Tobacco Cessation Counseling Training with Standardized Patients Sarah E. Walsh, M.P.H., C.H.E.S.; Jacqueline A. Singleton, R.D.H., M.Ed.; Celeste T. Worth, B.H.S., C.H.E.S.; Jacqueline Krugler, M.B.A.; Regan Moore, D.D.S., M.S.D.; Gina C. Wesley, Ph.D.; Charlene K. Mitchell, M.D., M.S.P.H. Abstract: A pilot study was conducted to assess clinician receptivity to tobacco cessation counseling training methods using standardized patients. Additionally, the study assessed changes in clinician knowledge and behavioral intentions following the training. Medical and dental residents and dental hygiene students from the University of Louisville attended a one- to two-hour lecture addressing the counseling strategies (the Five As/the Five Rs) and pharmacotherapy recommended in the U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence. Participants subsequently had three training encounters with standardized patients representing various stages of change including a patient ready to quit, a patient contemplating quitting, and a patient resistant to quitting. Thirty-six participants completed a preprogram survey prior to the lecture and a postprogram evaluation that included questions about their attitudes and beliefs about tobacco, their comfort level with various aspects of tobacco intervention, and eight knowledge questions. Participants demonstrated a statistically significant increase in objective knowledge about the practices recommended in the Clinical Practice Guideline following intervention. Results also indicate a significant increase in subjective measures of participant receptivity, self-reported comfort, and perceived skill with various aspects of tobacco intervention. Overall, participants were found to be very receptive to training sessions on tobacco cessation counseling with standardized patients. In light of the educational gains and positive response from participants, the use of standardized patients is a promising strategy for training on tobacco cessation counseling. Ms. Walsh is a Cancer Control Specialist, Kentucky Cancer Program, James Graham Brown Cancer Center, University of Louisville; Ms. Singleton is Assistant Professor, Dental Hygiene Program, Department of Periodontics, Endodontics, and Dental Hygiene, University of Louisville School of Dentistry; Ms. Worth is Professional Education Program Manager, Kentucky Cancer Program, James Graham Brown Cancer Center, University of Louisville; Ms. Krugler is Assistant Director, Standardized Patient Program, University of Louisville School of Medicine; Dr. Moore is Associate Professor and Director of Undergraduate Periodontics, Department of Periodontics, Endodontics, and Dental Hygiene, University of Louisville School of Dentistry; Dr. Wesley is Assistant Professor, Medicine Dean’s Office, Director of the Standardized Patient Program, and Director of Clinical Assessment Programs, University of Louisville School of Medicine; and Dr. Mitchell is Associate Professor, Internal Medicine and Pediatrics, University of Louisville School of Medicine. Direct correspondence and requests for reprints to Ms. Sarah E. Walsh, Kentucky Cancer Program, James Graham Brown Cancer Center, University of Louisville, 529 S. Jackson Street, Louisville, KY 40202; 502-852-6318 phone; 502-852-4554 fax;
[email protected]. Key words: tobacco use cessation, tobacco counseling, provider training, health care professionals, tobacco intervention, standardized patients, patient simulation Submitted for publication 10/31/06; accepted 5/15/07
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t is evident that health care professionals should provide tobacco cessation counseling (TCC) to their patients and families.1-11 The U.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence (TTUD) recommends that cessation counseling be provided to all tobacco users. This recommendation is considered to be the standard of care.1 Health care professionals have an important role in educating their patients about the negative consequences of tobacco use and providing cessation counseling.1,5,7,8,12-19 Recent studies have indicated that professionals are influential in motivating patients to stop tobacco use.4,10,11,13,17,19-21 Solberg et al. found that when smoking cessation interventions were offered during clinical visits, patient satisfaction increased.22
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Although health care professionals believe that TCC should be provided to all patients, studies show they do not routinely offer these therapies.9,11,17,19,23,24 Barriers exist that deter intervention.9,11,13,24,25 Barriers to the counseling process include providers’ lack of relevant knowledge and the failure to understand the chronic nature of tobacco dependence, as well as the lack of time, financial incentive, confidence in ability, clinical and institutional support, and resources.8,11,13,17,24-26 Warnakulasuriya concluded that the most significant barrier for health care providers is the lack of cessation education during the formative years of training.17 Recent research has revealed gaps in health care education in the area of cessation training.9,14,17, 26-32 Spangler et al. found a lack of research in ef-
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fective training methods and the long-term retention rates of TCC skills in medical schools. They also found an inadequate integration of these skills and cultural competency in the school curricula of health care professionals.27 Warnakulasuriya recommended that training modules be introduced into the curriculum at undergraduate levels,17 while Hartmann et al. urged health care systems to provide resources to facilitate intervention.9 Thomas found professional schools in Canada devoted more hours of education to diseases caused by smoking than to counseling interventions.32 The TTUD panel review and the national action plan of the Subcommittee on Cessation of the Interagency Committee on Smoking and Health recommended that health care professionals and those in training should be taught effective strategies to assist all tobacco users in quitting and stated that competency in tobacco dependence interventions should be a core graduation requirement.1,28 The TTUD guideline recommends that professionals help patients willing to quit tobacco use by employing counseling strategies appropriate for a patient’s readiness to quit and first-line pharmacotherapy.1 Prochaska and DiClemente’s transtheoretical model outlines the stages of change an individual passes through with tobacco cessation.33 Different intervention strategies are indicated based on each stage of change (precontemplation, contemplation, preparation, action, and maintenance). Individuals in the contemplation and preparation stages should be assisted in making a quit attempt. Patients in the action and maintenance stages require relapse prevention strategies. Individuals in the precontemplation stage should receive a motivational intervention to encourage them to consider quitting in the future. The Five As is a counseling strategy for patients willing to make a quit attempt that includes five components: asking about tobacco use, advising cessation, assessing willingness to quit, assisting the patient in making a quit attempt, and arranging follow-up to prevent relapse. The Five Rs, a counseling strategy for patients not willing to make a quit attempt, includes identifying why quitting is personally relevant, the risks of continued tobacco use, the potential rewards associated with quitting, and roadblocks that may impede potential quit attempts. The fifth R stands for repetition, because the motivational intervention should be repeated at every patient encounter. Assessment of health care provider implementation of TCC indicates that effective training programs are needed to assist professionals in teaching and
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learning effective strategies like the Five As and Five Rs.4-6,9-11,13,15-24,26,27,29-32,34-39 The effectiveness of using standardized patients (SP) to train professionals in TCC is well documented.6,29,31,35,39,40 SPs are actor/educators trained to portray patients in realistic clinical scenarios. Using SP interactions as a training method is an effective teaching and learning tool that offers a safe and controlled environment in which students can learn and practice interviewing and clinical skills. SPs are trained to evaluate the students’ counseling and clinical skills and then provide them immediate feedback on their strengths and on areas they need to continue to improve. In addition, instructors can observe the interactions and evaluate the students’ progress.41,42 Koerber et al. used SPs in training dental students in TCC and found that motivational interviewing increased patient involvement in counseling sessions.29 Other studies have found that using SPs may40,42-49 or may not be cost-efficient.39 Carter et al. found that student perceptions of the SP encounter can be enhanced if it is immediately preceded by a classic didactic lecture.50 One study found that encounters with SPs provide a valid method of scoring and standard setting for the student assessment and that SPs portray patients realistically and provide a standard of assessing clinical competence.51 Students provide positive evaluations of the SP experience and find it to be valuable.45 In summary, there is a substantial body of research demonstrating that using SPs is an educational, effective, and reliable method of teaching and learning interviewing and clinical skills.39,40,42-53 Although much is known about the benefits of education to increase TCC among health care professionals and the value of training conducted using SPs, their impact in combination is unknown. This study presents a novel approach to TCC training by utilizing SPs. The primary objective of this pilot project was to evaluate participant receptivity to TCC training using SPs. Additionally, the project provided initial assessment of the educational impact and behavior changes resulting from the training.
Methods Training Methodology The one-day training program pilot-tested in this study consisted of a preprogram survey, a oneto two-hour lecture on the core components of the Journal of Dental Education ■ Volume 71, Number 9
TTUD, three interactions with standardized patients, and a postprogram evaluation. After several sessions, a debriefing session was formally added to the training format following the postprogram evaluation. This session afforded participants an opportunity to ask any questions raised by the SP encounter and allowed the instructors to provide additional feedback and clarification as needed. The lecture emphasized the brief intervention strategies for patients who are willing to quit (the Five As) and for patients who are unwilling to quit (the Five Rs) outlined in the TTUD and FDA-approved first-line pharmacotherapy options. Lectures were given by cancer control specialists with advanced training in TCC strategies and were tailored to participants’ professions and specialties. Following the lecture, each participant had three ten-minute interactions with SPs. Each interaction was immediately followed by five minutes of feedback from the SP. The SPs at the University of Louisville School of Medicine undergo extensive training on provider-patient communication upon hire. They also completed a two-hour training on tobacco cessation and were presented the learning objectives of the pilot TCC program; this was intended to help the SPs tailor the feedback they would provide to participants. The three SP cases were designed to represent typical patients at different stages of readiness to quit, as outlined by Prochaska and DiClemente.33 The first case was a patient ready to quit (preparation/action stage) who was specifically visiting the clinician for assistance with cessation. The second case represented a patient who had considered quitting (contemplation stage). This patient would agree to make a quit attempt if the clinician offered appropriate assistance during the encounter. The third case represented a patient who was resistant to quitting (precontemplation stage) who could not be persuaded to quit at that time regardless of action by the clinician. Although the core structure of the cases was the same for all participants, as with the lecture, the cases were tailored to participant specialty.
TCC Training Participants Study participants were recruited from various professional education programs at the University of Louisville Schools of Medicine and Dentistry. Faculty were made aware of the training opportunity and elected to have students participate as determined by curriculum demands and scheduling availability. Pilot participants included thirty second-year dental September 2007 ■ Journal of Dental Education
hygiene students, eighteen first-year obstetrics and gynecology residents, twelve general practice (dental) residents, and six first-year periodontal residents. Completion of the preprogram survey and postprogram evaluation was voluntary for the training participants. Although participants were informed that their responses would be confidential, a portion of participants failed to provide any identifying information that would allow their surveys to be matched. Participants who did not complete all aspects of the training, or whose preprogram survey and postprogram evaluation could not be matched, were excluded from final analysis. In all, data were available from thirty-six participants for subsequent paired analysis although not all participants answered all questions. Forty-seven percent of participants were male and 53 percent were female. When asked about their highest degree obtained, five participants had high school diplomas, two indicated they had earned bachelor’s degrees, one had completed a master’s degree, fourteen had earned a D.M.D. or D.D.S., and eleven had earned an M.D. Three participants did not indicate their highest degree. The majority of participants (61 percent) were recent graduates, indicating that they had completed their highest degree within the past three years. Fifteen of the thirty-six participants included in the final analysis were dentists, with ten participants identifying themselves as general practice dental residents and five identifying themselves as periodontal residents. Eight participants were dental hygiene students and eleven were obstetrics/gynecology residents. Two participants did not indicate their specialty or field of training. One third of participants (34 percent) indicated they planned to pursue a subspecialty. Subspecialties of medicine or dentistry identified included orthodontics, endodontics, periodontics, reproductive endocrinology, and maternal and fetal medicine. Participants were also asked about their personal tobacco use and awareness of the TTUD on the preprogram survey. The majority of participants (74 percent) had never used tobacco, 6 percent were current tobacco users, and 20 percent were former tobacco users. Most participants (67 percent) had never heard of the TTUD Clinical Practice Guideline. Twenty percent indicated they had heard of the TTUD but had not read it, 6 percent had read the TTUD, and 6 percent reported that they had read the guideline and planned to follow its recommendations. Despite the differences in their training programs,
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all participants were routinely treating patients from the greater Louisville community. Their patient populations were assumed to include smokers, yet none of the participants reported that they were currently implementing the counseling strategies recommended in the TTUD.
Evaluation Participants completed a preprogram survey prior to the lecture and a postprogram evaluation following the SP encounters and before any debriefing session. The preprogram survey included questions about the participants’ attitudes and beliefs about tobacco, their comfort with and self-reported knowledge of various aspects of tobacco intervention, and eight fact-based objective knowledge questions about tobacco use and cessation strategies. The postprogram evaluation mirrored the preprogram survey; however, items were reworded on the postprogram evaluation to reflect behavioral intentions rather than current practices (e.g., the preprogram survey item “How often do you ask an individual patient about tobacco use?” was changed to “In the future, how often do you intend to ask an individual patient about tobacco use?” on the postprogram evaluation). All questions were presented in a multiple choice format. The preprogram survey also assessed participant demographics and current practices regarding tobacco cessation (the Five As). The postprogram evaluation assessed participant receptivity to the training and their intention to implement a brief intervention for tobacco cessation. Data from preprogram surveys and postprogram evaluations were entered into an SPSS (12.0) database, which was used to produce descriptive statistics for all participants. Matched data from the preprogram survey and postprogram evaluation were subsequently analyzed using Wilcoxon signed rank tests and McNemar’s test (for dichotomous variables) to determine significant differences in responses.
Results A major objective of the project was to assess the educational impact of the training. Several statements were used to measure participant attitudes and beliefs about tobacco use and the importance of tobacco cessation counseling. Participants were asked to indicate their level of agreement with the statements using a four-point Likert scale (strongly agree, somewhat agree, somewhat disagree, strongly disagree) with 4 indicating strong agreement. No 1174
meaningful change was observed from preprogram survey to postprogram evaluation with statements pertaining to the importance of the issue: “It is important for members of my profession to discuss tobacco use with patients”; “Tobacco use has serious negative health consequences”; and “Tobacco cessation is an effective method of reducing morbidity/mortality.” Virtually all participants strongly agreed with these statements prior to the training. Participants reported a change in their attitudes toward their own skill level and belief in the efficacy of a brief patient intervention that was statistically significant. Participants increased their level of agreement with the statement “I have sufficient skills/ knowledge to treat nicotine dependence” from a mean score of 2.50 (sd=0.811) on the preprogram survey to 3.47 (sd=0.506) on the postprogram evaluation (p
