literature review paper – smoking cessation PICO

SOLUTION AT Australian Expert Writers

Literature Review-Educating Clinicians on A Smoking Cessation Tool (5 A’s model)
Introduction
Despite immense efforts and progress made to ensure a decrease un  smoking rates among US adults in the past fifty years, tobacco smoking continues to account for an estimated 500,000 deaths annually and up to 18% of the adult population still smoke (Satterfield et al., 2018).  The rates of smoking exceed 30% in high-risk populations such as those with substance and mental health disorders, uninsured and those with a low income. Besides, vulnerable populations bear the highest burden of tobacco-related illnesses. Most smokers have the urge cease smoking. An estimated 60% of smokers visited a healthcare provider in 2017. However, most of them never got cessation help nor are they assessed for readiness to quit (Satterfield et al., 2018).
Based on the recommendations provided by the USPHS (the United States Public Health Service), every healthcare provider should assess patients for their smoking status and the urge to quit and recommend the 5A’s model as the most effective.  There is evidence from studies conducted in different settings to demonstrate that some healthcare providers use the 5A’s model to assess patients for the urge to quit. However, some of them Ask and Advice patients to…

PICO:Will clinician education regarding an evidence based smoking cessation tool (5A’s model) improve rate of smoking cessation counseling with patients in the community.
Chatham University  
Doctor of Nursing Practice (DNP) Program
NUR702 Developing Evidence-based Practice
Assignment Guidelines Integrative Review of the Literature
_______________________________________________________________________________________

Students will complete a review of the research literature specific to the problem of interest in order to uncover possible interventions that can be utilized in evidence-based practice.  The submitted paper will include relevant research findings that are offered as an intervention to address the clinical problem identified in the first assignment. The student is to critically appraise the studies that are shared in the paper. In addition to identifying 3-5 strong studies that will serve as the evidence base for evidence based practice, the student will also share general study findings related to addressing the problem using alternative interventions. Following your literature review, the student should be able to be knowledgeable about what the studies have found with regards to addressing a clinical problem and be able to ultimately identify the intervention they plan to use. This paper will briefly address the clinical problem, but mainly focus on studies found in the research literature that intervene upon the problem. This paper is NOT about the project you will design in NUR 704, but rather on the intervention you find in the research literature. This assignment will be used to support Chapter 2 in the final written capstone document.

The basic outline for the integrative review of the literature is as follows. This scholarly written assignment is to be formatted following the APA (6th edition).
Introduction (5 points). This section should be a very succinct introduction of the clinical problem, the proposed intervention (which will be supported by this paper). You will need to share some background information to help the reader understand why the clinical issue must be addressed. The section should conclude with a statement that states “The purpose of this paper is to….”  Total length of this section is no more than two paragraphs.
*Note, this section is the first section of your paper which is preceded by a level one heading which is the same as the title of your paper.  Do not use “Introduction” as a level one header.
Literature Search Methods (Total 10 points) – This section should discuss two major areas of content:
Sampling Strategies (5 points) – you used to conduct the search process, such as the databases accessed, year restrictions used, types of studies you focused on, and key terms (PICO elements) used in the search. You need to justify or help the reader understand why you used these strategies (ex. data bases and key terms).  Utilize the search strategy matrix you have been using during your search to write this paragraph. Refer to this document in this section (“see Appendix A” or B…).
Inclusion/Exclusion Criteria (5 points) – you need to discuss the criteria you used when evaluating and deciding to utilize a piece of literature. For example, article needed to be “published within the last 5 years” or only certain “levels of evidence” would be accepted.

Literature Review Findings (Total 25 points) – this section is composed of two parts:
General Findings –

This section generally highlights all possible interventions found in the literature, but should not focus on your chosen intervention. That goes in the next section.  This is a broad list of possible interventions found in the literature supported by a brief description of a few of the studies. If there were a lot of interventions found, it is not expected that you describe all of them but a sampling of them. Remember, this is NOT where you are describing your chosen intervention. This should not include the intervention used in your PICO statement but others you have uncovered during your literature review. Be sure to carefully cite all the studies found. Briefly explain why you aren’t using any of these interventions. Add additional level headings as appropriate.
Chosen Intervention–
Now introduce/present the 3 to 6 studies that support the exact practice change intervention you are considering. Each study should be presented sharing a clear, thorough description of the study including the setting, the sample, the methodology used including the intervention and the study’s outcomes (*Note you must share actual statistical data to reflect the positive outcomes achieved as a result of using the intervention).  Utilize your Evidence Matrix you have been completing to write this section. Attach the Matrix in the Appendix. Add additional level headings as appropriate. Be sure to cite your studies. **Remember, there must be evidence to support a practice change initiative.  The evidence table-matrix must be submitted with the final version of the assignment as an appendix. There must be at least 3 to 6 pieces of evidence that strongly support your chosen intervention/project.
 
 
 
Discussion – (Total 15 points) – This section discusses three parts:
Limitations-Identify limitations of the literature review process – some examples could be you only located literature that seems dated by our standards, there was a lack of published empirical studies on the topic (offer a rationale for using non-empirical studies), there was a lack of studies in nursing but did locate studies in another disciplines, etc. Explain why you needed to expand your search to other disciplines. You cannot say there wasn’t any support for your chosen intervention or else you cannot use it!!
Conclusion of Findings– Briefly highlight your chosen intervention. How robust was the evidence? Why did you choose it?
Potential Practice Change– Considering the information you provided in section B above, describe a potential practice change you can design for your problem using this intervention –remember, this is just a lead off to what you will actually design in NUR 704

Conclusion (5 points) – a short summary of what was presented in the paper. Address “key take aways.” Do not introduce new information in the conclusion.
References
Appendix (Total 10 points)
Search Strategy Log– 5 points
Evidence Matrix– 5 points

Structure and Format of Scholarly Writing Assignment (Total 30 points)
Written in APA (6th edition) format (10 points)
Correct spelling, grammar, and punctuation (10 points)
Organization and presentation of content (10 points) – Be sure to use transitioning sentences when moving between sections of the paper. You need to help your reader follow your thinking.
This paper should be 12-15 pages (Not including cover page, references or appendix). Maximum pages:

Total Possible Points=100 Points (40% of final grade)
The final problem and research evidence supporting the selected intervention must be approved by course faculty in order to pass the course and move on to NUR704 (second capstone course).

Grading Criteria
Possible Points
Student Score
Introduction
 5
 
Methods = 10 total
–          Sampling Strategies = 5
–          Criteria used = 5

10
 
Findings = 25 total
–          General findings
–          Chosen intervention

25
 
Discussion = 15 total
–          Limitations
–          General conclusions
–          Potential project

15
 
Conclusion
5
 
Appendix

10
 
Written in APA format
10
 
Correct spelling, grammar, punctuation
10
 
Organization and presentation
10
 
Total = 100 points
100
 

Important Tips for Successful Writing
(not just for this paper but for all formal writing assignments):
 
As doctoral level students, please plan to pay close attention to: grammar, spelling, sentence structure, paragraph development, format, word usage, and style of writing. 
Mechanics:
*Your paper should have a title page and a reference page.
*You should also have page numbers and subject level headings. (use the level headings provided to you in this guideline!)
*All citations and the reference page should follow the APA Manual (6th edition) guidelines.
*The text should be 12 font, Times New Roman.
*Your paper should be double-spaced.
*There should be one inch margins.

Writing:
*Refer to yourself at the Project Implementer or Project Manager.
Whatever you use, plan to use this through all 8 chapters of your final capstone.
*Do NOT write any formal paper in this program in first person (I, me, my, our, we) unless specifically asked for as a personal reflection.  This paper is not a personal reflection and should be written very formally.
*A paragraph should have at least three sentences.  A paragraph leads off with a single idea (first sentence) and then the rest of the sentences in that paragraph support the main idea. A single paragraph should not contain multiple topics.
*New information (cited information) should not be introduced in the summary/conclusion.  This is a summary of the entire paper/section/chapter.
*There should be a brief paragraph (at least three sentences) under each level heading introducing the section.
*Try to avoid writing  “Results showed…. or do not show……”, but “Results indicate, suggest, demonstrate, report, etc.
*Never state “Investigators or studies conclude….” for there is always some bias in results (except in the strictest of lab environments). Investigators or studies may suggest, indicate or demonstrate.

Misc tips
*Faculty may allow drafts for certain major papers in the program. Not all courses allow for drafts. This is a courtesy and should be taken full advantage because the feedback you get on the draft will greatly improve your paper. However, this does not mean that additional drafts or re-writes will be accepted or that all papers in the program will be preceded by a draft submission.
*Drafts are not complete corrections of every aspect in your paper by the instructor.  Rather, it is expected the student will investigate further, then apply suggestions offered in their drafts throughout future writing revisions.
*Many faculty use MS Word “Track Changes” to provide feedback. Be sure to familiar yourself with this feature using the resource available in the course. When reviewing feedback in Track Changes, view the feedback showing “All Markup”, not “Simple Markup”.  Most importantly, REMOVE all track changes when submitting final papers by selecting “Accept all changes-Stop Tracking” and remove all faculty comments by right clicking on the comment and selecting delete. Some faculty will not accept assignments if Track Changes is visible on the paper.
*Save all work and papers from each course on a separate drive for future use. For papers that will eventually be chapters in your capstone, make the changes suggested by your course faculty RIGHT AWAY so they are ready to go when you get into NUR 799. Your capstone will be graded in NUR 799 so you will want it to be the best it can be.
*Please proofread carefully.

Evidence Table-Matrix for Appendix in Review of the Literature Paper
NUR 702 Evidence as the Basis for Practice Change
This evidence table-matrix is provided as a tool to assist students in tracking relevant articles that contain key studies found when conducting their literature review. The tool will assist students in recording key articles that are relevant to their evidence-based practice (EBP) change project, more importantly, reflecting evidence to support the “intervention” they identified. The tool should be used continuously as students search the literature. Once an article has been selected that clearly contains evidence to support the intervention and is being considered for inclusion in the final literature review, complete the following exercise:
List each article that contains relevant evidence in the table below.
Across from each article, identify the level of evidence and the “key data/evidence/outcomes/findings” associated with that article. Actual statistical data should be listed as shown in example below.
Identify what you have concluded from the data/evidence and the article’s overall findings.
Indicate how you will use the article and evidence when planning the practice change project in NUR 704.
Important note: The evidence table-matrix should only include articles and data/evidence that support the intervention. Remember, if there is little or no evidence published on how to improve practice specific to the problem, then another problem must be identified.  It is not possible to plan an EBP change project if little or no evidence exists.  Also, when planning the project in NUR 704, each part of the plan must be based on quality evidence.
If you have found a Systematic Review that has shared a lot of studies to support your intervention, please pull out 3-6 studies and describe those individual studies rather than the entire Systematic Review.  If you go to the Reference list in the Systematic Review journal article, you can find the references for the individual studies and then retrieve those individual studies.
Please note, your review of the literature will be an ongoing process, therefore we do not expect this to be an all-inclusive table, but a representation of the evidence you have found to date.   In addition, this evidence table-matrix will assist you in writing the findings section of the literature review (see guidelines for the Integrative Review of the Literature Assignment–section III).  This evidence table-matrix also needs to be submitted as an appendix with the final submission of the integrative review of the literature assignment. Students can add rows to the table as needed.

Article
Level of Evidence
 (I to VII)

Data/Evidence
Findings

Conclusion
Use of Evidence in EBP Project Plan
Author (XXXX) study on the topic of fall reduction in dementia patients in a long-term care facility
 
Level VI

Initiating hourly rounds during the hours of 4P-6A was shown to decrease resident falls by 50%, decrease LOS by 20% and increase patient satisfaction by 25%.
Hourly rounding between the hours of 4P and 6A was effective in decreasing falls, LOS and increasing satisfaction
Include hourly rounding between the hours of 4P and 6A in the fall prevention practice change.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Literature Search Strategy Log
This search log is provided as a tool to assist you in tracking how you are conducting your literature review. The tool will assist you in recording key words you are using, databases you are accessing etc. The tool should be used continuously as you search the literature.

Please note, your review of the literature will be an ongoing process, therefore we do not expect this to be an all-inclusive log, but a representation of the searches you have completed to date.  In addition, this tool/log will assist you in writing the “Methods” section of your final literature review (see guidelines for the Integrative Review of the Literature Assignment–section II).

As you conduct your literature review below are a few points to consider:
Are you using key words that are relevant, appropriate and comprehensive that relate to the clinical question/problem? Are the combinations of words appropriate?
Are you using a variety of databases? Are you using manual and electronic methods? Are the search limits justified?
Are you seeing redundancies in databases? How many studies were relevant to your problem and intervention? Are you finding higher levels of evidence (ex. Systematic reviews)? Do not eliminate studies where the full text article is not available. Request a copy of the article from the library. You will be missing out on a great finding otherwise!!
What rational or reasons are you using to include, eliminate, or narrow your selection?
Does your literature search encompass all aspects of your PICO?
__________________________________________________________________________________________________________
 
PICO question:  For healthcare providers in the Emergency Department, does a standardized handoff communication tool improve patient admission and efficiency to the appropriate inpatient nursing unit?

Database
Key Word
Searches

Limits
# of Citations
Found / Kept

Rationale for  Inclusion / Exclusion
 CINAHL (EBSCOhost)
Emergency department AND delays AND admissions
5-10 year period
25 found 3 kept
1 redundant; kept articles directly related to clinical question
 
 
 
 
 

Literature Review-Educating Clinicians on A Smoking Cessation Tool (5 A’s model)
Student’s Name
Institution of Affiliation
Course Name
Date

Introduction
Despite immense efforts and progress made to ensure a decrease un  smoking rates among US adults in the past fifty years, tobacco smoking continues to account for an estimated 500,000 deaths annually and up to 18% of the adult population still smoke (Satterfield et al., 2018).  The rates of smoking exceed 30% in high-risk populations such as those with substance and mental health disorders, uninsured and those with a low income. Besides, vulnerable populations bear the highest burden of tobacco-related illnesses. Most smokers have the urge cease smoking. An estimated 60% of smokers visited a healthcare provider in 2017. However, most of them never got cessation help nor are they assessed for readiness to quit (Satterfield et al., 2018).
Based on the recommendations provided by the USPHS (the United States Public Health Service), every healthcare provider should assess patients for their smoking status and the urge to quit and recommend the 5A’s model as the most effective.  There is evidence from studies conducted in different settings to demonstrate that some healthcare providers use the 5A’s model to assess patients for the urge to quit. However, some of them Ask and Advice patients to quit smoking, they do not assess for their readiness (40%-65%), assist them (39%-58%) nor arrange for follow-up (3%-12%)(Satterfield et al., 2018).
The assisting step, which aims at offering help on cessation and pharmacotherapy, increases the quitting chances by 40%. Besides, the arranging step where adjustments are made in treatment based on relapses has been linked with a 45% increase in chances to quit (Ockene et al., 2016).  However, limited time, inadequate knowledge, the attitude of healthcare providers, competing demands and lack of self-efficacy are proven to result in non-adherence to the 5A’s.
The training of healthcare providers and the use of electronic prompts have demonstrated some improvement in adhering to the 5A’s (Warren, et al., 2015). However, most studies do not have the appropriate rigor and this limits the ability to make final recommendations. Apart from saving the time of healthcare providers and improving the quality of interventions, the implementation and acceptance of the 5A’s is still a challenge which influences the behavior of healthcare providers (Malone et al., 2019). Besides, sustaining the adherence of healthcare providers who use it is a huge challenge and this results in less robust outcomes. Ideally, currently, existing evidence suggests that training healthcare providers on the 5A’s tool would improve their understanding and implementation of the tool in clinical practice.
Literature Search Method
Sampling Strategy
I conducted an initial search for literature in numerous electronic databases. In Cochrane scientific database, I used the keywords tobacco cessation, smoking cessation, clinician education, nurse’s education, 5A’s tool, and counseling. For an even more refined search outcome, I used the Boolean search operators ‘or’ and ‘and’. This search resulted in three articles. One article was excluded as it focused on educating clinicians about the CAGE questionnaire as an assessment tool for smoking cessation while the other article was withdrawn. The PubMed database search used the following keywords: counseling, tobacco cessation, smoking cessation, 5A’s tool, and nurse’s education. I activated the following filters when conducting the PubMed database search: RCTs, meta-analysis and systematic reviews published in English in the last 5 years. This search resulted in twenty articles. When ‘or’ and ‘and’ additional search phrases were used, the number of articles decreased to 10.
Besides, the search included the reference lists of all the relevant articles. A similar search strategy was used to get more articles from weekly PubMed updates. However, this search paid a lot of emphasis on non-experimental and experimental articles with improved counseling rates or smoking cessation as the primary outcome measures. The search outcome included systematic reviews that discussed training clinicians on the 5A’s, used 5A’s as an assessment tool for smoking cessation and how relevant they were to the PICOT question.
Inclusion/Exclusion Criteria
The overall search incorporated English peer-reviewed articles. The articles used either non-experimental designs or experimental designs such as RCTs, systematic reviews and meta-analysis. The search also incorporated articles with the intervention of educating clinicians or medical students to use the 5A’s model to improve rates of smoking cessation counseling or smoking cessation as the primary outcome measure. Therefore, the overall search excluded articles published after the past 5 years, articles published in other languages apart from English and articles whose interventions were not educating clinicians about the 5A’s smoking cessation tool.
Studies that discussed educating healthcare providers about other smoking cessation tools other than the 5A’s smoking cessation tool were also excluded. This resulted in six articles. Seven of twenty-three articles met the inclusion criteria. However, based on how the topic was specific, some of the seven articles did not address the PICOT. The articles found addressed the following issues: educating clinicians on cessation, counseling, and using the 5A’s model.
Literature Review Findings
General Findings
Nurse’s Role in Smoking Cessation
 For quite long, nurses have served as patient counselors and educators. Nurses have also promoted health in community and primary care settings. They spend a long time with patients during consultations and share information to improve patients’ knowledge and understanding of specific issues to promote individual health and increase patient satisfaction rates (Park et al., 2015).  Therefore, nurses are more active in giving patients lifestyle modifications and behavioral interventions as an integral aspect of their practice. Nichter et al. (2018) explains that, for nurses increase their effectiveness, they should engage in healthy decisions and behaviors such as quitting smoking. This also positions them as role models to patients they attend to in community and primary care settings. Nichter et al. (2018) further proposes the use of cessation policies to encourage the sharing of tasks and collaboration between nurses and other healthcare providers in efforts towards smoking cessation.
There were evident barriers that prevent  nurses from counseling patients on cessation and providing cessation services. Currently, between 20-45% of nurses in the US smoke. According to Ocean (2018), the fact that some nurses’ smoke deters them from providing cessation counseling services to patients. Another barrier is that the nursing education curriculum provides very little information and instructions on counseling skills to use when advising patients about cessation (Hasan et al., 2019). Instead, patients only receive advice on how smoking is harmful. Without the appropriate training, nurses will continue to lack the appropriate knowledge and self-efficacy to counsel patients about smoking cessation. Neither will they take part in behavioral interventions.
Another barrier according to Ganz et al., (2015) is that most nurses have restricted time and competing priorities. This prevents them from counseling patients about smoking cessation and assisting them to quit. He further explains that it is very little or no reimbursements for smoking cessation and this deters most nurses from giving cessation counseling and helping patients quit.
ICAN (The Indigenous Counseling and Nicotine) QUIT intervention
Smoking in pregnancy is a major contributor towards potential health gaps with numerous contributing factors at provider, systemic, individual and community levels. However, according to Gould et al., (2017), most healthcare providers lack confidence, skills, knowledge, and optimism to address smoking in pregnant women. ICAN QUIT is an intervention that was implemented by Gould et al., (2017) through the Behavior Change Wheel to develop webinars for training healthcare providers to provide culturally competent cessation care. This included cessation counseling and Nicotine Replacement Therapy. The intervention incorporated appealing cultural resources to indigenous gravid women who accounted for lower literacy levels. The intervention proved to be highly efficient in improving strategies to manage smoking cessation in pregnant women and educating healthcare providers on how to counsel patients on cessation and initiate cessation treatment to pregnant women.
Quit Tobacco International
Nichter et al. (2018) refer to Turkish healthcare system that has undergone major transformations over the years to improve service delivery and the quality of care. A major shift was the transformation to output and a performance-oriented system where there are changes in the remuneration of the services provided by nurses with hospital revenue tied directly to the quality and volume of services provided. It is essential to understand the extent that shifts in the health policy of Turkey have influenced efforts to quit smoking in community and clinical settings. Very few studies have scrutinized nurses’ roles in smoking cessation in Turkey. Besides, there is very minimal information about the implementation of cessation counseling in clinical practice. Nichter et al. (2018) refer to Quit Tobacco International as an effective program to train nurses about basic cessation counseling which they should integrate into routine practice. Turkish nurses are undergoing training to understand the significance of cessation by talking about how smoking worsens an already existing health issue and how households are endangered by secondhand smoke. This training adds on current research on ways that patients can be encouraged to quit.
Chosen Intervention-Educating Clinicians on Smoking Cessation Tools.
Malone et al., (2019) conducted a mixed-methods study whose purpose was to establish the acceptability and feasibility of an intervention change by nurses in managing tobacco dependence among inpatients. The researchers used qualitative methods in a pre and post-study design to administer questions on the use of tobacco in routine nursing care and when filling admission assessment forms. Among patients who were ready to quit smoking, the researchers provided NRT and cessation counseling. Other inpatients were referred to a telephone tobacco cessation-counseling program ‘Quitline’. Malone et al., (2019) found no improvement in the smoking status of inpatients (83%-90%).
The provision of nurse-led NRT increased from 0-34% with a subsequent increase in acceptance of NRT from 50%-64% and referrals to telephone tobacco cessation-counseling program ‘Quitline’ (0-4%) (Malone et al., 2019). Besides, three major themes emerged from this study: a therapeutic alliance between tobacco smoking patients who want to quit and nurses, the involvement of nursing leadership and educating nurses about smoking cessation tools. Generally, the study showed that educating nurses on smoking cessation, cessation tools and cessation interventions increased the ability to provide NRT to inpatients (Malone et al., 2019). However, educating nurses on smoking cessation tools increases patient support for those who are not ready to quit or be counseled.
Ganz et al. (2015) conducted a study whose aim was to explore the beliefs, attitudes, and practices of nurses on providing cessation services to patients. The participants were 707 nurses who completed online surveys. The results revealed how nurses believed in the effectiveness of evidence-based managements that should be used to manage patients with the urge to quit smoking. Nevertheless, the study revealed that most occupational health nurses acknowledged the lack of appropriate knowledge of smoking cessation tools, guidelines, and training. It was concluded that training nurses on smoking cessation tools, evidence-based interventions and guidelines would improve nursing practice (Ganz et al., 2015).  Besides, nursing leaders should ensure that policies at organizational level that relate to providing services on cessation promote the efforts of patients’ to quit.
Most organizations have implemented the use of 5A’s model as supported by evidence-based research for smoking cessation. In the study by Martínez et al., (2017), the researchers examined behavioral, individual, cognitive and managerial issues associated with the performance and use of the 5A’s assessment tool among Catalonia clinicians. Cross-sectional surveys were held among clinicians who were enrolled in an online training course on smoking cessation. For the first 3A’s: Ask, Advise and Assess, the standard deviation was moderate: 6.4, 7.1 and 6.3 respectively (Martínez et al., 2017). For the last 2A’s; Assist and Arrange, the standard deviation was low: 4.4 and 3.2 respectively. There was a high correlation between Arrange and Assist. Increased competency and positive experiences were associated positively with using 5A’s model and support from the organization.
According to Martínez et al. (2017), the most relevant way to increase nurses’ competency to use the 5A’s assessment tool and improve counseling on smoking cessation is through continuous training. Martínez et al. (2017) also found that clinicians did completely conduct the 5A’s assessment. He therefore recommended the training of nurses and availing guidelines on smoking cessation. The researchers also emphasize the need for organizational support during the implementation of the ‘Assist’ and ‘Arrange’ steps.
According to Ockene et al. (2016), clinicians should develop the required competencies for counseling about smoking cessation and tobacco dependence treatment early in nursing education. In an RCT study whose aim was to determine how a tobacco dependence treatment curriculum affected skills in smoking cessation counseling, Ockene et al. (2016)  examined ten medical schools in the US that were to receive education on traditional tobacco treatment and counseling. The participants who were medical students filled objective structured clinical examinations, pre and post surveys. The primary outcome measure in this study was skilled in tobacco cessation counseling and treatment using 5A’s model. The secondary outcome was self-reported skills by students on performing the 5A’s, smoking cessation and pharmacotherapy counseling (Ockene et al. 2016).
Even though the findings of this study were not significant statistically, they were clinically significant. Most students used the 5A’s model for tobacco counseling (mean of 8.7). Most items completed by the medical students were ‘Assist’ and ‘Arrange’ items where information on Quitline and other behavioral strategies was shared. Besides, medical students reported a high self-efficacy for counseling on pharmacotherapy, ‘Assist’ and ‘Arrange’ items. Ockene et al. (2016) concluded that medical and nursing schools in the US should incorporate a curriculum or lessons on tobacco treatment. This includes knowledge of smoking cessation, smoking cessation tools (5A’s model) and pharmacotherapy.
DISCUSSION
Literature review findings illustrate that educating clinicians about the smoking cessation assessment tools increases the rates of cessation counseling in community and primary healthcare settings. The findings also demonstrated that there are very limited studies on the methods used to educate clinicians on the 5A’s smoking cessation tool. There were also limited findings on what clinicians should expect after applying the 5A’s tool to counsel patients in communities and primary care settings.
Limitations
A major limitation of this literature review is that most of the studies used small sample sizes, different healthcare providers and even medical students. This, therefore, limits the ability to apply the findings to the general population. Besides, some of the articles had significant recall biases such that, other than using audio-recordings of conversations with primary care providers, the studies used patient-reported data of the 5A’s. In other studies, the staff was briefly trained about the 5A’s smoking cessation tool and compliance rates on cessation counseling were only done through follow-up SMS texts and telephone calls.
Conclusion of Findings
This study purposed to determine whether educating clinicians on the smoking cessation tool (5A’s model) could influence an increase in the rates of cessation counseling in communities and primary care settings.  5A’s model was noted as a significant smoking cessation tool. The studies supported educating clinicians on smoking cessation tools (5A’s) to increase the rates of cessation counseling in community counseling. It was also noted that different clinician training methods were vital to adhere to the 5A’s smoking cessation tool in practice. Therefore, nurses should utilize effective training plans to educate clinicians on smoking cessation tools. Other important findings were incorporating organizational leadership in training and formulating policies that increase adherence to the use of cessation assessment tools.
Potential Practice Change
The available studies on the study topic support that clinicians should be educated on   cessation assessment tools, particularly the 5A’s model. If most clinicians fail to receive the appropriate training, most patients with the urge to quit or those who have tried to quit can fail to receive the necessary support to achieve good outcomes. Lack of knowledge on the best smoking cessation tools does not only affect clinicians but also patients who seek assistance to quit smoking. This effect worsens when there is a lack of knowledge to differentiate between withdrawal symptoms, aversive abstinence syndrome and actual cessation symptoms. Educating clinicians is not only a nurse leadership role. Instead, organizational leadership in primary care institutions and community leaders can also be involved. Ongoing evaluation should be done at specific intervals to determine if clinicians comply with all the requirements of the 5A’s model and if patients receive the required support at all stages in the model.
CONCLUSION
Tobacco smoking is a vital issue of public health significance and a major risk factor for numerous malignancies and chronic illnesses.  Globally, an estimated 3 million people die annually of diseases related to tobacco smoking. By the year 2030, this figure is expected to increase to more than 10 million deaths every year.             The United States Public Health Service recommends the screening of all patients for their smoking status with cessation assistance.
Healthcare professionals play an integral role in efforts to decrease the prevalence of smoking by giving smoking cessation counseling, active involvement in the tobacco control debate and supporting smoking-cessation efforts at the community level.
The findings of this study focus on the essence of ensuring that clinicians are educated on smoking cessation tools(5A’s model) as it increases the chances of smoking cessation counseling which is linked to high smoking cessation scores and subsequent follow-up. It is recommended that further studies should focus on different education/training strategies that can be used to educate clinicians about smoking cessation tools.

 
References
Golechha M. (2016). Health Promotion Methods for Smoking Prevention and Cessation: A Comprehensive Review of Effectiveness and the Way Forward. International journal of preventive medicine, 7, 7. https://doi.org/10.4103/2008-7802.173797
Ganz, O., Fortuna, G., Weinsier, S., Campbell, K., Cantrell, J., & Furmanski, W. L. (2015). Exploring smoking cessation attitudes, beliefs, and practices in occupational health nursing. Workplace health & safety, 63(7), 288-296.
Gould, G. S., Bar-Zeev, Y., Bovill, M., Atkins, L., Gruppetta, M., Clarke, M. J., & Bonevski, B. (2017). Designing an implementation intervention with the Behaviour Change Wheel for health provider smoking cessation care for Australian Indigenous pregnant women. Implementation Science, 12(1), 114.
Hasan, S. I., Hairi, F. M., Tajuddin, N. A. A., & Nordin, A. S. A. (2019). Empowering healthcare providers through smoking cessation training in Malaysia: a pre-intervention and post-intervention evaluation on the improvement of knowledge, attitude, and self-efficacy. BMJ Open, 9(9), e030670.
Martínez, C., Castellano, Y., Andrés, A., Fu, M., Anton, L., Ballbe, M., & Feliu, A. (2017). Factors associated with the implementation of the 5A’s smoking cessation model. Tobacco induced diseases, 15(1), 41.
Malone, V., Ezard, N., Clifford, B., Middleton, S., McInnes, E., & Bonevski, B. (2019). A systems change intervention for nurse-led smoking cessation care in hospitals. Collegian, 26(2), 235-241.
Nichter, M., Çarkoğlu, A., Nichter, M., Özcan, Ş., & Uysal, M. A. (2018). Engaging nurses in smoking cessation: Challenges and opportunities in Turkey. Health Policy, 122(2), 192-197.
Ockene, J. K., Hayes, R. B., Churchill, L. C., Crawford, S. L., Jolicoeur, D. G., Murray, D. M., & Adams, M. (2016). Teaching medical students to help patients quit smoking: outcomes of a 10-school randomized controlled trial. Journal of general internal medicine, 31(2), 172-181.
Ocean, A. (2018). Implementing a Smoking Cessation Educational Module for Clinical Staff Members Who Care for Mentally Ill Outpatients.
Park, E. R., Gareen, I. F., Japuntich, S., Lennes, I., Hyland, K., DeMello, S., & Rigotti, N. A. (2015). Primary care provider-delivered smoking cessation interventions and smoking cessation among participants in the National Lung Screening Trial. JAMA internal medicine, 175(9), 1509-1516. DOI:10.1001/jamainternmed.2015.2391
Satterfield, J. M., Gregorich, S. E., Kalkhoran, S., Lum, P. J., Bloome, J., Alvarado, N., Muñoz, R. F., & Vijayaraghavan, M. (2018). Computer-Facilitated 5A’s for Smoking Cessation: A Randomized Trial of Technology to Promote Provider Adherence. American journal of preventive medicine, 55(1), 35–43. https://doi.org/10.1016/j.amepre.2018.04.009
Warren, G. W., Dibaj, S., Hutson, A., Cummings, K. M., Dresler, C., & Marshall, J. R. (2015). Identifying targeted strategies to improve smoking cessation support for cancer patients. Journal of Thoracic Oncology, 10(11), 1532-1537.

VII. APPENDIX
Search Strategy Log
PICOT: Does educating clinicians (P) about evidence-based smoking cessation tools (5A’s model) compared to not educating them(C) improve rates of smoking cessation counseling in community settings (O)?
Database
Key Word
Searches

Limits
# of Citations
Found / Kept

Rationale for  Inclusion / Exclusion
Cochrane
Tobacco cessation, smoking cessation, clinician education, 5A’s tool, nurses’ education, and counseling.
5 year period
3 found 2 kept
1 was redundant, 2 directly addressed the topic of study
PubMed
Tobacco cessation, smoking cessation, clinician education, 5A’s tool, nurses’ education, and counseling.
5 year period
20 found 6 kept
2 were redundant, 4 comprehensively addressed the study topic

Evidence Matrix Table
Article
Level of Evidence
(I to VII)

Data/Evidence
Findings

Conclusion
Use of Evidence in EBP Project Plan
Ganz, O., Fortuna, G., Weinsier, S., Campbell, K., Cantrell, J., & Furmanski, W. L. (2015). Exploring smoking cessation attitudes, beliefs, and practices in occupational health nursing. Workplace health & safety, 63(7), 288-296.
 
Level VI

Nurses can benefit from training about using smoking cessation tools, interventions and guidelines in clinical practice.
 Training nurses on smoking cessation tools, interventions and guidelines improves the rates of cessation counseling.
Train nurses about smoking cessation tools (5A’s), cessation interventions and guidelines
Malone, V., Ezard, N., Clifford, B., Middleton, S., McInnes, E., & Bonevski, B. (2019). A systems change intervention for nurse-led smoking cessation care in hospitals. Collegian, 26(2), 235-241.
Level VI
There was no significant improvement in the smoking status of inpatients (83% – 90%). There was immense improvement in nurse-initiated NRT (0% – 34%. NRT acceptance improved from 50% – 64% and referral to Quitline improved from 0%- 4%).
Educating nurses and nursing leadership on 5A’s cessation assessment tool improved rates of enrollment to cessation treatment and counseling.
Educate nurses on 5A’s cessation assessment tool and incorporate nursing leadership.
Martínez, C., Castellano, Y., Andrés, A., Fu, M., Anton, L., Ballbe, M., & Feliu, A. (2017). Factors associated with the implementation of the 5A’s smoking cessation model. Tobacco induced diseases, 15(1), 41.
Level IV
The first 3A’s had a moderate standard deviation (Ask: 6.4, Advise: 7.1 and Assess: 6.3). The last 2A’s had a low standard deviation (Assist: 4.4, Arrange: 3.2). Increasing nurses’ competency and having organizational support increased the likelihood to conduct a full assessment using the 5A’s model.
One way to improve nurses’ competency in using the 5A’s model is through training and full organizational support.
Train nurses about the 5A’s model and mobilize for organizational support during implementation in clinical practice.
Ockene, J. K., Hayes, R. B., Churchill, L. C., Crawford, S. L., Jolicoeur, D. G., Murray, D. M., & Adams, M. (2016). Teaching medical students to help patients quit smoking: outcomes of a 10-school randomized controlled trial. Journal of general internal medicine, 31(2), 172-181
Level I
The findings were not statistically significant but had clinical significance. Most MME students completed the cessation counseling behaviors than TE students. Incorporating
Tobacco cessation curriculum should be incorporated in the training of medical students. This includes training on cessation counseling, assessment tools, and smoking cessation treatments.
Training about smoking cessation interventions, counseling and tools should start early in medical/nursing schools to improve chances of implementation in clinical practice.

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