APNA Nursing Competencies for Treating Tobacco Use Disorders

Preamble

Nursing guidelines for treating tobacco use and dependency (TUD) and discipline non-specific TUD competencies have been previously developed by other entities. The TUD guidelines and non-specific discipline competencies discovered would benefit from updating and specificity to nursing. It is critical for nurses to have current TUD competencies that are consistent with their nursing scope of practice. A distinction is made between guidelines, which serve as a course of action or skill set, and competencies. Competencies integrate knowledge, values, attitudes, professional judgment, and skills (Fukada, 2018).

Nursing-delivered TUD treatment interventions that are taught in academia and other educational formats vary widely in content and quality. This results in widely differing levels of nursing confidence in and the delivery of TUD interventions. Nursing TUD competencies are needed to provide a foundation for delivering effective nursing interventions and engaging in scientific inquiry, advocacy, and innovation. Professional nurses (RN) and advance practice registered nurses (APRN) require TUD treatment competency in order to be fully participating members of interdisciplinary treatment teams. Nursing competency in TUD treatment is also critical for nurses seeking to champion and participate in local, state, and national policy and guideline development.

The PMH-RN/APRN competencies are founded on current extant qualitative and quantitative evidence, consensus opinions, findings from TUD subject matter experts and national committees, and a wide variety of professional healthcare organizations. PMH-RNs and APRNs work in a variety of clinical and non-clinical settings and as greater emphasis is placed on treating the whole person, these treatment settings are not limited to historically typical psychiatric settings. These competencies are designed to be interpreted and adapted in any clinical setting for treating patients with TUD inclusive of any diagnostic group, age group, race or ethnicity, gender orientation, or socioeconomic background.

All patients with TUD would benefit from accessible, effective care whether they have been diagnosed with a mental health condition or not. Therefore, all nurses would benefit from foundational competency in providing TUD care. The psychiatric-mental health nursing scope of practice specifically encompasses the treatment of all substance use, including tobacco use, and thus uniquely places psychiatric nurses to demonstrate leadership in role modeling, teaching evidence-based TUD treatment, and engaging in innovative TUD treatment strategies. The tobacco competencies are written with the PMH RN and APRN in mind but can be adapted by nurses of all specialties.

Nurses who are competent in tobacco treatment use knowledge, values, attitudes, and professional judgment to demonstrate the skills listed below:

1. Engages in self-reflection activities to expand the therapeutic use of self in treating tobacco and nicotine dependence.

The PMH-RN and PMH-APRN: 

• Appraises personal beliefs related to treating persons with tobacco use and dependence (TUD)
• Demonstrates therapeutic use of self in facilitating access to care for persons with TUD, especially persons challenged with chronic relapses
• Uses current evidence based local, state and national resources to deliver effective TUD treatment

2. Uses patient-centered recovery language to create a safe environment for collaborative communication and interventions with persons who are dependent on tobacco and nicotine.

The PMH-RN and PMH-APRN:

• Establishes knowledge of recovery language as it applies to treating persons with TUD
• Employs recovery language to create a safe environment for patients
• Assesses and reports tobacco use and responses to treatment
• Demonstrates use of recovery language with patients to encourage patient confidence and hope in achieving and sustaining abstinence from tobacco

3. Understands the effects of nicotine and tobacco use on specific populations and the treatment needs for patients in a variety of clinical settings.

The PMH-RN and PMH-APRN:

• Demonstrates knowledge of physical and mental health outcomes for patients with TUD including high risk vulnerable populations
• Acknowledges that vulnerable populations may include, but are not limited to, persons who are:
• Experiencing addictions, mental and behavioral health issues
• Children, adolescents, pregnant women
• Homeless and/or those living in poverty
• Experiencing or have experienced physical or mental trauma
• At risk due to life-threatening infectious diseases or immune-compromised
• Vulnerable due to their racial or ethnic characteristics
• Experiencing sexual orientation and gender identity issues
• Identifies accessible, cost effective TUD treatment options for personalized care in a variety of clinical settings
• Delivers evidence-based individualized TUD nursing interventions that are inclusive of patient-identified significant others
• Integrates cultural humility in the provision of TUD nursing care
• Adapts TUD nursing interventions to a variety of settings through available media

4. Performs an evidence-based comprehensive tobacco and nicotine dependency assessment for the basis of applying diagnostic criteria.

The PMH-RN and PMH-APRN:

• Selects evidence based TUD screening and assessment tools based on patient demographic and tobacco use patterns
• Applies knowledge of health diagnoses, medications, and treatments that may be affected by TUD disorders
• Within the nurse’s scope of practice, uses TUD diagnostic criteria to facilitate, improve, and guide access to care

5. Applies existing and emerging evidence-based pharmacotherapies for treating nicotine dependency to prevent physical and mental health problems associated with tobacco use and dependency.

The PMH-APRN and RN:

• Establishes knowledge of FDA-approved TUD pharmacotherapies
• Translates technical TUD pharmacotherapy evidence into realistic, pragmatic, culturally respectful information for individuals who use tobacco
• Identifies opportunities and maximizes occasions to dispel pharmacotherapy myths and misinformation

The PMH-RN:

• Establishes TUD pharmacotherapy knowledge that is consistent to the nurse’s licensure, scope of practice, and facility policies
• Uses knowledge of over the counter Nicotine Replacement Therapy (NRT) pharmacotherapy to deliver effective TUD interventions

The PMH-APRN:

• Establishes knowledge of the pharmacodynamics and pharmacokinetics of FDA-approved medications to treat TUD
• Collaboratively formulates a TUD pharmacotherapeutic plan of care that is safe and effective given possible co-occurring disorders and medication use
• Identifies opportunities to engage in multidisciplinary collaboration to make available TUD pharmacotherapy to patients in a variety of settings

6. Applies health teaching about neuro-biological and psychological problems due to tobacco use and nicotine dependence to dispel myths and misinformation. 
The PMH-RN and PMH-APRN:

• Establishes foundational knowledge of neuro-biological and psychological problems related to TUD
• Recognizes that risks associated with neuro-biological, psychological, and physical disorders due to TUD vary depending on the type of tobacco one is exposed to and delivery system that is used
• Appraises the possible health risks associated with the chemicals found in a variety of tobacco products
• Monitors emerging trends related to unsafe or unproven practices, devices, or treatment methodologies

7. Engages relevant multidisciplinary team members to strategize evidence-based care coordination.
The PMH-RN and PMH-APRN:

• Proposes evidence-based TUD treatment strategies respectful of patient autonomy to participate in multidisciplinary care planning
• Demonstrates ability to translate evidence-based TUD knowledge into practice as a full participating member of a multidisciplinary treatment team
• Maximizes cost-effective multidisciplinary TUD treatment
• Develops opportunities to improve and streamline access to innovative coordinated care

8. Combines evidence-based counseling and psychotherapies with FDA-approved tobacco treatment medications to achieve the best practice gold standard treatment. 
The PMH-RN and PMH-APRN:

• Recognizes the therapeutic role of counseling as an integral component of TUD treatment that also includes FDA-approved TUD pharmacotherapy
• Arranges referral to psychotherapy as indicated, collaboratively agreed upon with the patient, and as available
• Differentiates between psychotherapy and TUD treatment strategies that are therapeutic
• Demonstrates an understanding of psychotherapy and therapeutic interactions to practice within the nurse’s licensure, scope of practice, and facility policies

9. Recognizes how integrative therapies can be used to honor patient preferences in treating tobacco use and dependency.
The PMH-RN and PMH-APRN:

• Appraises emerging evidence for integrative TUD therapies including acupuncture, hypnosis, aromatherapy, and milieu therapy
• Formulates TUD treatment strategies that provides patients with evidence-based integrative therapy information that supports autonomous treatment decisions
• Discusses potential positive effects and limitations of integrative therapies and implications of placebo effect

10. Understands the health implications of perceptions of potential benefit or harm around emerging practices, devices, or treatment methodologies that do not have an evidence base and/or are potentially unsafe.
The PMH-RN and PMH-APRN:

• Identifies the impact and influences of tobacco manufacturer advertisement targeted at vulnerable populations
• Differentiates the evidence between effective, well-studied TUD treatment strategies in comparison to unproven and potentially harmful treatment methodologies
• Appraises the potential influences of findings disseminated through tobacco manufacturer-funded studies

11. Analyzes current tobacco and nicotine policies, regulations, and clinical practice guidelines to address health disparities in TUD treatment.
The PMH-RN and PMH-APRN:

• Operationalizes evidence-based local, state, and national policies and guidelines for TUD
• Serves and advocates for patients with TUD as a fully participating member of committees to form or update TUD policies, regulations, and guidelines
• Assembles emerging TUD treatment evidence in advocating for regular updates to local, state, and national policies and guidelines

12. Engages in scientific inquiry to effectively synthesize tobacco and nicotine dependency treatment evidence into clinical practice, and local, state, and national tobacco treatment policies. 
The PMH-RN and PMH-APRN:

• Identifies opportunities for TUD treatment innovation
• Engages in scientific inquiry to test innovative treatment strategies
• Uses valid methods of scientific inquiry to critically evaluate and disseminate TUD treatment evidence

13. Utilizes systems change processes and evidence-based practice to engage in or lead in the development, implementation, and evaluation of tobacco and nicotine dependence programs. 
The PMH-RN and PMH-APRN:

• Incorporates systems change strategies to improve treatment and access to care
• Assesses novel applications of established TUD treatment strategies with cohorts of patients with TUD through emerging secure media
• Applies implementation science to translate innovative TUD treatment strategies into regular practice
• Evaluates innovative TUD treatment strategies
• Disseminates findings of scientific inquiry of TUD innovation and novel use of established TUD treatment practices

View References

Tobacco Treatment Nursing Competencies Task Force

Carol Essenmacher, PMHCNS-BC, DNP, NCTTP – Chair

Sara Adams PhD, RN, CNE
Carolyn Baird, DNP, MBA, RN-BC, CARN-AP, CCDPD, FIAAN
Julia Houfek, PhD, APRN-CNS, BC
M. Rene Spielmann, DNP, ARNP, FNP-BC, PMHNP-BC
Barbara Warren, PhD, RN, APRN-CNS, PMH-BC, FNAP, FAAN