Schools of nursing have been mandated by the American Nurses Association (1993), the National League for Nursing (1993), and the American Association of Colleges of Nursing (1997) to provide communitybased education, emphasizing health promotion and disease reduction, in which collaborative partnerships with agencies in the community are developed and maintained. The main goal of these partnerships is to improve health care delivery to all clients served. The focus of this article is one such partnership that offered a smoking cessation program to all smoking clients at a large county pregnancy clinic.
The adverse health effects of smoking are widely known, well documented, and currently are the cause for litigation against tobacco companies. Smoking results in the unnecessary premature deaths of more than 200,000 American women annually (DiGuiseppi, Atkins, & Woolf, 1996). The adverse effects smoking has on the fetus and infant are primarily related to birth weight, preterm delivery, and sudden infant death syndrome (Brooke, Gibson, Tappin, & Brown, 1997; Slotkin, 1998). In addition, pregnancy outcomes resulting from smoking include increased risk of placenta previa, abruptio placentae, bleeding during pregnancy, and premature and prolonged rupture of membranes (Castles, Adams, Melvin, Kelsch, & Boulton, 1999).
It has been established that approximately 25% of pregnant women smoke throughout their pregnancy (Floyd, Zahniser, Gunter, & Kendrick, 1991), although an estimated 6.4% of pregnant smokers quit without intervention, usually prior to the first prenatal visit (Viswesvaran & Schmidt, 1992). Many studies demonstrate that smoking cessation during pregnancy or during the first trimester will result in improved pregnancy outcomes and statistically normal birth weights (DiGuiseppi et al., 1996; Hebel, Fox, & Sexton, 1988; Wainwright, 1983; Windsor & Orleans, 1986).
In 1994, the Agency for Health Care Policy and Research (AHCPR) convened a panel to develop guidelines for the treatment of tobacco addiction. Their recommendations included (AHCPR, 1996):
* Systematic identification of smokers by primary physicians.
* Providing consistent advice to quit smoking.
* Offering support in terms of pharmacologic interventions, counseling, selfhelp materials, intervention groups, or some combination of these.
Currently, obstetrical clinics are pressured to provide such interventions from accreditation agencies. However, reasons provided by clinic staff, physicians, and family nurse practitioners for not routinely engaging in this activity include (DiGuiseppi et al., 1996; Mullen, Pollack, Titus, Sockrider, & May, 1998):
* Lack of training.
* Lack of time.
* Sense of apathy and powerlessness to change clients' behavior.
* Lack of funds for the materials to offer clients.
* Lack of awareness of the expert panel reports and recommendations for prenatal care.
It is estimated that less than 40% of clinicians routinely advise their patients to stop smoking (Fiore & Baker, 1995). In addition, the reasons pregnant women offer for not participating in smoking cessation programs include (Lacey et al., 1993):
* Inconvenience of group classes.
* Lack of available child care.
* Lack of support.
* Too much going on in their lives.
Many of these obstacles potentially could be solved by using nursing students to implement such programs at the convenience and in the homes of the pregnant clients. Seeker-Walker, Solomon, Flynn, Skelly, and Mead (1998) called for practical methods, which involves contact between prenatal visits, to help pregnant women quit smoking.
Using The Pregnant Woman's Guide to Quit Smoking handbook,* 45 senior nursing students delivered a smoking cessation program. The smoking cessation guide, a self-help modular program specifically tailored to pregnant women, was shown to be more effective than nonspecific approaches (Windsor et al., 1985). In addition, instruction-based programs were shown to be more effective than advice alone and eversive techniques, and significantly more effective than pharmacology-based programs (Viswesvaran & Schmidt, 1992). Finally, counseling in the clients' homes produced more favorable results than counseling in the antenatal clinic (King & Eisner, 1981; Rajan & Oakley, 1990).
Nursing students delivered the program in the homes, or a mutually agreedon place, of pregnant women who reportedly smoked daily and were at fewer than 20 weeks gestation. The steps in the process were:
* The authors spoke with the medical director and nursing supervisor of the pregnancy clinic to discuss the possibilities and establish the process.
* The authors obtained permission to conduct this project as a research project by the Human Subjects Review Committees at both the pregnancy clinic and university.
* The authors provided a 2-hour seminar on the general effects of smoking and specifically the hazards of smoking to pregnant women and fetuses and reviewed the four components of the Becker's (1974) Health Belief Model.
* The students practiced and demonstrated their ability to deliver Windsor's A Pregnant Woman's Guide to Quit Smoking in a laboratory period. Students' peers evaluated their effectiveness in delivering the smoking cessation program.
* The authors reviewed charts at the pregnancy clinic to determine the smoking status of clients. Names, addresses, and telephone numbers of women who smoked were given to the nursing students. In addition, information about parity, expected due date, and any pregnancy data was given to the students.
* A flyer was sent to the women, and a flyer was given to new clients at the pregnancy clinic, explaining the program, and stating that the women would be telephoned by a senior nursing student and asked to participate.
* Each student telephoned two women and scheduled times to meet with them at their homes or another convenient location. It was expected that the students would continue this process of obtaining names and calling pregnant smokers until at least one agreed to participate in the smoking cessation program. Clinical faculty accompanied students on the first visit.
During the first visit:
* Clients reviewed and signed the consent form.
* Students reviewed the steps of The Pregnant Woman's Guide to Quit Smoking* with the clients.
* The date, time, and place for the next follow-up visit was scheduled for 10 to 14 days later.
During the first 8 days of this selfguided program, smoking was reduced. After the eighth day, clients were encouraged to adhere to the quit date set at the first meeting and stop smoking. The women received telephone support from the nursing students who instructed them in the use of the program.
At the follow-up visit, clients were asked if they were able to accomplish their goal successfully and were encouraged to keep working with the program. Following this visit, clients using the program were telephoned by students approximately once a month to "check in" on their progress. After the birth of the baby, clients were called to determine their smoking status. The birth record was reviewed for relevant data.
The benefit of this program was that the women were able to use the program in the convenience of their homes, because only approximately 5% of smokers were willing to participate in group intervention strategies (Cromwell, Bartosch, Fiore, Hasselblad, & Baker, 1997). This was particularly beneficial for women with other children. Meeting times were scheduled at mutually convenient times. The students and the women also could have chosen to meet in a suitable public place or in the antenatal clinic.
Twenty-two women agreed to participate in the program, which was far fewer than was hoped. Many women indicated that "of all they had going on in their lives, smoking was the least of their problems." The 22 women were called by the primary author at 1 month and 6 months following their initial participation in the program.
The results were:
* Three women quit smoking and at the 6-month follow-up telephone call remained nonemokers.
* One woman had quit but had resumed smoking at the 6-month followup telephone call.
* Initially, nine women reported reducing smoking. At the 6-month followup telephone call, one woman had quit smoking, and others had continued to reduce their smoking from their previous rates.
* Nine women had not quit and continued to smoke at the 6-month follow-up contact. Several of these women had been able to reduce their smoking from their previous smoking rates, but two women reported they were smoking more than ever.
* In the final analysis, at the 6-month contact, 18% of the women had quit, and more than 40% had reduced the amount they smoked.
These findings compared favorably to the rates of quitting smoking reported by other studies. In a study of 309 women in three clinics, the group that simply was advised to quit smoking had a 2% rate of quitting at the end of pregnancy; the group that received the manual from the American Lung Association Freedom From Smoking in 20 Days had a 6% rate of quitting; and 14% of women who used The Pregnant Woman's Guide to Quit Smoking reported they had quit at the end of their pregnancy (Windsor, Warner, & Cutter, 1988).
In a controlled study that used a selfhelp manual distributed by an obstetrician, 12.6% in the treatment group quit smoking, compared to 8.6% who quit and received no materials (Hjalmarson, Hahn, & Svanberg, 1991). In a study by O'Connor et al. (1992), the treatment group received a 20-minute counseling session by a public health nurse about smoking cessation and the benefits to the fetus, a self-help manual, and follow-up telephone calls. This group had a 13.3% quit rate, compared to a 6% quit rate in the control group. Seeker-Walker et al. (1998) found a 14% quit rate at their 36week follow up when women received a booklet and brief advice from a nurse. These studies and others (Schwartz, 1992) demonstrate, at least from the preliminary findings, that nursing students are as effective as, or more effective than, their professional counterparts in providing counseling and materials and following up with telephone calls.
As a pilot program using students, this process was effective in producing four new nonsmokers and more than nine women who attempted to reduce their smoking. The remaining nine women, although they did not quit or significantly reduce their smoking, retained The Pregnant Woman's Guide to Quit Smoking and were encouraged to try again at a time most opportune for them. Many women who eventually are successful in quitting smoking have had one or more previous failed efforts (Crittenden, Manfredi, Lacey, Warnecke, & Parsons, 1994). Prochaska and DiClemente (1992) outlined a 5-step process for change:
* Preparation for action.
* Maintenance, in which they note that for successful intervention, clients must be beyond the precontemplation and even the contemplation stage.
Allowing the women to participate and to keep the materials for future efforts is one way to move them along the continuum.
Unexpected outcomes of this program were that the husband of one of the pregnant women quit smoking by following the basic program outlined in the manual. One participant's mother-in-law attempted the program and reduced the number of cigarettes she smoked. In addition, one nursing student quit smoking using the program.
The pregnancy clinic was pleased with the overall results and planned to continue the project in future semesters. The opportunity to expand the services offered through the clinic without additional expense or staff training was considered very attractive. In light of the potential cost savings of reducing the number of neonates admitted to the neonatal intensive care unit for low birth weight, the program is highly regarded by the managed care affiliates.
Finally, the opportunities presented to the nursing students to refine their nursing communication skills, encourage health promotion, and collaborate with other health professionals was substantial. Students reported:
* Once I received a name, the process went smooth, [sic] client hasn't quit yet but she has the tools to keep trying.
* The smoking cessation program is an excellent way for the student nurse to exercise their teaching-learning skills and is a non-threatening way to learn about general psychosocial issues.
* This program is great for women who really already want to quit. It seems she was on her way but just needed a push.
* The process made me more interested in my own health. I plan to use the program to try and quit myself.
* This is a really good program!
Students who were able to provide the program enjoyed the process. They reported that the manual was "easy to follow," "helpful," and "effective." They stated they had to "get over their fear and telephone the participant," which for some of them was the "hardest part." More training and practice in telephoning or having the faculty or a graduate teaching assistant make the initial calls is suggested.
Breaking the ice seemed to be the most difficult barrier for students. Students had multiple opportunities to evaluate the social and environmental factors conducive to making lifestyle changes. They often made observations about the environmental factors that mitigated against the women's potential success in quitting smoking. One common observation was that "when the significant others smoked, the participant was less likely to be successful in their quitting effort."
In the process, the authors learned more about collaboration with a community agency. It was clear that some barriers were produced by the agency itself. The routinization of care provided to a large number of pregnant clients made it difficult to "add one more thing," such as handing out the smoking cessation flyer or talking about the program to pregnant clients. Although there had been four meetings with the clinic nursing supervisor, and two meetings and several telephone conversations with the director of medical services, there never was full "buy in" by staff. There was a "fine with me if you do this" attitude, but there was no direct ownership of the project by the clinic staff.
Although the director and nursing supervisor were supportive and encouraged the project, their enthusiasm did not translate into any real action (i.e., flyers were not handed out; women who were contacted by telephone often said they had not heard anything about the project; when students agreed to meet with clients at the clinic, there was no space provided for them so they had to conduct the program in the often-crowded break room). It was not until the authors and the students expended greater effort to become acquainted with the clinic staff that the staff put forth a consistent effort to inform clients about the program, hand out the flyers, and provide private counseling space.
Tse and Schoultz (1999) recommended a "hanging out" approach as a method for developing mutual participation between the organization(s) and the faculty and students. Still, more effort should be made to offer some incentive for staff to participate.
Community and academic partnerships must be forged and maintained for the mutual benefit of all involved. Patients are better served when primary care providers offer smoking cessation services in which counseling, education, and active support are provided. Although group methods are most cost effective, they are least attended by pregnant women, many of whom have other children at home. Using nursing students for home visitations was an effective means to accomplish this goal, while providing opportunities for students to develop their communication skills and engage in health promotion activities. This model can be adapted by other nursing programs, and collectively nurse educators can help the United States reach its Healthy People 2010 goals (Office of Disease Prevention and Health Promotion, U.S. Department of Health and Human Services, 2000).
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