Gallup poll results reveal nurses are regarded by the public as important and trusted health role models, ranking highest on honesty and ethical standards. Nurses at Wake Forest University Baptist Medical Center, a designated Magnet organization, have an obligation and responsibility to advocate for and model, through evidence-based policies and practices, behaviors that address health disparities, support health promotion, and reduce or eliminate disease burden.
Special segments of the U.S. Surgeon General's report have even been devoted to the health benefits of tobacco cessation.1 Nursing's concerns and contributions in communities, hospitals, and with population groups are documented throughout numerous healthcare related publications.
The U.S. Public Health Service's Clinical Practice Guideline purports that at each professional-patient encounter, all healthcare providers implement five action-oriented brief interventions, known as the 5A's: ask, assess, assist, advise, and arrange follow-up.2,3
Recognizing the negative impact of tobacco on health, members of the behavioral health nursing leadership team at Wake Forest University Baptist Medical Center, Winston-Salem, NC, developed strategies to eliminate tobacco use among hospitalized inpatients, while simultaneously addressing and treating the potential for nicotine withdrawal.
What We Knew
Wake Forest University Baptist Medical Center, an 830-plus-bed level I tertiary academic hospital, is in a city with a long history associated with tobacco. References to tobacco are found throughout Winston-Salem, in surnamed and brand-named streets, schools, buildings and developments. In fact, Winston-Salem is home to R.J. Reynolds Tobacco Company headquarters.
On our child, adolescent and adult behavioral health units, nurses decided to make a change in tobacco use trends. We acknowledged hospitalized patients (and their families/visitors) represent a "captive" audience who are entitled to lifestyle modification education designed to promote health, and perhaps avert or delay disease processes.
We knew our patient population - individuals with mental illness - have higher tobacco use rates than the general population.4 We also knew although the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Text Revision endorses specific and separate criteria for nicotine dependence and nicotine withdrawal, it has no standards to assess dependence severity.
We had seen the myriad symptoms of nicotine withdrawal, such as dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite or weight gain. These symptoms sabotage treatment efforts by enabling patients to learn ways to earn off-unit privileges so they can leave the unit to smoke, often at times which coincided with therapy group.
So in 2004, with support from the behavioral health nursing leadership team (director, clinical nurse specialist, manager, nurse-educator) and under the guidance of our medical director, we sought ways to promote a tobacco-free atmosphere in our inpatient behavioral health settings. The need was apparent and literature reviews identified an objective metric for determining potential severity of nicotine withdrawal that performs as well with smokers who have a mental illness, as well as among those without.
Armed with this knowledge, we implemented this tobacco elimination plan on our child, adolescent and adult behavioral health units on Jan. 1, 2005.
One component to our plan was the Fagerstrom Test for Nicotine Dependence (FTND), a six-item evidence-based objective clinical tool that helps to estimate the severity level of nicotine dependence. At Wake Forest Baptist, the physician will order the nurse to administer the FTND to tobacco users at the time of admission.
The FTND is computer-generated in the admission assessment, which translates and automatically populates and sums a score. Scores range from 1 to 10, with higher scores prompting the nurse to order higher doses of the patch or gum in a dose-response pattern. Summed responses yield a score that guides the nurse to order, per protocol, the most effective nicotine replacement patch (7 mg, 14 mg or 21 mg) or nicotine replacement gum (2 mg or 4 mg). Facsimile notification to the pharmacy allows for medication reconciliation and ends with approval granted to the nurse to offer individualized nicotine replacement treatment that is based on their FTND score.