Structured Smoking Cessation Training for Health ... · Web viewStructured Smoking Cessation Training for Health Professionals on Cardiology Wards: a prospective study Tobias Raupach1,2,

Raupach et al.accepted for publication in EJPC

Structured Smoking Cessation Training for Health Professionals on Cardiology Wards: a prospective study

Tobias Raupach1,2, Jan Falk1, Eleni Vangeli2, Sarah Schiekirka1,

Christa Rustler3, Maria Caterina Grassi4, Andrew Pipe5, Robert West2

1 Department of Cardiology and Pneumology, University Medical Centre Göttingen,

Germany2 Cancer Research UK Health Behaviour Research Centre, UCL, London, UK3 Deutsches Netz Rauchfreier Krankenhäuser & Gesundheitseinrichtungen4 Department of Physiology and Pharmacology, School of Medicine, Sapienza

University of Rome, Italy5 Minto Prevention & Rehabilitation Centre, University of Ottawa Heart Institute,

Canada

Address for Correspondence and Reprint Requests:

Tobias Raupach

University Medical Centre Göttingen

Department of Cardiology and Pneumology

D-37099 Göttingen, Germany

E-mail: [email protected]

Full word count including references: 4495

Conflict of interest

TR has received honoraria from Pfizer, Novartis, Glaxo Smith Kline, Astra Zeneca

and Roche as a speaker in activities related to continuing medical education. AP has

received honoraria from Pfizer, Glaxo Smith Klineand Johnson & Johnson; he has

received research support from Pfizer. RW undertakes consultancy and research for

and receives travel funds and hospitality from manufacturers of medications for

smoking cessation. He also undertakes training for smoking cessation advisors and

has a share of a patent for a novel nicotine delivery device. All other authors have no

conflict of interest to declare.


Abstract

Background: Smoking is a major cardiovascular risk factor, and smoking cessation is

imperative for patients hospitalised with a cardiovascular event. This study aimed to

evaluate a systems-based approach to helping hospitalised smokers quit and to

identify implementation barriers.

Design: Prospective intervention study followed by qualitative analysis of staff

interviews

Methods: The prospective intervention study assessed the effects of implementing

standard operating procedures (SOPs) for the provision of counselling and

pharmacotherapy to smokers admitted to cardiology wards on counselling frequency.

In addition, a qualitative analysis of staff interviews was undertaken to examine

determinants of physician and nurse behaviour; this sought to understand barriers in

terms of motivation, capability and/or opportunity.

Results: A total of 150 smoking patients were included in the study (75 before and 75

after SOP implementation). Before the implementation of SOPs, the proportion of

patients reporting to have received cessation counselling from physicians and nurses

was 6.7% and 1.3%, respectively. Following SOP implementation, these proportions

increased to 38.7% (p < 0.001) and 2.7% (p = 0.56), respectively. Qualitative analysis

revealed that lack of motivation, e.g. role incongruence, appeared to be a major barrier.

Conclusions: Introduction of a set of standard operating procedures for smoking

cessation advice was effective with physicians but not nurses. Analysis of barriers to

implementation highlighted lack of motivation rather than capability or opportunity as a

major factor that would need to be addressed.

Abstract word count: 229

Key words: smoking, smoking cessation, hospitalised smokers, cardiovascular

disease, physician counselling, nurse counselling


Introduction

Cardiovascular disease including myocardial infarction accounts for approximately one-

third of smoking-related deaths worldwide . Intensive smoking cessation interventions

significantly reduce morbidity and mortality following an acute cardiovascular event

and have been shown to be at least as cost-effective as other recommended

treatments in this patient group . International guidelines on the management of

myocardial infarction emphasize the importance of helping patients with cardiovascular

disease to quit smoking . There is increasing recognition of the responsibility of

cardiovascular specialists to be proficient in the delivery of smoking cessation

interventions , and patients should receive smoking cessation assistance during any

hospitalization .

Standard operating procedures (SOPs) have been introduced in various fields of

medicine. They are used to specify physician and nurse tasks in relation to specific

treatments (e.g., transfemoral aortic valve replacement). By specifying these roles and

behaviours, SOPs may contribute to patient safety and an enhanced quality of care.

The SOP approach lends itself to be used to improve the provision of smoking

cessation interventions for hospitalised smokers by defining who needs to deliver

counselling and pharmacotherapy at which stages of a patient’s hospital stay. A recent

study evaluating such a system (the “Ottawa Model” ) found considerable differences in

the extent to which a given SOP was implemented at different hospitals and reported

specific challenges associated with their implementation. These typically included staff

regarding smoking as a ‘lifestyle choice’ and a lack of support from key opinion leaders

and clinical managers. We are not aware of any formal evaluations of determinants of

staff behaviour which would be necessary to inform the design of future interventions.


A structured approach is needed to capture all relevant behaviour determinants.

Behaviour arises from three interrelated factors: capability (physical and mental ability,

including knowledge and understanding), opportunity (physical and social factors that

make the behaviour possible, including physical access, material resources and

adequate time) and motivation (plans, beliefs, desires and impulses that direct the

individual towards that behaviour more than any competing behaviours). This “COM-B”

model provides a basis for determining what conditions would need to be in place to

achieve a change in behaviour. For example, in one case an individual may not know

how to do the behaviour even if they have the motivation and opportunity to do it. In

another case the capability and opportunity may be present but the behaviour is always

competing with others that have a higher priority at each moment when the behaviour

could have occurred [11]. This therefore provides a basis for assessing what factors

may explain why a particular behaviour change intervention was or was not successful,

and for designing behaviour change interventions that have a greater likelihood of

being effective.

The aims of this study were as follows:

Study aim 1: to assess the impact of smoking cessation SOPs on the proportion of

patients who received a cessation intervention and in whom this was documented in

the clinical record, and

Study aim 2: to identify factors impacting on physician and nurse behaviour with

regards to the management of hospitalised smokers, using the COM-B model.


Methods

Study design

A mixed approach combining quantitative and qualitative research methods was

undertaken to address the two study aims. Effects of SOP implementation on patient

care were assessed in a prospective intervention study involving smokers admitted to

the cardiology wards at Göttingen Medical Centre. During an initial three-month data

collection period (phase I: February – April 2011), the frequency of cessation

interventions (counselling pharmacotherapy) and their documentation was assessed

using a patient survey and a review of discharge notes. Following phase I, physicians

and nurses were trained to counsel smokers, prescribe medication and instruct patients

on its use. Following the implementation of SOPs for the management of smoking

patients, data collection from patients was repeated for another three-month period

(phase II: May – July 2011).

Data obtained in this longitudinal intervention study were analysed quantitatively and

formed the basis for a qualitative study involving physicians and nurses who had been

responsible for the care of smokers hospitalised during phase II. Semi-structured

interviews of these staff members were conducted to elicit their views on the

management of smoking patients in general and implementation of the smoking

cessation SOP in particular.

SOP implementation and training

Following phase I, SOPs were implemented on cardiology wards. One aim of the SOPs

was to ensure systematic identification of smokers admitted to the wards. This was


achieved by asking every patient to complete a short questionnaire on admission, the

results of which were entered into the patient’s chart by the attending nurse. Names of

smokers were highlighted on each ward’s patient list to remind the attending physician

that counselling was to be provided. Physicians were asked to document counselling

activities in patients’ charts and to prescribe medication as indicated or to arrange a

referral to the hospital’s smoking cessation service.

SOPs were introduced in a physician team meeting in May 2011; indications for, and

dosing strategies regarding cessation medication were discussed at this time. The

complete SOP text was e-mailed to all physicians, and flowcharts containing basic

information were displayed on all wards (see Online Supplement, Part A). Nurses

were provided with a 90-minute training session addressing the effects of smoking

cessation on cardiovascular health and outlining the 5 A approach (Ask, Advise,

Assess, Assist, Arrange) . The greater part of this training consisted of practical

demonstrations of appropriate clinical, smoking cessation interactions between nurses

and patients.

Measures

Two questionnaires were used in the longitudinal intervention study:

1) Admission questionnaire: This questionnaire was administered to patients soon (i.e.

1-2 days) after admission to hospital.

2) Discharge questionnaire: Patients were asked to complete a second questionnaire

on the night prior to hospital discharge. It addressed cessation interventions

received during the hospital stay, quit attempts made during hospitalisation and


motivation to quit. Both questionnaires and additional information on their

construction are provided in the Online Supplement (Part B).

Patients’ discharge notes were scanned to identify the principal diagnoses as well as to

ascertain the documentation of smoking status and actions taken to promote cessation.

Interviews with physicians and nurses were conducted in German, lasted up to 30

minutes and were guided by a semi-structured interview template addressing nine

areas. The interviews explored the nurses’ or physicians’ (1) appraisal and (2) thoughts

regarding the SOP; (3) perceptions of any changes that had occurred after the formal

implementation of the SOP; (4) the effects of SOP implementation on their daily work

routine; (5) their experiences in discussing smoking cessation with their patients; (6)

their views on the use of medication to support quit attempts; (7) satisfaction with the

training provided when the SOPs were introduced; (8) whether they thought further

training would be useful and (9) an appraisal of how relevant the management of

smokers was perceived to be at their institution.

Analysis

The primary endpoint of the longitudinal intervention study was the proportion of

patients reporting to have received cessation counselling during their hospital stay.

Based on previous data , we expected this proportion to be 20% before the intervention

and aimed at identifying a 15% increase after SOP implementation at an level of 5%.

In order to detect such a difference with 80% power, 48 patients needed to be enrolled

in each phase of the study.


Six-point scales used in the patient questionnaire were transformed to dichotomous

variables by aggregating the two most positive options to reflect an affirmative

response. Results are displayed as proportions of study respondents providing

affirmative responses. Continuous variables are displayed as means standard

deviations. Independent samples t-tests were used to compare metric variables across

groups; 2 tests were used to compare proportions between groups.

Interviews were transcribed verbatim and a template approach applied to their analysis.

This approach involves the development of a coding template to summarise themes

that are identified from individual quotes in interview transcripts. These themes are

then organised in a hierarchical manner by which broad themes encompass

successively narrower, more specific ones (for details please see ). For the purpose of

this study, the broad themes identified in staff interviews were mapped within the

coding template provided by the COM-B model . Grouping of codes, definition of

themes and template mapping were performed by two authors (TR and EV) via a

process of iterative assessment to maintain a systematic and data-grounded approach

to analysis and interpretation.

Ethics approval was obtained from the Ethics Committee at Göttingen Hospital Medical

School (Application number 11/10/10). All personal patient and staff data were

removed prior to data analysis to ensure participant anonymity.


Results

Longitudinal intervention study (Study aim 1)

In phase I, 78 smokers were screened for participation in the study; three were

excluded (no informed consent, mechanical ventilation, insufficient language skills). In

phase II, 79 smokers were screened, four of whom were excluded (no informed

consent, mechanical ventilation). Thus, a total of 75 patients participated in each phase

of the study.

Patient characteristics and admission diagnoses are provided in Table 1. Before the

implementation of SOPs, the proportion of patients reporting they had received

counselling from physicians and nurses was 6.7% and 1.3%, respectively. The

proportion of patients expressing a high motivation to quit was 57.3% on admission and

remained at a similar level prior to discharge (58.7%, p = 0.869).

In phase II following staff training and the implementation of the SOP, the proportion of

patients reporting counselling from physicians and nurses increased to 38.7% and

2.7%, respectively. This increase was significant regarding counselling from physicians

(p < 0.001) but not from nurses (p = 0.560).

A majority of those 30 patients who recalled any counselling in phase II indicated that

they had been motivated to quit by hospital staff (53.3%), that counselling had been

helpful (66.7%) and that counselling was important to them (86.7%). Only one patient

reported having been annoyed by the intervention.


Following SOP implementation, the proportion of patients motivated to quit increased

non-significantly from admission (60.0%) to discharge (68.0%, p = 0.307). Table 1

indicates that in phase II, all smokers made a quit attempt while hospitalized; more

than 90% of these attempts were made without the prescription or provision of

medication. A review of patient charts confirmed the low rate of the use of cessation

pharmacotherapy.

Identification of determinants of behaviour (Study Aim 2)

After phase II, ten nurses and five physicians who had been caring for smokers on

cardiology wards during phase II volunteered to complete a semi-structured face-to-

face-interview. Table 2 displays the themes identified in interview transcripts in relation

to the COM-B framework. Over half of all themes in both physician and nurse

interviews were related to motivation.

1) Motivation

Most of the staff interviewed believed that the SOPs were useful in helping to structure

the approach to hospitalised smokers. Some physicians and nurses felt that the

introduction of SOPs had raised staff awareness of smoking as an important issue.

However, two physicians and eight nurses had not noticed any major change in their

daily routine following SOP implementation. Both nurses and physicians noted that

they had not received any feedback regarding the effects of the SOPs.

The SOPs state that smoking cessation counselling should be provided to all smokers.

Selective implementation of smoking cessation support, however, was common. One

physician for example explained he did not counsel patients who were not willing to


quit. On the contrary, another physician stated he would not offer help even to smokers

who were interested in quitting (“When a patient says ‘Yeah, I’ll quit smoking’, one does

not feel inclined to push the issue any further by prescribing medication.”). Some

nurses explained that they did not provide counselling to occasional smokers and those

who were unwilling to quit or did not ask for advice.

A key theme relating to staff motivation was their perception of smoking cessation

counselling as a professional responsibility, i.e. role congruence. About half of all

interviewees in both groups stated that all health professionals had a role to play in

counselling hospitalised smokers, but five out of ten nurses and four out of five

physicians believed that this was primarily a physician’s role. There was wide

agreement that nurses should document smoking status and provide basic quit advice

while physicians should educate patients about smoking-related health risks and offer

further help. In addition, nurses felt that patients were more likely to respect a

physician’s than a nurse’s quit advice.

While the issues addressed above relate to reflective motivation (i.e., cognitive

processes involving evaluations and plans), some 15-20% of themes were related to

‘automatic’ motivation involving emotions and impulses. Among the latter, patient

reactions to interventions delivered by staff appeared to be important: According to

physicians, most smokers perceived the need to quit, but at least some patients

wanted to quit without help and did not want to be prescribed any medication or be

referred to the in-house cessation service. Some nurses had encountered

uncomfortable experiences when discussing smoking with patients: “Well

sometimes...patients would be upset about being asked about their smoking”; “Yes, it is

unpleasant for patients. They feel a bit as if they got caught.” Providing counselling was


described as frustrating by one nurse who had experienced negative reactions from

patients.

Some physicians believed that hospitalised smokers overestimated the effectiveness of

their own willpower. At the same time, five out of ten nurses viewed smoking as a

personal choice. Staff smoking status was acknowledged as a barrier to the provision

of cessation counselling to smoking patients.

Finally, both nurses and physicians admitted they were not fully aware of SOP content

and their activities related to smoking had decreased steadily after a brief increase

following SOP implementation.

2) Capability

Nurses’ and physicians’ remarks regarding their ability to implement the SOPs reflected

issues relating to factual knowledge, practical skills and the need for more training.

While two out of five physicians stated they believed pharmacotherapy was effective in

supporting quit attempts, there was some uncertainty regarding dosing, titration,

adverse effects and contraindications of these drugs. Physicians felt competent to

discuss smoking with patients, but four out of five felt less competent in prescribing

cessation medication with two physicians reporting no experience with pharmacological

approaches to smoking cessation at all. Two physicians noted that their competence to

counsel smokers was considerably lower than their competence to treat cardiovascular

conditions. All physicians indicated that they would appreciate additional training

regarding the use of pharmacotherapy.


Nine out of ten nurses agreed that further training would be helpful, eight indicated they

wanted to know more about pharmacotherapy, and four suggested further training on

counselling techniques. Medication was thought to be effective by a minority of nurses.

Four out of ten nurses felt competent to discuss smoking with patients, but eight did not

feel competent to explain medication use to smokers.

3) Opportunity

Less than 20% of the comments from each group of staff concerned opportunities to

implement the SOPs. Four nurses stated that wards were too busy to include

counselling for smokers, and one physician noted that SOP information material was

not readily accessible on the wards. Physicians identified the short duration of in-

patient treatment as a barrier to providing comprehensive support for smokers. Nurses

largely felt that despite spending more time with patients, their opportunities to fully

implement the SOPs (including advice on medication use) were limited because

physicians were hesitant to prescribe medication. Both physicians and nurses pointed

out that these products had not been readily available on the wards on the first day the

SOPs were implemented.

Although six out of ten nurses believed that smoking cessation was of high priority in

the cardiology setting, five also felt that it did not have a high priority at the institutional

level of the hospital (“Well, patients who are able to walk...and who really are heavy

smokers...they are allowed to smoke on the ward balcony.”). One physician further

illustrated this point by stating that nurses themselves were still smoking on ward

balconies.


Discussion

In this longitudinal intervention study, implementation of SOPs for the management of

hospitalised smokers increased the proportion of patients who recalled having been

counselled by a physician while there was no effect on the proportion of smokers

recalling the receipt of advice from a nurse. Even after SOP implementation, fewer than

40% of smokers with cardiovascular disease received counselling, no more than 7%

were prescribed nicotine replacement therapy, and less than 10% were referred to an

in-house cessation service. Qualitative analysis of staff interviews revealed that

motivation and role incongruence were major barriers to translating the SOPs into

practice. In addition, the data suggest that incomplete SOP implementation reflected a

lack of knowledge and skills, a perceived lack of importance as well as adverse

reactions from some patients who had received counselling. Labelling of smoking as a

lifestyle choice and misperceptions of the effectiveness of methods to achieve

cessation may have further decreased nurses’ and physicians’ motivation to adhere to

SOP recommendations.

Determinants of behaviour

We used the COM-B model to identify barriers and challenges to SOP implementation

and grouped them according to the three main determinants of behaviour, i.e.

motivation, capability and opportunity. The analysis reveals that education and training

are important (capability) but that interventions need to take into account barriers in the

domain of automatic motivation. There was a striking discrepancy between the

patients’ perceptions of counselling (which was mainly positive) and those of the

nurses who perceived the same patients as feeling uncomfortable and refusing to be

counselled. Nurse-patient interactions might not have been as constructive as they


should have been. The fact that cessation may appear to be low priority for some

patients should not discourage nurses from providing basic counselling as nursing

interventions have been shown to be successful in helping smokers quit .

Although physicians believed it to be their role to address smoking with patients, it was

interesting to note that their perceived competence in prescribing cessation

pharmacotherapy and explaining its use to patients was low. Both a lack of training

opportunities as well as low perceived priority in relation to other professional activities

might have contributed to this mismatch.

Implications for future research

Our findings suggest that enhancing and supporting motivation are key issues in

implementing SOPs for the management of hospitalised smokers. In addition, we found

a lack of training as one major challenge to providing evidence-based behavioural and

pharmacological support to smokers willing to quit. This finding is in line with a recent

report of German medical education failing to equip physicians with the knowledge and

skills needed to provide that support . In order to further improve the quality of care for

hospitalised smokers, the barriers identified in this study need to be addressed. This

requires the development, delivery and evaluation of appropriate interventions and

policy measures in future studies .

Limitations

Our study had several limitations. First, smoking status was not biochemically

validated. However, successful cessation was not an endpoint of this study; instead,


we aimed at assessing the effect of SOP implementation on intervention rates. The

effectiveness of such interventions has been reported elsewhere .

Proportions of patients remembering counselling from physicians and nurses in phase I

were well below those found in an earlier study at the same institution . This may be

due to a different wording in the questionnaire or recall bias. However, this does not

invalidate our findings regarding the difference in rates of intervention between phase I

and phase II.

According to FTND values, patients in phase II appeared to be less dependent than

patients in phase I. It might be hypothesised that patients in phase II were more

receptive to counselling as their degree of addiction was lower. More patients in phase

I than in phase II, however, were admitted as a consequence of an acute coronary

syndrome. Admission with an acute cardiac condition might be expected to significantly

increase a patient’s receptiveness to counselling. Thus, the impact of these differences

on our results is hard to estimate.

Our findings may not be representative of the practices and beliefs of all the ward staff

at our institution, and they may not be applicable to other hospitals both within and

outside Germany. Since staff signed up for the interviews voluntarily, selection bias is

likely to have favoured individuals who were more interested in the issue than staff who

did not volunteer to be interviewed. Qualitative analyses are generally not designed to

be representative in terms of statistical generalisability but aim at providing an insight in

the processes underlying observations in quantitative studies, thereby facilitating the

generation of hypotheses and deriving impulses to guide interventions to improve

patient care. We decided to perform Template Analysis on the interview data as this

approach is well embedded in healthcare qualitative research . Matching interview


themes to the COM-B model permitted an examination of attitudes to the SOP and

smoking cessation interventions and signalled a number of important issues regarding

their implementation.

Conclusion

We found that, following SOP implementation, there was a significant increase in the

proportion of hospitalised smokers who reported having been counselled by their

physicians. However, as few as 6.7% were prescribed pharmacotherapy to support a

quit attempt. SOP implementation appeared to have no impact on counselling provided

by nurses. Issues related to motivation appear to play a major role in determining

physician and nurse behaviour. These need to be addressed in order to design more

effective interventions.


References

1. Mathers, C.D., D. Loncar, Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med, 2006; 3: e442.

2. Mohiuddin, S.M., A.N. Mooss, C.B. Hunter, et al., Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease. Chest, 2007; 131: 446-52.

3. Wilson, K., N. Gibson, A. Willan, et al., Effect of smoking cessation on mortality after myocardial infarction: meta-analysis of cohort studies. Arch Intern Med, 2000; 160: 939-44.

4. Van de Werf, F., J. Bax, A. Betriu, et al., Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J, 2008; 29: 2909-45.

5. Perk, J., G. De Backer, H. Gohlke, et al., European Guidelines on cardiovascular disease prevention in clinical practice (version 2012): The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. Eur Heart J, 2012.

6. Pipe, A.L., M.J. Eisenberg, A. Gupta, et al., Smoking cessation and the cardiovascular specialist: Canadian Cardiovascular Society position paper. Can J Cardiol, 2011; 27: 132-7.

7. Fiore, M.C., E. Goplerud, S.A. Schroeder, The Joint Commission's new tobacco-cessation measures--will hospitals do the right thing? N Engl J Med, 2012; 366: 1172-4.

8. Reid, R.D., K.A. Mullen, M.E. Slovinec D'Angelo, et al., Smoking cessation for hospitalized smokers: an evaluation of the "Ottawa Model". Nicotine Tob Res, 2010; 12: 11-8.

9. Michie, S., M.M. van Stralen, R. West, The behaviour change wheel: A new method for characterising and designing behaviour change interventions. Implement Sci, 2011; 6: 42.

10. Fiore, C., C.R. Jaén, T.B. Baker, et al., Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. 2008, U.S. Department of Health and Human Services. Public Health Service.: Rockville, MD.

11. Raupach, T., J. Merker, G. Hasenfuss, et al., Knowledge gaps about smoking cessation in hospitalized patients and their doctors. Eur J Cardiovasc Prev Rehabil, 2011; 18: 334-41.

12. King, N., Using Templates in the thematic analysis of text., in Essential Guide to qualitative methods in organizational research., C. Cassell and G. Symon, Editors. 2004, Sage Publications: London. p. 256-270.

13. Rice, V.H., L.F. Stead, Nursing interventions for smoking cessation. Cochrane Database Syst Rev, 2008: CD001188.

14. Strobel, L., N.K. Schneider, H. Krampe, et al., German medical students lack knowledge of how to treat smoking and problem drinking. Addiction, 2012.


Tables

Table 1: Patient characteristics, main admission diagnosis, responses to the discharge

questionnaire and chart documentation. Data are given as mean standard deviation

or proportions (absolute numbers), as appropriate.

Phase I Phase IIp value

(n = 75) (n = 75)Patient characteristics (derived from the admission questionnaire)

Sex (proportion of males) 66.7 (50) 69.3 (52) 0.726Age (years) 55.9 ± 12.8 55.9 ± 11.3 0.973Pack Years 36.3 ± 23.8 35.3 ± 22.5 0.811FTND 5.0 ± 2.2 3.7 ± 2.1 <0.001Years smoked 34.4 ± 12.5 35.9 ± 11.9 0.471Cigarettes per day 20.1 ± 9.9 18.5 ± 9.6 0.305Proportion of cigarette smokers 97.3 (73) 97.3 (73) 1Proportion of patients who tried to quit in the past 70.7 (53) 68.0 (51) 0.723

Main admission diagnosis (derived from discharge letters)Acute coronary syndrome (STEMI/NSTEMI) 45.3 (34) 30.7 (23)Stable coronary artery disease 12.0 (9) 13.3 (10)Pneumonia 4.0 (3) 1.3 (1)Chronic-obstructive pulmonary disease 5.3 (4) 4.0 (3)Heart failure and cardiomyopathies 10.7 (8) 10.7 (8)Valvular disease 5.3 (4) 1.3 (1)Arrhythmia 6.7 (5) 20.0 (15)Other 10.7 (8) 18.7 (14)

Patient response to the discharge questionnaireReported counselling by a physician 6.7 (5) 38.7 (29) <0.001Reported counselling by a nurse 1.3 (1) 2.7 (2) 0.56Quit attempt during hospital stay 94.7 (71) 100 (75) 0.043Quit attempt without help (e.g., medication) 94.7 (71) 90.7 (68) 0.008Appointment with smoking cessation service 0 (0) 2.7 (2) 0.152

Documentation in patients' notesSmoking' mentioned as a diagnosis in the discharge letter 37.3 (28) 52.0 (39) 0.006

Documentation of smoking status in patient notes 88.0 (66) 86.7 (65) 0.806Documentation of cessation intervention in patient notes 0 (0) 9.3 (7) 0.007

Prescription of cessation medication 0 (0) 6.7 (5) 0.023Referral to smoking cessation service 0 (0) 8.0 (6) 0.012

p values are derived from unpaired T tests and c2 tests as appropriate.


Table 2: Themes derived from interview transcripts in relation to the COM-B framework. Physicians (n = 5) provided a total of 149 quotes

that were grouped into 16 themes. Nurses (n = 10) provided a total of 269 quotes that were grouped into 18 themes.

Aspect of the COM-B model Theme

Proportion of quotesPhysicians

(149 quotes)Nurses

(269 quotes)

Motivation

Appraisal of the SOP (e.g., ‘The SOP facilitates a more structured approach to documenting smoking status and offering help.’) 17,4% 10,4%

Selective implementation of the SOP (e.g., advising only smokers interested in quitting / advising only daily smokers) 4,0% 5,9%

Effects of the SOP on daily routine (e.g., no perceived change following SOP implementation) 6,0% 4,1%

Role congruence (e.g., ‘It’s primarily the physician’s role to address smoking with patients.’) 10,7% 18,2%

General attitudes towards smoking and cessation methods (e.g., ‘Smoking is a personal choice.’) 1,3% 2,2%

Staff smoking as a barrier against counselling patients 1,3% 1,1%Awareness of SOP content (e.g., awareness of and activity related to SOP decreased since its implementation) 4,7% 4,5%

Lack of priority of SOP implementation on the wards 0,0% 1,9%Patient reactions (e.g. ‘most patients thought they did not need help to quit’ / ‘some patients reject advice’ / ‘Patients don’t want support from nurses.’)

12,8% 5,6%

Personal experience with and feelings about counselling (e.g., ‘feels like inflicting the issue on patients’ / disappointment when pts. did not take the advice that was given)

1,3% 1,9%

CapabilityNeed for additional training on counselling and medication use 10,7% 13,8%Lack of knowledge regarding the effectiveness of pharmacotherapy 5,4% 4,8%Lack of skills to discuss smoking and explain medication use to patients 11,4% 7,4%

Opportunity Opportunities to discuss smoking and cessation medication with patients 6,7% 4,8%


(e.g., ‘Physicians have multiple opportunities to discuss smoking with their patients’)Priority of helping smokers at the institutional level (e.g., ‘Treatment of smokers is not a priority in this hospital.’) 4,0% 5,9%

Priority of smoking cessation for patients (e.g., ‘Patients do not ask for counselling.’ / ‘Quitting smoking is not their priority.’) 0,0% 3,0%

Difficulties with SOP implementation on busy wards 1,3% 1,5%Lack of accessibility of SOP material on ward computers 0,7% 0,0%Lack of time 0,0% 3,0%

Documents

Structured Smoking Cessation Training for Health ... · Web viewStructured Smoking Cessation Training for Health Professionals on Cardiology Wards: a prospective study Tobias Raupach1,2,