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Educational Methodologies |
Key words: tobacco cessation, smoking cessation, smokeless tobacco, tobacco use cessation, smoking/prevention and control, dental hygiene education, educational methodologies
Submitted for publication 08/11/06; accepted 02/21/07
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Abstract |
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 Top Abstract Indiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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The Journal of Dental Education recently published an article by Davis et al., which clearly outlined the obstacles faced by educators in providing sufficient tobacco cessation training to dental hygiene students.1 In that article, the authors identified external sources that encourage implementing tobacco cessation strategies within the curriculum. The article reports the U.S. Public Health Service has established intervention guidelines for tobacco cessation. Called the "5 As" (Ask, Advise, Assess, Assist, Arrange),2 the guidelines include activities to be performed by the health care provider with patients using tobacco. It has been reported that while dentists are active in asking if patients smoke or use tobacco, fewer than 20 percent actively help patients through the process of quitting.3,4 Dental hygienists fare no better than their employers. When asked why they failed to follow through in assisting patients to quit using tobacco, reasons cited include a lack of training and confidence, which prohibited them from consistently providing intervention strategies to their patients.5,6
To educators in dental hygiene programs, it is apparent there is a need for revision of current curricula to assist students (and subsequently future practitioners) in overcoming these barriers. In fact, studies report that educators, while aware of the need for change, had their own reasons for not making these changes in programs. They reported a lack of integration between didactic content and clinical practice and a failure to provide supportive intervention skills (such as interviewing, pharmacotherapy options, and instruction in dealing with relapses) as missing pieces within curricula.7 In addition, other studies of educators reported the lack of faculty time, student interest, current materials, and a perceived lack of faculty expertise as reasons for not fully integrating tobacco cessation strategies into practice.8,9
Over the years, there have been concerted efforts to encourage increasing tobacco cessation education within dental and dental hygiene curricula. The document Healthy People 2010 specifically addresses tobacco cessation interventions. In objective 3–10c, this document establishes for dental professionals the goal of increasing cessation interventions by 15 percent by the year 2010.10 The American Dental Education Association has a policy statement within Section V of the Health Promotion and Disease Prevention document that specifically states that "institutional and individual members are to . . . provide training in tobacco cessation."11 In addition, the American Dental Association (ADA) Accreditation Standards for Dental Hygiene Programs identify in the competency statements for dental hygiene programs that graduates "must be competent in providing the dental hygiene process of care which includes . . . risk assessment (i.e., tobacco . . .)."12 Dental hygienists have also been recognized by the ADA as appropriate team members to provide tobacco cessation interventions to patients. The ADA lists tobacco cessation counseling under Section II 3.3.2, Provision of Clinical Dental Hygiene Services and in the National Board Dental Hygiene Examination’s specifications.
The American Dental Hygienists’ Association (ADHA) has also contributed to the promotion of dental hygienists as tobacco cessation experts. It was reported in a December 2005 ADHA press release that the Smoking Cessation Initiative (SCI) was awarded a third-year grant from the Robert Wood Johnson Foundation (gift of approximately $150,000). This grant allows the ADHA to continue its dedication to oral and systemic health by the concerted efforts of registered dental hygienists. The ADHA explains that it is "proud to make such a positive impact on the oral and overall health of the public by encouraging dental hygienists to help smokers quit." The grant will help the ADHA offer additional educational materials to members of the association. The SCI is focused on increasing the number of hygienists who actively incorporate intervention strategies into clinical practice. The ADHA reports that the objective for the year is to "further establish dental hygienists as advocates of cessation intervention and to place dental hygiene on the frontline of smoking cessation intervention."13
To this end, dental educators at Indiana University School of Dentistry sought to investigate, develop, and implement means to overcome identified barriers of dental hygiene students and faculty in providing tobacco cessation interventions to the patients they serve and to report the results of student perceptions of the effectiveness in curricular changes in the dental hygiene program.
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Indiana University Nicotine Dependence Program |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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This program, which is being used today, is adapted from the Mayo Clinic model and uses multicomponent treatment options with the following features:
Prior to serving as tobacco cessation counselors, dental and dental hygiene faculty are taught to become expert nicotine cessation clinicians for IUSD by attending a five-day Mayo Clinic Nicotine Dependence Conference. These conferences are oriented towards health care professionals who are interested in incorporating effective nicotine dependence treatment into their practices and/or otherwise developing a service to meet the needs of tobacco-dependent patients. Faculty members who complete the conference have patients referred to them from the faculty and student body at IUSD. In addition, referrals from other health care professionals are common.
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Dental Hygiene Curriculum Prior to 2002 |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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Lecture materials provided by the in-house experts and based on the content identified above were given to both dental and dental hygiene students at IUSD. Within the prior curriculum for dental hygiene students, early in the fall semester of the second year, a dental hygiene faculty member skilled in teaching tobacco cessation strategies prepared the students for the tobacco cessation experiences by delivering three hours of lecture in two sessions. The curricular content of these presentations included:
After the didactic presentation and testing based on lecture and reading materials, in the old curriculum, dental hygiene students were instructed to begin screening all patients seen in the clinic for tobacco use. In the event that a patient using tobacco reported they were ready to set a "quit date," the student was instructed to refer the patient to the IUNDP. Once a student identified that a client used tobacco and made a referral to the program, the student was deemed "experienced" in tobacco cessation. There was no further requirement for students to document interactions with patients using tobacco. There also was no further follow-up provided for patients who reported an interest in setting a quit date except at subsequent dental hygiene visits, when patients were again screened for tobacco use. Again, while students were expected to counsel all future patients who use tobacco (advise them to quit and offer a referral to a tobacco cessation program), there was no documentation in place recording the number of experiences the students may or may not have had during their tenure at IUSD. Nor was there any mechanism in place to record numbers of patients who were referred to tobacco cessation programs or success rates of patients who tried to quit. Further, while students had received content material and had been tested over that material, students nonetheless reported feeling insecure in approaching and counseling patients in tobacco cessation strategies. (These feelings were documented on exit surveys completed by students for the dental hygiene program.)
Consequently, while in theory patients’ needs in the area of tobacco cessation had been met, it was questionable whether, in fact, information and advice had been received by the patient at a level that would support a decision to quit using tobacco. It was also difficult to determine whether any of these patients attempted or were successful in quitting since no follow-up was in place to document outcomes. Additionally, the experience did not actually measure competence of students in tobacco cessation strategies; rather, it was only a means to ensure that a student could identify a tobacco user and make a referral to a cessation program. Another concern was for students who hoped to practice in locations outside of the availability of the Indiana University Nicotine Dependence Program. This limited experience may have resulted in students having little idea of what to do with tobacco-dependent patients they would be seeing in more rural areas.
Due to the ineffectiveness of this approach in actually assisting patients to quit tobacco use and in development of skills in cessation strategies for students, faculty members sought to develop alternative methods to encourage development of skills that would improve students’ perceived self-efficacy.
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Dental Hygiene Curriculum Post-2002 |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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Methods |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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Forty-six dental hygiene students from the Indiana University School of Dentistry class of 2006 were required to complete a tobacco cessation experience by having a tobacco user complete a PAQ and participating in a counseling session with the tobacco cessation expert. Following the session, students were expected to make a presentation to the tobacco user. Prior to scheduling the experience, the students were required to complete a reading assignment,18 a three-hour lecture/discussion session with a tobacco cessation expert, and an examination over the materials.
Although any patient assigned to them from their clinical rotation could be selected, students were encouraged to choose a friend or family member as the person whom they hoped to assist in quitting tobacco. It was hypothesized that if there were personal stakes in who was selected for the assignment, students would be more engaged and committed to outcomes during and following the experience. In addition, it was hoped that this experience would translate into dedication to incorporating tobacco cessation strategies into their future practices. All forms of tobacco use were considered for this assignment. Students were given two options for completing the tobacco cessation experience.
Plan A was for traditional observation by hygiene faculty. This first method was to make a cessation presentation to a patient in clinic who used tobacco while being observed by a dental hygiene faculty member. The faculty member would determine whether or not the student made a successful presentation simply by observing the communications between the student and the patient. This option did not provide any additional content other than what has been described above through the lecture and reading materials. Students’ patient presentations and evaluation criteria were based on the "Ask Advise Assess Assist Arrange" strategies.2 If the student followed these guidelines and then referred the patient to the IUNDP, the experience was considered complete. The patient did not receive any materials other than a referral to the Indiana University Nicotine Dependence Program. (This option was offered in the pilot study due to uncertainty in the availability of meeting with all forty-six IUSD dental hygiene students for the second option due to faculty time constraints. Future classes did not have this option available, and all future students completed only Plan B described below.)
Plan B was for one-to-one training and evaluation with a cessation expert. This second option included distribution of assessment materials from the IU Nicotine Dependence Program (specifically, the questionnaire) to patients and then a required meeting with a tobacco cessation expert for one-toone training and analysis of the IUNDP PAQ prior to making the patient cessation presentation, which included customized recommendations. The rationale for offering this option was based on students’ perceived lack of knowledge and confidence in discussing tobacco cessation with patients.
Further, faculty members recognized that, before exploring effective ways to help a tobacco user to quit, one must understand the nature of the addictive process, how it operates in that specific individual, and how it affects both the person’s nicotine use and cessation attempts. Both clinician and patient need to identify those factors that have created nicotine dependency in that individual. Additionally, they must both confront and deal with the entire addictive process and co-create an individualized treatment modality that can be used over an extended period of time.
The Nicotine Dependence Program Patient Assessment Questionnaire (PAQ)
For the past fourteen years and in the current dental hygiene curriculum, the IUSD cessation team from the IUNDP has used an eleven-page, highly structured, confidential questionnaire that documents the social, psychological, and nicotine addiction aspects of each tobacco user. The questionnaire consists of the following elements:
A description of these elements can be located in the IUSD document A Smoking Cessation Program for the Dental Office.14 (Copies are available upon request from the corresponding author.) This questionnaire was provided to students, and they were given suggestions in helping their chosen tobacco user fill out the forms.
Development and Presentation of Treatment Plan
After the tobacco user (with student assistance) completed the assessment survey, students scheduled an appointment for a one-hour private training session with the tobacco cessation expert. Together, they analyzed the questionnaire page by page. A specific, step-by-step treatment plan, which included the use of nicotine replacement therapy (NRT) options, was developed while the student took detailed notes of this interaction for use in the upcoming patient presentation. Later, the student met with the patient individually and presented the personalized information. Students were encouraged to end the presentation session with their patients using words to the effect of "if you are considering quitting the use of tobacco at this time, I have given you some ideas to consider. However, the decision is yours." This strategy establishes ownership of the addiction to the patient and thus assists the student in motivating the patient to seriously consider cessation. In the event that the patient was ready to set a quit date, the student assisted the patient in this process and arranged for referrals to the IUNDP as appropriate. Information of the counseling session was documented in the chart if the person was a patient of record at IUSD.
At the conclusion of the one-to-one training session with the tobacco cessation expert, a form was signed by the expert and returned to the course director confirming participation by the student in the session. Since (for this option) students did not necessarily use a patient of record of the school, students were not required to make the presentation in the presence of dental hygiene faculty. In fact, many students made the presentation outside of the IUSD campus setting. In order for the assignment to be completed, following the presentation, students who chose this option completed a written report and reflection piece. This report described the details of the interaction with both the expert and the patient, identified the most helpful aspects of the training session including a self-assessment of confidence levels, a statement of whether or not they felt the exercise was a useful opportunity for the program, a description of how they might employ these strategies with other patients, and an educated guess regarding the patient’s likelihood of quitting as a result of the interaction.
Students were asked to complete a special honor code that stated the student did, in fact, make the presentation to the person selected. (IUSD and the dental hygiene program have adopted a Code of Professional Conduct,21 which all students are expected to understand and by which they are to abide. Severe penalties may result from breaching any honor code while in the program.)
While faculty recognized the risk of breaches in ethical conduct during this option, it was believed that the benefits students would receive in participating in this exercise with a person they cared about far outweighed the chance that a student would be unprofessional in carrying out the expectations for the assignment. However, there was risk that an unsupervised presentation may omit specific elements that an observing faculty member would likely recognize and be able to intervene or remediate. Nonetheless, due to the extent of detail required in the written report, the faculty believed that the assignment would be completed satisfactorily. Faculty also believed that this option allowed for a greater potential for meaningful learning due to the added personal connection with the selected tobacco user. Once fully engaged in this process, it was hoped that students could apply similar strategies for patients with whom they were not otherwise connected. While we recognized that this pilot study focuses more on qualitative rather than quantitative evidence, it was conducted with the intent of being a starting point for further quantitative research.
Following completion of the semester and after all tobacco cessation experiences for the class had been completed by either option, students were asked to voluntarily complete an anonymous survey related to the tobacco cessation curricula and their experiences in making the presentation (see Tables 1
, 2, and 3). There were no consequences for failing to complete the survey. The survey was administered online using CourseEval 3TM software (Academic Management Systems, Amhurst, NY), a web-based product that allows online anonymous evaluation and provides a means for analysis. No identifying mechanisms were available to researchers. Students were informed of the inclusion criteria for participation in the study and gave informed consent by completing the survey. Institutional Review Board (IRB) proceedings were completed and accepted by Indiana University-Purdue University at Indianapolis IRB (EX0604-10B).
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Results |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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In questions relating to the didactic component of the curriculum, most students (88 percent) agreed or strongly agreed that they were experienced enough to make a cessation presentation to a patient who used tobacco based on these materials alone (see Table 1
). Eighty-four percent of the students who had attended the session with the expert reported that the one-toone interaction was useful in learning more about cessation strategies and in helping patients to consider quitting tobacco. Eighty-three percent reported that the session helped to boost their confidence levels in making cessation presentations (see Table 2).
In questions relating to the future application of information from the one-to-one session with the tobacco cessation expert, the majority of students (83 percent) believed they would use the techniques with other patients. Eighty-six percent stated they would recommend this opportunity to future dental hygiene students for more in-depth study of tobacco cessation strategies. Interestingly, 51 percent of the students reported they believed that the patient selected for the exercise was likely or very likely to stop using tobacco. In fact, within the narrative comments segment of the survey, students reported three confirmed instances whereby persons selected for this exercise had in fact quit using tobacco (see Table 3).
Additional (optional) narrative comments revealed that students enjoyed the interaction with the expert and had, in fact, applied these strategies with other patients since the assignment. Several students reported that while the textbook provided "most of what you need to know," it was the one-to-one session that "added the most meaning" to learning cessation strategies. Some also commented that the individualized suggestions for their particular patient greatly impacted the success of specific patients quitting tobacco. In this pilot study, students reported three confirmed cases of patients quitting tobacco. One student commented that while specific recommendations were useful for one patient, having more general suggestions would have been helpful.
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Discussion |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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Future studies could include surveying students and employers after graduation to determine whether they include tobacco cessation as part of the dental hygiene services offered in practice and whether techniques learned during this experience are routinely employed. Other surveys could determine successful quit rates of patients who were counseled.
While the written reflection piece provided the course director with responses to specific questions from all students who participated, it is only assumed that all students did, in fact, complete the process as prescribed. One problem encountered during this process included lack of faculty supervision during the presentation. However, the personal relationship between most students and the tobacco user they counseled led the course director to believe in the integrity of the students in completing the assignment without breaches in professional conduct.
Future changes to the Indiana University School of Dentistry dental hygiene program include a mandatory one-to-one session with the tobacco cessation expert (as described in Option 2 above) as the only option available for completing the experience for all students. In addition, to accommodate everyone, the presentation of tobacco cessation strategies will occur earlier within the curriculum to allow sufficient time for all students to have the additional expert faculty interactions. Students will also record total numbers of all tobacco users seen during their tenure at IUSD and document conversations relating to cessation in the health record. Following the initial experience with the tobacco cessation expert and a loved one, the dental hygiene curriculum committee is investigating ways students may also be required to demonstrate competence in tobacco cessation counseling in the clinical setting under the supervision of a faculty member with a patient of record. Specific mechanisms are being developed to track progress of the tobacco user in quitting the addiction and to assess the effectiveness of cessation strategies offered by the students and experts.
Developing skills in allied health professionals to aid in tobacco cessation remains an important part of the climate of health promotion for the public. Academic administration supports such efforts. IUSD is part of the IUPUI campus in Indianapolis, Indiana, which initiated a new policy for a tobacco-free campus effective September 14, 2006. To date, only twenty-five colleges and universities have tobacco-free campuses nationwide.22
In January 2007, IUSD and the IU School of Medicine were awarded a grant for a Signature Center, which will be called the Tobacco Cessation and Biobehavioral Center and will be housed within IUSD. The opportunity to apply for this was made available to all IUPUI programs. A Signature Center has been defined as one that will engage in work that takes advantage of the urban location in Indianapolis and establishes partnerships with the local community and cultural organizations. The center will collaborate with other institutions in its work. The Tobacco Cessation and Biobehavioral Center will involve collaboration between the IU School of Medicine and the IU School of Dentistry. The dental hygiene program will also be involved in this new endeavor.
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Conclusion |
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TopAbstractIndiana university nicotine...Dental hygiene curriculum prior...Dental hygiene curriculum post...MethodsResultsDiscussionConclusionReferences |
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Footnotes |
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REFERENCES |
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