Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans: Nurse Attitudes and Performance

Katz DA, Fu S, Grant K, Prochazka A, Battaglia C, Johnson SR, Hillis SL, Titler M, Vander Weg MW, Buchannan L. Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans: Nurse Attitudes and Performance. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 16; National Harbor, MD.

Related HSR&D Project(s)

• IIR 07-113 – Improving the Delivery of Smoking Cessation Guidelines in Hospitalized Veterans

Objectives: Although adherence to smoking cessation guidelines has been mandated by VA since 1997, inpatient nurses may not perceive smoking cessation to be a high priority or believe that they have the time or the skills to provide cessation counseling. This preliminary study aims to determine the impact of a nurse-targeted intervention on 1) delivery of the 5A's (Ask-Advise-Assess-Assist-Arrange follow-up), and 2) nurses' perceptions of smoking cessation counseling. Methods: We conducted a pre- post-intervention trial involving 205 hospitalized smokers ( > 1 cigarette/day) on the medicine inpatient wards at one University-affiliated VA medical center. Intervention included: 1) nurse training in delivery of brief cessation counseling, 2) documentation of 5A's in the electronic medical record, 3) referral of motivated inpatients for proactive telephone counseling, and 4) enlisting the aid of nursing facilitators on each ward. Based on subject interviews just prior to discharge, we calculated a nursing 5A's composite score for each patient (ranging from 0-5). We used linear regression with generalized estimating equations to compare the 5A's composite score (logistic regression to compare individual A's) across periods. We surveyed 29 nurses, and used the Wilcoxon signed-rank test to compare their self-efficacy and decisional balance ("pros" and "cons") with regard to cessation counseling before and after intervention. Results: Of 193 smokers who completed the pre-discharge interview, the mean nursing 5A's composite score was higher during intervention compared to pre-intervention (3.2 vs. 2.7, adjusted difference 0.6, 95% CI 0.2-1.0). More patients were advised to quit (62 vs. 48%, adjusted OR = 1.9, 95% CI = 1.0-3.5) and were assisted in quitting (66 vs. 43%, adjusted OR = 1.8, 95% CI = 1.1-3.0) by a nurse during intervention. Nurses' attitudes toward cessation counseling improved following intervention (35.3 vs. 32.7 on the "pros" subscale, p = .01), without significant change on the "cons" subscale. Nurses' self-efficacy in cessation counseling also tended to improve following the intervention (3.2 vs. 2.8 on a 5-point Likert scale, p = .08). Implications: In addition to assessing tobacco use, inpatient nurses can advise and assist hospitalized Veterans in quitting smoking. Impacts: The proposed intervention can be used to improve the depth of smoking cessation services in medical inpatients, beyond "ask" and "assess" performance measures.