- Email: [email protected]
Tobacco dependence curricula in u.s. baccalaureate and graduate nursing education
Tobacco dependence curricula in U.S. baccalaureate and graduate nursing education Mary Ellen Wewers, PhD, MPH, FAAN Kellie Kidd, BS Debra Armbruster, MS Linda Sarna, DNS, FAAN
The overwhelming majority of nurses express a desire to help patients stop smoking but most nurses report a lack of training in tobacco dependence treatment. The purpose of the study was to assess tobacco content and extent of tobacco education and intervention skills among a national sample of baccalaureate and graduate U.S. nursing programs. A crosssectional survey design was implemented. A questionnaire that measured tobacco content curriculum was sent to 909 baccalaureate and graduate nursing program associate deans who were member institutions of the American Association of Colleges of Nursing. The majority of tobacco content curricula focused on the health effects of tobacco. Nursing students, especially undergraduates, lacked curricular content in the area of clinical tobacco cessation techniques. Increased instructional efforts concerning the clinical treatment of tobacco dependence are critical for achieving a nationwide reduction in tobacco use prevalence.
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obacco use contributes significantly to morbidity and mortality in the United States, with an estimated 440,000 tobacco-attributable deaths reported annually.1 According to the Agency for Healthcare Research and Quality (AHRQ), tobacco cessation treatment, when delivered by a variety of health care providers, significantly increases abstinence rates.2 Meta-analytic findings have determined that physicians and other health care providers are effective interventionists. Results from 29 randomized controlled trials indicated that physician intervention improves abstiMary Ellen Wewers is a Professor at the Ohio State University College of Nursing, Columbus, OH. Kelly Kidd is a Graduate Student at the Ohio State University College of Nursing, Columbus, OH. Debra Armbruster is a Graduate Student at the Ohio State University College of Nursing, Columbus, OH. Linda Sarna is a Professor at the University of California, Los Angeles, School of Nursing, Los Angeles, CA. Reprint requests: Mary Ellen Wewers, PhD, MPH, FAAN, 1585 Neil Avenue, Columbus, OH 43210-1289. E-mail: [email protected] Nurs Outlook 2004;52:95-101. © 2004 Elsevier Inc. All rights reserved. 0029-6554/$–see front matter doi:10.1016/j.outlook.2003.09.007
nence rates significantly as does treatment delivered by other providers such as nurses, dentists, dental hygienists, psychologists, and pharmacists.2 Scientifically-based smoking cessation strategies have been recommended by national agencies in both the United States2 and United Kingdom.3 These recommendations urge all health care professionals to assess and document tobacco use by every patient and offer assistance with quitting at every visit to patients who smoke. The most effective components of smoking cessation treatment include clinician-delivered social support, skills training, and pharmacotherapy (eg, nicotine replacement or bupropion SR). These guidelines support the delivery of tobacco cessation treatment by a variety of health professionals. Numerous studies in the U.S. and other developed countries have supported the efficacy of nurses in the delivery of tobacco cessation treatment.4-8 Although the majority of nurses believe it is their responsibility to instruct patients about smoking cessation, the percentage of nurses who report actually counseling patients remains low.9 Goldstein and others10 have reported that 43% of hospital-based nurses identified a lack of knowledge about how to provide smoking cessation treatment. One national survey of oncology nurses found the overwhelming majority (88%) wanted to help patients stop smoking but 92% reported needing additional training.11 Knowledge deficits about tobacco treatment have been documented in other health professions as well. According to Ferry, Grissino and Runfola,12 the majority of medical school graduates are not adequately trained to treat nicotine dependence. In a national survey of medical schools, these authors noted a major deficit is the lack of smoking cessation instruction and evaluation in the clinical years. The findings of this survey provided valuable information for medical school educators and guided the redesign of their curricula to address the significant health burden of tobacco.13 To date, the tobacco content provided students in U.S. baccalaureate and graduate nursing programs has not been described. As such, the purpose of the current study was to assess tobacco content and M
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extent of tobacco education and intervention skills among a national sample of baccalaureate and graduate U.S. nursing programs.
and resource materials used. Tobacco control experts in nursing (educators and clinicians) reviewed the tool for content validity prior to pilot testing. Next, several associate deans from undergraduate and graduate nursing programs were asked to complete the instrument to assess ease of administration. The final survey was then distributed to all AACN-member baccalaureate and graduate nursing program Deans or Directors. All 631 surveys used in the analyses were returned within eight months of the first mailing. To assess the reliability of responses, after return of the initial instrument, a random sample of schools (n⫽25) were asked to complete the survey again. Of these, twenty-one schools complied (84%). The percent agreement between the first and second survey was estimated at 78.4%, representing an acceptable degree of consistency.17
METHODS A cross-sectional survey design was used. The study was approved for exemption status by the Institutional Review Board at The Ohio State University. A cover letter that explained the study and the survey questionnaire were mailed in May 2001 to each Dean or Director at every baccalaureate (n⫽545) and graduate (n⫽364) nursing program whose school or college was a member of the American Association of Colleges of Nursing (AACN). AACN serves as the national, professional association for 550 public and private colleges and universities that offer baccalaureate and higherdegree nursing education programs.14 In the letter, each Dean or Director was instructed to give the survey questionnaire to the appropriate undergraduate and graduate associate dean, or designee, for completion. A self-addressed, stamped envelope was attached to each survey questionnaire for return to the Principal Investigator (Mary Ellen Wewers) when completed. Using the recommendations of Salant and Dillman15 for a sample that involved a specialized group or population (eg, nursing programs), up to four separate mailings were conducted to achieve the recommended response rate of 70%. In this study, 909 programs were mailed surveys for completion. Of the total number of baccalaureate programs (n⫽545), 385 responded (70.6%). For graduate programs (n⫽364), 246 program respondents returned a survey, for a response rate of 67.6%.
Statistical Analyses All data was analyzed using SPSS for Windows software (Version 11.0). Frequency analyses were conducted to summarize the survey information. Chisquare analyses were performed to ascertain regional differences in the extent of tobacco education and intervention skills. Regions were categorized geographically into four areas: (1) Northeast, (2) Midwest, (3) South, and (4) West. This categorization scheme was identical to a previous study that described tobacco prevalence estimates by region in the United States.18
FINDINGS Content Areas As depicted in Table 1, questions about tobacco-related curriculum content were divided into two major categories: Health effects of tobacco use and cessation. Most baccalaureate and graduate survey respondents reported the inclusion of content about the health effects of tobacco use as part of a required course. Fewer programs (67.5% baccalaureate and 62.3% graduate) included material related to the subtopic “contents of cigarette smoke” in their curriculum. Ninety percent or more of respondents indicated they taught about the cancer risks from smoking and the health effects of tobacco-related diseases. However, only 45.5% of baccalaureate programs and 66.5% of graduate programs included content about clinical smoking cessation techniques as a portion of required course curriculum. Over half (51.1%) of baccalaureate programs and greater than one-quarter (27.1%) of graduate programs reported that they do not offer any material on clinical smoking cessation techniques.
Survey Questionnaire The questionnaire was based on a survey instrument that was originally developed for use among U.S. medical school associate deans.12 Permission was obtained from the study investigators to refine the instrument for use with nursing school educators (personal communication, L. Ferry). In this study, the survey items were identical to the original instrument with two exceptions: (1) The words “nursing school” were substituted for the words “medical school”, and (2) responses that identified the curricular placement of tobacco cessation techniques were changed to “undergraduate years 2 – 4” and “masters core course or sub-specialty (theory or clinical) courses”, rather than “medical school years 1– 4”. The tobacco curricular content was based on recommendations for treatment from the updated AHRQ Treating Tobacco Use and Dependence Clinical Practice Guideline2 and a National Cancer Institute Training Guide.16 The final survey consisted of 23 items which requested information about didactic and clinical tobacco curricular content that was covered, its placement in curriculum, the number of hours of instruction, 96
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Tobacco Intervention Techniques Table 2 depicts responses to questions concerning curriculum in major tobacco treatment areas: (1) Recommendations from AHRQ with regard to the “5 As” of treatment (Ask, Advise, Assess, Assist and Arrange O
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Table 1. Tobacco curriculum content in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs Percent (%a) Part of required course
na Content Area
BSN
Health Effects of Tobacco Use 1. Cancer risk from 374 smoking 2. Health effects of 373 tobacco related diseases 3. Effects of 372 passive smoking 4. Contents of 360 cigarette smoke Cessation Topics 5. Symptoms of 357 withdrawal from nicotine 6. High risk groups 363 (difficulty quitting, increased risk of initiating) 7. Clinical smoking 385 cessation techniques 8. Pharmacologic 359 agents a
Required course on tobacco related diseases
Elective
Not offered
Grad
BSN
Grad
BSN
Grad
BSN
Grad
BSN
Grad
228
97.1
90.4
0.3
1.3
1.3
1.3
1.3
7.0
229
96.5
90.0
0.8
1.3
1.3
1.3
1.3
7.4
226
90.3
85.8
1.1
0.9
1.6
2.2
7.0
11.1
215
67.5
62.3
0.8
0.9
1.9
3.3
29.7
33.5
211
74.2
73.9
0.6
0.5
2.0
2.8
23.2
22.7
221
82.4
77.8
0.3
0.5
2.5
3.6
14.9
18.1
221
45.5
66.5
0.0
0.5
3.4
5.9
51.1
27.1
224
78.6
82.6
1.4
1.3
1.7
3.1
18.4
12.9
Number of respondents varied; percentages reflect number of respondents for each item.
follow-up),2 (2) nicotine replacement therapy, (3) antidepressant therapy; and (4) anti-hypertensive therapy. Results demonstrated that most programs covered these topics briefly. Nicotine replacement therapy (NRT) was most frequently noted as being covered only briefly in both baccalaureate (72.3%) and graduate (58.7%) programs. However, another 26.9% of graduate programs covered NRT in detail. Coverage of the “5 As” was most frequently omitted from curriculum content according to 37.3% of baccalaureate programs and 28.7% of graduate programs who responded to the survey. Although percentages were low in both programs, more graduate programs (16.1%–32.7%) indicated they covered tobacco treatment content in detail, as compared to baccalaureate programs (6.9%–12.3%). Analyses by region failed to detect any differences in intensity of coverage, based on geography. The overwhelming majority of baccalaureate programs (79.5%) did not require any clinical experience related to tobacco treatment, and very few required any clinical experience in the area of tobacco dependence. Results indicated that interventions were taught either
in a simulated setting (6.8%), with actual patients (5.5%) or actual patients with a required evaluation (1.6%). A similar pattern was noted in graduate programs. A total of 68.2% of programs did not require a clinical experience, while 11.7% used a simulated approach, 14.3% implemented exposure in actual clinical practice and 1.8% required a clinical experience with student evaluation.
Tobacco Content Curriculum Placement and Number of Hours Taught Few respondents provided information regarding placement of tobacco curriculum content in baccalaureate or graduate nursing programs. Most respondents indicated that tobacco content is taught for less than one hour in each of the three years contained in the undergraduate curriculum. More graduate program respondents reported teaching this material for 1–3 hours, as compared to baccalaureate programs. At the graduate level, tobacco curriculum content was most often covered in subspecialty theory (48.1%) and subspecialty clinical courses (46.1%). Less than 13% of baccalaureate and M
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Table 2. Tobacco treatment content in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs Percent (%a) na
Not covered
Covered briefly
Covered in detail
Content Area
BSN
Grad
BSN
Grad
BSN
Grad
BSN
Grad
1. Five As: Ask, Advise, Assess, Assist, and Arrange 2. Nicotine replacement 3. Antidepressant therapy 4. Antihypertensive therapy
362
223
37.3
28.7
53.9
55.2
8.8
16.1
368 367 361
223 223 223
20.4 24.0 34.3
14.3 15.2 23.8
72.3 63.8 58.7
58.7 52.0 57.4
7.3 12.3 6.9
26.9 32.7 18.8
a
Number of respondents varied; percentages reflect number of respondents for each item.
graduate programs spent more than 3 hours each year teaching this material. Once again, regional differences were not identified.
scribe tobacco content curriculum in a national sample of U.S. baccalaureate and graduate nursing programs. Findings indicated the majority of undergraduate and graduate nursing programs devote a sizeable portion of tobacco curriculum content to its health effects, primarily as part of a required course. However, students lacked curricular content in the area of clinical smoking cessation techniques. In fact, this content was absent in approximately 50% of baccalaureate programs responding to the survey. Specific evidence-based techniques were not covered in up to one-third of baccalaureate programs, while most baccalaureate programs covered specific elements of cessation techniques only briefly. Respondents indicated the majority of programs that were addressing tobacco content, used only one hour or less each year to cover the topic entirely. This deficit was less apparent among graduate programs as there was a more equitable distribution between less than one hour and one to three hours of tobacco treatment content instruction each year. As expected, given its advanced practice component, more emphasis was placed on pharmacotherapy for tobacco dependence at the graduate nursing program level. These findings were congruent with the results of a recent survey of tobacco dependence curricula in U.S. medical school education.12 Specifically, Ferry and others noted that most medical schools (69.2%) did not require clinical training in smoking cessation techniques, while 31% averaged less than 1 hour of instruction in cessation strategies each year. The authors concluded that U.S. medical school graduates are not adequately trained, and this lack of training is most notable during the clinical years of medical education. The current study among nursing programs is consistent with medical school findings that clinical smoking cessation instruction is noticeably inadequate. These results are striking, given the prevalence of tobacco users and tobacco-attributable diseases in clinical envi-
Resource Materials Used for Development of Tobacco-Related Curriculum The majority of baccalaureate and graduate program respondents provided information about resources used to develop tobacco-related curriculum. These percentages are delineated in Table 3. The three resources cited most frequently by baccalaureate program respondents were scientific literature reviews (37.8%), volunteer agencies (36.8%) and the National Cancer Institute’s publication How to Help Your Patient Stop Smoking (25.9%). Only 21% of baccalaureate programs reported using the U.S. Department of Health and Human Service’s Guide to Clinical Preventive Services and 21.9% used the national AHRQ Clinical Practice Guideline as a resource for developing curriculum. Among graduate programs, the most frequently reported resource materials included review of scientific literature (56.8%), USDHHS Guide to Clinical Preventive Services (55.1%) and the AHRQ Clinical Practice Guideline (46.2%).
DISCUSSION The burden of tobacco has significant health and economic consequences for the United States. In 2000, the prevalence of current smoking among adults was estimated at 23.3% and approximately 3000 adolescents used tobacco daily.19 An abundance of literature indicates that efficacious tobacco dependence treatment is available, including recommendations from a national evidence-based tobacco treatment clinical practice guideline.2 Unfortunately, as our findings demonstrated, nurses may lack adequate education to deliver these scientifically-valid treatments. This study represents the first investigation to de98
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Table 3. Resource materials used for development of tobacco-related curriculum in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs na
%
Resource
BSN
Grad
BSN
Grad
1. Guide to Clinical Preventive Services: USDHHS 2. Review of scientific literature 3. Nat’l Cancer Institute, “How to Help Your Patient to Stop Smoking” 4. Volunteer agency (e.g. American Lung Association, American Heart Association, American Cancer Society, etc.) 5. Brown University’s Project ADEPT Publication 6. American Association of Family Practice Guidelines 7. Agency for Health Care Policy and Research/AHRQ Guidelines 8. Putting Prevention into Practice: CDC 9. Private agency 10. Other
352
198
20.5
55.1
352 352
199 199
37.8 25.9
56.8 39.7
351
199
36.8
32.2
352
199
1.1
2.5
352
199
3.1
28.1
352
199
21.9
46.2
352
199
16.2
41.7
352 350
199 196
2.3 8.9
1.5 11.2
a
Number of respondents varied; percentages reflect number of respondents for each item.
ronments. Twenty-five percent of adults in the U.S. are current smokers, with reports of prevalence among hospitalized patients at or above adult general population estimates.20 In addition, approximately 70% of smokers visit a health care provider on an annual basis.2 Given the frequency of exposure to current smokers among clinicians, greater efforts to educate nursing and medical students about tobacco treatment in classroom and clinical settings are warranted. It has been clearly demonstrated in previous studies that the most common barrier to the delivery of smoking cessation treatment by nurses is a lack of education about efficacious therapy.11,21 While educators cover a plethora of topics in a compressed amount of time, increased instructional efforts must be directed at treatment for a condition that is responsible for 440,000 deaths in the U.S. annually. According to Der and co-workers,22 even student providers with minimal clinical experience can effectively deliver cessation interventions. Their findings indicated that a comprehensive smoking intervention program provided by specially trained first and second-year medical students were comparable to established treatment programs. Curricular models to guide health professional training in the area of tobacco treatment are still lacking. To address this gap, Spangler and colleagues,23 in a 2002 meta-analytic review of medical school curricula, identified that enhanced instructional methods (eg, patient-
centered counseling, standardized patient instructors, role playing, or a combination of methods) are more effective for teaching tobacco intervention than traditional didactic methods alone. In a similar line of research, Roche and others24 demonstrated that, among senior medical students, interactive approaches, such as audio feedback through the use of audio-taped role plays, role play with peer feedback, and video feedback were each more effective than a traditional didactic lecture mode for improving student skills in smoking intervention. The investigators concluded that traditional teaching methods are ineffective in developing smoking cessation intervention skills. These interactive methods of role-playing, patient-centered counseling and standardized patient instructors are already utilized in nursing school curricular models for other content and could be adapted for use. It has been suggested that health care educators collaborate to develop a body of core teaching materials that all health professional schools could integrate throughout multiple years of classroom and clinical education.12 Since the AHRQ guideline contains identical recommendations for all clinicians (eg, physician, nurse, dentist, pharmacist), this collaborative approach seems logical and would be an efficient use of resources. Finally, given the nursing profession’s emphasis on health promotion, these interactive techniques could also be useful for teaching about management of other risky behaviors, such as M
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alcohol abuse or obesity, which is now emerging as a national epidemic.25 With regard to instructional resources, the AHRQ Clinical Practice Guideline, first released in 1996, represents an excellent example of scientifically-valid recommendations for tobacco dependence treatment in clinical practice. Unfortunately, many educators and clinicians, including nurses, have not taken advantage of this resource. For example, a recent survey, conducted among the membership of the Oncology Nursing Society, noted that less than 10% had ever heard of this guideline.11 Future efforts must determine the most effective mechanism for disseminating evidence-based tobacco treatment guidelines for use by educators, providers and health care administrators. There is also compelling evidence that clinicians who smoke do not intervene with patients who smoke.2 Among health care professionals, nurses reportedly have a higher prevalence of smoking.26 Taken together, the higher prevalence estimates among nurses and the lack of instructional training about tobacco treatment dilute clinically-based tobacco control efforts. Of note, analyses of regional differences in the extent of instruction pertaining to tobacco curriculum content were not apparent, even though considerable regional smoking prevalence distinctions are known to exist (eg, higher in the South).18 The results of this study are generalizeable to AACN-member baccalaureate and graduate nursing programs in the United States. The findings are based on a response rate of 70%, which is considered representative of valid findings among special populations.15 No differences were noted between survey respondents and non-respondents, in terms of region, program size, or public/private designation. Limitations of the study included the lack of information gained about the integration of tobacco-related content throughout the curriculum and whether the survey respondent was well versed with regard to tobacco content. Healthy People 2010, the nation’s agenda for health, has set an adult smoking prevalence goal of 12%.27 Nurses, representing the largest number of health care professionals in the United States28 are well-suited to participate in the delivery of existing efficacious tobacco dependence therapies. Increased instructional efforts that prepare nurses to deliver scientifically-valid tobacco treatment are crucial and must soon be implemented to assist in achieving a significant reduction in tobacco use by the year 2010.
2. Fiore MC, Bailey WC, Cohen SJ, Dorfman S, Goldstein M, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2000. 3. Raw M, McNeill A, West R. (1998). Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Health Education Authority. Thorax, 53 Supplement 5 Part 1:S1-19. 4. Browning KK, Ahijevych KL, Ross P, Wewers ME. Implementing the Agency for Health Care Policy and Research’s Smoking Cessation Guideline in a lung cancer surgery clinic. Oncol Nurs Forum 2000;27:1248-54. 5. Clarke JM, Rowe K, Jones K. Evaluating the effectiveness of the coronary care nurses’ role in smoking cessation. J Clin Nurs 1993;2:313-22. 6. Hollis JF, Lichtenstein E, Vogt TM. Nurse-assisted counseling for smokers in primary care. Annals Intern Med 1993; 118:521-25. 7. Rice VH. Nursing intervention and smoking cessation: A meta analysis. Heart Lung 2000;28:438-54. 8. Taylor CB, Miller NH, Herman S, Smith PM, Sobel D, Fisher L, et al. A nurse-managed smoking cessation program for hospitalized smokers. Am J Public Health 1996;86:115760. 9. Center for Disease Control. Physician and other health care professionals counseling of smokers to quit: 1991. MMWR 1993;42:854-57. 10. Goldstein AO, Hellier A, Fitzgerald S, Stegall TS, Fischer PM. Hospital nurse counseling of patients who smoke. Am J Pub Health 1987;77:1333-34. 11. Sarna LP, Brown JK, Lillington L, Rose M, Wewers ME, Brecht ML. Tobacco interventions by oncology nurses in clinical practice: report from a national survey. Cancer 2000;89:881-9. 12. Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. JAMA 1999;282:825-29. 13. Spangler JG, Goerge G, Foley KL, Crandall SJ. Tobacco intervention training: Current efforts and gaps in US medical schools. JAMA 2002;288:1102-09. 14. American Association of Colleges of Nursing. Mission Statement 2002 Available at: www.aacn.org. 15. Salant P, Dillman DA. How to conduct your own survey. New York, NY: John Wiley and Sons, Inc., 1994. 16. Glynn TJ, Manley MW. How to help your patients stop smoking: A National Cancer Institute manual for physicians. Washington, DC: U.S. Department of Health and Human Services, Public Health Services, National Institutes of Health; 1993. Publication No. 93-3064. 17. Waltz CF, Strickland OL, Lenz ER. Measurement in nursing research. Philadelphia, PA: F.A. Davis Co; 1986. 18. Shopland DR, Hartman AM, Gibson JT, Mueller MD, Kessler LG, Lynn WR. Cigarette smoking among US adults by state and region: Estimates from the current population survey. J Ntl Ca Inst 1996;88:1748-58. 19. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2000. MMWR 2000;51: 642-45. 20. Smith PM, Reilly K, Miller NH, DeBusk RF, Taylor CB. Application of a nurse-managed inpatient smoking cessation program. Nicotine Tobacco Res 2002;4:211-22.
The authors wish to thank the American Association of Colleges of Nursing for providing their membership list.
REFERENCES 1. Centers for Disease Prevention and Control. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995-1999. MMWR 2002; 51:300-03.
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21. McCarty MC, Zander KM, Hennrikus DJ, Lando HA. Barriers among nurses to providing smoking cessation advice to hospitalized smokers. Am J Health Prom 2001;16:85-87. 22. Der DE, You UQ, Wolter TD. A free smoking intervention clinic initiated by medical students. Mayo Clinic Proceedings 2001;76:144-51. 23. Spangler JG, George G, Foley KL, Crandal SJ. Tobacco intervention training: Current efforts and gaps in US medical schools. JAMA 2002;288:1102-09. 24. Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: A blockrandomized controlled trial of four different approaches. Prev Med 1996;25:251-58.
25. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22. 26. Nelson DE, Giovino GA, Emont SL, Brackbill R, Cameron LL, Peddicord J, et al. Trends in cigarette smoking among US physicians and nurses. JAMA 1994;271:1273-75. 27. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. 2001. Available at: www.healthypeople.gov. 28. United States Department of Health & Human Services. Projected supply, demand and shortages of registered nurses 2000-2020. Rockville, MD: Health Resources and Services Administration. Bureau of Health Professions; 2000.
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The overwhelming majority of nurses express a desire to help patients stop smoking but most nurses report a lack of training in tobacco dependence treatment. The purpose of the study was to assess tobacco content and extent of tobacco education and intervention skills among a national sample of baccalaureate and graduate U.S. nursing programs. A crosssectional survey design was implemented. A questionnaire that measured tobacco content curriculum was sent to 909 baccalaureate and graduate nursing program associate deans who were member institutions of the American Association of Colleges of Nursing. The majority of tobacco content curricula focused on the health effects of tobacco. Nursing students, especially undergraduates, lacked curricular content in the area of clinical tobacco cessation techniques. Increased instructional efforts concerning the clinical treatment of tobacco dependence are critical for achieving a nationwide reduction in tobacco use prevalence.
T
obacco use contributes significantly to morbidity and mortality in the United States, with an estimated 440,000 tobacco-attributable deaths reported annually.1 According to the Agency for Healthcare Research and Quality (AHRQ), tobacco cessation treatment, when delivered by a variety of health care providers, significantly increases abstinence rates.2 Meta-analytic findings have determined that physicians and other health care providers are effective interventionists. Results from 29 randomized controlled trials indicated that physician intervention improves abstiMary Ellen Wewers is a Professor at the Ohio State University College of Nursing, Columbus, OH. Kelly Kidd is a Graduate Student at the Ohio State University College of Nursing, Columbus, OH. Debra Armbruster is a Graduate Student at the Ohio State University College of Nursing, Columbus, OH. Linda Sarna is a Professor at the University of California, Los Angeles, School of Nursing, Los Angeles, CA. Reprint requests: Mary Ellen Wewers, PhD, MPH, FAAN, 1585 Neil Avenue, Columbus, OH 43210-1289. E-mail: [email protected] Nurs Outlook 2004;52:95-101. © 2004 Elsevier Inc. All rights reserved. 0029-6554/$–see front matter doi:10.1016/j.outlook.2003.09.007
nence rates significantly as does treatment delivered by other providers such as nurses, dentists, dental hygienists, psychologists, and pharmacists.2 Scientifically-based smoking cessation strategies have been recommended by national agencies in both the United States2 and United Kingdom.3 These recommendations urge all health care professionals to assess and document tobacco use by every patient and offer assistance with quitting at every visit to patients who smoke. The most effective components of smoking cessation treatment include clinician-delivered social support, skills training, and pharmacotherapy (eg, nicotine replacement or bupropion SR). These guidelines support the delivery of tobacco cessation treatment by a variety of health professionals. Numerous studies in the U.S. and other developed countries have supported the efficacy of nurses in the delivery of tobacco cessation treatment.4-8 Although the majority of nurses believe it is their responsibility to instruct patients about smoking cessation, the percentage of nurses who report actually counseling patients remains low.9 Goldstein and others10 have reported that 43% of hospital-based nurses identified a lack of knowledge about how to provide smoking cessation treatment. One national survey of oncology nurses found the overwhelming majority (88%) wanted to help patients stop smoking but 92% reported needing additional training.11 Knowledge deficits about tobacco treatment have been documented in other health professions as well. According to Ferry, Grissino and Runfola,12 the majority of medical school graduates are not adequately trained to treat nicotine dependence. In a national survey of medical schools, these authors noted a major deficit is the lack of smoking cessation instruction and evaluation in the clinical years. The findings of this survey provided valuable information for medical school educators and guided the redesign of their curricula to address the significant health burden of tobacco.13 To date, the tobacco content provided students in U.S. baccalaureate and graduate nursing programs has not been described. As such, the purpose of the current study was to assess tobacco content and M
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extent of tobacco education and intervention skills among a national sample of baccalaureate and graduate U.S. nursing programs.
and resource materials used. Tobacco control experts in nursing (educators and clinicians) reviewed the tool for content validity prior to pilot testing. Next, several associate deans from undergraduate and graduate nursing programs were asked to complete the instrument to assess ease of administration. The final survey was then distributed to all AACN-member baccalaureate and graduate nursing program Deans or Directors. All 631 surveys used in the analyses were returned within eight months of the first mailing. To assess the reliability of responses, after return of the initial instrument, a random sample of schools (n⫽25) were asked to complete the survey again. Of these, twenty-one schools complied (84%). The percent agreement between the first and second survey was estimated at 78.4%, representing an acceptable degree of consistency.17
METHODS A cross-sectional survey design was used. The study was approved for exemption status by the Institutional Review Board at The Ohio State University. A cover letter that explained the study and the survey questionnaire were mailed in May 2001 to each Dean or Director at every baccalaureate (n⫽545) and graduate (n⫽364) nursing program whose school or college was a member of the American Association of Colleges of Nursing (AACN). AACN serves as the national, professional association for 550 public and private colleges and universities that offer baccalaureate and higherdegree nursing education programs.14 In the letter, each Dean or Director was instructed to give the survey questionnaire to the appropriate undergraduate and graduate associate dean, or designee, for completion. A self-addressed, stamped envelope was attached to each survey questionnaire for return to the Principal Investigator (Mary Ellen Wewers) when completed. Using the recommendations of Salant and Dillman15 for a sample that involved a specialized group or population (eg, nursing programs), up to four separate mailings were conducted to achieve the recommended response rate of 70%. In this study, 909 programs were mailed surveys for completion. Of the total number of baccalaureate programs (n⫽545), 385 responded (70.6%). For graduate programs (n⫽364), 246 program respondents returned a survey, for a response rate of 67.6%.
Statistical Analyses All data was analyzed using SPSS for Windows software (Version 11.0). Frequency analyses were conducted to summarize the survey information. Chisquare analyses were performed to ascertain regional differences in the extent of tobacco education and intervention skills. Regions were categorized geographically into four areas: (1) Northeast, (2) Midwest, (3) South, and (4) West. This categorization scheme was identical to a previous study that described tobacco prevalence estimates by region in the United States.18
FINDINGS Content Areas As depicted in Table 1, questions about tobacco-related curriculum content were divided into two major categories: Health effects of tobacco use and cessation. Most baccalaureate and graduate survey respondents reported the inclusion of content about the health effects of tobacco use as part of a required course. Fewer programs (67.5% baccalaureate and 62.3% graduate) included material related to the subtopic “contents of cigarette smoke” in their curriculum. Ninety percent or more of respondents indicated they taught about the cancer risks from smoking and the health effects of tobacco-related diseases. However, only 45.5% of baccalaureate programs and 66.5% of graduate programs included content about clinical smoking cessation techniques as a portion of required course curriculum. Over half (51.1%) of baccalaureate programs and greater than one-quarter (27.1%) of graduate programs reported that they do not offer any material on clinical smoking cessation techniques.
Survey Questionnaire The questionnaire was based on a survey instrument that was originally developed for use among U.S. medical school associate deans.12 Permission was obtained from the study investigators to refine the instrument for use with nursing school educators (personal communication, L. Ferry). In this study, the survey items were identical to the original instrument with two exceptions: (1) The words “nursing school” were substituted for the words “medical school”, and (2) responses that identified the curricular placement of tobacco cessation techniques were changed to “undergraduate years 2 – 4” and “masters core course or sub-specialty (theory or clinical) courses”, rather than “medical school years 1– 4”. The tobacco curricular content was based on recommendations for treatment from the updated AHRQ Treating Tobacco Use and Dependence Clinical Practice Guideline2 and a National Cancer Institute Training Guide.16 The final survey consisted of 23 items which requested information about didactic and clinical tobacco curricular content that was covered, its placement in curriculum, the number of hours of instruction, 96
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Tobacco Intervention Techniques Table 2 depicts responses to questions concerning curriculum in major tobacco treatment areas: (1) Recommendations from AHRQ with regard to the “5 As” of treatment (Ask, Advise, Assess, Assist and Arrange O
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Table 1. Tobacco curriculum content in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs Percent (%a) Part of required course
na Content Area
BSN
Health Effects of Tobacco Use 1. Cancer risk from 374 smoking 2. Health effects of 373 tobacco related diseases 3. Effects of 372 passive smoking 4. Contents of 360 cigarette smoke Cessation Topics 5. Symptoms of 357 withdrawal from nicotine 6. High risk groups 363 (difficulty quitting, increased risk of initiating) 7. Clinical smoking 385 cessation techniques 8. Pharmacologic 359 agents a
Required course on tobacco related diseases
Elective
Not offered
Grad
BSN
Grad
BSN
Grad
BSN
Grad
BSN
Grad
228
97.1
90.4
0.3
1.3
1.3
1.3
1.3
7.0
229
96.5
90.0
0.8
1.3
1.3
1.3
1.3
7.4
226
90.3
85.8
1.1
0.9
1.6
2.2
7.0
11.1
215
67.5
62.3
0.8
0.9
1.9
3.3
29.7
33.5
211
74.2
73.9
0.6
0.5
2.0
2.8
23.2
22.7
221
82.4
77.8
0.3
0.5
2.5
3.6
14.9
18.1
221
45.5
66.5
0.0
0.5
3.4
5.9
51.1
27.1
224
78.6
82.6
1.4
1.3
1.7
3.1
18.4
12.9
Number of respondents varied; percentages reflect number of respondents for each item.
follow-up),2 (2) nicotine replacement therapy, (3) antidepressant therapy; and (4) anti-hypertensive therapy. Results demonstrated that most programs covered these topics briefly. Nicotine replacement therapy (NRT) was most frequently noted as being covered only briefly in both baccalaureate (72.3%) and graduate (58.7%) programs. However, another 26.9% of graduate programs covered NRT in detail. Coverage of the “5 As” was most frequently omitted from curriculum content according to 37.3% of baccalaureate programs and 28.7% of graduate programs who responded to the survey. Although percentages were low in both programs, more graduate programs (16.1%–32.7%) indicated they covered tobacco treatment content in detail, as compared to baccalaureate programs (6.9%–12.3%). Analyses by region failed to detect any differences in intensity of coverage, based on geography. The overwhelming majority of baccalaureate programs (79.5%) did not require any clinical experience related to tobacco treatment, and very few required any clinical experience in the area of tobacco dependence. Results indicated that interventions were taught either
in a simulated setting (6.8%), with actual patients (5.5%) or actual patients with a required evaluation (1.6%). A similar pattern was noted in graduate programs. A total of 68.2% of programs did not require a clinical experience, while 11.7% used a simulated approach, 14.3% implemented exposure in actual clinical practice and 1.8% required a clinical experience with student evaluation.
Tobacco Content Curriculum Placement and Number of Hours Taught Few respondents provided information regarding placement of tobacco curriculum content in baccalaureate or graduate nursing programs. Most respondents indicated that tobacco content is taught for less than one hour in each of the three years contained in the undergraduate curriculum. More graduate program respondents reported teaching this material for 1–3 hours, as compared to baccalaureate programs. At the graduate level, tobacco curriculum content was most often covered in subspecialty theory (48.1%) and subspecialty clinical courses (46.1%). Less than 13% of baccalaureate and M
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Table 2. Tobacco treatment content in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs Percent (%a) na
Not covered
Covered briefly
Covered in detail
Content Area
BSN
Grad
BSN
Grad
BSN
Grad
BSN
Grad
1. Five As: Ask, Advise, Assess, Assist, and Arrange 2. Nicotine replacement 3. Antidepressant therapy 4. Antihypertensive therapy
362
223
37.3
28.7
53.9
55.2
8.8
16.1
368 367 361
223 223 223
20.4 24.0 34.3
14.3 15.2 23.8
72.3 63.8 58.7
58.7 52.0 57.4
7.3 12.3 6.9
26.9 32.7 18.8
a
Number of respondents varied; percentages reflect number of respondents for each item.
graduate programs spent more than 3 hours each year teaching this material. Once again, regional differences were not identified.
scribe tobacco content curriculum in a national sample of U.S. baccalaureate and graduate nursing programs. Findings indicated the majority of undergraduate and graduate nursing programs devote a sizeable portion of tobacco curriculum content to its health effects, primarily as part of a required course. However, students lacked curricular content in the area of clinical smoking cessation techniques. In fact, this content was absent in approximately 50% of baccalaureate programs responding to the survey. Specific evidence-based techniques were not covered in up to one-third of baccalaureate programs, while most baccalaureate programs covered specific elements of cessation techniques only briefly. Respondents indicated the majority of programs that were addressing tobacco content, used only one hour or less each year to cover the topic entirely. This deficit was less apparent among graduate programs as there was a more equitable distribution between less than one hour and one to three hours of tobacco treatment content instruction each year. As expected, given its advanced practice component, more emphasis was placed on pharmacotherapy for tobacco dependence at the graduate nursing program level. These findings were congruent with the results of a recent survey of tobacco dependence curricula in U.S. medical school education.12 Specifically, Ferry and others noted that most medical schools (69.2%) did not require clinical training in smoking cessation techniques, while 31% averaged less than 1 hour of instruction in cessation strategies each year. The authors concluded that U.S. medical school graduates are not adequately trained, and this lack of training is most notable during the clinical years of medical education. The current study among nursing programs is consistent with medical school findings that clinical smoking cessation instruction is noticeably inadequate. These results are striking, given the prevalence of tobacco users and tobacco-attributable diseases in clinical envi-
Resource Materials Used for Development of Tobacco-Related Curriculum The majority of baccalaureate and graduate program respondents provided information about resources used to develop tobacco-related curriculum. These percentages are delineated in Table 3. The three resources cited most frequently by baccalaureate program respondents were scientific literature reviews (37.8%), volunteer agencies (36.8%) and the National Cancer Institute’s publication How to Help Your Patient Stop Smoking (25.9%). Only 21% of baccalaureate programs reported using the U.S. Department of Health and Human Service’s Guide to Clinical Preventive Services and 21.9% used the national AHRQ Clinical Practice Guideline as a resource for developing curriculum. Among graduate programs, the most frequently reported resource materials included review of scientific literature (56.8%), USDHHS Guide to Clinical Preventive Services (55.1%) and the AHRQ Clinical Practice Guideline (46.2%).
DISCUSSION The burden of tobacco has significant health and economic consequences for the United States. In 2000, the prevalence of current smoking among adults was estimated at 23.3% and approximately 3000 adolescents used tobacco daily.19 An abundance of literature indicates that efficacious tobacco dependence treatment is available, including recommendations from a national evidence-based tobacco treatment clinical practice guideline.2 Unfortunately, as our findings demonstrated, nurses may lack adequate education to deliver these scientifically-valid treatments. This study represents the first investigation to de98
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Table 3. Resource materials used for development of tobacco-related curriculum in U.S. baccalaureate (BSN) and graduate (Grad) nursing programs na
%
Resource
BSN
Grad
BSN
Grad
1. Guide to Clinical Preventive Services: USDHHS 2. Review of scientific literature 3. Nat’l Cancer Institute, “How to Help Your Patient to Stop Smoking” 4. Volunteer agency (e.g. American Lung Association, American Heart Association, American Cancer Society, etc.) 5. Brown University’s Project ADEPT Publication 6. American Association of Family Practice Guidelines 7. Agency for Health Care Policy and Research/AHRQ Guidelines 8. Putting Prevention into Practice: CDC 9. Private agency 10. Other
352
198
20.5
55.1
352 352
199 199
37.8 25.9
56.8 39.7
351
199
36.8
32.2
352
199
1.1
2.5
352
199
3.1
28.1
352
199
21.9
46.2
352
199
16.2
41.7
352 350
199 196
2.3 8.9
1.5 11.2
a
Number of respondents varied; percentages reflect number of respondents for each item.
ronments. Twenty-five percent of adults in the U.S. are current smokers, with reports of prevalence among hospitalized patients at or above adult general population estimates.20 In addition, approximately 70% of smokers visit a health care provider on an annual basis.2 Given the frequency of exposure to current smokers among clinicians, greater efforts to educate nursing and medical students about tobacco treatment in classroom and clinical settings are warranted. It has been clearly demonstrated in previous studies that the most common barrier to the delivery of smoking cessation treatment by nurses is a lack of education about efficacious therapy.11,21 While educators cover a plethora of topics in a compressed amount of time, increased instructional efforts must be directed at treatment for a condition that is responsible for 440,000 deaths in the U.S. annually. According to Der and co-workers,22 even student providers with minimal clinical experience can effectively deliver cessation interventions. Their findings indicated that a comprehensive smoking intervention program provided by specially trained first and second-year medical students were comparable to established treatment programs. Curricular models to guide health professional training in the area of tobacco treatment are still lacking. To address this gap, Spangler and colleagues,23 in a 2002 meta-analytic review of medical school curricula, identified that enhanced instructional methods (eg, patient-
centered counseling, standardized patient instructors, role playing, or a combination of methods) are more effective for teaching tobacco intervention than traditional didactic methods alone. In a similar line of research, Roche and others24 demonstrated that, among senior medical students, interactive approaches, such as audio feedback through the use of audio-taped role plays, role play with peer feedback, and video feedback were each more effective than a traditional didactic lecture mode for improving student skills in smoking intervention. The investigators concluded that traditional teaching methods are ineffective in developing smoking cessation intervention skills. These interactive methods of role-playing, patient-centered counseling and standardized patient instructors are already utilized in nursing school curricular models for other content and could be adapted for use. It has been suggested that health care educators collaborate to develop a body of core teaching materials that all health professional schools could integrate throughout multiple years of classroom and clinical education.12 Since the AHRQ guideline contains identical recommendations for all clinicians (eg, physician, nurse, dentist, pharmacist), this collaborative approach seems logical and would be an efficient use of resources. Finally, given the nursing profession’s emphasis on health promotion, these interactive techniques could also be useful for teaching about management of other risky behaviors, such as M
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alcohol abuse or obesity, which is now emerging as a national epidemic.25 With regard to instructional resources, the AHRQ Clinical Practice Guideline, first released in 1996, represents an excellent example of scientifically-valid recommendations for tobacco dependence treatment in clinical practice. Unfortunately, many educators and clinicians, including nurses, have not taken advantage of this resource. For example, a recent survey, conducted among the membership of the Oncology Nursing Society, noted that less than 10% had ever heard of this guideline.11 Future efforts must determine the most effective mechanism for disseminating evidence-based tobacco treatment guidelines for use by educators, providers and health care administrators. There is also compelling evidence that clinicians who smoke do not intervene with patients who smoke.2 Among health care professionals, nurses reportedly have a higher prevalence of smoking.26 Taken together, the higher prevalence estimates among nurses and the lack of instructional training about tobacco treatment dilute clinically-based tobacco control efforts. Of note, analyses of regional differences in the extent of instruction pertaining to tobacco curriculum content were not apparent, even though considerable regional smoking prevalence distinctions are known to exist (eg, higher in the South).18 The results of this study are generalizeable to AACN-member baccalaureate and graduate nursing programs in the United States. The findings are based on a response rate of 70%, which is considered representative of valid findings among special populations.15 No differences were noted between survey respondents and non-respondents, in terms of region, program size, or public/private designation. Limitations of the study included the lack of information gained about the integration of tobacco-related content throughout the curriculum and whether the survey respondent was well versed with regard to tobacco content. Healthy People 2010, the nation’s agenda for health, has set an adult smoking prevalence goal of 12%.27 Nurses, representing the largest number of health care professionals in the United States28 are well-suited to participate in the delivery of existing efficacious tobacco dependence therapies. Increased instructional efforts that prepare nurses to deliver scientifically-valid tobacco treatment are crucial and must soon be implemented to assist in achieving a significant reduction in tobacco use by the year 2010.
2. Fiore MC, Bailey WC, Cohen SJ, Dorfman S, Goldstein M, et al. Treating tobacco use and dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2000. 3. Raw M, McNeill A, West R. (1998). Smoking cessation guidelines for health professionals. A guide to effective smoking cessation interventions for the health care system. Health Education Authority. Thorax, 53 Supplement 5 Part 1:S1-19. 4. Browning KK, Ahijevych KL, Ross P, Wewers ME. Implementing the Agency for Health Care Policy and Research’s Smoking Cessation Guideline in a lung cancer surgery clinic. Oncol Nurs Forum 2000;27:1248-54. 5. Clarke JM, Rowe K, Jones K. Evaluating the effectiveness of the coronary care nurses’ role in smoking cessation. J Clin Nurs 1993;2:313-22. 6. Hollis JF, Lichtenstein E, Vogt TM. Nurse-assisted counseling for smokers in primary care. Annals Intern Med 1993; 118:521-25. 7. Rice VH. Nursing intervention and smoking cessation: A meta analysis. Heart Lung 2000;28:438-54. 8. Taylor CB, Miller NH, Herman S, Smith PM, Sobel D, Fisher L, et al. A nurse-managed smoking cessation program for hospitalized smokers. Am J Public Health 1996;86:115760. 9. Center for Disease Control. Physician and other health care professionals counseling of smokers to quit: 1991. MMWR 1993;42:854-57. 10. Goldstein AO, Hellier A, Fitzgerald S, Stegall TS, Fischer PM. Hospital nurse counseling of patients who smoke. Am J Pub Health 1987;77:1333-34. 11. Sarna LP, Brown JK, Lillington L, Rose M, Wewers ME, Brecht ML. Tobacco interventions by oncology nurses in clinical practice: report from a national survey. Cancer 2000;89:881-9. 12. Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. JAMA 1999;282:825-29. 13. Spangler JG, Goerge G, Foley KL, Crandall SJ. Tobacco intervention training: Current efforts and gaps in US medical schools. JAMA 2002;288:1102-09. 14. American Association of Colleges of Nursing. Mission Statement 2002 Available at: www.aacn.org. 15. Salant P, Dillman DA. How to conduct your own survey. New York, NY: John Wiley and Sons, Inc., 1994. 16. Glynn TJ, Manley MW. How to help your patients stop smoking: A National Cancer Institute manual for physicians. Washington, DC: U.S. Department of Health and Human Services, Public Health Services, National Institutes of Health; 1993. Publication No. 93-3064. 17. Waltz CF, Strickland OL, Lenz ER. Measurement in nursing research. Philadelphia, PA: F.A. Davis Co; 1986. 18. Shopland DR, Hartman AM, Gibson JT, Mueller MD, Kessler LG, Lynn WR. Cigarette smoking among US adults by state and region: Estimates from the current population survey. J Ntl Ca Inst 1996;88:1748-58. 19. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2000. MMWR 2000;51: 642-45. 20. Smith PM, Reilly K, Miller NH, DeBusk RF, Taylor CB. Application of a nurse-managed inpatient smoking cessation program. Nicotine Tobacco Res 2002;4:211-22.
The authors wish to thank the American Association of Colleges of Nursing for providing their membership list.
REFERENCES 1. Centers for Disease Prevention and Control. Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995-1999. MMWR 2002; 51:300-03.
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21. McCarty MC, Zander KM, Hennrikus DJ, Lando HA. Barriers among nurses to providing smoking cessation advice to hospitalized smokers. Am J Health Prom 2001;16:85-87. 22. Der DE, You UQ, Wolter TD. A free smoking intervention clinic initiated by medical students. Mayo Clinic Proceedings 2001;76:144-51. 23. Spangler JG, George G, Foley KL, Crandal SJ. Tobacco intervention training: Current efforts and gaps in US medical schools. JAMA 2002;288:1102-09. 24. Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: A blockrandomized controlled trial of four different approaches. Prev Med 1996;25:251-58.
25. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991-1998. JAMA 1999;282:1519-22. 26. Nelson DE, Giovino GA, Emont SL, Brackbill R, Cameron LL, Peddicord J, et al. Trends in cigarette smoking among US physicians and nurses. JAMA 1994;271:1273-75. 27. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. 2001. Available at: www.healthypeople.gov. 28. United States Department of Health & Human Services. Projected supply, demand and shortages of registered nurses 2000-2020. Rockville, MD: Health Resources and Services Administration. Bureau of Health Professions; 2000.
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