Implementing Smoking Cessation Guidelines for Hospitalized Veterans: Effects on Nurse Attitudes and Performance
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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.
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.
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.
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 WORDSsmoking cessation Veterans counseling guideline-based intervention
- 1.Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults-United States, 2006. MMWR Morb Mortal Wkly Rep. 2007;56(44):1157–1161.Google Scholar
- 2.U.S. Department of Health and Human Services. The health benefits of smoking cessation: A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. DHHS Publication No. (CDC) 90–8416;1990. DHHS Publication No. (CDC) 90–8416.Google Scholar
- 6.Fiore M, Bailey W, Cohen S, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville: US Department of Health and Human Services, US Public Health Service; 2008.Google Scholar
- 8.VA/DoD Evidence Based Practice Working Group. Management of tobacco use (MTU). 2008; http://www.healthquality.va.gov/Management_of_Tobacco_Use_MTU.asp. Accessed 4/1/2013.
- 17.National Cancer Institute. Clearing the Air: Quit Smoking Today. . 2008; http://www.smokefree.gov/pubs/Clearing-The-Air_acc.pdf. Accessed 4/1/2013.
- 19.U.S. Department of Health and Human Services. The health consequences of smoking: a report of the surgeon general. Rockville: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General; 2004.Google Scholar
- 21.Hughes JR. Background on the Minnesota Withdrawal Scale-Revised (MNWS-R). 2012; http://www.uvm.edu/~hbpl/minnesota/minnesota/2012/Background_8_2012.pdf, Accessed 4/1/2013.
- 28.Neter J, Kutner M, Nachtsheim C, Wasserman W. Applied linear statistical models. 4th ed. Homewood: Irwin; 1996.Google Scholar
- 30.Bernard H, Ryan G. Analyzing qualitative data: Systematic approaches. Thousand Oaks: Sage Publications; 2010.Google Scholar
- 31.Miles MB, Huberman AM. Qualitative data analysis: An expanded sourcebook. 2nd ed. Newbury Park: Sage Publications; 1994.Google Scholar
- 43.Shadish W, Cook T, Campbell D. Experimental and quasi-experimental designs for generalized causal inference. Boston: Houghton Mifflin; 2002.Google Scholar