Kelly Henson-Evertz DNP, RNC, CTTS

Transcription

1 Kelly Henson-Evertz DNP, RNC, CTTS

2 Identify the public health significance of tobacco use and dependency Identify the costs of tobacco use and dependency in the United States Cite large educational gap of tobacco dependence treatment education in existing nursing curricula Recognize need to incorporate tobacco dependence treatment into nursing curricula Describe an effective EBP tobacco dependence treatment educational intervention that increased undergraduate and graduate nursing students knowledge, skills, and self-efficacy to deliver tobacco dependence treatment to patients Illuminate the cost effectiveness of providing tobacco cessation treatment education in nursing curricula

3 Tobacco is the chief, single, avoidable cause of death in our society and the most important public health issue of our time" C. Everett Koop Former Surgeon General (United States Department of Health and Human Services [USDHHS], 1988)

4 The short answer is that cigarettes are addicting. The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine Dr. Everett Koop; Surgeon General: Nicotine is, ah, one of the most addictive drugs known to man, and one of those most destructive substances in our society (USDHHS, 1988)

5 480,000 U.S. deaths annually as a result of cigarette smoking or exposure to secondhand smoke Smokers die an average of 14 years earlier More than 12 million premature deaths occurred between (since 1 st Surgeon General report) Up to 1 billion deaths worldwide will occur in the 21 st century if current trends persist (Centers for Disease Control and Prevention [CDC], 2012; USDHHS, 2014, WHO, 2013)

6 19% of U.S. population smokes 3.5% are smokeless tobacco users High School-23.3% tobacco; 14% cigarettes, 12.6% cigars, 6.4% smokeless Middle schoolers-6.7% tobacco; 3.5% cigarettes, 2.8 % cigars, 1.7% smokeless Dual tobacco use on the rise! (2.9% in Delaware to 13.7% in Wyoming) >70% of polled U.S. smokers want to quit, with 44% of smokers attempting to quit every year (Fiore et. al, 2008; CDC, 2011; CDC, 2012, CDC, 2014; USDHHS, 2014)

7 Significant quality of life impact-cad, COPD, Cancer, CVA 90% of lung cancer deaths are cause by smoking 80% of COPD deaths are caused by tobacco Smoking is a cause of type 2 diabetes mellitus and makes it harder to control Risk of developing diabetes is 30 40% higher for active smokers than nonsmokers (USDHHS, 2014)

8 Cancer Patients Aid

9 National health care cost of $179.9 billion (7-9% of annual health care costs) Lost productivity cost of $157 billion annually (CDC, 2014)

10 Individuals who want to quit need information, support, and assistance Deliver Effective EBP Tobacco Dependence Treatments Counseling, cessation medications, and patient education Treating Tobacco Use and Dependence Clinical Practice Guidelines (TTUD-CPG;1996, 2000, 2008), based on 8,700 findings 7 FDA approved cessation medications Motivational Interviewing Cognitive and Behavioral strategies (Fiore et al., 2008)

11 Tobacco dependence treatment education is not mandated Most nursing programs: Include health effects of tobacco use Lack tobacco cessation education Lack clinical cessation materials and/or practice Fail to incorporate TTUD-CPG recommendations into curricula Most nurses/students Lack necessary knowledge, skills, and self-efficacy to deliver cessation treatment to patients (Lenz, 2009; Sarna, Bialbous, Rice & Wewers, 2009; Wewers, Kidd, Armbruster, & Sarna, 2004)

12 PICO- Does tobacco treatment education impact nursing students knowledge, skills, and self-efficacy to treat tobacco dependent patients?

13 Kelley, Heath and Crowell, APN students-6 hour class (one 6-hour or two 3-hour) Increased knowledge and self-efficacy to treat (p 0.001) 71.3% of participants report will use information with patients 59% will definitely increase the number of patients counseled 67.6% improved quality of counseling Butler et al., BSN students (2-hour didactic or 6-hour didactic and skills) Increased knowledge, skills, and confidence to treat (p 0.05)

14 Sheffer, Barone, and Anders, nurses (54 APN s, 250 RN s, and 55 LPN s) 1-Hour didactic o Increased perceived importance, effectiveness, knowledge, and attitudes (p 0.05) Matten, et al., o 107 nurses (3-hour didactic and role playing simulations) o Surveys pre and post and every three months x 12-months o Increased knowledge, skills, and confidence to treat (p 0.05) o Increased treatment of tobacco dependent patients in practice after intervention

15 Participants-offered to all M/F BSN & MSN FNP students in CON Recruitment- s, informational flyers, faculty 3-hour didactic 8-hour optional adjunct skills practice simulations Before and after design with pre and post surveys

16 Implementation guided by Roger s DOI Theory Intervention Grounded in Health Belief Model IRB approved Implemented in May and June of didactic and 9 skills practice sessions delivered

17 TTUD-CPG recommendations Neurobiology of addiction Tobacco products Tobacco marketing 7 FDA approved cessation medications Coping skills Motivational Interviewing Quit Kits 5 A s (Ask, Advise, Assess, Assist, Arrange) Role Playing simulations

18 Ø n=83 linkable surveys (BSN: n=30, MSN FNP: n=53) Ø Mean age 34.9 years Par%cipant Racial/Ethnic Iden%ty Black/African American 3.6% 1% 6% 20.4% 24.1% 44.6% White La;no/Hispanic Other (Dominican/Hai;an/ Puerto- Rican) Asian American Indian Figure 1.1. Schematic of percentages of participants racial/ethnic identity

19 Class content- 91.8% considered important 63.7 % considered completely new 28.1% taught before, but needed review Information use in practice- All intended to use information 74.4% intend to utilize % of information in practice Increase # of patients counseled to quit- 79.5% definitely 18.1% probably Improve quality of counseling delivered- 74.1% definitely 21% probably

20 12 knowledge questions (p 0.05) 6 self-perceived skills (p 0.05) 11 self-efficacy (p 0.05) Grouped means/ paired t-tests (p 0.05) Group Comparative Means Table 1.1. Pre-Training Post-Training Group Comparative Survey Survey t-value Sig. Means Mean Mean Knowledge 37% 64.6% Skills to Counsel Self-Efficacy <.0001 Note. Sig. = significance, p 0.05; knowledge = percentage of correct answers; skills to counsel score based on five-point Likert type scale group mean; self-efficacy score based on five-point Likert type scale group mean.

21 Note. Mean = percentage of participants who answered question correctly; * question 5=negative significance.

22 Pre-Overall Skill Post-Overall Skill Pre-Ask Post-Ask Pre-Advise Post-Advise Poor Fair Good VeryGood Excellent Figure 1.1. Schematic of pre and post: overall counseling skills, skills to ask, and skills to advise

23 Pre-Assess Post-Assess Pre-Assist Post-Assist Pre-Arrange Post-Arrange Poor Fair Good Very Good Excellent Figure 1.2 Schematic of pre and post: overall counseling skills, skills to ask, and skills to advise

24 Self-efficacy to treat Pre-Training Post-Training Self-efficacy Questions Figure 1.3. Schematic of pre and post-training Self-efficacy questions on a 5-point Likert scale; 1-not at all confident, 2- somewhat confident, 3- confident, 4- very confident, 5- extremely confident. All answers p<.0001.

25 A CBA evaluates the economic efficiency of a social and/or health-related program or intervention (Pinkerton, Johnson-Masotti, Derse, & Layde, 2002)

26 Intervention Costs Item Quantity Expense Total Office supplies Pre- survey Post-survey Post-Simulation survey Pens Cover letters Consent forms Teaching materials Handouts Set of laminated cards/ book Straws Simulation handouts Faculty salary Hourly wage Classroom rental Per hour Travel expenses Per mile Tolls Total Costs $

27 Return on Investment $13, per smoker saved annually $13, $1, = $11, $13,012.96/$1, = $8.37 to 1 ROI 20 x $13, = $260, $ 1, (cost of class)= $258, (if every student who attended class (20) helped 1 patient to quit smoking) $260,259.20/$1,554.98= $ to 1 ROI Costs based on 40 year-old smoking male. Does not include dry cleaning expenses, potential increased homeowners and/or car insurance premiums, and/or depreciation of car/home values (which are difficult to quantify). Life insurance premium is based on 40 year-old male smoker v non-smoker for a $1 million 20 year term life insurance policy. According to the CDC (2013) most smokers die an average of 14 years earlier than nonsmokers. The total benefits gained does not calculate in saved annual wages due to avoiding early death, which would be 2080 $23= $47, x 14 years ($669,760) (CDC, 2013; USDL-BLS, 2012)

28 Benefits Gained Item Quantity Expense Total Un-smoked cigarettes Per pack Saved loss of productivity/illness Saved tobacco related medical costs Saved health insurance premiums Saved healthcare costs for secondhand smoke exposure Saved workers compensation employers payout Saved increased smoker life Insurance premium Annually Annually Annually Family members/ Annually Annually Monthly Unpaid tobacco related taxes Annually Total Saved $13, Difference $11,457.98

29 n=30; 2-day (16-hour) training for nursing faculty members Purpose-assess time spent teaching, and perceived effectiveness of teaching tobacco dependence treatment to ACNP students Findings: Ø Post-intervention surveys administered 12-months after intervention Ø Ø Ø Ø Perceived value of the TTUD-CPG went from least (pre) to most valuable resource (post-intervention) Overall time teaching tobacco dependence treatment education in ACNP programs jumped from 22% of faculty teaching 3 hours or more, to 74.1% teaching more than 3 hours 1200 students received partial or complete tobacco dependence treatment education (more than 900 faculty hours of teaching) as a result of the faculty members receiving training Trickle-down effect of tobacco dependence treatment education in nursing curricula (Heath et al., 2007)

30 Randomized trials of educational interventions for health care workers, with outcomes of patient smoking for at least six months of follow-up Findings: Significant for patient point prevalence abstinence 31 studies: intervention significantly impacted odds of a patient quitting Outcomes dose dependent The greater the intensity of treatment provided, the more likely the patient was to quit Nurses interventions statistically and clinically significant (Carson et al., 2012; Rice and Stead, 2009)

31 Mandate tobacco dependence treatment education in all U.S. nursing curriculum Standardize tobacco dependence treatment education Require continuing education for already licensed nurses at licensure renewal Establish train the trainer programs

32 DNP s- Can impact health and reduce healthcare costs, by facilitating tobacco cessation through nursing education. Are prepared to effectively communicate the significant problem of tobacco dependence, and collaborate interprofessionally to affect positive change in tobacco dependence rates and healthcare policies. Can facilitate change through leadership, shared clinical expertise, and integrated EBP education and care focused on health promotion and disease

33 A large tobacco dependence treatment educational gap exists in U.S. nursing curricula Providing tobacco dependence treatment education to nursing students increases students : knowledge, skills, and self-efficacy to treat tobacco dependent patients Nurses who possess the necessary knowledge, skills, and self-efficacy to treat tobacco dependent patients are more likely to treat tobacco dependent patients Providing cessation treatment positively impact health care outcomes, which lowers costs! Educating nurses/students to deliver cessation treatments is cost effective

34 Continually failing to provide tobacco dependence treatment education in nursing curricula is not only unacceptable, it is a missed opportunity to mobilize the largest group of healthcare providers in the U.S., to: treat tobacco dependence, positively impact patient outcomes, reduce health disparities, and reduce healthcare costs. If half the working population of nurses were to assist one patient a week to make a quit attempt, the 15.4 million people who attempt a quit every year would increase to 59 million quit attempts per year (TFN, 2012)

35 American Association of Colleges of Nursing. (2012). Race/ethnicity of students enrolled in generic (entrylevel) baccalaureate, master s, and doctoral (research-focused) programs in nursing, Retrieved from Tbl.pdf Butler, K., Rayens, M., Zhang, M., Maggio, L., Riker, R., & Hahn, E. (2009). Tobacco dependence treatment education for baccalaureate nursing students. Journal of Nursing Education, 48(5), Carson, K. V., Verbiest, M. E., Crone, M. R., Brinn, M. P., Esterman, A. J., Assendelft, W. J., & Smith, B. J. (2012). Training health professionals in smoking cessation. Cochrane Database of Systematic Reviews 5. doi: / CD pub2. Centers for Disease Control and Prevention. (2012). Smoking and tobacco use: Health effects of cigarette smoking. Retrieved from _statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm#definition Centers for Disease Control and Prevention. (2011). Smoking and tobacco use: Smokeless tobacco facts. Retrieved from data_statistics/fact_sheets/smokeless/ Centers for Disease Control and Prevention. (2014). Smoking and tobacco use: Youth and tobacco use. Retrieved from Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W., Benowitz, N., Curry, S., Wewers, M. E. (2008). Treating tobacco use and dependence: Clinical practice guideline 2008 update. Rockville, MD: United States Department of Health and Human Services: Public Health Services.

36 Heath, J., Kelley, F., Andrews, J., Crowell, N., Corelli, R., & Hudmon, K. (2007). Evaluation of a tobacco cessation curricula intervention among acute care nurse practitioner faculty members. American Journal of Critical Care, 16(3), Kelley, F., Heath, J., & Crowell, N. (2006). Using the Rx for change tobacco curriculum in advanced practice nursing education. Critical Care Nursing Clinics of North America, 18(1), Lenz, B. (2009). Nursing students' response to tobacco cessation curricula in Minnesota baccalaureate nursing programs. Journal of Nursing Education, 48(10), doi: / Matten, P., Morrison, V., Rutledge, D., Chen, T., Chung, E., & Wong, S. (2011). Evaluation of tobacco cessation classes aimed at hospital staff nurses. Oncology Nursing Forum, 38(1), doi: /11.ONF Miller, W., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2 nd ed.). New York, NY: Guilford Rice, V. H., & Stead, L. F. (2009). Nursing interventions for smoking cessation. Cochrane Database of Systematic Review, 1, doi: / CDC pub3 Rogers, E. (2003). Diffusion of innovations (5 th ed.). New York, NY: Free Press. Sarna, L., Bialous, S., Rice, V., & Wewers, M. (2009). Promoting tobacco dependence treatment in nursing education. Drug & Alcohol Review, 28(5), doi: /j x

37 Sheffer, C., Barone, C., & Anders, M. (2010). Training nurses in the treatment of tobacco use and dependence: Pre- and post-training results. Journal of Advanced Nursing, 67(1), doi: /j x Tobacco Free Nurses. (2012). Media. Retrieved from United States Department of Health and Human Services. (1988). The health consequences of smoking: Nicotine addiction: A report of the surgeon general. Retrieved from U.S. Department of Health and Human Services. (2014). The health consequences of smoking 50 Years of progress. A report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Retrieved from full-report.pdf United States Department of Labor: Bureau of Labor Statistics. (2012). Occupational outlook handbook, 2012 (13th ed.), Registered Nurses, Retrieved from ooh/ healthcare/registered-nurses.htm Wewers, M. E., Kidd, K., Armbruster, D., & Sarna, L. (2004). Tobacco dependence curricula in U.S. baccalaureate and graduate nursing education. Nursing Outlook, 52(2), doi: /j.outlook World Health Organization. (2013). Tobacco fact sheet 339. Retrieved from factsheets/fs339/en/