Spring 2008 Progress in Cardiovascular Nursing 79

www.lejacq.com ID: 7745

Health professionals and, in par-ticular, nurses and physicians,

play a major role in promoting smok-ing cessation.1,2 Nurses and physicians serve as strong and influential role models for patients and the public, and they are in a first-line position to screen smokers and advise them to quit smok-ing.3–5 Thus, they have a critical role in the control of tobacco use.6,7

The behaviors of health profes-sionals can influence patients’ atti-tudes, encouraging patients to adopt change in their risky health behaviors, such as smoking. Health professionals, whether or not they smoke tobacco, believe that physicians and nurses who smoke are less likely to advise their patients to stop smoking.8 Nurses and doctors who have successfully quit smoking are known to be among the most effective smoking cessation interventionists.2,9 Conversely, those who smoke may be ineffective in this role, and they send conflicting mes-sages to both patients and the public.

The health dangers of tobacco use are widely known. Nonetheless, smok-ing rates are high. Jordan has the 4th highest (48%) smoking rates among Arab countries.10 Conducting periodic surveillance of smoking rates among health professionals provides a database with which to monitor rate changes in response to interventions. These rates can then be compared with rates of smoking patterns in the public to docu-ment the need for persistent encour-agement of smoking cessation among health professionals by offering incen-tives to quit smoking and disincen-tives to continue smoking. Effective and proven strategies both for the public and for individuals are well documented.2

The purpose of this study was to assess Jordanian health professionals’ training and counseling needs regard-ing smoking cessation

MethodsdesignA descriptive cross-sectional design was used to answer the study research questions.

setting and sampleOf 98 hospitals that met the crite-ria, 5 were randomly selected. Within each of the selected hospitals, all regis-tered nurses and physicians were invited to participate in the study. Eligibility

criteria included all nurses and physi-cians who were current employees of the 5 hospitals. Exclusion criteria included part-time employees and the inability to read and respond in English.

human Participant ProtectionParticipants were informed of the study purpose, benefits, and risks. The confidentiality of information and the voluntary nature of participation were explained, and the opportunity to ask questions and discuss the study was offered. Institutional approval for this study was obtained from the Ministry of Health research ethics committee in Jordan.

O r i g i n a l P a p e r

Jordanian Nurses’ and Physicians’ Learning Needs for Promoting Smoking CessationKawkab Shishani, RN, PhD;1 Hani Nawafleh, RN, PhD;2 Erika Sivarajan Froelicher, RN, PhD3

Smoking causes many health problems, including myocardial infarction, stroke, and peripheral vascular disease, and has devastating effects on the cardiovascular system. This study was performed to assess: (1) the prevalence of smoking among Jordanian nurses and physicians, (2) the differences in prevalence of smoking by sex, and 3) nurses’ and physicians’ learning needs for promoting smoking cessa-tion. A descriptive cross-sectional design was used. Five Jordanian hospitals were randomly selected; 164 nurses (65.3%) and 87 physicians (34.7%) participated in the study. Prevalence of smoking among nurses and physicians was 41.5% (n=66) and 43.6% (n=38), respectively, and significantly more men than women smoked (odds ratio, 5.45; confidence interval, 2.52–11.74 [P=.00]). Many Jordanian nurses and physicians do not recognize the addictive aspect of smoking, and health professionals receive no formal training in smoking cessation approaches to use with patients. Most nurses and physicians recognize that University cur-ricula must include information about smoking cessation. Prog Cardiovasc Nurs. 2008;23;79–83. ©2008 Le Jacq

From the Faculty of Nursing, The Hashemite University, Zarqa, Jordan;1 the Faculty of Nursing, Mu’tah University, Karak, Jordan;2 and the Department of Physiological Nursing, School of Nursing, and Epidemiology and Biostatistics, School of Medicine, University of California San Francisco, San Francisco, CA3

Address for correspondence: Kawkab Shishani, RN, PhD, The Hashemite University, PO Box 150459, Zarqa, 13115 JordanE-mail: kawkab.shishani@gmail.comManuscript received September 20, 2007; revised February 18, 2008; accepted March 12, 2008

Progress in Cardiovascular Nursing Spring 200880

data Collection ProceduresThe Global Health Professional Survey (GHPS) was used to collect data on tobacco use and cessation counseling among participating nurses and physi-cians. The GHPS was developed by the World Health Organization, Centers for Disease Control and Prevention, and the Canadian Public Health Association in 2004 as part of the Global Tobacco Surveillance System.11

The GHPS consists of a 66-item questionnaire that consists of 7 domains: (1) demographic questions (11 items); (2) tobacco use prevalence among health professionals (8 items); (3) exposure to environmental tobacco smoke (8 items); (4) attitudes toward tobacco (13 items); (5) smoking cessation (10 items); (6) curriculum/training (7 items); and (7) assessment of argileh (9 items). An arg-ileh, or water pipe, is a popular device used for smoking in Arab countries. Argileh can be used interchangeably with nargiley, hookah, or waterpipe. The argileh is used to inhale water-filtered tobacco. It consists of 4 parts: a head, body, water bowl, and hose. Charcoal is placed on the head and covered with aluminum foil, and burning charcoal is placed on the top of the foil. The water bowl is half-filled with water. The hose is connected from one end of the water bowl, and on the other end is the mouthpiece connection. Inhalation from the other end of the hose produces bubbles in the water because the smoke passes from the head through the water. An argileh can be shared among several users, each user having their own dispos-able mouthpiece.

GHPS items consist of yes/no or ordinal responses. Because other forms of tobacco use (eg, chewing tobacco) are not available in Jordan, questions on their consumption were not necessary.

Quality Control of data CollectionFour research assistants (RAs) were trained by the primary investigator for data collection to ensure standardiza-tion of protocol. The RAs were senior nursing students. Training included demonstration and return demon-stration, using role modeling for the

response options of possible questions or requests from participants regarding explanations of certain items or words and prompting to achieve optimum quality data.

Nursing and medical offices at each hospital were contacted to identify potential participants. The estimated time to complete the survey was 10 minutes. Participants were asked to complete the survey in their own time, and boxes were provided at the nurs-ing and medical offices for anonymous return of surveys; RAs collected the surveys daily.

data Management and Analysis PlanData entry and statistical analysis pro-cedures were performed using SPSS for Windows (version 11.5; SPSS Inc, Chicago, IL). Descriptive statistics was used to generate the following: (1) the number and proportions of nurses and physicians who smoke; (2) the separate sex-specific analysis, which was carried out by using stepwise logistic regression; and (3) the learning needs, skill build-ing, and behavioral counseling needs of the nurses and physicians. Descriptive statistics, such as the frequencies and chi-square test, were used to summarize and compare results across health pro-fessional groups. Multivariate logistic regressions were used to estimate the odds ratios and 95% confidence inter-vals. Means and standard deviations were used to report the findings from the interval data.

Resultssample CharacteristicsA total of 261 participants (nurses and physicians) participated in this study during June 2007. About 500 questionnaires were distributed and 261 were completed, for a response rate of 65%. Sample demographic characteristics are shown in Table I. In brief, 75% of the participants were men (n=188) and 25% were women (n=62); 11 participants did not iden-tify their sex. Participants ranged in age from 22 to 74 years (mean age, 32.7±9 years).Verification of the age range indicated that one physician was

still working at age 74. The total num-ber of participants who identified their parents as smokers was 115 (41%).

differences in smoking by sex and ProfessionOf 261 participants, 104 (42.3%) were smokers, 27 (11.7%) were former smok-ers, and 114 (46%) were nonsmokers. The tobacco products used were ciga-rettes in 82.8% (n=108) and argileh in 17.2% (n=24) of participants (Table I). Smoking a water pipe was significantly more prevalent among women than men (χ2 =9.6; P=. 00), and smok-ing cigarettes was significantly more prevalent among men (85.7%; n=102) compared with women (46.1%; n=6) (χ2 =38.8; P=.00).

The proportion of nurses and phy-sicians who were current smokers was 41.5% (n=66) and 43.6% (n=38), respectively. Considering that a higher proportion of physicians are men in Jordan, we evaluated the relationship between sex and profession. We found a significant interaction (P=.00) as a result of the unequal distribution of sex. After controlling for profession, sex was regressed on smoking status by using stepwise logistic regression. Smoking was statistically significantly more prevalent in men than in women (odds ratio, 5.45; confidence interval, 2.52–11.74; P=.00).

Jordanian Nurses’ and Physicians’ learning Needs for smoking Cessation CounselingOverall, 81.2% of participants respond-ed that health professionals should have an active role in advising patients who smoked to quit. Health professionals who were nonsmokers (87.6%) were significantly more willing to advise their patients to quit smoking than were current smokers (79.6%) (χ2 =5.94; P=.00). Table II shows the knowledge deficit for nurses and physicians. A high proportion (71.6%) responded that they need training in smoking ces-sation techniques. None of the schools of nursing or medicine in Jordan offer training about smoking cessation in their curricula.

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The greatest deficit in awareness was in the understanding “that record-ing tobacco use history needs to be obtained as part of every patient’s assessment” at every health care encounter. From the authors’ clinical experience, a patient’s smoking history is not taken at any visit to the clinic or even when a patient is hospitalized at many institutions. Even though health professionals know the importance of taking the history, they do not include it in practice. Even more important is that only 37.2% of nurses and 52.2% of physicians know that cigarettes and argileh are both addictive.

A small proportion of participants (35.9% of nurses and 26.6% of physi-cians) responded affirmatively to the question “Have you ever received any formal training in smoking cessation approaches to use with patients?”. When asked, “Do you think it is important to learn about smoking cessation during study at University?”, a much higher proportion indicated that it is important.

disCussioNNurses and physicians from 3 regions in Jordan provided the 261 question-naires assessed in this study within 3 weeks. The sites represented rural and urban areas where nurses and phy-sicians work, allowing considerable generalizability. The response rate, as compared with rates for other self-administered questionnaires, was very high (65%).12 This high response rate suggests a high level of interest in health research.

Smoking rates are on the rise, and health professionals in Jordan and in the rest of the Middle East are no exception in the populations respon-sible for this alarming increase.10,13–16 As in many other developing countries, rates of smoking among Jordanian health professionals are high.17

This study showed that cigarette smoking among male Jordanian health professionals is highly significant as compared with their female counter-parts. More women than men, however, smoke argileh. There are 3 main reasons

for this practice among women: (1) there is a perception that the water pipe has fewer ill effects on health and is not as harmful as cigarettes, (2) it is a social activity, and (3) it is thought to be attrac-tive.18 Nonetheless, the practice may have serious consequences. Argileh is more harmful than cigarettes. Moreover, women smoke a water pipe in their homes with their children surrounding

them, and the fumes produced from water pipe smoking will have an impact the health of the children because they are, in effect, passive smokers.18

Health professionals are expected to educate their patients and advise them to quit smoking.1,2 Well-established, evidence-based interventions exist to attain smoking cessation.1,19 It cannot be assumed, however, that nurses and

Table I. Characteristics of the Sample (N=261)a

CharaCteristiC Women, % (n) men, % (n) total, % (n)

Marital status

Single 51.6 (32) 40.1 (75) 42.9 (107)

Marriedb 48.1 (30) 59.8 (112) 57.1 (142)

Profession

Registered nurse 93.5 (58) 55.9 (104) 65.3 (164)

Physician 6.5 (4) 44.1 (82) 34.7 (87)

Smoking status

Current smoker 15.8 (9) 50.5 (95) 42.3 (104)

Former smoker 1.8 (1) 13.8 (26) 11.7 (27)

Never smoked 82.5 (47) 35.6 (67) 46 (114)

Tobacco products used

Cigarettes 46.1 (6) 85.7 (102) 82.8 (108)

Argileh 53.8 (7) 14.3 (17) 17.2 (24)aDue to missing values, rounding may not always add up to exactly 100%. bMarried, separated, or divorced.

Table II. Jordanian Nurses’ and Physicians’ Learning Needs for Smoking Cessation Counseling (N=261)a

learning need assessment nurses, % PhysiCians, % total, %

Cigarettes and argileh are both addicting.

37.2 52.2 41.9

Were you taught in your classes about the dangers of smoking?

65.7 72.5 67.6

Did you discuss in any of your classes why people smoke?

53.1 60.6 55.1

Have you ever received any formal training in smoking cessation approaches to use with patients?

35.9 26.6 32.3

Did you learn that it is important to record tobacco use history as part of a patient’s medical history?

78. 8 86.3 80.7

Did you learn that it is important to provide materials to support smoking cessation to patients?

54.2 63.6 56.9

Do you think it is important to learn about smoking cessation during studying at University?

81.5 84.8 71.6

Have you ever heard of nicotine replacement products?

74.0 81.0 75.8

aDue to missing values, rounding may not always add up to exactly 100%.

Progress in Cardiovascular Nursing Spring 200882

physicians know how to use behav-ioral interventions as part of smoking cessation counseling.15,20 This study showed that Jordanian health profes-sionals received insufficient training in their undergraduate and postgraduate studies on the specifics of tobacco use and control. Although this study did not measure how much information was provided in the formal training received by participants, the discrep-ancy in having training but not know-ing why people smoke—or even that tobacco is addictive—demonstrates that the training content received was either incomplete or inaccurate or that trainees’ retention is low. Furthermore, knowledge of the addictive aspect of smoking showed the largest differ-ence between nurses and physicians. Physicians know more than nurses that cigarettes are addicting.

Nurses and physicians need educa-tion, counseling, and behavioral inter-vention skills (skill building) regarding smoking cessation in their undergradu-ate curriculum, their postgraduate edu-cation courses, or both. Health profes-sional schools must take the initiative to include content about smoking ces-sation interventions in the curriculum. While both professional groups in this study scored very low in the provision of formal training in this area, participants’ responses indicated that schools of nurs-ing were more proactive in offering such training (35.9%); fewer participants attending schools of medicine (26.6%) acknowledged training. There is a clear mandate for nursing and medical

schools6,21–23 to incorporate content rel-evant to smoking cessation counseling and interventions, because it is the single most important, cost-effective, proven preventive health strategy.24

The important new findings this study provides with respect to learning needs of nurses and physicians in Jordan with respect to smoking cessation are: (1) a considerable knowledge deficit exists among both professional groups; and (2) a lack of recognition—as evidenced by the large proportion of nurses and physi-cians who were unaware—that tobacco is addictive suggests that nurses and physicians may have unrealistic expecta-tions of and approaches to patients who are smokers. Although the majority of participants (71.6%) recognized that information about smoking cessation is important for inclusion in University curricula or in subsequent postgraduate work, it appears that the critical aspects of information about smoking cessation counseling are still lacking from the professional repertoire. The encouraging findings from the survey are the consid-erable interest expressed by participants in acquiring information in the future. This high level of interest suggests that plans and future educational interven-tions are likely to be positively received among nurses and physicians.

limitationsLike most cross-sectional study designs, this study is no exception in that causal associations cannot be assumed due to the lack of an appropriate temporal sequence between the independent and

dependent variables in a cross-sectional design. Also, the following biases are more likely to occur in a cross-sec-tional design: (1) mobility bias, (2) survival bias, and (3) information bias. Mobility bias is more likely due to the greater chance that heavy smokers may have smoking-related symptoms and may be on sick leave or request earlier retirement because of medical reasons. Regarding survival bias, there is greater likelihood that people who are heavier smokers may not be in the sample because of smoking-related death. All studies that require reporting of health behaviors and health patterns may be impaired by the participants’ inaccurate memory, resulting in information bias. Finally, GHPS is a widely used tool by the World Health Organization; how-ever, no documents could be found that reported on its reliability and validity.11

CoNClusioNsThis study has several strengths: (1) to our knowledge, this is the first Jordanian national study on smok-ing status and patterns of smoking among health care professionals; (2) the simple random sample allows gen-eralizability of the findings to other health professionals in Jordan; and (3) the previously used standardized questionnaire used to obtain the data lends credibility to the internal valid-ity and, therefore, generalizability, of our results. The study findings are likely to be useful in guiding the next steps in smoking cessation research and program development in Jordan.

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