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

Implementing smoking cessation in routine primary care-a qualitative study

Background

The use of digital tools has been proposed as a solution to some of the challenges of providing preventative services in primary care. Although there is a general acceptance among patients to use digital self-help tools to quit smoking, and healthcare organizations are increasingly urged to incorporate these tools in clinical practice, it is unclear how and for whom these innovations can be incorporated into clinical practice.

Objectives

To explore health care professionals' perceptions about smoking cessation practice in routine primary care and the use of digital tools in this work.

Methods

A qualitative study with nine in-depth telephone interviews with health care professionals working in primary care in Sweden. Convenience sampling and snowball technique was used as recruitment strategy. Informants included registered, district and auxiliary nurses as well as behavioral therapists. All informants were female, between 43 and 57 years old and experience of working with smoking cessation in primary care and possibility to recommend digital interventions to smokers.

Results

Informants described smoking cessation practice in primary care as (i) identifying smoking patients, (ii) pursuing standardized routines for smoking cessation practice and (iii) keeping smoking cessation practice on the agenda. Digital tools were described by informants to be used in different ways: (i) replicating practice, (ii) complementing practice and (iii) enabling access to health care practitioners. Finally, the analysis showed that patients' expectations and behaviors contributed to how and when smoking cessation practice was conducted, including the use of digital tools.

Conclusions

Implementing smoking cessation practice in primary care in Sweden encompass continuous work of reaching smoking patients, building buy-in among peers and keeping tobacco on the practice agenda. Digital interventions are used to replicate, complement and enabling access to care. The findings suggest that poor continuity of staff and negative attitudes towards preventative work may challenge smoking cessation practice. However, societal changes in the awareness of the health risks of tobacco use including shifting social norms regarding the acceptance of smoking may contribute to a normalization of speaking about smoking in primary care practice. Increased knowledge is needed on how, and for whom digital tools can be incorporated in clinical practice.

When primary care providers and smokers meet: a systematic review and metasynthesis

Primary Care Providers (PCPs) often deal with patients on daily clinical practice without knowing anything about their smoking status and willingness to quit. The aim of this metasynthesis is to explore the PCPs and patients who are smokers perspectives regarding the issue of smoking cessation within primary care settings. It relies on the model of meta-ethnography and follows thematic synthesis procedures. Twenty-two studies are included, reporting on the view of 580 participants. Three main themes emerge: (i) What lacks, (ii) Some expectations but no request, and (iii) How to address the issue and induce patients' motivation. Our results reveal a global feeling of a lack of legitimacy among PCPs when it comes to addressing the issue of tobacco and smoking cessation with their patients, even though they have developed creative strategies based on what is at the core of their practice, that is proximity, continuity, long-term and trustworthy relationship.

The delivery of smoking cessation interventions by nurses who smoke: A meta-ethnographic synthesis

AIMS

To gain new insights into the experiences of nurses who smoke and to understand the impact of those experiences on their delivery of smoking cessation interventions.

DESIGN

A meta-ethnographic synthesis.

DATA SOURCES

CINAHL, Embase, MEDLINE, PsychINFO, Web of Science and grey literature databases were searched from their inception to April 2019.

REVIEW METHODS

Meta-ethnography was employed to synthesize findings from included studies. The CASP qualitative checklist was used to appraise the quality of each study, and the GRADE-CERQual approach to appraise review findings. The synthesis is reported in accordance with the eMERGe reporting guidance.

RESULTS

From an initial search outcome of 6,019 citations, 13 studies were included detailing the experiences of 195 nurses who were smokers or ex-smokers. Four main themes were identified beliefs, dissonance, coping mechanisms and workplace policies. An integrated conceptual map was proposed on the basis of findings. Nurses who smoke were aware of tobacco harms and their role in addressing tobacco use, which resulted in experiences of guilt and stigma. Workplace policies played a crucial role in the creation of cognitive dissonance. Nurses used different strategies to cope with dissonance such as rationalizing smoking benefits, hiding their smoking behaviour, denial of smoking risks, and failing to engage with smoking cessation interventions. Some nurses expressed more positive aspirations to cope with their dissonance, including a willingness to quit and to embrace smoking cessation interventions with their patients.

CONCLUSION

Implementing smoke-free policies and supportive interventions targeting nurses' cognitive dissonance may assist them to quit smoking and improve their engagement in smoking cessation practices.

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.

Health professionals' personal behaviours hindering health promotion: A study of nurses who smoke

AIM

To explore the views of current and ex-smoker nurses on their role in supporting patients to stop smoking.

BACKGROUND

Long-term conditions are closely linked to harmful lifestyle behaviours, including smoking and overeating. Health professionals have an important role to play in promoting healthier lifestyles. It has been described that nurses' health behaviours may be a barrier to their health promotion practice. There is a need to gain further understanding on why nurses' health promotion activity is influenced by their own health behaviour.

DESIGN

A secondary analysis of qualitative data gathered in 2010 in the context of a project that aimed to develop a smoking cessation intervention for nurses.

METHODS

Eleven transcripts of semi-structured interviews conducted with nurses (current and ex-smokers) working in one university hospital in Spain. Data were analysed using framework analysis.

FINDINGS

Nurses who smoked engaged in social justification in terms of social norms and work stress. Only nurses who had quit smoking were able to identify the negative feelings it generated and the effect that it had on their past health promotion practice. This was expressed by ex-smokers as an internal conflict that prevented them from supporting patients with their own habit.

CONCLUSION

Nurses who smoke may be inhibited as health promoters without being aware of it. Interventions that focus on helping these professionals deal with the challenges associated with these encounters are necessary if health promotion practices are to be enhanced. Targeting this conflict might also work to improve their lifestyle, which would expand the potential impact to professionals' own health.

Nurses' smoking habits and their professional smoking cessation practices. A systematic review and meta-analysis

BACKGROUND

A better understanding of whether nurses' own smoking behaviours influence their engagement with smoking cessation interventions is needed.

AIM

To establish whether the smoking status of nurses is associated with their professional smoking cessation practices.

METHODS

Twelve electronic databases covering English and Spanish language publications from 01 Jan, 1996 to 25 Mar, 2015 were systematically searched. Studies were included if they reported nurses' smoking cessation practices in relation to their personal smoking habits. Proportions of nurses' smoking status and smoking cessation practices were pooled across studies using random effects meta-analysis.

RESULTS

Fifteen studies were included in this systematic review. Levels of reportedsmoking cessation interventions were generally low across the studies. The meta-analyses suggested that nurses' personal smoking status was not associated significantly with nurses always asking patients about their smoking, but nurses who smoked were 13% less likely to advise their patients to quit and 25% less likely to arrange smoking cessation follow-up. More intense interventions (assessing motivation and assisting) were not significantly associated with the smoking status of the nurse.

CONCLUSIONS

The smoking status of nurses appears to have a negative impact in the delivery of smoking cessation practices. The overall level of nurses' engagement with the delivery of smoking cessation interventions requires attention if nurses are to be effective agents of smoking cessation.

The relationship between health professionals' weight status and attitudes towards weight management: a systematic review

This systematic review aims to address the question of whether health professionals' weight status is associated with attitudes towards weight management. Twelve eligible studies were identified from a search of the Cochrane Library, Ovid MEDLINE, EMBASE, PsycINFO, CINAHL and three Chinese databases, which included 14 independent samples comprising a total of 10 043 respondents. Attitudes towards weight management were classified under eight attitude indicators. Quantitative synthesis of the findings of included studies showed that health professionals of normal weight were more likely to be more confident in their weight management practice, perceive fewer barriers to weight management and have more positive outcome expectations, have stronger role identity and more negative attitudes towards obese individuals than health professionals who were overweight or obese. However, there was no difference between overweight and non-overweight health professionals in their perceptions of the causes and outcomes of obesity. In addition, being female and having relevant knowledge and clinical experience of weight management appeared to predict positive attitudes towards obesity/obese patients and high self-efficacy in weight management, respectively. Future research should focus on prospectively theory-driven studies, and employ appropriately validated instruments and multivariate analyses to identify the relative contribution of weight status to attitudes towards weight management.

Frequency of nurses' smoking cessation interventions: report from a national survey

AIMS AND OBJECTIVES

To describe the frequency of nurses' delivery of tobacco cessation interventions ('Five A's': Ask, Advise, Assess, Assist, Arrange) and to determine the relationship of interventions to nurses' awareness of the Tobacco Free Nurses initiative.

BACKGROUND

Tobacco cessation interventions can be effectively provided by nurses. The delivery of smoking cessation interventions by healthcare providers is mandated by several organisations in the USA and around the world. Lack of education and resources about tobacco cessation may contribute to the minimal level of interventions. The Tobacco Free Nurses initiative was developed to provide nurses with easy access to web-based resources about tobacco control.

DESIGN

Cross-sectional survey of nurses (n = 3482) working in 35 Magnet-designated hospitals in the USA (21% response rate).

METHOD

A valid and reliable questionnaire used in previous studies to assess the frequency of the nurse's delivery of smoking cessation interventions ('Five A's') was adapted for use on the web.

RESULTS

The majority of nurses asked (73%) and assisted (73%) with cessation. However, only 24% recommended pharmacotherapy. Only 22% referred to community resources and only 10% recommended use of the quitline. Nurses familiar with TFN (15%) were significantly more likely to report delivery of all aspects of interventions, including assisting with cessation (OR = 1.55, 95% CI 1.27, 1.90) and recommending medications (OR = 1.81, 95% CI 1.45, 2.24).

CONCLUSIONS

Nurses' delivery of comprehensive smoking cessation interventions was suboptimal. Awareness of Tobacco Free Nurses was associated with increased interventions. Relevance to clinical practice. Further efforts are needed to ensure that nurses incorporate evidence-based interventions into clinical practice to help smokers quit. These findings support the value of Tobacco Free Nurses in providing nurses with information to support patients' quit attempts.

Do you need to smoke to get a break?: smoking status and missed work breaks among staff nurses

INTRODUCTION

The prevalence of missed work breaks by smoking status in healthcare settings is unknown. The work routines of nurses (Registered Nurses [RNs] and Licensed Practical Nurses [LPNs]), who smoke at higher rates than other health professionals, may be influenced by smokers who use breaks to avoid nicotine withdrawal. The purpose of this study was to examine the relationship between nurses' smoking status and work breaks and to explore the relationships among personal, professional, and workplace variables associated with missed work breaks.

METHODS

A web-based survey of 2589 staff nurses from 34 hospitals was conducted in 2006. Each hospital had been designated as a Magnet hospital by the American Nurses Credentialing Center. Data analysis included descriptive statistics, chi-square tests, and multivariate logistic regression.

RESULTS

The majority (90%) were nonsmokers; 97% were RNs. Missed breaks were common (70%) and differed by smoking status: 59% of smokers and 72% of nonsmokers frequently missed work breaks. Multivariate logistic regression determined that nonsmokers (OR=1.81, 95% CI=1.36, 2.42), LPNs (OR=2.37, 95% CI=1.16, 4.84), older nurses (OR 1.02, 95% CI=1.01, 1.03), those in emergency rooms (OR=1.75, 95% CI=1.25, 2.47), and in intensive care units (OR=1.60, 95% CI=1.22, 2.09) were more likely to miss breaks.

CONCLUSIONS

Missed work breaks were common among nurses. Those who did not smoke were almost twice as likely to miss their work breaks as compared to smokers. Inequities in breaks, especially by smoking status, may cause dissension in the workplace and negatively affect patient care. Policies that support work breaks for all nurses are needed.

Healthy and fit for prevention: the influence of clinician health and fitness on promotion of healthy lifestyles during health supervision visits

To understand the relationship between pediatricians' personal health and the delivery of pediatric preventive care, Illinois pediatricians were surveyed by mail. Responses from 387 pediatricians (55% response rate) regarding personal characteristics, their practice, and perceptions about preventive care patterns for children aged 2 through 10 years and management of overweight children were analyzed. Overall, 28% of pediatricians were healthy and fit (excellent/very good health and extremely/ very fit), 40% were either healthy or fit, and 33% were neither healthy nor fit. In logistic regression models controlling for personal and practice characteristics, healthy and fit pediatricians (vs neither healthy nor fit pediatricians) more routinely provided recommended care on child diet (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.6-6.2) and physical activity (OR, 3.2; 95% CI, 1.6-6.3) and assessed television time (OR, 4.4; 95% CI, 2.0-10.1). Pediatricians who were either healthy or fit (vs pediatricians who were neither healthy nor fit) more often assessed television time. Therefore, clinician health influenced application of preventive care.

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.

Using evidence-based educational strategies to increase knowledge and skills in tobacco cessation

To meet the demand for improved patient outcomes and accountability for healthcare delivery, nurses must embrace a culture of evidence-based practice (EBP). Integrating EBP for tobacco cessation in nursing practice is particularly important for the 44.5 million smokers in the United States who contribute to 157 billion dollars of healthcare costs annually. Unfortunately, studies reveal that healthcare providers are not aware of what is considered the best evidence, the United States Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence, resulting in missed opportunities to promote optimal health outcomes for individuals wanting to quit smoking. Fortunately, leading healthcare authorities such as the Joint Commission of Accreditation for Healthcare Organizations and Centers for Medicare and Medicaid Services now require providers to offer tobacco cessation services. The challenges and opportunities to do this effectively are many and with limited resources it will be increasingly important to ensure that nurses have the necessary knowledge and skills to improve tobacco cessation outcomes. For tobacco cessation interventions to become a standard of nursing practice, strategic efforts must be directed at advancing nursing research that evaluates best educational strategies for promoting tobacco cessation interventions within nursing curricula. In this article, a framework to help address nursing strategies to bridge the gap between EBP and tobacco cessation will be described.

Application of the Synergy Model with the surgical care of smokers

The Synergy Model for Patient Care, developed by the American Association of Critical-Care Nurses (AACN), demonstrates that positive patient outcomes are achieved when patient characteristics are matched with nurse competencies. This article describes how effective nursing practice, whether providing smoking cessation counseling or evaluating preoperative laboratory tests, must be centered around the needs and characteristics of patients. Smokers requiring surgical intervention have unique needs and require nurses with competent skills to help promote optimal pulmonary, cardiovascular, and wound healing outcomes.

Strategies to implement tobacco control policy and advocacy initiatives

Critical care nursing organizations and individual critical care nurses can have an important impact on tobacco-related health policies. This article reviews the importance of critical care nursing involvement in policy efforts to achieve tobacco control goals, barriers to such involvement, and strategies to implement successful tobacco control policy initiatives. The involvement of the Association of Critical-Care Nurses and other nursing organizations in the Nursing Leadership in Tobacco Control Task Force is described.

Meeting Joint Commission on Accreditation of Healthcare Organizations requirements for tobacco cessation: the St. Joseph's/Candler Health System approach to success

Health care institutions can no longer treat only the sequelae of tobacco use. Smoking-cessation programs must be instituted to meet health promotion and education goals developed on admission for all patients. Leading authorities, such as the Joint Commission on Accreditation of Health Care Organizations and the Centers for Medicare and Medicaid Services, now include tobacco-cessation counseling as quality performance measures. This article discusses successful strategies that health care professionals have used at St. Joseph's/Candler Health System in Savannah, Georgia, to meet these standards.

Providing Smoking Cessation Counseling: A National Survey Among Nurse Anesthetists

Current research has demonstrated that smokers have an increased incidence of intraoperative and postoperative complications. Certified registered nurse anesthetists (CRNAs) have knowledge of a patient's smoking status and are in a unique position to provide smoking cessation counseling (SCC). The results from a national survey about SCC practice among CRNAs is revealed in this article.

The use of the nicotine inhaler in smoking cessation

PURPOSE

To raise awareness among nurse practitioners (NPs) about the nicotine inhaler by providing clinical and practical information about the use of the nicotine inhaler as a treatment option for smoking cessation.

DATA SOURCES

This included data-based and review articles in the medical literature, tobacco use and dependence clinical practice guideline, and Medline and Cinahl search engines. Criteria for search keywords were "nicotine inhaler" and "nicotine replacement therapy." Initial search was done in December 2004.

CONCLUSIONS

The nicotine inhaler has been tested as safe and efficacious in the treatment of tobacco cessation. Clinical trials show the nicotine inhaler to be useful alone or as an adjunct to other pharmacological therapies. Current national guidelines recommend that the nicotine inhaler be used in smoking cessation therapy.

IMPLICATIONS FOR PRACTICE

The nicotine inhaler is appropriate for many different smokers, including certain types of cardiac patients. NPs can include the nicotine inhaler in a group of nicotine replacement therapies to ensure that smokers are successful in tobacco cessation.