Original Research

Journal of General Internal Medicine

, Volume 28, Issue 11, pp 1420-1429

Implementing Smoking Cessation Guidelines for Hospitalized Veterans: Effects on Nurse Attitudes and Performance

  • David A. KatzAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)Department of Medicine, University of IowaDepartment of Epidemiology, University of Iowa Email author 
  • , John HolmanAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)
  • , Skyler JohnsonAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)
  • , Stephen L. HillisAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)Department of Biostatistics, University of IowaDepartment of Radiology, University of Iowa
  • , Sarah OnoAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)
  • , Kenda StewartAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)
  • , Monica PaezAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)
  • , Steven FuAffiliated withCenter for Chronic Disease and Outcomes Research, Minneapolis VA Medical Center
  • , Kathleen GrantAffiliated withMental Health and Behavioral Sciences Department, VA Nebraska-Western Iowa Health Care System
    • , Lynne BuchananAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)The College of Nursing, University of Nebraska
    • , Allan ProchazkaAffiliated withDepartment of Medicine, VA Eastern Colorado Health Care System
    • , Catherine BattagliaAffiliated withDepartment of Medicine, VA Eastern Colorado Health Care System
    • , Marita TitlerAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)University of Michigan School of Nursing
    • , Mark W. Vander WegAffiliated withComprehensive Access & Delivery Research and Evaluation (CADRE) Center, VA Iowa City Health Care System (152)Department of Medicine, University of IowaDepartment of Psychology, University of Iowa

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ABSTRACT

BACKGROUND

A minority of hospitalized smokers actually receives assistance in quitting during hospitalization or cessation counseling following discharge. This study aims to determine the impact of a guideline-based intervention on 1) nurses’ delivery of the 5A’s (Ask-Advise-Assess-Assist-Arrange follow-up) in hospitalized smokers, and 2) nurses’ attitudes toward the intervention.

METHODS

We conducted a pre-post guideline implementation trial involving 205 hospitalized smokers on the inpatient medicine units at one US Department of Veterans Affairs (VA) medical center. The intervention included: 1) academic detailing of nurses on delivery of brief cessation counseling, 2) modification of the admission form to facilitate 5A’s documentation, and 3) referral of motivated inpatients to receive proactive telephone counseling. Based on subject interviews, we calculated a nursing 5A’s composite score for each patient (ranging from 0 to 9). We used linear regression with generalized estimating equations to compare the 5A’s composite score (and logistic regression to compare individual A’s) across periods. We compared 29 nurses’ ratings of their self-efficacy and decisional balance (“pros” and “cons”) with regard to cessation counseling before and after guideline implementation. Following implementation, we also interviewed a purposeful sample of nurses to assess their attitudes toward the intervention.

RESULTS

Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A’s composite score was higher after guideline implementation (3.9 vs. 3.1, adjusted difference 1.0, 95 % CI 0.5–1.6). More patients were advised to quit (62 vs. 48 %, adjusted OR = 2.1, 95 % CI = 1.2–3.5) and were assisted in quitting (70 vs. 45 %, adjusted OR = 2.9, 95 % CI = 1.6–5.3) by a nurse during the post-implementation period. Nurses’ attitudes toward cessation counseling improved following guideline implementation (35.3 vs. 32.7 on “pros” subscale, p = 0.01), without significant change on the “cons” subscale.

CONCLUSIONS

A multifaceted intervention including academic detailing and adaptation of the nursing admission template is an effective strategy for improving nurses’ delivery of brief cessation counseling in medical inpatients.

KEY WORDS

smoking cessation Veterans counseling guideline-based intervention