Álvaro Meléndez Gutiérrez

77820208F
Psychology, year 3
Community Psychology
Universidad de Sevilla

PRACTICAL CASE ANALYSIS

Implementation of the Tobacco Tactics intervention versus usual care

in Trinity Health community hospitals
Abstract

In the context of RE-AIM, an implementation framework which responds to Reach, Effectiveness,

Adoption, Implementation, and Maintenance, it was developed a Health-sponsored program to
enhance the smoking quitting strategies offered by five Michigan (USA) hospital nurses with a
new nurse-administered program called Tobacco Tactics. This intervention understands that
nurses are the widest first-line providers of advice to the community of smokers, which allows
them to approach a bigger population, and if effectively done, decreasing smoking, morbidity and
mortality among inpatient smokers. There were significant results in pre- and post- interventions,
increases in self-reported receipt of print materials, positive feedback from instructed nurses, and
continuation in the providing of the intervention after the study ended.

Keywords: Smoking, Intervention, Healthcare, Cessation, Inpatient

Summary of the Experience

It is a fact that smoking is one of the first causes of death in nowadays

communities, one of the biggest health issues the 21st century society faces. The
psychology that lays beneath addiction, consumption, social relations,
environmental pressure and its consequences has been widely studied, and it still
is, but still numbers account for themselves in statistical annual reports. There are
several approaches that come from Intervention Psychology dealing with issues
like the one presented in this case, this is, addressing addiction, and its impact in
communities. I have found some interventions in healthcare professionals (see
references for a series of quitting smoking program interventions) as providers of
first-hand information and attention in smoking communities, which means there
is some literature in regards to the effectiveness of this sort of approach. This wide
list of references sets basic premises on top of which our current program might
have been developed, or at least from where it could have extracted its basic
premises.

The program that will be analysed in this GTO practise for Community Psychology
focuses on the ability behavioural scientist have to study the psychosocial aspects
of a contextualised problem and its relations, in this case, for example, the brilliant
idea of intervening nurses in primary healthcare facilities to have first hand access
to inpatients (hospitalised patients) that smoke, and help them quit from that same
environment. This approach of the program requires the understanding of the
psychology of the patient (for example, his/her predisposition to be healed, or
healthier, due to another condition that they already bring in the first place), and
taking advantage of such a knowledge prepare a training program for those who
will be with this target population all way down the read back to health: the nurses.
First, we find a well-designed program that is supposed to centre its effectiveness
in its simplicity and affordability of materials, as we will discover in depth during
the GTO analysis that will be performed. Five hospitals were selected (not-
randomly) from which three would have the program implemented. This one
consisted on a training program to nurses that would enhance their abilities to
intervene in counselling of inpatients with smoking-cessation techniques. A pre-
test and a post-test were used as methods of assessing the effectiveness of the
intervention and the appropriate acquisition of knowledge and competences.
Smoking cessation interventions that include counselling, medications, and
telephone follow-up for hospitalized smokers have been shown to be efficacious,
and this is the work frame upon which the program stands.

Among the psychosocial variables that work in the underlying processes,

hospitalisation seems to provide an excellent opportunity for patients to quit
smoking because they are a captive audience, are often motivated to quit due to
illness, and often quit temporarily due to hospital smoking bans. Moreover, meta-
analyses suggest that nurse-administered interventions are efficacious, particularly
among hospitalised patients. Despite the strong evidence for the efficacy of
inpatient smoking interventions, a large gap exists between the availability of
effective smoking cessation interventions and their widespread dissemination in

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hospitals. The challenge rests with disseminating smoking cessation interventions
into standard practice. Overall, this details present the need for an intervention
program that would address the issues reported in an ambit that would benefit not
only the individuals who would receive the treatment, but the communities
involved and the resources of the institutions that need to give account for such
communities, in this case the big health-care institutions.

The results of the program were outstanding, and they reflect how a correct way
of approaching a problem can produce good results. Replicability and maintenance
of the programs were guaranteed, and high level of satisfaction of participants and
target population proves it.

Commentary on the Case

Smoking is a risk factor for several diseases, including coronary heart disease and
lung cancer. Stopping smoking lowers that risk. From the field of Psychology there
is a wide literature that focuses on Psychosocial smoking cessation interventions
such as behavioural therapy, telephone support and self-help materials are
effective in helping prevent patients to stop smoking, if they are provided by
healthcare professionals. The evidence points towards psychosocial interventions
increased quit rates after 6 months, as we will analyse further in the development
of the text.

I feel it is necessary to explain, first, that this commentary has been produced after
the ending of the rest of the document, which means that these following
paragraphs of this section is intended to gather the conclusions derived from the
intensive analysis of the case. Details on this analysis are given, hopefully
accurately, in the ten GTO questions that intend to guide its correct performance.

We find ourselves with a very neat case presented on this paper, an experience of
intervention that seems to exemplify in a very precise manner the potential
workings of community psychology. We can appreciate through all over the
process that idiosyncratic mixture of theory and practice in the way in which the

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approach is designed and the model implemented. Following the methodology of
RE-AIM as a developed tool eminently developed by intervention teams, we walk,
step by step, across an example of how interventions should work.

It is notable the way in which the situation and needs are analysed and understood,
specially in the way the problem is approached and solved. Still, it is important to
mention that this intervention is not definite, as it aims to a large-scale
implementation which in the future might have a very significant impact If
replication and re-utilisation takes place.

I would like to comment briefly on the creative aspect of innovative ideas, such as
approaching a target population from a certain community (as the community of
smokers, in this case) attending not to the habits themselves (as a personal trait,
typical in Psychology), but as the possibilities of intervention dependant on the
context. This approach of intervening the target population in the context of
hospitalisation through a training program that focuses on the nurses seems to me
a brilliant idea, and a very neat way of understanding not only the psychology of
the individuals, but its contexts and its consequent reactions and predispositions to
the contexts, as we can agree that the psychology of a smoker is different when the
smoker is also a patient at a hospital.

From this experiences, then, we can extract the virtues of implementation

strategies as having been correctly exemplified, and an innovative way of applying
the Behavioural Sciences to the service and well-being of the Community.
Prevention and intervention programs such as the presented should be rule, not
exceptions.

From an anecdotic perspective, as I obviously did not participate in the program, I

can only report the inferences of what was presented by the actual participants of
the workshop, the nurses themselves (the healthcare professionals) in the
evaluations that were made in the final stages of the project. Apparently, there was

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a general satisfaction and a very good mood in regards to the whole
implementation process, which probably made some impact in the whole
smoothness when developing the courses and the further intervention with the
inpatients.

We will proceed now with the detailed analysis provided by the Getting to
Outcomes methodology used for this module of the Undergrad program of
Community and Intervention Psychology.

***

GTO 1: Situation and Needs

The context of intervention serves itself challenge was providing smoking
from smoking cessation interventions cessation interventions in the common
which include counselling, medications, day to day practise.
and telephone follow-up in a population
Research on the needs of the population
of hospitalized smokers. Hospitalisation
were done via meta-analyses, where was
seems to provide a good opportunity for
first suggested that nurse-administered
patients to quit smoking motivated due
interventions are efficacious, especially
to illness, and often quit temporarily due
among hospitalized patients. The
to hospital smoking restrictions. The
efficacy of the Tobacco Tactics
problems presented by this community,
intervention kind that we are dealing
therefore, are obviously the high
with in this article is the most immediate
morbidity and mortality that tobacco
antecedent of the case, and its base study
causes.
is explained in the article as tested in a
Necessities identified derive from the previous randomised controlled trial
strong evidence of the efficacy of with 184 patients of head and neck
inpatient smoking interventions and the cancer in which smoking quitting rates
gap that exists between the availability were 47% compared to the usual 31% of
of effective smoking cessation normal intervention programs (p < 0.05).
interventions and their widespread In these antecedent case, though,
dissemination in hospitals. The intervention program was not

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maintained, but in our actual case, as we
will see in other GTO section, the
program was effectively continued after
the ending of the study due to its
efficacy.
Social justification of the program
implementation comes in hand with the
necessity of diminishing the rates of
smokers and subsequent diseases
associated with such condition, and its
impact in the community and healthcare
resources, as well as in the social
wellbeing of individuals as a whole. The
justification of this particular article is
the needs of evaluation of the mentioned
implementation for future reference and
re-application.
Additionally, it is stated that Trinity
Health is one of the largest multi-
institutional Catholic health care
delivery systems in the nation.
Committed to those who are poor and
underserved in its communities, Trinity
Health serves people and communities in
21 states with 124 continuing care
locations, and 91 hospitals, of which five
Michigan hospitals were included in the
study.
GTO 2: Aim, Target Population and
Objectives
I understand that the specific aims of the
intervention were (1) To train nurses in
Tobacco Tactics appropriately, (2)
Change in nurse attitudes, behaviours
and barriers in relation to previous
standard programs. These aims, as I see
them, have a significant relationship to
the actual objectives of the intervention,
more related to the target population (or
populations, in our case), which will be
explained next.
Target population can be divided into
two categories: nurses, as the receptacles
of the training program, and the local
hospital inpatient smokers under the care
of these nurses, as real target population
where benefits will show.
When it comes to objectives of the
intervention, I can deduce that the main
ones might have been (1) To reduce the
amount of tobacco consumption among
inpatients, (2) To enhance the services
provided by these hospital nurses with a
program that is easy to understand and
implement (3) to maintain the continuity
of the framework.
GTO 3: Justifying Intervention
Strategy
The intervention is justified as a smart
program implementation in a very
sensitive environment, critical for
diminishing in a drastically significant
way the number of smokers by giving the
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necessary and innovative
(prominently psychological, in the sense
of formation of the body of nurses in
these hospitals), so that they can benefit
the community as a whole, in a wide
range and with very high replicability.
tools consistency of delivery as intended and
the time and cost of the intervention.
Finally, Maintenance is The extent to
which a program or policy becomes
institutionalized or part of the routine
organizational practices and policies.i

It is theoretically based in the Reach, Utilization of the RE-AIM framework is

Effectiveness, Adoption, intended to enhance the applicability of
Implementation, and Maintenance (RE- research-based interventions in clinical
AIM) framework, which has been used practice and ease the process of
in other dissemination and planning, conducting, reporting, and
implementation health behaviour and selecting interventions to be
smoking studies. For a better implemented on a large scale. We can
understanding of its psychological conclude from the analysis of such a
functioning, we can analyse each of the technical framework that there are
components of the theoretical previous and enough references that
framework. background the implementation program
in order to guarantee the success, as we
Reach is about striking the appropriate
will see in further sections of this GTO
population, the absolute number,
analysis. We noted such in the previous
proportion, and representativeness of
section, when explaining the antecedents
individuals who are willing to participate
of the case in the randomised controlled
in a given initiative. Efficacy refers to the
trials.
impact of an intervention on important
outcomes, including potential negative GTO 4. Community Adjustment of
effects, quality of life, and economic the Intervention
outcomes. Adoption is the absolute I believe that strategies and contents
number, proportion, and have been adapted appropriately to the
representativeness of settings and attended population. Target population
intervention agents who are willing to being the smokers, in fact, have been
initiate a program. Implementation addressed in a very sensitive and precise
stands for the intervention agents’ manner, as it is the sanitary personnel
fidelity to the various elements of an (nurses in primary attention services)
intervention’s protocol. This includes where the focus of the implementation

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has been settled, having an accurate
access to the former mentioned target
population. We could defend on these
premises, that the peculiarities of the
intervention, its creativeness, adjusted
more than well to demands of the
community serving itself from the same
health-care environment to promote,
accordingly, healthier habits.
In regards to accessibility,
modifications to facilitate
effectiveness of the main components of
the program, no special strategies or
approaches were mention, probably
because of the very good disposition
among the people who received the
training in a program that has already
been used in previous reference
situations and has been polished and
adapted repeatedly. But, again, explicit
statements on this concrete issue are not
presented.
GTO 5: Organisational Aspects
Basically, the implementation of the
program was performed by
researchers from the University of
Michigan (Heath Sciences
Behavioural Sciences), in collaboration
with the Trinity Health Hospitals (that is
to say, main organisation was the former,
may the latter be tagged as an
“organisation that took part in the
development of the program”, as the
GTO question demands).
Organisational resources were all the
materials produced by the University
researchers to distribute the formation in
the tobacco prevention program for the
nurse workers in three of the five
hospitals (the other two were control
group for contrast purposes). As it is
described in the article, these user-
and
friendly toolkits that were distributed,
the
being the results noticed from pre- to
post- in sessions shorter than 1h of
training. These materials include
brochures, manuals, paper-guides and
DVD’s that nurses would have learned to
use during the sessions. More important
were the human resources, which were
the psychologists (or behavioural
scientists) in charge of the program and
of the education of the nurses in these
new techniques.
GTO 6. Action Plan
The temporal logics of the program and
its organisation into an action plan are, in
the fact, quite easy to understand. After the
previous study results that were already
and commented in former sections of this
analysis, and after the selection of the
establishments (i.e. Hospitals) that were
having the treatment applied (in terms of
scientific research – three out of five,
being the left two for control purposes),
the scheme of activities was: 1) pre-test
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evaluation of currently-in-use strategies
for approaching the smoking cessation in
inpatients, 2) development and
implementation of the program, being
this the nurse training in the selected
hospitals, 3) post-test evaluation for
contrasting the results. This logic follow
precisely the scientific method of
intervention.
It is interesting to explain in regards to
the action plan that the implementation
of standard protocols, which have been
shown to be effective in increasing
smoking cessation counselling
interventions provided by nurses, it
enhanced service delivery. It is
explained that, as nurses are ideally
positioned to deliver cessation
interventions because (1) physician time
is at a premium, (2) nurses are educated
in psychosocial and physiological
interventions, (3) nurses have access to
and immediate rapport with patients as
well as respect from physicians, (4)
nurses understand the patient’s medical
condition and can tailor the intervention
accordingly, and (5) nurses can read
charts, initiate medication orders, and
write nursing notes. These aspects
sustain the choice of intervention the
way it was approached in the program.
GTO 7. Evaluation of the Intervention
Program evaluation was done as an
integral part of the implementation
design, which means that in the pre-test,
post-test methodology, ratings of the
effectiveness of the program were feed-
backed during the intervention itself.
Additionally, though we will develop
this point a little further in GTO 10, a
certain index of evaluation might be
provided through the fact that the
intervention outcomes and
methodologies that were learnt by the
nurses were still used several months
after the implementation, being such an
index an interesting point to consider the
program in terms of evaluation.
Overall, it was a within (intern)
evaluation, although the article itself is
an evaluation of such evaluation (and it
does provide conclusive results), though
performed at different moment. This
“second order” evaluation, the proper
one of the paper, might be considered
“external”, following the GTO
questions.
Evaluation, in this case, affects
positively the implementation (nurses
knew their performance was being
tested, which would make them effort
more towards the patients), effectiveness
(this effort, accompanied by a well-
designed program impacts in its
appropriate working) and, continuity (as
already commented).
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Actual mathematical indexes used were
the nurse recruitment logs, which
showed that across both intervention and
control hospitals, 63.5 % of targeted
nurses and 47 non-targeted providers
returned 3-month follow-up surveys, for
a total of 1145 participants. Post-
intervention nurse survey response rates
were 62.0 % at intervention sites and
67.7 at control sites. Nurse surveys
showed that characteristics of the post-
intervention sample of nurses was
similar to the pre-intervention sample
with one exception (educational
differences). That is on one hand.
On the other hand, we have the formal
methodology of evaluation, what we
called in the previous paragraph the
second order or external evaluation of
the program. This was done following
the aspects of the RE-AIM project, as a
guide to plan, conduct, and report on
interventions that are implemented on a
large scale in real-world settings. In this
aspect, surveys and percentage ratings of
participation and smoking ceasing were,
also, employed. Indexes were reliable
and valid as the tools employed by the
RE-AIM ratings intend to be.
GTO 8. Results of the Intervention
Results of the intervention, as already
commented in the previous sections,
were largely positive after only 1 hour of
nurse training. The acceptance among
the personnel, the improvement of
attitudes, abilities and knowledge not
only from the workers of the three
hospitals intervened, but also allegedly
by the patients who received the benefits
of such a training are reflected in the
continuity of the program.
The intervention had high impact as
demonstrated by post- intervention
patients in the intervention sites
reporting receiving significantly more
handout materials. The results have
shown that inpatient cessation programs
delivered by nurses do have the potential
to reach a large number of captive
smokers, and this is one of the main
results.
I think one of our best measures for
evaluating the success and results of the
case is that over three quarters of
targeted nurses participated in the
Tobacco Tactics training on targeted
units with additional participation from
non-targeted units. The high satisfaction
with the training was likely discussed
among nurses and their managers
resulting in many nurses attending from
non-targeted units.
The main impact originated by the
program was the improvement of nurse
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qualifications and intervention in means actual improvements would focus
tobacco ceasing practices at primary more on obtaining diversity to increase
services of health attention. There were variability in order to being able to test
no explicit indirect effects as a the program in different settings and test
consequence of the application of the its, let’s say, “universal” validity.
program.

GTO 10. Continuity

GTO 9. Improvements
Prognostic of the activity of the program
As one of the main improvements, it is
is unnecessary as we already have the
proposed the extension of the
results of factual continuity, as stated
intervention to various types of intensive
previously in other GTO questions. The
care units, outpatient, emergency room,
nurse-delivered Tobacco Tactics
psychiatric, substance abuse, and
program remained sustainable 1 year
obstetric units (including expectant
after the researchers withdrew from the
fathers) speaks not only to the to the
settings, and longer term sustainability
quality of the program but also for the
has been verified. I believe this
need for training providers to conduct
implementation program has little issues
tobacco cessation interventions in
in maintaining its continuity, as material
hospital settings.
is very accessible and training is short
From the program analysis perspective, and highly replicable. It does not require
we could state that while this a large amount of resources or
“pragmatic” design is more feasible and capabilities, not in trainers, not in
allows for implementation in natural trainees, and its application is so
environments, there was a lack of eminently practical that its effectiveness
randomization, which could be is almost warranted from its beginning.
translated as internal validity problems. As long as nurses do not forget the other
Still, I believe nurse and patient sample duties in pro of what can be considered a
sizes in the other two control hospitals second order intervention (as we are
were large enough to allow clinically and speaking of inpatients that are already in
statistically meaningful comparisons hospital for a primary condition, prior
with the intervention hospitals, which this smoking cessation intervention).

Summary

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We find ourselves with a very neat intervention program, well designed, focused,
implemented and assessed, with an optimal use of resources, which have been minimised
to adequate standards of use that makes the overall performance an excellent example of
the way in which understanding the psychological workings of a certain community can
benefit in the creation of labours such as the present one. Results speak for themselves in
the maintenance and continuity of the program long after the activity has been developed,
evaluated and finished. The combination of good research on the community status,
neat and affordable design and accessibility of the treatment makes the Tobacco
Tactics intervention an example of a well implemented program.

References

Duffy, S. A., Ronis, D. L., Ewing, L. A., Waltje, A. H., Hall, S. V., Thomas, P. L., …
Landstrom, G. L. (2016). Implementation of the Tobacco Tactics intervention
versus usual care in Trinity Health community hospitals. Implementation Science,
11(1), 147. http://doi.org/10.1186/s13012-016-0511-6

Maya Jariego, I., García, M. & Santolaya, F. J. (2007). Estrategias de intervención

psicosocial. Casos prácticos. Madrid: Pirámide.

Quitting Smoking Intervention Program References

https://www.albertaquits.ca/learning/tobacco-intervention/tobacco-intervention

http://mdquit.org/cessation-programs/psychosocial-interventions

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022453/

i
http://re-aim.org

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