Registered Nurse Initiation of a Tobacco Intervention Protocol

ArticleinThe Journal of cardiovascular nursing 23(5):443-8 · September 2008with82 Reads
Impact Factor: 2.05 · DOI: 10.1097/01.JCN.0000317451.64778.e9 · Source: PubMed
Abstract

This article summarizes the development and implementation of a registered nurse-initiated protocol to intervene with hospitalized patients who are tobacco-dependent, may be experiencing tobacco withdrawal, and who are hospitalized in a smoke-free environment. Tobacco use is the leading cause of preventable death in the United States. Hospitalization provides a unique teachable moment to treat tobacco dependence. Nurses can be effective in talking with patients about tobacco use. The clinical nurse specialist spheres of influence model and the role of the clinical nurse specialist were important for developing a tobacco use intervention protocol. A multi-disciplinary team created key objectives. These included identifying and assessing all patients who use tobacco, providing treatment to manage both withdrawal and address tobacco dependence, providing comfort to patients while hospitalized in a tobacco-free environment, encouraging lifelong cessation. The bedside admitting nurse was chosen as the pivotal professional to trigger tobacco use interventions. A protocol was finalized that requires the bedside nurse to assess all patients for past and current tobacco use. The nurse is then prompted to (1) provide information about tobacco dependence and treatment, (2) ask if the patient wants nicotine patch therapy to address withdrawal and, (3) order a consult with a specialist at the patient's request. Extensive and varied educational programs were developed to support the implementation of the protocol. The tobacco use intervention protocol has become important for providing assessment and intervention to patients who use tobacco. It has increased the number of specialist consults provided to patients. It has increased compliance with quality reporting data by national quality accrediting bodies.

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Available from: Thomas R Gauvin, Feb 13, 2014
Journal of Cardiovascular Nursing
Vol. 23, No. 5, pp 443Y448
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Copyright B 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
Registered Nurse Initiation of a Tobacco
Intervention Protocol
Leading Quality Care
Kathleen K. Zarling, MS, ACNS-BC, RN-BC, FAACVPR; Michael V. Burke, EdD;
Kim A. Gaines, MS, RN; Thomas R. Gauvin, MA
This article summarizes the development and implementation of a registered nurseYinitiated protocol to intervene
with hospitalized patients who are tobacco-dependent, may be experiencing tobacco withdrawal, and who are
hospitalized in a smoke-free environment. Rationale: Tobacco use is the leading cause of preventable death in
the United States. Hospitalization provides a unique teachable moment to treat tobacco dependence. Nurses can
be effective in talking with patients about tobacco use. Development: The clinical nurse specialist spheres of
influence model and the role of the clinical nurse specialist were important for developing a tobacco use
intervention protocol. A multi-disciplinary team created key objectives. These included identifying and assessing all
patients who use tobacco, providing treatment to manage both withdrawal and address tobacco dependence,
providing comfort to patients while hospitalized in a tobacco-free environment, encouraging lifelong cessation. The
bedside admitting nurse was chosen as the pivotal professional to trigger tobacco use interventions. Implementation:
A protocol was finalized that requires the bedside nurse to assess all patients for past and currrent tobacco use. The
nurse is then prompted to (1) provide information about tobacco dependence and treatment, (2) ask if the patient
wants nicotine patch therapy to address withdrawal and, (3) order a consult with a specialist at the patient’s request.
Extensive and varied educational programs were developed to support the implementation of the protocol.
Outcomes: The tobacco use intervention protocol has become important for providing assessment and intervention to
patients who use tobacco. It has increased the number of specialist consults provided to patients. It has increased
compliance with quality reporting data by national quality accrediting bodies.
KEY WORDS: CNS spheres of influence, inpatient protocols, quality improvement,
quality performance measures, nursing practice innovations, RN-initiated practice change,
smoking cessation, smoking interventions
Rationale
Nurses can make an impact on the leading, prevent-
able cause of death and disability in the United
States. Tobacco use causes multiple morbidities
including cardiovascular disease, stroke, numerous
cancers, and chronic obstructive pulmonary disease.
1
Tobacco kills an estimated 438,000 people each
year.
1
Clinical practice guidelines have been devel-
oped to help address this widespread health prob-
lem. The guidelines call for each patient entering a
healthcare environment to receive a 5 As approach:
ask about tobacco use, advise to quit, assess for
motivation to quit, assist with a quit attempt, and
arrange follow-up.
2
Hospitalization provides a unique opportunity to
treat tobacco dependence.
3
National monitoring
groups such as the Joint Commission on Accredita-
tion of Healthcare Organizations (JCAHO) and the
National Quality Forum recognize this by requiring
tobacco screening and advice/counseling as manda-
tory performance measures for hospitalized patients
with particular health problems such as congestive
heart failure, myocardial infarction, or community-
acquired pneumonia.
4
Hospitals are required by groups such as JCAHO
and National Quality Forum to be smoke-free en-
vironments. Patients who are addicted to tobacco
443
Kathleen K. Zarling, MS, ACNS-BC, RN-BC, FAACVPR
Clinical Nurse Specialist, Department of Nursing, Mayo Clinic,
Rochester, Minnesota.
Michael V. Burke, EdD
Treatment Program Coordinator, Nicotine Dependence Center,
Mayo Clinic, Rochester, Minnesota.
Kim A. Gaines, MS, RN
Nurse Administrator, Department of Nursing, Mayo Clinic,
Rochester, Minnesota.
Thomas R. Gauvin, MA
Counselor and Tobacco Treatment Specialist, Nicotine Dependence
Center, Mayo Clinic, Rochester, Minnesota.
Corresponding author
Kathleen K. Zarling, MS, ACNS-BC, RN-BC, FAACVPR, St Mary’s
Nursing Service, St Mary’s Hospital, Mayo Clinic, Rochester, MN
55902 (zarling.kathleen@mayo.edu).
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 1
products will frequently experience nicotine withdrawal
symptoms and tobacco cravings when hospitalized.
Because of this, they are more likely to violate
hospital policies.
5
Nicotine replacement can help
alleviate the patients’ withdrawal symptoms, but it is
underused and frequently not provided to hospital-
ized patients.
6
Nurses can be effective in providing treatment.
Bedside nurses are uniquely placed to understand and
meet the patients’ need for comfort and support.
7
Schultz
8
conducted a comprehensive review of the
literature regarding nursing and tobacco use inter-
ventions. Ten studies demonstrating the effectiveness
of nurse-delivered hospital interventions were pub-
lished from 1996 to 2003. Intensive interventions
were more likely to be effective, particularly those
with extended follow-up. The authors found that
it was important to provide nurses with education
to enhance their comfort level and communication
skills in addressing tobacco use with patients. System
enhancements such as chart reminders were found
to be helpful in increasing tobacco use interventions
by nurses. McEwen et al
9
randomly sampled general
practitioners and practice nurses in England and
Wales to assess their interventions with smoking
patients. Ninety-nine percent of the nurses declared
that helping smokers stop tobacco use was part
of their role. Almost all reported that they recorded
smoking status when the patient first entered the
healthcare system. Ninety-five percent of the nurses
indicated that they occasionally provided advice
to stop smoking. Seventy-one percent reported that
they advised at nearly all consultations. Nurses who
reported being educated in treating tobacco depend-
ence were more knowledgeable, engaged more
actively in helping patients, and had more positive
attitudes toward treating tobacco dependence.
Rice and Stead
10
reviewed 42 studies of nursing
interventions for smokers. Thirty-one of the studies
compared a nursing intervention to a control or
usual care group. These studies showed a significant
increase in the odds of quitting tobacco among those
in the intervention groups. Advice and support from
nursing staff were especially successful for increased
success in quitting smoking when delivered in a
hospital setting. The recommendation was to mon-
itor tobacco use and smoking cessation interventions
as an integral part of standard practice, so that all
patients were asked about tobacco use and provided
support if needed. Below, we describe a project that
translated these findings into practice.
At Mayo Clinic in Rochester, Minnesota, a
registered nurse (RN)Yinitiated protocol was proac-
tively developed to comprehensively address tobacco
use and dependence among hospitalized patients.
The protocol empowers the bedside nurse to (1)
assess each patient for tobacco use, (2) provide
nicotine patch replacement for comfort from with-
drawal, and (3) order a behavioral consult with a
tobacco treatment specialist.
This article will review the process by which this
RN-initiated protocol was developed and imple-
mented; describe the impact that the clinical nurse
specialist (CNS) practice model has had upon the
process; describe the resulting protocol and practice
change; and discuss the performance measures,
practice guidelines, and quality care standards being
met through the use of the protocol.
Specific Steps in the Development of the
‘‘Tobacco Use Intervention Protocol’’
A CNS championed the development and implemen-
tation for this system change. Clinical nurse special-
ists have unique skills for addressing patient needs,
engaging nurses, and promoting system changes.
11
In
this process, the CNS, as a change agent, was
uniquely poised to engage key players, execute
system changes, and develop procedures that were
critical for creating this practice change.
The CNS spheres of influence model was the
framework for creating, developing, and implement-
ing the protocol (see Figure 1).
12,13
The model describes 3 spheres through which the
CNS can impact patient care: the patient/client
sphere, the nurses/nursing practice sphere, and the
institutional/system sphere. This model helped to
systematically identify and engage a multidiscipli-
nary team. It provided the framework to incorporate
appropriate steps of development and implementa-
tion in a way that addressed patient needs, nurse
practice needs, and institutional needs.
The first step in the process was to formulate a
work group. In addition to the CNS, the team
consisted of representatives from nursing staff,
nursing education, physicians from medicine and
surgery, pharmacists, tobacco treatment specialists,
and quality/continuous improvement staff.
The group identified key objectives to be accom-
plished through the change process:
1. Identify and intervene with all hospitalized
patients who use tobacco or have used tobacco
in the previous 12 months.
2. Include interventions to treat withdrawal symp-
toms as well as treatment for ongoing abstinence
from tobacco.
3. Engage bedside nurses because they are uniquely
poised to work with all patients, monitor tobacco
withdrawal, and discuss tobacco use with all patients.
4. Provide patients with more intensive specialized
treatment as requested or indicated.
444
Journal of Cardiovascular Nursing
x
September/October 2008
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 2
Input from staff nursing was considered vital to
the engagement and support for all hospital nurses,
as they would ultimately implement and deliver the
protocol. It was crucial to work with key insti-
tutional practice committees throughout the process,
from beginning to end. Input from physicians, phar-
macists, and tobacco treatment specialists assured
that evidence-based assessment and treatment were
applied and sufficient medication use was provided
to address withdrawal and ensure patient safety.
In addition, quality improvement staff and a nurse
education specialist helped ensure that the pro-
tocol would meet standards and performance mea-
sures as well as incorporate competency-based best
practice.
Through collaboration, the work group developed
a draft protocol. On admission, the bedside nurse
was required to ask every patient if he/she had used
tobacco in his/her lifetime, and if so, had he/she used
tobacco in the past 12 months? The protocol
allowed the nurse to request nicotine replacement
patches to alleviate the patients’ withdrawal and/or
request a consultation with a tobacco treatment
specialist for patients.
Once the draft protocol was developed, it was
presented to a number of institutional committees for
review to encourage support and obtain approval.
These committees included the nursing practice com-
mittee, medical practice committee, surgical practice
committee, and pharmacy practice committee. All
departments within the institution that needed to
review and give input were identified, and meetings
were held with each group to obtain feedback and
revise the protocol. Our experience suggested that
these meetings should be scheduled early in the
process to allow the highest degree of input and
FIGURE 1. Clinical Nurse Specialist Spheres of Influence which guided the tobacco protocol development.
14,15
RN Initiation of Tobacco Intervention 445
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 3
FIGURE 2. The registered nurseYinitiated tobacco use intervention protocol. This protocol may not be duplicated without
the expressed permission of Mayo Clinic.
446 Journal of Cardiovascular Nursing
x
September/October 2008
Copyright @ 2008 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Page 4
buy-in from all groups that would participate in
approving and implementing the practice changes.
The protocol was piloted on 4 cardiovascular units.
These were considered key areas, where patients
often are tobacco users and frequently have illnesses
caused or worsened by tobacco use. Continual Btrou-
bleshooting[ and response to questions from all staff
and departments within the institution were coordi-
nated by the CNS. The input, feedback, and continual
updates created a Bpolished[ protocol, which met the
4 key outcome objectives (see Figure 2).
As the protocol was approved and endorsed by
the necessary committees, an extensive education
program was developed. The education was in-
tended to facilitate a smooth, timely initiation,
education, and orientation for all involved nursing
staff. Within the Mayo Clinic, Rochester, more than
6,000 nursing department employees were oriented
and educated to use the protocol. It was imperative
to have a simple, implicit, understandable process of
education, orientation, and implementation. A num-
ber of communication outlets were used to ensure
thorough delivery of the education.
h
Power point presentations were provided to all units.
h
Questions were answered in a timely fashion, and
frequent e-mail updates were delivered.
h
Project leaders attended Bteam days[ on all nurs-
ing units to answer questions and educate staff.
h
Presentations were provided at Bbest practice
sessions.[ (These are mandatory, quarterly, medi-
cal centerwide, educational sessions to introduce
new practice changes.)
h
Posters and other written information were placed
on all units to inform staff about the implementa-
tion of the protocol.
Implications for Practice
We believe that the RN-initiated protocol has
provided a number of advantages for our patients.
It helps to ensure that there is a provision of
consistent care for all patients who use tobacco,
and it empowers the bedside nurse to initiate the
protocol. The nursing role is critical because the
bedside nurse has a unique vantage from which to
observe nicotine withdrawal and discuss treatment
options with patients. The protocol triggers tobac-
co treatment specialist interventions for patients
through communication between the patient and
the bedside nurse. The protocol provides hospital-
ized patients with options for treatment including
nicotine patch therapy, which can be requested from
the nurse directly; information about tobacco
dependence and treatments provided by the bedside
nurse; and more intensive interventions from a
tobacco treatment specialist when requested. The
specialist can provide additional pharmacotherapy
options, cognitive behavioral therapy, and resources
for ongoing support and relapse-prevention. This
care is provided in collaboration with the primary
physician.
As discussed earlier, the JCAHO requires that
tobacco use be addressed with every patient diag-
nosed with myocardial infarction, heart failure, or
community-acquired pneumonia.
4
The nursing pro-
tocol is one measure to ensure that this is done with
all patients and the intensity of the intervention can
match what is requested by the patient. Patients who
must be tobacco-free while hospitalized report being
comfortable and experiencing fewer withdrawal
symptoms from tobacco. The number of specialist
interventions requested since the protocol was ini-
tiated has increased by approximately 50%, from
742 hospitalized patients seen in 2004 to 1,086
patients seen in 2006.
Currently, the protocol is being changed from
paper documentation to electronic documentation.
This will allow us to evaluate more fully the use and
effectiveness of the protocol. Nursing competencies
have been developed enabling uniform implementa-
tion of the protocol. This contributes to high quality
outcomes. Studies are also being planned to evaluate
the eventual impact of the protocol upon ongoing
abstinence from tobacco.
Acknowledgment
The authors would like to thank Dr Richard D. Hurt
for his review, input, and support of this project
and article.
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Page 6
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