidence that nursing curricular gaps with tobacco education exist and that national efforts are needed to ensure that widespread changes occur to help reduce the morbidity and mortality related to tobacco use.

Nurses? perceptions, understanding and experiences of health promotion

AIM

This paper presents an account of nurses' perceptions and understanding of health promotion in an acute setting.

BACKGROUND

Health promotion is considered the remit of every nurse. To engage in health-promoting practice, however, nurses need to understand the term 'health promotion' clearly.

METHOD

A single qualitative embedded case study was used. Purposive sampling of eight nurses was employed. Initially, theses nurses were observed in practice and, following this, a semi-structured one-to-one interview was conducted with each observed nurse. Qualitative data analysis guided by work of Miles and Huberman was employed.

RESULTS

The data revealed one main theme: health-promoting nursing practice and this consisted of six categories and five subcategories. The findings indicated that nurses struggled to describe their understanding of health promotion, their understanding was limited and the strategies described to conduct health promotion were narrow and focused on the individual. Their perceptions and descriptions of health promotion were more in keeping with the traditional health education approach. Overall health promotion was reported to occur infrequently, being added on if the nurse had time. Factors relating to education, organizational and management issues were identified as key barriers prohibiting health-promoting nursing practice.

CONCLUSIONS

Nurses must recognize that health promotion is a broad concept that does not exclusively focus on the individual or lifestyle factors. Nurses must be educated to recognize health-promoting opportunities in the acute setting, as well as how to plan for and conduct health promotion so that it becomes integral to practice. A review of the methods of organizing and delivering nursing care is also advocated.

RELEVANCE TO CLINICAL PRACTICE

Ward managers have an important role in supporting nurses, creating a culture for health promotion and sharing power in decision-making processes, so that nurses feel valued and empowered.

Participation of Icelandic nurses in smoking cessation counselling

AIMS AND OBJECTIVES

The purpose of this study was to investigate the participation and knowledge of Icelandic nurses in smoking cessation counselling and to find barriers to smoking interventions by nurses.

BACKGROUND

Research has shown that clinical intervention as brief as three minutes can substantially increase smoking cessation success. Several studies have revealed that majority of nurses agree that smoking cessation counselling is within their duties. However, the percentage of nurses who report advising and/or counselling patients remains low.

DESIGN AND METHODS

An anonymous mail survey of all practicing nurses in Iceland was conducted in September 2004. A self-administered questionnaire was used, consisting of 74 questions in six sections: asking about smoking behaviour, to advise, to assess/assist/arrange, children and passive smoking, other questions and demographic questions.

RESULTS

Of 2453 questionnaires, 868 complete questionnaires were returned, giving a 36% response rate. While the majority of nurses 'asked' about smoking behaviour, a minority 'advised' or 'assisted' their clients with smoking cessation. However, if the clients had no smoking-related symptoms, less than half of the nurses asked about smoking behaviour. Failure to ask and advise clients about the importance of smoking cessation and assisting with smoking cessation correlated (p < 0.001) with several factors, including: lack of time, insufficient knowledge or training and not considered as a part of daily duty. Nurses who smoked were less likely to advise against smoking (p < 0.05).

CONCLUSIONS

Nurses frequently neglect to counsel clients about smoking cessation. Common barriers to the delivery of smoking cessation interventions by nurses include insufficient education and training in smoking cessation therapy.

RELEVANCE TO CLINICAL PRACTICE

The number of patients with tobacco-related illnesses is increasing worldwide. Effective smoking cessation interventions by nurses have the enormous potential of reducing smoking prevalence and improve health.

Nurses' opportunistic interventions with patients in relation to smoking

AIM

This paper reports a study exploring nurses' provision of opportunistic health education on smoking for hospital patients.

BACKGROUND

Smoking cessation guidelines recommend assessment of patients' smoking habits and provision of smoking cessation advice when possible, and highlight the importance of the role of nurses in health promotion and health education. In the past, nurses have been criticized for lack of knowledge, skills and confidence in relation to health education and the perception that it is additional to, rather than integrated with, nursing care.

METHODS

A qualitative case study design was selected to explore the health education practice of 12 nurses working in acute wards in three general hospitals in Scotland. Data were collected in 2000 through non-participant observation, semi-structured interviews and the use of a radio-microphone to record nurse-patient interactions. The data analysis was guided by four key elements of health education practice: 'the teachable moment', 'readiness to learn', 'the provision of health information' and 'oral communication'.

FINDINGS

Smoking was part of the nurses' agenda, as most recognized opportunities to introduce health education on smoking during nursing care, suggesting a tentative move towards the integration of health education with nursing care. Evidence from patients' interactions indicated ample opportunity for nurses to provide smoking-related health information. However, the content of nurses' interactions on smoking was variable, with some limited by poor communication skills and inadequate knowledge of smoking and smoking cessation. The context of the interactions was also important in understanding some of the restrictions on conversational progress.

CONCLUSIONS

Nurses require the knowledge and skills to perform a health education role, and the inclusion of smoking cessation guidelines in nursing curricula would contribute to this. Where patients are in hospitals for short periods of time, opportunistic health education on smoking needs to be introduced as the basis for more specialist intervention.

Caught in the middle: experiences of tobacco-dependent nurse practitioners

PURPOSE

To explore how tobacco-dependent nurse practitioners (NPs) describe their experiences with health promotion and disease prevention practices with patients who smoke.

DATA SOURCES

Twelve NPs who completed a graduate level NP program of study participated in face-to-face interviews and/or online chat room interviews.

CONCLUSIONS

Participants' responses revealed three themes relevant to their experience as tobacco-dependent clinicians with health promotion responsibilities. These themes centered around (a) living as an insider in the world of tobacco addiction, (b) having the outside-in view of living with a tobacco addiction, and (c) being caught in the middle of a tobacco addiction.

IMPLICATIONS FOR PRACTICE

All of the tobacco-dependent participants described limited smoking-cessation interventions with their patients. A barrier to implementation of more aggressive interventions, perhaps, is the provider's own tobacco addiction. With increasing evidence that tobacco-dependent health care professionals are not adequately intervening with tobacco-dependent patients, effective strategies are needed to assist and/or support not only tobacco-dependent patients but providers as well.

Efficacy of a smoking-cessation intervention for elective-surgical patients

We tested an intervention to help smokers abstain (fast) from smoking before surgery, maintain abstinence postoperatively, and achieve long-term cessation. A randomized experiment included 237 patients admitted for presurgical assessment who smoked. The intervention included counseling and nicotine replacement therapy. Treatment group participants (73.0%) were more likely to fast than were controls (53.0%): chi(2)(1, N = 228) = 8.89, p =.003, and more likely to be abstinent 6 months after surgery (31.2% vs. 20.2%). There was no significant difference in the abstinence rates at 12 months after surgery, chi(2)(1, N = 169) <.001, p = 1.00. Encouraging patients to fast from smoking before surgery and postoperative support are efficacious ways to reduce preoperative and immediate post-operative tobacco use.