Nurses’ Role with Nurses’ Role with Clients/Patients Clients/Patients

Who Use TobaccoWho Use TobaccoCreated by the Registered Nurses’

Association of Ontario

RNAO BPG “Integrating Smoking RNAO BPG “Integrating Smoking Cessation into Daily Nursing Practice”Cessation into Daily Nursing Practice”

Practice Recommendations:1. Nurses implement minimal smoking cessation intervention

(4As) with all clients. 2. Nurses introduce intensive smoking cessation intervention

(more than 10 minutes duration) when possible. 3. Nurses recognize possibility of relapse and need to re-

engage clients in the smoking cessation process. 4. Nurses should be knowledgeable about community

smoking cessation resources, for referral and follow-up. 5. Nurses implement smoking cessation interventions and

tailor strategies to the diverse needs of populations. 6. Nurses implement, wherever possible, intensive

intervention with women who are pregnant and postpartum.

7. Nurses encourage people to make their homes smoke-free, to protect from exposure to second-hand smoke.

Role of Nurses & Nursing StudentsRole of Nurses & Nursing Studentswith clients/patients who use tobaccowith clients/patients who use tobacco

Key intervention: ◦Introduce topic with a question

Comfortable, non-judgmental, not coercive ◦Use reflective practice with answers◦Offer assistance when the smoker is ready to quit◦Offer advice and guidance in choosing cessation

method◦Support the quitting process

Nursing students can act as peer-to-peer counselors

Provide self-help material

4As vs. 5As protocol4As vs. 5As protocol

4As Protocol: Minimal Tobacco Intervention 1-3 minutes in duration

Ask Ask every client/patient if they use tobacco.“Have you used any form of tobacco in the past six months?”Document tobacco use status (ie. Non-smoker, smoker, ex-smoker)

Advise Advise every tobacco user of the importance of quitting.“I am concerned about how smoking is affecting your health. Have you thought about quitting?”

Assist Assist the smoker to quit by providing appropriate self-help materials and referrals.

Arrange Arrange a follow-up or referral appointment to discuss quitting.

4As vs. 5As protocol4As vs. 5As protocol5As Protocol: Intensive Tobacco Intervention

Over 10 minutes in duration

AskAdvise

Same protocol as for 4As

Assess Assess nicotine dependence level and readiness to quit. Review the client/patient’s quitting history.

Assist Assist the smoker with the choice of:- quit date- cessation method - general quitting planThis can involve providing self-help material and possibly prescriptions.

Arrange Arrange for follow-up visit(s) - on quit day & afterwards

Stages of Change TheoryStages of Change Theory

Originally developed in the late 1970's & early 1980's by James Prochaska and Carlo DiClemente at the University of Rhode Island

Views behaviour change as a dynamic process

Applied to a broad range of behaviours • smoking cessation• weight loss• injury prevention etc.

Basic PremiseBasic Premiseof Stages of Change Theoryof Stages of Change Theory

People quit smoking by progressing through a series of five successive stages

People in each stage differ from those in other stages in important ways (dynamic)

Stages reflect how we plan, deliver and evaluate smoking cessation interventions.

Stages of Change ModelStages of Change Model

Pre-ContemplationPre-Contemplation Unaware or unwilling to change Not thinking of quitting in the next 6 months Spend little time thinking about smoking May not see it as a problem

Goal:• To help the client/patient begin to think seriously about

quitting

What to do:◦ Ask regarding feelings about smoking◦ Ask about pros and possible cons of smoking◦ Advise by offering quitting information & assistance at

any time

ContemplationContemplation Thinking about smoking May be thinking about quitting within 6 months Feel ambivalent about taking the next step

Goal:• To help smoker move towards a decision to stop

smoking• To help the client/patient feel more confident

What to do:• Ask about pros and possible cons of smoking (decision

balance)• Acknowledge ambivalent feelings• Assist by reinforcing reasons for change & exploring

new ones• Suggest they cut back or stop for a day• Assist by offering a future visit and information

PreparationPreparation Getting ready to stop within the next 30 days Have set a stop smoking date Have made a 24-hour quit attempt in the last 12

months

Goal:• To help the smoker prepare for an anticipate positively a

quit date

What to do:• Ask about concerns, preparations and lessons learned

from previous attempts• Advise by identifying barriers to stopping and elicit

solutions• Assist by Booklet, Action Plan, Nicotine Replacement,

Date for quitting (BAND)

ActionAction Have quit smoking within the past 6 months May try several different techniques Are at greatest risk of relapse

Goal:• To help client/patient stay off tobacco products and

recover from relapses

What to do:• Ask how the client is doing: relapses, temptations,

successes, NRT use• Advise re: relapse prevention, weight gain, triggers• Assist by focusing on successes, encourage self rewards

and increase support, elicit solutions for problems

MaintenanceMaintenanceHave quit for more than 6 monthsIntegrating smoke-free living into their

routine

Goal:• To help the client/patient remain smoke-free for a life

time

What to do:• Ask how the client is doing: risk situations, relapses• Assist by offering suggestions for difficult times, support,

encouragement• Congratulate!

The Cycle of ChangeThe Cycle of Change

Most smokers will cycle through the stages 3-4 times before quitting for life

Each attempt offers new learning opportunities

Relapse is a normal event in the process of making behavioural change

Motivational InterviewingMotivational Interviewingfor health behaviour changefor health behaviour change

Designed to take 3 – 5 minutes per session

Psychosocial or socio-behavioural approach (rather than biomedical)

Focused, goal directed, client-centred councelling style

Aimed at eliciting behaviour change by helping clients explore and resolve ambivalence

5 Principles 5 Principles (Counselling Techniques)(Counselling Techniques)

1. Express Empathy2. Avoid Arguments3. Develop Discrepancy (Dissonance)4. Roll with Resistance5. Support Self-efficacy

6 General Skills 6 General Skills

for Motivational Interviewingfor Motivational Interviewing 1. Asking Open-ended Questions2. Reflective Listening3. Affirmations4. Summarizing or Reframing5. Self-motivational Statements6. Personalized Feedback

See the guideline Appendix G for a detailed description of the motivational interviewing process

Referrals to Community for Referrals to Community for Cessation SupportCessation Support

Communities vary in the amount of cessation support resources they havebased on size, location, etc.◦Most communities offer cessation support through

their local public health department

Other resources are more consistently available for clients/patients who are trying to quit smoking• Self help booklets & resources • Online resources