PMH Nursing Smoking Cessation Initiatives

In 2014, APNA partnered with the Smoking Cessation Leadership Center to support psychiatric-mental health nurses’ innovative strategies aimed at decreasing tobacco use in persons with mental health and/or substance use disorders. After an open call for proposals, thirteen psychiatric-mental health nurses received an honorarium and training and support in implementing smoking cessation initiatives using evidence-based practices. The projects were generally small in scale but impactful locally across a number of clinical and academic settings. Below are select final summaries of these projects, including process, outcomes, and lessons learned. Our hope is that other nurses will use these ideas as jumping off points for implementing similar grassroots initiatives in their workplaces.

Marissa Abram, RN, CASAC-T
Lights Out Phoenix House
Phoenix House – Hauppaug, New York

Summary
Project included guardian education group at program initiation, peer-led groups, staff-led seminars, and tobacco screening, cessation education, & medical assistance at physical and psychiatric exams and follow-ups at adult and adolescent male facilities.

Highlighted Results

• 456 adult & adolescent clients served vs. 125 at baseline
• 45 guardians received education (not listed at baseline)
• Number & types of providers: 6 nurses, 3 MDs, & 2 LPNs vs. 4 nurses, 2 MDs, & 2 LPNs at baseline à
• Additional 28 program staff (not listed at baseline)

Conclusions / Lessons Learned
Continued checking & support is important and essential to address differences in belief systems & to correct misinformation.

Jennifer Armentrout, BSN, RN, PHN
Living Well
Sharp Mesa Vista Hospital – San Diego, California

Summary
Project included groups & Nicotine Anonymous, incorporation of tobacco cessation into existing recovery model, and surveys on confidence in and importance of tobacco cessation in a tobacco-free hospital..

Highlighted Results

• 300 patients served vs. 140 at baseline
• Number & types of providers: 70 nurses and other providers (vs 0 at baseline)
• 50% indicated a desire to reduce/quit use upon admission, and 90% maintained this desire at discharge

Conclusions / Lessons learned
Culture change is difficult, coping strategies are important and essential to target the emotional & physical discomfort experienced by patients (which was reported as the greatest barrier).

11-12-16 update
Sharp Mesa Vista continues to offer nicotine anonymous and tobacco cessation groups.  Staff members embrace culture of tobacco free hospital. On admission, every patient is asked if they have used tobacco in the past 30 days, and if so tobacco cessation counseling and nicotine replacement therapy is provided.

Suzan Blacher, MSN, RN, CARN, CCIT
An Adolescent Tobacco Dependence Intervention and Cessation Program 
Family Recovery Specialists – Miami, Florida

Summary
Project included several tobacco dependence screening measures and assessment questionnaires used in sessions with clients at a private outpatient substance abuse treatment program. Goal was to offer adolescents education for prevention, health promotion, and cessation, as well as strategies and/or treatments for quitting that are based on the unique needs of adolescents.

Highlighted Results

• 24 clients (ages 15-26) seen during 89 sessions vs. 0 at baseline
• Number & types of providers: 1 nurse, 3 LMHC vs. 0 at baseline
• Anecdotal reports of clients self-reporting occasional use becoming tobacco free; 2 specific clients reduced/quit use

Conclusions / Lessons learned
Inconsistent attendance at sessions and broad age range of clients was not optimal. Create separate groups for those seeking information and for those trying to quit.

Janick Bridges, RN, FNP-C
Stop Smoking – Quit Choking
Healthcare for the Homeless-Houston – Houston, Texas

Summary
Project included NRT and support groups to homeless participants who desired assistance with smoking cessation, as well as educational information to providers to increase knowledge and referrals to smoking cessation treatment. Additionally, nursing students were invited to participate in the support groups to enhance their knowledge of smoking cessation resources and treatment options.

Highlighted Results

• 30 patients served vs. 20 at baseline
• Number & types of providers: 7 nurses, 2 family physicians, 1 psychiatrist, 10 case managers, 2 counselors, 5 medical assistants vs. 3 nurses, 5 MDs at baseline
• 2 organizations involved vs 1 at baseline
• 1 patient quit smoking, 29 decreased to 2-5 cigarettes/day
• Awareness increased in providers & patients; increased use of PAP program for prescribing Chantix & Bupropion by providers; 3 providers making referrals

Conclusions / Lessons learned
Exposure & involvement are key to motivate providers and so is making time.

Nicole Rozek-Brodrick, APRN, RN, NP, CNS, DNP
Teaching Tobacco Cessation to Undergraduate Nursing Students in a Psychiatric Clinical Rotation 
University of Colorado Colorado Springs School of Nursing – Colorado Springs, Colorado

Summary
Project included curriculum on tobacco cessation which integrated concepts of motivational interviewing geared to specific populations, information on community resources, and other educational resources in the classroom and post-conference settings. Assessment surveys on overall knowledge base given at beginning and end of class/clinical.

Highlighted Results

• 44 total undergraduate & graduate students served in 3 cohorts vs. 15 students at baseline
• Increase in agreement with assessment statements regarding knowledge of tobacco cessation in general, medication treatment options, harm reduction strategies, and community resources.

Conclusions / Lessons learned
Learners were receptive, though 2 of the 3 cohorts had a limited timeframe. Champion left the university and was not able to continue the research but continues to advocate for inclusion of tobacco dependence content in nursing curricula in new position at another university

Sarah Farwick, BSN, RN
No Smoking! No Butts About It!
Chicago Lakeshore Hospital – Chicago, Illinois

Summary
Project implemented a smoking cessation program with education and materials for patients at a hospital with 42 beds on an adult acute inpatient psychiatric unit and 32 beds on a general adult unit. The program included posters in dayrooms, weekly groups (12 sessions) with educational toolkit, inclusion of tobacco dependence in multidisciplinary treatment plan, and a “cravings box”.

Highlighted Results

• 60 patients served vs. 40 at baseline
• Number & types of providers:  2 nurses, 6 psychiatrists, 1 medical physician participated in the program à provided only nicotine patches prior to project  (providers not listed at baseline)
• 2 units involved: Adult Acute Inpatient Psychiatric Unit, General Adult Unit
• Average number of patients in Smoking Cessation Groups: 5
• 19 total surveys returned completed – All 19 stated that they found the program useful.
• 17 of the patients indicated that they would remain smoke-free post-discharge, one was unsure and one did not respond to that question.

Conclusions / Lessons learned
Groups and patient engagement were particularly difficult on the acute unit. Motivational interviewing may be a better approach to engaging patients, which would require a different format for delivery of care. Changes in administration during the project did not allow for a smoke free campus policy.

Constance Green, RN, MS, NPP
Let’s Quit Together
Suffolk County Community College – Selden, New York
Hands Across Long Island (HALI)

Summary
Project included agency cigarette counts, a smoking cessation support table, “Ask me how I quit” buttons, and reward/incentive tokens at an outpatient mental health agency where smoking was prevalent. The goals were to reduce the number of cigarettes smoked by both clients and employees, create an environment that encourages no smoking, and encourage nursing students to be more comfortable conducting smoking cessation programs.

Highlighted Results

• 270 clients served vs. 0 at baseline
• 38 visits to the support table
• Number & types of providers: 20 student nurses, 1 APRN vs. 1 DO at baseline
• 8 clients completed the post-project survey. All 8 wanted to see the program continue.

Conclusions / Lessons learned
Follow-through was difficult with providers only present once/week, people were hesitant to report the number of cigarettes smoked. Use of team approach crucial to increase non-judgmental discussion of tobacco cessation.

Erica Joseph, FNP-C
The Importance of Tobacco Cessation Classes in Conjunction with Pharmacological Interventions
Southeast Louisiana Veterans Healthcare System – Baton Rouge, Louisiana

Summary
The project included face-to-face onsite tobacco cessation classes in conjunction with drug interventions in veterans at a veterans healthcare system community outpatient clinic. The goal was to offer classes close to home to those who were ready to stop smoking by discussing and developing an action plan and to develop mental coping and behavioral strategies.

Highlighted Results:

• 12 participants were served vs. 0 at baseline
• 20 referrals were made to the program
• 2 veterans quit smoking, 1 reduced from 2 packs/day to 1 pack/day, 6 reduced from 1 pack/day to a half pack/day, and 3 reduced to 1-2 cigarettes/day.

Conclusions / Lessons learned
Follow-up phone calls to program dropouts and monthly followup or support sessions to program completers were recommended.

Jeanette Lee, MS, NPP
Smoking Cessation Program for Clients with Mental Illness
Broome County Mental Health – Binghamton, New York

Summary
The project included individual and small group counseling sessions utilizing the Five As and the ‘Intensive Tobacco Dependence Intervention with Persons Challenged by Mental Illness: Manual for Nurses’ at a mental health facility.

Highlighted Results

• Project was unable to be completed during the program period due to changes with policy and clinic restructuring in the community.
• Plans to complete the project at a new facility are underway.

Conclusions / Lessons learned
Anything can happen before the conclusion of a project! It’s important to educate not only clients but also staff and providers about smoking cessation.

Chizimuzo Okoli, PhD, MSN, MPH, RN
Developing a Tailored Tobacco Treatment Program for Individuals with Schizophrenia
University of Kentucky – Lexington, Kentucky

Summary
The purpose of this project was to develop a tailored tobacco treatment program focused on the specific cessation needs of smokers with schizophrenia. The goal was to adapt, tailor, and test the effectiveness of an evidence-based tobacco treatment approach specific to individuals with schizophrenia. Individual and key information interviews about the approach were conducted and transcribed.

Highlighted Results:

• 6 key informant interviews with tobacco treatment specialists (2 physicians, 2 counselors, 2 nurses)
• 8 interviews with current smokers with schizophrenia and 4 interviews with former smokers with schizophrenia
• 4 organizations involved
• Preliminary results were used to apply for an NIH grant & the study remains ongoing with recruitment.
• No direct health care delivery or tobacco treatment outcomes resulted from this project, but the linkages made between organizations and institutions were a valuable outcome. Study findings have been presented at the APNA 30th Annual Conference, 2016

Conclusions / Lessons learned
Involving consumers (both providers & individuals with mental illness) in the design of tobacco treatment interventions is an important patient-centered approach that can result in feasible, applicable, and acceptable tailored interventions.

Leigh Powers, DNP, APRN, PMHNP-BC
Educating Clinicians for Successful Implementation of a Tobacco Cessation Program
East Tennessee State University – Johnson City, Tennessee

Summary
The project included an educational module through an online course program with advanced practice psychiatric nursing students. Materials included text readings, powerpoints, links, video vignettes, and teaching/record keeping tools. Toolkits were also provided for use when educating their patients about smoking cessation.

Highlighted Results

• 89 encounters with patients were recorded vs. 0 at baseline
• Initial pilot included only 2 DNP students
• Average scores on pre-test: 63%; average scores on post-test: 83%

Conclusions / Lessons learned
Obtaining buy-in from one clinic required a change in strategy and the study.

Bridgette Vest, DNP, RN, PMHNP, GNP
Tobacco Cessation for Veterans
Veterans Affairs Medical Center – Salem, Virginia

Summary:
The project monitored the number of consults to the Tobacco Cessation Clinic using tracking reports, screening data, interventions and outcomes following the intervention. The goal was to improve access to tobacco use screening and treatment by educating nurses in the use of the clinical reminder system for tobacco use screening and referrals to treatment.

Highlighted Results:

• 977 clients served
• Number & types of providers: 62 nurses vs. 3 nurses at baseline
• Additional providers included physicians, physician assistants, psychologists, social workers, and case managers
• 15 units within the organization were involved in the initiative vs. 3 at baseline
• Access to tobacco treatment for veterans was increased. Many nurses and other employees quit smoking as a result of the project.

Conclusions / Lessons learned
The workload for the Tobacco Treatment Team (prescribers and telephone clinic nurse) increased dramatically as more units participated, becoming overwhelming at times. Unable to track outcomes or conduct follow-ups as desired due to lack of manpower. The project empowered nurses!