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Using the Rx for Change Tobacco Curriculum in Advanced Practice Nursing Education
Crit Care Nurs Clin N Am 18 (2006) 131 – 138
Using the Rx for Change Tobacco Curriculum in Advanced Practice Nursing Education Frances J. Kelley, PhD, APRN, BC-FNPa,T, Janie Heath, PhD, APRN, BC-ANP, ACNPb, Nancy Crowell, MAc a
Family Nurse Practitioner Program, Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA b Acute Care Nurse Practitioner and Acute and Critical Care Clinical Nurse Specialist Program, Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA c Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA
In today’s health care system driven by quality outcome indicators and performance care measures, it is essential for nurses to know how to intervene with tobacco-dependent patients. This article discusses pilot results from the ‘‘Rx for Change: Clinician Assisted Tobacco Cessation Curriculum’’ intervention conducted at Georgetown University School of Nursing and Health Studies using advanced practice students. The results reveal that 6 hours of tobaccocessation training can increase knowledge and selfefficiency scores.
Significance of the problem Tobacco use is both a national and a global problem. The Centers for Disease Control estimate that tobacco use results in approximately 440,000 deaths each year. The reality is that tobacco use is the single most avoidable cause of disease, disability, and death in the United States [1]. From 1995 to 1999, it is estimated that the annual smoking costs included $75 billion for direct medical costs and $82 billion in lost productivity [2]. From a global perspective, the
T Corresponding author. Family Nurse Practitioner Program, Georgetown University School of Nursing and Health Studies, Box 571107, 3700 Reservoir Road NW, Washington, DC 20057. E-mail address: [email protected] (F.J. Kelley).
World Health Organization reports that tobacco is the second major cause of death worldwide and that tobacco is responsible for about 5 million deaths each year [3]. Tobacco use is a leading health indicator, and specific risk-reduction objectives, such as reducing the initiation of cigarette smoking among adolescents and adults, are key components of Healthy People 2010 [4]. Acute and primary care providers, such as acute care nurse practitioners (ACNPs) and family nurse practitioners, are in significant positions to help decrease the damaging health effects related to tobacco use. The magnitude of the problems caused by tobacco use serves as a mandate that advanced practice nurses (APN) have the knowledge and skills to identify and advise tobacco users. Health care professionals who receive training are more likely to perform tobacco-cessation interventions [5]. Several studies, however, have documented that students in the health professions do not receive the training that is needed to intervene with patients who use tobacco [6 – 11]. Graduate curricula offer an opportunity for future APNs to learn more about tobacco, nicotine, and smoking-cessation counseling skills.
Tobacco-dependence curricula Information about the extent and specific content of tobacco curricula that are taught in nursing
0899-5885/06/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2005.11.003
ccnursing.theclinics.com
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programs is limited. In 2002, a study was conducted to determine the extent of tobacco education in ACNP education. The authors of the study found that 70% of the respondents (50 of 63 targeted ACNP program directors/coordinators) reported teaching 1 to 3 hours of tobacco content [7]. The ACNP faculty was also asked about use of the US Public Health Service Treating Tobacco Use and Dependence national guidelines as a reference. Only 40% of the schools reported using these national guidelines [7]. A larger national study of baccalaureate and graduate programs across the United States also focused on tobacco-dependence content within the nursing curriculum. Participants provided information about tobacco curricula content in didactic as well as clinical courses, the placement of the content within the program of study, the number of hours of instruction, and the resources used in the development of the tobacco content for the curriculum. Again, 1 to 3 hours of time was reported for tobacco content within the graduate curriculum [8]. A statewide survey of tobacco-cessation curricula in undergraduate nursing programs in Kansas found that the programs focused more on the pathophysiology of tobacco-related diseases and that the majority of programs either did not provide or provided only brief instruction in the use of the ‘‘Five ‘A’s’’ (ask, advise, assess, assist, and arrange) framework [9]. In an effort to address the lack of tobacco-related curricula content and to provide a more comprehensive approach to teaching smoking-cessation strategies, Georgetown University’s School of Nursing and Health Studies received funding from the American Legacy Foundation to develop and implement the Summer Institute for Tobacco Control Practices in Nursing Education as a 2-day intensive train-thetrainer program. As part of the initiative, the school partnered with faculty from the University of California, San Francisco School of Pharmacy for the implementation of the program. The first participants were ACNP faculty from across the country. The curriculum used for the training was Rx for Change: Clinician Assisted Tobacco Cessation, initially developed by Hudman and Corelli for schools of pharmacy [12]. The curriculum adheres to the guidelines from the US Public Health Service Treating Tobacco Use and Dependence, teaching students to apply the Five A’s within a framework that can be used in practice to tailor interventions [13]. Today, the curriculum has been adapted for use by other schools for health care professionals, including dentistry, medicine, and nursing. When patients die, and health care costs related to tobacco use soar, there is a heightened sense of
responsibility to teach both APN faculty and students how to intervene better with tobacco-dependent patients and their families. Investing in training and education is a leading recommendation made by the Subcommittee on Cessation of the Interagency Committee on Smoking and Health for health care providers to help prevent millions of premature deaths and help millions of smokers quit [14]. Implementing and evaluating such innovations as the Rx for Change curriculum are necessary if future health care providers are to help reduce the prevalence and human costs of smoking. This study helps to begin the process.
The study Purpose The purpose of this pilot study was to evaluate APN student outcomes after a 6-hour training session on tobacco cessation. After implementation of the Rx for Change Clinician-Assisted Tobacco Cessation Curriculum at Georgetown University School of Nursing and Health Studies, the following specific research questions were evaluated 2 weeks after training: Do APN students demonstrate increased ability
to provide tobacco-cessation counseling? Do APN students demonstrate increased knowl-
edge about tobacco cessation? Do APN students demonstrate increased self-
efficacy about tobacco cessation? Do APN students demonstrate increased ability
to help patients quit using tobacco?
Design: a pretest/posttest design Sample The participants were APN students (family nurse practitioners, ACNPs, acute and critical care clinical nurse specialists, and nurse midwives) at Georgetown University School of Nursing and Health Studies who attended the Rx for Change training as part of their required coursework. Students were in the beginning semesters of clinical core coursework, because all the participating programs begin their first clinical course in the fall semester. The first sample group received training in the fall semester of 2003, and the second sample group received split training in the fall semester of 2004 and the spring semester of 2005.
the rx for change curriculum in apn education
The curriculum The Rx for Change curriculum includes comprehensive materials described in detail elsewhere with instructor notes and complete current literature references [12,15]. There are six core modules of the Rx for Change curriculum, such as Epidemiology of Tobacco Use and Aids for Cessation and Pharmacotherapy (nicotine-replacement therapy agents and non – nicotine-replacement therapy agents). The curriculum also includes optional modules, ancillary handouts, and role-playing case scenarios. The Rx for Change curriculum has been extensively reviewed by experts in the field of tobacco prevention and tobacco cessation and is available for registered users at http:// rxforchange.ucsf.edu [16]. Measures For this pilot study, anonymous surveys were administered before and after training. Both surveys included items to evaluate self-perceived abilities to counsel patients about tobacco cessation, including (1) overall ability, (2) five items related to the Five A’s (ask, advise, assess, assist, and arrange), (3) 10 items related to self-efficacy (confidence in providing tobacco-cessation information), and (4) 10 items related to knowledge about tobacco cessation. In addition, the surveys addressed demographic variables and general questions concerning the role of nursing and tobacco control. Responses for the items addressing overall ability to help patients quit using tobacco and for using the Five A’s were scored on a scale of 1 to 5 with a score of 1 equaling poor performance and a score of five equaling excellent performance. Responses for the items addressing self-efficacy (confidence in providing tobacco-cessation counseling) were scored on a 1 to 5 scale with a score of 1 indicating no confidence and a score of 5 representing great confidence. Internal consistency and reliability estimates for the measures were tested in previous research. The Cronbach alpha estimate of internal consistency was reported as 0.85 for the items addressing the 5 A’s and as 0.92 for items addressing self-efficacy [12]. Procedure After approval was obtained from the Georgetown University Institutional Review Board, two Rx for Change training sessions were conducted. The first participants attended a 6-hour Saturday workshop. Participants in the second Rx for Change training session attended two split sessions of 3 hours each on separate Saturdays, one in the fall semester and one in the following spring semester. Immediately before all training sessions, informed consent was obtained, and
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pretraining measures were administered. Two weeks after the initial training, posttraining measures were administered during class. For both groups, the second author of this article taught the six core modules (epidemiology, nicotine pharmacology, principles of addiction, drug interactions, assisting patients to quit, and aids for cessation) and one optional module (forms of tobacco) from the Rx for Change curriculum. Although the modules presented during training were standardized, the format and hours varied by group. The first group received training on all six core modules and one optional module in 1 day over 6 hours. The second group received training on four core modules (epidemiology, nicotine pharmacology, principles of addiction, drug interactions) and one optional module (forms of tobacco) over 3 hours in 1 day and the remaining three core modules (assisting patients to quit, aids for cessation, and role playing) over 3 hours the following semester. Results Demographics During the study period (fall semester 2003 through spring semester 2004), 65 APN students were enrolled in classes that participated in the program. Of these 65 APN students, 29 (45%) were enrolled in the Family Nurse Practitioner program, 18 (28%) in the ACNP program, 15 (23%) in the Nurse Midwifery program, and 3 (5%) in the Acute and Critical Care Clinical Nurse Specialist program. Analyses were run separately by year, yielding similar results for both groups, so both years were pooled to increase the size of the sample. Thirty-eight students completed the pretraining questionnaire, and 37 completed the posttraining assessment. Thirty-five APN students had linkable pre- and posttraining assessments that were used in this study. As detailed in Table 1, most students (97%) were female and white (86%). The mean age was 29 years with a range of 23 years to 45 years. Most of the students were in either a Family Nurse Practitioner program (54%) or an Acute Care Nurse Practitioner program (31%). Less than one fourth of the participants (23%) had a history of tobacco use. Program evaluation Students reported that more than half (52.3%) of the tobacco-cessation material was new to them. An additional 34.9% was material students had learned before but needed to have reviewed. Only 13.9% of the material was reported to be material that students knew well enough to not need a review.
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Table 1 Demographics of 35 participants who completed assessments both before and after training Characteristic
Frequency (%)
Male Female Program ACNP FNP NM CCNS Ethnicity White African American Asian Hispanic Positive tobacco history
1 (3) 34 (97) 11 19 4 1
(31) (54) (11) (3)
30 1 4 0 8
(86) (3) (11) (23)
Abbreviations: ACNP, acute care nurse practitioner; CCNS, acute and critical care clinical nurse specialist; FNP, family nurse practitioner; NM, nurse midwife.
Before the training, students rated their overall ability to help patients quit using tobacco as only fair. As seen in Fig. 1, there was a significant increase (P <.001) in this rating after the program, from a mean of 2.06 (SD = 0.81) to 3.38 (SD = 0.78). Before training, more than one fourth of the students (26.6%) assessed their ability to help patients quit using tobacco as poor. After the training, no students rated their ability as poor. Before training, only 2.9% of students rated their abilities as either very good or
excellent. After training, 45.7% of students assessed their skills as being very good or excellent. Skill ratings were given on each of the Five A’s (Fig. 2). These five items make up the tobaccocessation counseling competency scale [12]. The mean pretraining score on this scale was 2.5 (SD = 0.59). Participants were most confident of their ability to ask patients about tobacco use, giving a mean rating of 3.7 (SD = 0.94) and were least confident of their ability to arrange follow-up counseling, with a mean rating of 1.7 (SD = 0.77). Training significantly improved scores on the tobacco-cessation counseling competency scale (Cronbach alpha in this sample, 0.86) from 3.5 (SD = 0.73) (t = 8.76; P < .001). Participants remained most confident of their ability to ask about tobacco (mean, = 4.2; SD = 0.79) and least confident of arranging follow-up counseling (mean = 3.1; SD = 1.0). Self-efficacy for counseling was assessed by a 10-item scale of skills relevant to counseling patients who use tobacco (Table 2). Cronbach’s alpha for this sample was 0.91. The average score on the selfefficacy scale was 2.2 (SD = 0.62) before training. Participants were most confident of their skills in sensitively suggesting tobacco cessation to their patients who use tobacco (mean = 2.8; SD = 1.0) and in providing motivation to their patients who are trying to quit (mean = 2.7; SD = 1.0). They were least confident in their knowledge of pharmaceuticals to assist cessation (mean = 1.7; SD = 0.70). After training, the average self-efficacy score for counseling patients increased significantly from 2.2 to
50 45
Percentage of students
40 35 30 25 20 15 10 5 0 Poor
Fair
Good
Very Good
Excellent
Student self-ratings
Fig. 1. Students’ self-ratings of overall ability to help patients quit using tobacco. Responses were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). (dark bars, pre-training assessment; light bars, post-training assessment)
the rx for change curriculum in apn education
Fig. 2. Students’ before and after training in tobacco-cessation counseling skills. a, All means increased significantly from before to after training at P<.001 using paired t-tests. 135
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Table 2 Changes in self-efficacy scores on patient counseling before and after training
Know appropriate questions to ask patients when providing counseling Have the skills needed to counsel for an addiction Can provide motivation to patients who are trying to quit Have the skills to monitor and assist patients throughout their attempt to quit Have sufficient therapeutic knowledge of pharmaceutic products for tobacco cessation Can make patient aware of reasons physicians should ask questions about tobacco use and encourage quitting Can sensitively suggest tobacco cessation to patients who use tobacco Are able to provide adequate counseling when time is limited Can help recent quitters learn how to cope with situations or triggers that might lead to relapse back to smoking Can counsel patients who are not interested in quitting Self-efficacy average
Before \training N = 35
After training N = 35
Mean
Mean
SD
SD
t
P
2.1
.68
3.4
.69
8.47
.000
1.9 2.7 2.0
.98 1.0 .76
3.1 3.8 3.1
.70 .63 .69
6.83 5.96 7.08
.000 .000 .000
1.7
.70
3.4
.81
10.98
.000
2.5
1.1
3.8
.76
7.21
.000
2.8
1.0
3.9
.70
6.76
.000
2.0
.87
3.2
.87
6.75
.000
1.9
.78
3.3
.82
7.73
.000
1.9 2.2
.80 .62
3.1 3.4
.91 .57
6.97 9.31
.000 .000
3.4 (SD = 0.57). Ratings on each of the 10 individual skills significantly improved from pre- to posttraining (Table 2 gives t and P values). The largest improvement was seen in the knowledge of pharmaceuticals, with an increase from a mean score of 1.7 before training to 3.4 after training. A set of 10 multiple-choice questions concerning information relevant to helping patients quit tobacco use were asked before the initiation of the Rx for Change program. A mean of 6.25 (SD = 1.70) correct responses was given before training. After the training, the same 10 questions were again evaluated. The mean number of correct responses increased significantly to 7.41 (SD = 1.74; t = 3.0; P = .006). There were no differences in knowledge scores before and after training by smoking status. Participating students were well informed in several content areas before training and maintained that knowledge after training. Sixty-five percent knew the correct approach to take with patients not yet considering quitting. Eighty-four percent were aware that most successful quitters have made multiple attempts to quit before succeeding and knew what symptoms are associated with nicotine withdrawal. Training was particularly successful in improving knowledge in three areas: advice for patch users experiencing sleep disturbances, duration of nicotine withdrawal symptoms, and the most rapid nicotinereplacement delivery system. After training, 56% of participants went from incorrect to correct answers
about sleep disturbance advice, as did 44% on length of withdrawal and 42% on most rapid nicotinedelivery system. Overall, students expected to use 71.3% of the material covered in the training with patients. Nearly three fifths of the students (58.8%) reported that the training would definitely increase the number of patients they counsel to quit using tobacco. Two thirds of the students (67.6%) indicated that participation in the training would definitely improve the quality of the tobacco-cessation counseling they will be able to provide to their patients. Underscoring the perceived usefulness of the training program, 94.3% of the students believed that students at other schools of nursing would benefit from similar training. Most of these APN students also believe that the nursing profession should increase its role in tobacco cessation. Ninety-seven percent said that nurses should be more active in helping patients quit smoking and in preventing patients from starting to smoke.
Discussion Findings from this pilot study of APN students in their beginning clinical coursework provide valuable data about implementing tobacco education in graduate curricula. The researchers found significant improvement in the students’ posttraining scores on the tobacco-cessation counseling competency scale,
the rx for change curriculum in apn education
the ability to intervene in terms of the Five A’s. The APN students were most confident in their abilities to ask about tobacco use; they were least confident about arranging for follow-up counseling. This finding is somewhat expected, in that all the participants had completed a graduate/advanced health assessment course that included, as part of patient history, an assessment for tobacco use, but this session may have been the first time students were provided an opportunity to role-play in sessions that addressed follow-up strategies for tobacco cessation. Perhaps most relevant for APN education in terms of their future roles are the significant improvements in self-efficacy or confidence in providing tobaccocessation counseling to patients (see Table 2). These practitioners will need the counseling skills related to assessing tobacco use and the knowledge about pharmaceutical products that are available for tobacco cessation. This theme is also demonstrated by the significant increase in the scores on the multiplechoice questions about providing advice for patch users experiencing sleep disturbance and the duration of nicotine withdrawal symptoms. Although the students reported that they expected to use tobacco-cessation information and believed that the training would increase the number of patients they counsel to quit using tobacco, further studies are needed to document the effect of this type of training on actual cessation rates with tobacco users. It may be that actual clinical practice will further enhance the sense of self-efficacy in counseling that has been reported.
Summary In today’s health care system, nurses, in particular APNs, must be accountable for and driven by quality outcome indicators and performance measures. APN students who have the knowledge and skills to intervene in tobacco-cessation interventions will be in a better position to meet Joint Commission on the Accreditation of Healthcare Organizations standards for counseling patients who have myocardial infarction, heart failure, and pneumonia [17]. Additionally, the integration of tobacco-cessation content into APN programs will meet the academic standards or competencies established by the AACN [18] and the National Organization of Nurse Practitioner Faculty [19] that focus on health promotion and disease prevention. Implementing curricular change, especially when considering the addition of content, has challenges [20], but nursing faculty must ensure that students receive an education that is relevant for
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practice and that is evidence based. Six hours of a nursing curriculum intervention, such as the Rx for Change, can go a long way to reduce the prevalence and human costs of smoking. At the very least, nurses should learn more about tobacco, nicotine, and tobacco-cessation counseling at www/rxforchange. org; the next patient’s life may depend on it.
References [1] Centers for Disease Control and Prevention. Targeting tobacco use: the nation’s leading cause of death (2005). Available at: http://www.cdc.gov/gov/nccdphp/aag/ aag_osh.htm. Accessed July 27, 2005. [2] US Department of Health and Human Services. The health consequences of smoking (executive summary). A report of the Surgeon General. Rockville (MD)7 US Department of Health and Human Services, Centers for Disease Control and Prevention; 2004. Available at: http://www.cdc.gov/tobacco/sgr/sgr_2004. Accessed July 27, 2005. [3] World Health Organization. Tobacco free initiative. Why is tobacco a public health priority? Available at: http://www.who.int/tobacco/health_priority/en/index. html. Accessed July 27, 2005. [4] US Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd edition. Washington (DC)7 US Department of Health and Human Services; 2000. [5] Lancaster TS, Silagy C, Fowler G. Training health professionals in smoking cessation. Cochrane Database Syst Rev 2000;3:CD000214. [6] Ferry LH, Grissino LM, Runfola PS. Tobacco dependence curricula in US undergraduate medical education. JAMA 1999;290(9):825 – 9. [7] Heath J, Andrews J, Thomas SA, et al. Tobacco dependence curriculum in acute care nurse practitioner education. Am J Crit Care 2002;11(1):27 – 32. [8] Wewers ME, Kidd K, Armbruster D, et al. Tobacco dependence curricula in US baccalaureate and graduate nursing education. Nurs Outlook 2004;52(2):95 – 101. [9] Hornberger CA, Edwards LC. Survey of tobacco cessation curricula in Kansas nursing programs. Nurse Educ 2004;29(5):212 – 6. [10] Montalto NJ, Ferry LH, Stanhiser T. Tobacco dependence curricula in undergraduate osteopathic medical education. J Am Osteopath Assoc 2004;104(8): 317 – 23. [11] Spangler JG, George G, Foley KL, et al. Tobacco intervention training: current efforts and gaps in US medical schools. JAMA 2002;288(9):1102 – 9. [12] Hudmon KS, Correlli RL, Chung E, et al. Development and implementation of a tobacco cessation training program for students in the health professions. J Cancer Educ 2003;18(3):142 – 9. [13] US Department of Health and Human Services. Treating tobacco use and dependence. Clinical Practice
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[14]
[15]
[16]
[17]
kelley et al Guideline. Rockville (MD)7 US Department of Health and Human Services, Public Health Service; 2000. Fiore MC, Croyle R, Curry S, et al. Preventing 3 million premature deaths and helping 5 million smokers quite: a national action plan for tobacco cessation. Am J Public Health 2004;94(2):205 – 10. Corelli RL, Kroon LA, Chung EP, et al. Statewide evaluation of a tobacco cessation curriculum for pharmacy students. Prev Med 2005;40:888 – 95. University of California San Francisco School of Pharmacy. The Rx for change: clinician-assisted tobacco cessation curriculum. Available at: http:// www.rxforchange.org. Accessed May 1, 2005. Joint Commission of Accreditation for Healthcare Organizations. 2004 Specification manual for national
hospital quality measures: AMI-4, HF-4, PN-4. Available at: http://www.jcaho.org. Accessed January 10, 2005. [18] American Association of Colleges of Nursing. The essentials of master’s education for advanced practice nursing. Washington (DC)7 American Association of Colleges of Nursing; 1996. [19] National Organization of Nurse Practitioner Faculties. Domains and competencies of acute care nurse practitioner practice. Washington (DC)7 National Organization of Nurse Practitioner Faculties; 2004. [20] Hull E, St.Romain JA, Alexander P, et al. Moving cemeteries: a framework for curriculum revision. Nurse Educ 2001;26(6):280 – 2.
Using the Rx for Change Tobacco Curriculum in Advanced Practice Nursing Education Frances J. Kelley, PhD, APRN, BC-FNPa,T, Janie Heath, PhD, APRN, BC-ANP, ACNPb, Nancy Crowell, MAc a
Family Nurse Practitioner Program, Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA b Acute Care Nurse Practitioner and Acute and Critical Care Clinical Nurse Specialist Program, Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA c Georgetown University School of Nursing and Health Studies, 3700 Reservoir Road NW, Washington, DC 20057, USA
In today’s health care system driven by quality outcome indicators and performance care measures, it is essential for nurses to know how to intervene with tobacco-dependent patients. This article discusses pilot results from the ‘‘Rx for Change: Clinician Assisted Tobacco Cessation Curriculum’’ intervention conducted at Georgetown University School of Nursing and Health Studies using advanced practice students. The results reveal that 6 hours of tobaccocessation training can increase knowledge and selfefficiency scores.
Significance of the problem Tobacco use is both a national and a global problem. The Centers for Disease Control estimate that tobacco use results in approximately 440,000 deaths each year. The reality is that tobacco use is the single most avoidable cause of disease, disability, and death in the United States [1]. From 1995 to 1999, it is estimated that the annual smoking costs included $75 billion for direct medical costs and $82 billion in lost productivity [2]. From a global perspective, the
T Corresponding author. Family Nurse Practitioner Program, Georgetown University School of Nursing and Health Studies, Box 571107, 3700 Reservoir Road NW, Washington, DC 20057. E-mail address: [email protected] (F.J. Kelley).
World Health Organization reports that tobacco is the second major cause of death worldwide and that tobacco is responsible for about 5 million deaths each year [3]. Tobacco use is a leading health indicator, and specific risk-reduction objectives, such as reducing the initiation of cigarette smoking among adolescents and adults, are key components of Healthy People 2010 [4]. Acute and primary care providers, such as acute care nurse practitioners (ACNPs) and family nurse practitioners, are in significant positions to help decrease the damaging health effects related to tobacco use. The magnitude of the problems caused by tobacco use serves as a mandate that advanced practice nurses (APN) have the knowledge and skills to identify and advise tobacco users. Health care professionals who receive training are more likely to perform tobacco-cessation interventions [5]. Several studies, however, have documented that students in the health professions do not receive the training that is needed to intervene with patients who use tobacco [6 – 11]. Graduate curricula offer an opportunity for future APNs to learn more about tobacco, nicotine, and smoking-cessation counseling skills.
Tobacco-dependence curricula Information about the extent and specific content of tobacco curricula that are taught in nursing
0899-5885/06/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccell.2005.11.003
ccnursing.theclinics.com
132
kelley et al
programs is limited. In 2002, a study was conducted to determine the extent of tobacco education in ACNP education. The authors of the study found that 70% of the respondents (50 of 63 targeted ACNP program directors/coordinators) reported teaching 1 to 3 hours of tobacco content [7]. The ACNP faculty was also asked about use of the US Public Health Service Treating Tobacco Use and Dependence national guidelines as a reference. Only 40% of the schools reported using these national guidelines [7]. A larger national study of baccalaureate and graduate programs across the United States also focused on tobacco-dependence content within the nursing curriculum. Participants provided information about tobacco curricula content in didactic as well as clinical courses, the placement of the content within the program of study, the number of hours of instruction, and the resources used in the development of the tobacco content for the curriculum. Again, 1 to 3 hours of time was reported for tobacco content within the graduate curriculum [8]. A statewide survey of tobacco-cessation curricula in undergraduate nursing programs in Kansas found that the programs focused more on the pathophysiology of tobacco-related diseases and that the majority of programs either did not provide or provided only brief instruction in the use of the ‘‘Five ‘A’s’’ (ask, advise, assess, assist, and arrange) framework [9]. In an effort to address the lack of tobacco-related curricula content and to provide a more comprehensive approach to teaching smoking-cessation strategies, Georgetown University’s School of Nursing and Health Studies received funding from the American Legacy Foundation to develop and implement the Summer Institute for Tobacco Control Practices in Nursing Education as a 2-day intensive train-thetrainer program. As part of the initiative, the school partnered with faculty from the University of California, San Francisco School of Pharmacy for the implementation of the program. The first participants were ACNP faculty from across the country. The curriculum used for the training was Rx for Change: Clinician Assisted Tobacco Cessation, initially developed by Hudman and Corelli for schools of pharmacy [12]. The curriculum adheres to the guidelines from the US Public Health Service Treating Tobacco Use and Dependence, teaching students to apply the Five A’s within a framework that can be used in practice to tailor interventions [13]. Today, the curriculum has been adapted for use by other schools for health care professionals, including dentistry, medicine, and nursing. When patients die, and health care costs related to tobacco use soar, there is a heightened sense of
responsibility to teach both APN faculty and students how to intervene better with tobacco-dependent patients and their families. Investing in training and education is a leading recommendation made by the Subcommittee on Cessation of the Interagency Committee on Smoking and Health for health care providers to help prevent millions of premature deaths and help millions of smokers quit [14]. Implementing and evaluating such innovations as the Rx for Change curriculum are necessary if future health care providers are to help reduce the prevalence and human costs of smoking. This study helps to begin the process.
The study Purpose The purpose of this pilot study was to evaluate APN student outcomes after a 6-hour training session on tobacco cessation. After implementation of the Rx for Change Clinician-Assisted Tobacco Cessation Curriculum at Georgetown University School of Nursing and Health Studies, the following specific research questions were evaluated 2 weeks after training: Do APN students demonstrate increased ability
to provide tobacco-cessation counseling? Do APN students demonstrate increased knowl-
edge about tobacco cessation? Do APN students demonstrate increased self-
efficacy about tobacco cessation? Do APN students demonstrate increased ability
to help patients quit using tobacco?
Design: a pretest/posttest design Sample The participants were APN students (family nurse practitioners, ACNPs, acute and critical care clinical nurse specialists, and nurse midwives) at Georgetown University School of Nursing and Health Studies who attended the Rx for Change training as part of their required coursework. Students were in the beginning semesters of clinical core coursework, because all the participating programs begin their first clinical course in the fall semester. The first sample group received training in the fall semester of 2003, and the second sample group received split training in the fall semester of 2004 and the spring semester of 2005.
the rx for change curriculum in apn education
The curriculum The Rx for Change curriculum includes comprehensive materials described in detail elsewhere with instructor notes and complete current literature references [12,15]. There are six core modules of the Rx for Change curriculum, such as Epidemiology of Tobacco Use and Aids for Cessation and Pharmacotherapy (nicotine-replacement therapy agents and non – nicotine-replacement therapy agents). The curriculum also includes optional modules, ancillary handouts, and role-playing case scenarios. The Rx for Change curriculum has been extensively reviewed by experts in the field of tobacco prevention and tobacco cessation and is available for registered users at http:// rxforchange.ucsf.edu [16]. Measures For this pilot study, anonymous surveys were administered before and after training. Both surveys included items to evaluate self-perceived abilities to counsel patients about tobacco cessation, including (1) overall ability, (2) five items related to the Five A’s (ask, advise, assess, assist, and arrange), (3) 10 items related to self-efficacy (confidence in providing tobacco-cessation information), and (4) 10 items related to knowledge about tobacco cessation. In addition, the surveys addressed demographic variables and general questions concerning the role of nursing and tobacco control. Responses for the items addressing overall ability to help patients quit using tobacco and for using the Five A’s were scored on a scale of 1 to 5 with a score of 1 equaling poor performance and a score of five equaling excellent performance. Responses for the items addressing self-efficacy (confidence in providing tobacco-cessation counseling) were scored on a 1 to 5 scale with a score of 1 indicating no confidence and a score of 5 representing great confidence. Internal consistency and reliability estimates for the measures were tested in previous research. The Cronbach alpha estimate of internal consistency was reported as 0.85 for the items addressing the 5 A’s and as 0.92 for items addressing self-efficacy [12]. Procedure After approval was obtained from the Georgetown University Institutional Review Board, two Rx for Change training sessions were conducted. The first participants attended a 6-hour Saturday workshop. Participants in the second Rx for Change training session attended two split sessions of 3 hours each on separate Saturdays, one in the fall semester and one in the following spring semester. Immediately before all training sessions, informed consent was obtained, and
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pretraining measures were administered. Two weeks after the initial training, posttraining measures were administered during class. For both groups, the second author of this article taught the six core modules (epidemiology, nicotine pharmacology, principles of addiction, drug interactions, assisting patients to quit, and aids for cessation) and one optional module (forms of tobacco) from the Rx for Change curriculum. Although the modules presented during training were standardized, the format and hours varied by group. The first group received training on all six core modules and one optional module in 1 day over 6 hours. The second group received training on four core modules (epidemiology, nicotine pharmacology, principles of addiction, drug interactions) and one optional module (forms of tobacco) over 3 hours in 1 day and the remaining three core modules (assisting patients to quit, aids for cessation, and role playing) over 3 hours the following semester. Results Demographics During the study period (fall semester 2003 through spring semester 2004), 65 APN students were enrolled in classes that participated in the program. Of these 65 APN students, 29 (45%) were enrolled in the Family Nurse Practitioner program, 18 (28%) in the ACNP program, 15 (23%) in the Nurse Midwifery program, and 3 (5%) in the Acute and Critical Care Clinical Nurse Specialist program. Analyses were run separately by year, yielding similar results for both groups, so both years were pooled to increase the size of the sample. Thirty-eight students completed the pretraining questionnaire, and 37 completed the posttraining assessment. Thirty-five APN students had linkable pre- and posttraining assessments that were used in this study. As detailed in Table 1, most students (97%) were female and white (86%). The mean age was 29 years with a range of 23 years to 45 years. Most of the students were in either a Family Nurse Practitioner program (54%) or an Acute Care Nurse Practitioner program (31%). Less than one fourth of the participants (23%) had a history of tobacco use. Program evaluation Students reported that more than half (52.3%) of the tobacco-cessation material was new to them. An additional 34.9% was material students had learned before but needed to have reviewed. Only 13.9% of the material was reported to be material that students knew well enough to not need a review.
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Table 1 Demographics of 35 participants who completed assessments both before and after training Characteristic
Frequency (%)
Male Female Program ACNP FNP NM CCNS Ethnicity White African American Asian Hispanic Positive tobacco history
1 (3) 34 (97) 11 19 4 1
(31) (54) (11) (3)
30 1 4 0 8
(86) (3) (11) (23)
Abbreviations: ACNP, acute care nurse practitioner; CCNS, acute and critical care clinical nurse specialist; FNP, family nurse practitioner; NM, nurse midwife.
Before the training, students rated their overall ability to help patients quit using tobacco as only fair. As seen in Fig. 1, there was a significant increase (P <.001) in this rating after the program, from a mean of 2.06 (SD = 0.81) to 3.38 (SD = 0.78). Before training, more than one fourth of the students (26.6%) assessed their ability to help patients quit using tobacco as poor. After the training, no students rated their ability as poor. Before training, only 2.9% of students rated their abilities as either very good or
excellent. After training, 45.7% of students assessed their skills as being very good or excellent. Skill ratings were given on each of the Five A’s (Fig. 2). These five items make up the tobaccocessation counseling competency scale [12]. The mean pretraining score on this scale was 2.5 (SD = 0.59). Participants were most confident of their ability to ask patients about tobacco use, giving a mean rating of 3.7 (SD = 0.94) and were least confident of their ability to arrange follow-up counseling, with a mean rating of 1.7 (SD = 0.77). Training significantly improved scores on the tobacco-cessation counseling competency scale (Cronbach alpha in this sample, 0.86) from 3.5 (SD = 0.73) (t = 8.76; P < .001). Participants remained most confident of their ability to ask about tobacco (mean, = 4.2; SD = 0.79) and least confident of arranging follow-up counseling (mean = 3.1; SD = 1.0). Self-efficacy for counseling was assessed by a 10-item scale of skills relevant to counseling patients who use tobacco (Table 2). Cronbach’s alpha for this sample was 0.91. The average score on the selfefficacy scale was 2.2 (SD = 0.62) before training. Participants were most confident of their skills in sensitively suggesting tobacco cessation to their patients who use tobacco (mean = 2.8; SD = 1.0) and in providing motivation to their patients who are trying to quit (mean = 2.7; SD = 1.0). They were least confident in their knowledge of pharmaceuticals to assist cessation (mean = 1.7; SD = 0.70). After training, the average self-efficacy score for counseling patients increased significantly from 2.2 to
50 45
Percentage of students
40 35 30 25 20 15 10 5 0 Poor
Fair
Good
Very Good
Excellent
Student self-ratings
Fig. 1. Students’ self-ratings of overall ability to help patients quit using tobacco. Responses were scored using a five-point scale (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent). (dark bars, pre-training assessment; light bars, post-training assessment)
the rx for change curriculum in apn education
Fig. 2. Students’ before and after training in tobacco-cessation counseling skills. a, All means increased significantly from before to after training at P<.001 using paired t-tests. 135
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Table 2 Changes in self-efficacy scores on patient counseling before and after training
Know appropriate questions to ask patients when providing counseling Have the skills needed to counsel for an addiction Can provide motivation to patients who are trying to quit Have the skills to monitor and assist patients throughout their attempt to quit Have sufficient therapeutic knowledge of pharmaceutic products for tobacco cessation Can make patient aware of reasons physicians should ask questions about tobacco use and encourage quitting Can sensitively suggest tobacco cessation to patients who use tobacco Are able to provide adequate counseling when time is limited Can help recent quitters learn how to cope with situations or triggers that might lead to relapse back to smoking Can counsel patients who are not interested in quitting Self-efficacy average
Before \training N = 35
After training N = 35
Mean
Mean
SD
SD
t
P
2.1
.68
3.4
.69
8.47
.000
1.9 2.7 2.0
.98 1.0 .76
3.1 3.8 3.1
.70 .63 .69
6.83 5.96 7.08
.000 .000 .000
1.7
.70
3.4
.81
10.98
.000
2.5
1.1
3.8
.76
7.21
.000
2.8
1.0
3.9
.70
6.76
.000
2.0
.87
3.2
.87
6.75
.000
1.9
.78
3.3
.82
7.73
.000
1.9 2.2
.80 .62
3.1 3.4
.91 .57
6.97 9.31
.000 .000
3.4 (SD = 0.57). Ratings on each of the 10 individual skills significantly improved from pre- to posttraining (Table 2 gives t and P values). The largest improvement was seen in the knowledge of pharmaceuticals, with an increase from a mean score of 1.7 before training to 3.4 after training. A set of 10 multiple-choice questions concerning information relevant to helping patients quit tobacco use were asked before the initiation of the Rx for Change program. A mean of 6.25 (SD = 1.70) correct responses was given before training. After the training, the same 10 questions were again evaluated. The mean number of correct responses increased significantly to 7.41 (SD = 1.74; t = 3.0; P = .006). There were no differences in knowledge scores before and after training by smoking status. Participating students were well informed in several content areas before training and maintained that knowledge after training. Sixty-five percent knew the correct approach to take with patients not yet considering quitting. Eighty-four percent were aware that most successful quitters have made multiple attempts to quit before succeeding and knew what symptoms are associated with nicotine withdrawal. Training was particularly successful in improving knowledge in three areas: advice for patch users experiencing sleep disturbances, duration of nicotine withdrawal symptoms, and the most rapid nicotinereplacement delivery system. After training, 56% of participants went from incorrect to correct answers
about sleep disturbance advice, as did 44% on length of withdrawal and 42% on most rapid nicotinedelivery system. Overall, students expected to use 71.3% of the material covered in the training with patients. Nearly three fifths of the students (58.8%) reported that the training would definitely increase the number of patients they counsel to quit using tobacco. Two thirds of the students (67.6%) indicated that participation in the training would definitely improve the quality of the tobacco-cessation counseling they will be able to provide to their patients. Underscoring the perceived usefulness of the training program, 94.3% of the students believed that students at other schools of nursing would benefit from similar training. Most of these APN students also believe that the nursing profession should increase its role in tobacco cessation. Ninety-seven percent said that nurses should be more active in helping patients quit smoking and in preventing patients from starting to smoke.
Discussion Findings from this pilot study of APN students in their beginning clinical coursework provide valuable data about implementing tobacco education in graduate curricula. The researchers found significant improvement in the students’ posttraining scores on the tobacco-cessation counseling competency scale,
the rx for change curriculum in apn education
the ability to intervene in terms of the Five A’s. The APN students were most confident in their abilities to ask about tobacco use; they were least confident about arranging for follow-up counseling. This finding is somewhat expected, in that all the participants had completed a graduate/advanced health assessment course that included, as part of patient history, an assessment for tobacco use, but this session may have been the first time students were provided an opportunity to role-play in sessions that addressed follow-up strategies for tobacco cessation. Perhaps most relevant for APN education in terms of their future roles are the significant improvements in self-efficacy or confidence in providing tobaccocessation counseling to patients (see Table 2). These practitioners will need the counseling skills related to assessing tobacco use and the knowledge about pharmaceutical products that are available for tobacco cessation. This theme is also demonstrated by the significant increase in the scores on the multiplechoice questions about providing advice for patch users experiencing sleep disturbance and the duration of nicotine withdrawal symptoms. Although the students reported that they expected to use tobacco-cessation information and believed that the training would increase the number of patients they counsel to quit using tobacco, further studies are needed to document the effect of this type of training on actual cessation rates with tobacco users. It may be that actual clinical practice will further enhance the sense of self-efficacy in counseling that has been reported.
Summary In today’s health care system, nurses, in particular APNs, must be accountable for and driven by quality outcome indicators and performance measures. APN students who have the knowledge and skills to intervene in tobacco-cessation interventions will be in a better position to meet Joint Commission on the Accreditation of Healthcare Organizations standards for counseling patients who have myocardial infarction, heart failure, and pneumonia [17]. Additionally, the integration of tobacco-cessation content into APN programs will meet the academic standards or competencies established by the AACN [18] and the National Organization of Nurse Practitioner Faculty [19] that focus on health promotion and disease prevention. Implementing curricular change, especially when considering the addition of content, has challenges [20], but nursing faculty must ensure that students receive an education that is relevant for
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practice and that is evidence based. Six hours of a nursing curriculum intervention, such as the Rx for Change, can go a long way to reduce the prevalence and human costs of smoking. At the very least, nurses should learn more about tobacco, nicotine, and tobacco-cessation counseling at www/rxforchange. org; the next patient’s life may depend on it.
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kelley et al Guideline. Rockville (MD)7 US Department of Health and Human Services, Public Health Service; 2000. Fiore MC, Croyle R, Curry S, et al. Preventing 3 million premature deaths and helping 5 million smokers quite: a national action plan for tobacco cessation. Am J Public Health 2004;94(2):205 – 10. Corelli RL, Kroon LA, Chung EP, et al. Statewide evaluation of a tobacco cessation curriculum for pharmacy students. Prev Med 2005;40:888 – 95. University of California San Francisco School of Pharmacy. The Rx for change: clinician-assisted tobacco cessation curriculum. Available at: http:// www.rxforchange.org. Accessed May 1, 2005. Joint Commission of Accreditation for Healthcare Organizations. 2004 Specification manual for national
hospital quality measures: AMI-4, HF-4, PN-4. Available at: http://www.jcaho.org. Accessed January 10, 2005. [18] American Association of Colleges of Nursing. The essentials of master’s education for advanced practice nursing. Washington (DC)7 American Association of Colleges of Nursing; 1996. [19] National Organization of Nurse Practitioner Faculties. Domains and competencies of acute care nurse practitioner practice. Washington (DC)7 National Organization of Nurse Practitioner Faculties; 2004. [20] Hull E, St.Romain JA, Alexander P, et al. Moving cemeteries: a framework for curriculum revision. Nurse Educ 2001;26(6):280 – 2.