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Kalisch, B.J., Xie, B. & Ronis, D.L. (2013). Train-the-trainer
intervention to increase nursing teamwork and decrease missed
nursing care in acute are patient units. Nursing Research, 62(6),
405-413. doi: 10.1097/NNR.0b013e3182a7a15d
The feasibility of a train-the-trainer
approach to end of life care training in care
homes: an evaluation
Andrea Mayrhofer1*, Claire Goodman1, Nigel Smeeton1,
Melanie Handley1, Sarah Amador2 and Sue Davies1
Abstract
Background: The ABC End of Life Education Programme
trained approximately 3000 care home staff in End of Life
(EoL) care. An evaluation that compared this programme with
the Gold Standards Framework found that it
achieved equivalent outcomes at a lower cost with higher levels
of staff satisfaction. To consolidate this learning, a
facilitated peer education model that used the ABC materials
was piloted. The goal was to create a critical mass of
trained staff, mitigate the impact of staff turnover and embed
EoL care training within the organisations. The aim of
the study was to evaluate the feasibility of using a train the
trainer (TTT) model to support EoL care in care homes.
Methods: A mixed method design involved 18 care homes with
and without on-site nursing across the East of England.
Data collection included a review of care home residents’
characteristics and service use (n=274), decedents’ notes
n= 150), staff interviews (n=49), focus groups (n=3), audio

diaries (n= 28) and observations of workshops (n= 3).
Results: Seventeen care homes participated. At the end of the
TTT programme 28 trainers and 114 learners
(56 % of the targeted number of learners) had been trained
(median per home 6, range 0–13). Three care homes
achieved or exceeded the set target of training 12 learners.
Trainers ranged from senior care staff to support workers and
administrative staff. Results showed a positive association
between care home stability, in terms of leadership and staff
turnover, and uptake of the programme. Care home ownership,
type of care home, size of care home, previous training
in EoL care and resident characteristics were not associated
with programme completion. Working with facilitators was
important to trainers, but insufficient to compensate for
organisational turbulence. Variability of uptake was also linked
to
management support, programme fit with the trainers’ roles and
responsibilities and their opportunities to work with staff
on a daily basis.
Conclusion: When there is organisational stability, peer to peer
approaches to skills training in end of life care can, with
expert facilitation, cascade and sustain learning in care homes.
Keywords: End of life care, Training, Care homes, Programme
implementation
Background
Residents in care homes are in the last years of life and
often present with multiple health needs, cognitive impairment,
and particular palliative care needs due to
their advanced age [1]. The implementation of education
and training targeted at end of life (EoL) care is, therefore,
particularly important for those working in long
term care [2–4]. The challenge is how to equip and
sustain the workforce to provide generalist palliative care
in settings where the staff have limited access to specialist
services, many do not have a formal qualification,
and turnover of staff is high [5, 6].

In October 2012 NHS Health Education East of England
(formerly East of England Multi-professional Deanery)
commissioned a local specialist palliative care
service to develop the Train the Trainer (TTT) End of
Life Care Education Programme for care home staff.
This built on the success of the ABC End of Life
Education Programme that had trained approximately
3000 care home staff across the East of England in
* Correspondence: [email protected]
1Centre for Research in Primary and Community Care
(CRIPACC), University
of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK
Full list of author information is available at the end of the
article
© 2016 Mayrhofer et al. Open Access This article is distributed
under the terms of the Creative Commons Attribution 4.0
International License
(http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate
credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were
made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to
the data made available in this article, unless otherwise stated.
Mayrhofer et al. BMC Palliative Care (2016) 15:11
DOI 10.1186/s12904-016-0081-z
EoL care [7]. When the ABC programme was compared
with another EoL training framework (Gold
Standards Framework)[8] for care homes it achieved
equivalent outcomes in terms of impact on staff satisfaction,
confidence and competence, and in satisfaction
of next-of-kin [8]. The ABC programme was
preferred by participants, because trainees felt they
were personally supported by the visiting nurse specialists
in palliative care [9]. It was also considered to

be the more cost effective of the two schemes
reviewed [8] and reported a modest reduction in
death rates in hospital, unscheduled admissions and
bed days.
Building on the ABC programme, and working with
the same network of specialist palliative care services,
the Train the Trainer (TTT) project aimed to train two
‘trainers’ per care home, who in turn were to train six
‘learners’ each (n = 12 per care home). In order to become
a ‘trainer’ one had to have participated in the ABC
programme, which consisted of six EoL care training
modules, some input pertaining to learning and teaching
methods, and practice workshops with EoL care
educators/facilitators (EFEs). Trainers’ responsibilities
included the preparation of on-line and face-to-face
teaching sessions, the organisation and facilitation of
group discussions, and ideally offering learners bite-size
micro-teach sessions in daily practice. Full teaching
sessions were observed and evaluated by End of Life Care
Educators/Facilitators (EFEs). The EFEs were employed by
a range of organisations and held various clinical and
education roles including palliative link nurse, palliative
care nurse, practice-development nurses for care
homes, EoL care specialist and EoL educator. The
configuration that underpins the TTT model process
is depicted in Fig. 1.
The goal of the TTT pilot project was to consolidate
the success of the ABC EoL care programme, increase
the capacity of the care home workforce to provide EoL
care, and develop a model that could sustain training in
and provision of EoL care in care homes. The pilot ran
for nine months (Oct 2012–June 2013). The research
questions focused on what supported or hindered the
uptake of the programme. Number of learners trained
was used as a proxy measure by which to judge the TTT
model’s effectiveness in embedding and extending the

knowledge and practice of EoL care across care homes.
Methods
Eighteen care homes across three counties in the East of
England were recruited to the project. Thirty six care
home staff, who had completed ABC training, were selected
to be ‘trainers’ in EoL care. Recruitment of individual
care homes was based on criteria such as their
endorsement of the programme, geographical fit with
existing palliative care services, their previous engagement
with ABC EoL care training and identification of
staff who had completed ABC training and could take
on the role of trainer. As the evaluation of the TTT
training model was commissioned after the programme
had been implemented a before-after study design was
not possible.
Data collection
A mixed method design using qualitative and quantitative
data was used. Quantitative data consisted of Service
Use Logs and data collected using modified InterRAI
forms [10] from a 30 % randomly selected sample of
residents (n = 274) in participating care homes. These
data were used to establish a baseline of resident characteristics
and care requirements, and to estimate resource
use such as visits from primary care services and admission
to hospital. Resident Service Use data were collected
for three months from April to June 2013. The
study also reviewed care notes of residents who had died
(n = 150) post intervention, between October 2012 and
July 2013, to establish if previously observed findings
from the ABC evaluation of advance care planning
(ACP), documentation of palliative care, symptom management
and place of death were sustained [8, 9].
Findings from data collected via care notes have been reported
elsewhere [9].
To understand the implementation process of the
TTT model semi-structured face to face interviews

(n = 39) were conducted (Table 1), and focus groups
(n = 3) were held with trainers, EFEs, a project lead
and care home managers.
Trainers were also given audio diaries to record reflections
and experiences arising from their role, but staff
found these diaries cumbersome to use. The yield of
Fig. 1 TTT Team configuration between EFEs, trainers and
learners
Mayrhofer et al. BMC Palliative Care (2016) 15:11 Page 2 of 8
data was negligible. Data collection took place from
October 2012 until the end of July 2013. Participating
care homes granted permission to collect audit
data, and written consent was obtained from all
interviewees.
Data analysis
Quantitative variables were summarised by medians,
ranges and percentages. The number of learners
trained in each care home was compared by type of
ownership (for profit organisation versus not for
profit organisation), type of care home (residential
versus on-site nursing), size of the care home (less
than 60 versus 60 or more residents), and previous
and/or additional EoL care training (yes versus no),
using the Mann–Whitney U test. Statistical analyses
were performed using SPSS [11].
Qualitative data collected in interviews were recorded,
transcribed, anonymised and analysed using QSR NVivo
Version 10 [12]. Qualitative data analysis involved
crosssectional
and categorical indexing across care homes to
enable comparisons. Three researchers were involved in
the analysis of data. The study was approved by the
National Institute for Social Care and Health Research
(REC 12/WA/0384). Social Care Research Governance
Approval was obtained from Local Authorities (LAs).
Results

Three of the 18 eligible care homes left the programme
soon after it commenced. In two care homes staff were
no longer available to attend the training workshops and
in the other the reasons were unknown. Two further
care homes were recruited as replacements, which resulted
in a total of 17 participating care homes. Of 34
trainers (two per care home) 28 completed the three
skills training workshops to support their trainer role.
All trainers had completed the ABC training and held a
variety of roles, ranging in seniority from General
Manager to Support Worker, including Care Home
Trainers who held responsibilities for all mandatory
training, but were not directly involved in caring for
residents (Table 2).
Learners recruited were care home staff with similarly
varying levels of seniority. At the end of the TTT project
114 learners had been trained (median per home 6,
range 0–13). Three care homes achieved or exceeded
the set target of training 12 learners. Two care homes
had not trained any learners at the end of the pilot.
This variability was investigated in relation to care
home and resident characteristics to see if the uptake
of the programme might have been linked to factors
such as (for care homes) how a care home was
funded, on site nursing provision, size of care home,
and how many staff had already received EoL care
training, and (for residents) the presence of individuals
with more complex health care needs or shorter
life expectancies.
Care home characteristics
Table 3 reflects type of care home, type of ownership,
and additional training by county.
More learners were trained in care homes owned by for
profit organisations (median = 7.5) than in care homes
owned by non-profit organisations (median = 5), but there
was no statistical evidence for a difference (p = 0.475,

Table 1 Number of interviewees per care home
Study site Trainers Learning facilitators (EFEs) Managers Total
S1 10 4 1 15
S2 11 4 0 15
S3 6 2 1 9
Total 27 10 2 39
Table 2 Roles of trainers by site
Study site Role of trainer 1 Role of trainer 2
S1 Trainer in Care Home Carer
S1 General Manager Carer
S1 Carer Care Team/Unit Manager
S1 Nurse Carer
S1 Clinical Manager Receptionist
S1 Carer Care Team/Unit Manager
S2 Care Team/Unit Manager Only 1 trainer
S2 Deputy Manager Carer
S2 Deputy Manager Care Team/Unit Manager
S2 Care Team/Unit Manager Carer
S2 Care Team/Unit Manager Carer
S2 Care Team/Unit Manager Night Unit Manager
S3 Trainer in Care Home Only 1 trainer
S3 Carer Only 1 trainer
S3 Nurse Nurse
S3 Trainer in Care Home Only 1 trainer
S3 General Manager Deputy Manager
Table 3 Type of care home, type of ownership, and additional
training by site
Site 1
(n = 6)
Site 2
(n = 6)
Site 3
(n = 5)
Care home residential 2 5 2
Care home with on-site nursing 4 1 3
Care home ‘for profit’ 6 0 4

Care home ‘not for profit’ 0 6 1
Additional EoL Care training (Gold Standards
Framework) completed or in progress
5 1 1
Mann–Whitney U test). The comparisons of the median
number of learners by type of care home (residential = 7.5,
nursing = 5.0: p = 0.423), size of care home (less than 60
residents = 7.5, 60 or more = 6.0: p = 0.888), and previous
or additional EoL care training in some care homes
(yes = 9.0, no = 5.5: p = 0.475) were also not statistically
significant.
Resident characteristics and resource use
Table 4 presents summary information on the residents
and their use of health care resources. The
number of learners trained in each care home could
have been influenced by differences in the resident
population of participating care homes and the services
received. For example, residents in some care
homes might have needed more support from visiting
health care professionals than residents in other care
homes or been identified as approaching the end of
life. However, the sample of 274 residents fitted the
national profile of care home residents in terms of
gender, cognitive ability, co-morbidities and function
as indicated in the literature [13, 14]. Literature does
not report any association of these factors with care
home staff engagement. Likewise, based on the qualitative
data in this study there was nothing to suggest
that residents’ characteristics or care needs influenced
whether a care home was more or less likely to engage
with the programme.
Factors influencing programme uptake
As discussed in the following section, the qualitative
data suggested that the variation in uptake was attributable
to three key contextual factors. These were the

role and responsibilities of trainers within the care
home, the uptake of EFE facilitation by the care
home, and the stability of the care home in terms of
leadership and staff.
Trainers’ professional roles and responsibilities
As indicated in Table 2, trainers’ professional roles varied
greatly, and this determined their opportunities to spend
time with learners during programme implementation.
Where teaching could be integrated with patterns of
working there was a greater likelihood of staff engagement
and discussion. For example, the teaching impact seemed
greater when a ‘trainer’ and a ‘learner’ worked on the same
unit and had opportunities to discuss the application of
theory to ‘real life’ situations. As expressed by a trainer:
“…if we know that someone is very near EoL we discuss
every aspect i.e. what we are going to do, what the care
plans say, what they [the residents] need, do they need
mouth care, what’s working for them, what pain relief
they are on… so we do a catch-up session and pre-plan
what we are going to do in relation to all the topics we
have covered” [Trainer, experienced carer, T01011].
Due to staff shifts it was often difficult to get six individuals
together for group work at the same time.
Trainers were encouraged by EFEs to adapt their support
of learners to reflect the preferences of individuals
and the working patterns of the care homes. This required
a level of flexibility and autonomy that was not
always possible because of the trainer’s role and other
commitments in the care home.
The ability to incorporate the trainer’s role into the
existing work schedule also had an impact on the uptake
of the TTT programme. When trainers held managerial
posts, this often meant that they had to create time to
carry out training within the specified timeframe, as it
was difficult to use routine encounters with staff and
residents as opportunities for learning and review. As

expressed by one of the managers who acted as trainer:
“This is extra to my job and time consuming”
[Trainer T01051SA].
This was also commented on by an EFE (training facilitator,
palliative care specialist) who concluded:
“…if I were to choose a care home [to participate in a
TTT EoL care education and training intervention] I
would be thinking very carefully about the manager
and the person who is going to be the trainer [in
relation to] what their other commitments are. It has
been very difficult to work with a trainer who is
managing a unit and has numerous other
responsibilities going on. You need to make sure you
have someone with passion [for EoL care] and
dedicated [ring-fenced] time to become involved in
training learners” [E0205].
In addition, not all learners were equally ready to receive
training at a particular level. For example, some
less experienced care staff found it difficult to watch
emotionally challenging content about death and dying
Table 4 Resident characteristics and resource use
Age at admission (years) median (range) 83 (38–99)
Female (%) 189/254 (74.4)
Diagnosis of dementia (%) 166/252 (65.9)
Condition reaching end-stage (%) 34/250 (13.6)
Advance Care Planning in place (%) 116/225 (51.6)
No admission to hospital (%) 227/238 (95.4)
Total GP visits, median (range) 1 (0–10)
Palliative care visit (%) 3/268 (1.1)
on DVDs on their own. They preferred group work and
discussions that could offer immediate debriefing. As
stated by a trainer, the ability to be present during
learning helped to address emotional reactions to the
training:
“…some emotional issues were dealt with during

training (in relation to talking about death); this was
an opportunity to discuss how they could/would best
support each other…” [T01011].
Not only trainers in relation to learners, but also Educators/
Facilitators (EFEs) in relation to trainers were
aware of this critical part of EoL care training. As one
palliative care specialist emphasised:
“An EFE role needs to be in place for mentorship
debrief, support, and on-going training …” [E0207].
This was also a critical part of post-training support
until staff had formed their own support groups within
care homes.
Uptake of EFE facilitation by care homes
The TTT programme did not specify how EFE facilitators
should work with care homes. Care homes’
different uptake of facilitator training support is
shown in Table 5.
Significantly more learners were trained in stable care
homes (median = 10.5) than in those that were not stable
(median = 4.0) (p = 0.001, Mann–Whitney U test).
http://web.a.ebscohost.com.ezp.waldenulibrary.org/ehost/pdfvie
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Sarna, L. P., Bialous, S. A., Kraliková, E., Kmetova, A.,
Felbrová, V., Kulovaná, S., & ... Brook, J. K. (2014). Impact of
a smoking cessation educational program on nurses'
interventions. Journal of Nursing Scholarship, 46(5), 314-321.
doi:10.1111/jnu.12086
CLINICAL SCHOLARSHIP
Impact of a Smoking Cessation Educational Program on Nurses’
Interventions
Linda P. Sarna, RN, PhD, FAAN1, Stella Aguinaga Bialous,
RN, DrPH, FAAN2, Eva Kralikova´ , MD, PhD3,
Alexandra Kmetova, MD4, Vladislava Felbrova´ , RN5,
Stanislava Kulovana´ , RN6, Katerina Mala´ , RN7,

Eva Roubickova´ , RN8, Marjorie J. Wells, RN, PhD9, & Jenny
K. Brook, MS10
1 Gamma Tau Chapter, Professor and Lulu Wolf Hassenplug
Endowed Chair, School of Nursing, University of California,
Los Angeles, CA and
2 President, Tobacco Policy International, San Francisco, CA,
USA
3 Associate Professor, Institute of Hygiene and Epidemiology,
First Faculty of Medicine, Charles University in Prague and the
General University Hospital
& Centre for Tobacco-Dependent of the Third Medical
Department, First Faculty of Medicine, Charles University in
Prague and the General University
Hospital, Czech Republic
4 Institute of Hygiene and Epidemiology, First Faculty of
Medicine, Charles University in Prague and the General
University Hospital & Centre for
Tobacco-Dependent of the Third Medical Department, Czech
Republic
5 Centre for Tobacco-Dependent of the Third Medical
6 Centre for Tobacco-Dependent of the Third Medical
7Military University Hospital, First Faculty of Medicine,
Charles University in Prague, Czech Republic
8 Faculty Hospital Kralovske Vinohrady, Clinic of Radiotherapy
& Oncology, Prague, Czech Republic
9 Psi Chapter-at-Large, Project Director, Tobacco Free Nurses,
School of Nursing, University of California, Los Angeles, CA,
USA
10 Statistician, David Geffen School of Medicine, University of
California, Los Angeles, CA, USA

Key words
Smoking, nurses, intervention, tobacco, Eastern
Europe, Czech Republic
Correspondence
Dr. Linda Sarna, UCLA School of Nursing, 700
Tiverton Avenue, Los Angeles, CA 90095-6918.
E-mail: [email protected]
Accepted: March 1, 2014
doi: 10.1111/jnu.12086
Abstract
Purpose: To evaluate a brief educational program about smoking
cessation
on the frequency of nurses’ interventions with smokers, and
impact of nurses’
smoking status on outcomes.
Design: Prospective, single group design with prestudy and 3
months poststudy
data.
Methods: Nurses in the Czech Republic attended hospital-based
1-hr educational
programs about helping smokers quit. They completed surveys
about
the frequency (i.e., always, usually, sometimes, rarely, never) of
their smoking
cessation interventions with patients using the five A’s
framework (i.e.,
ask, advise, assess, assist, arrange), and their attitudes prior to
and 3 months
after the course. Demographic data included smoking status.
Findings: Among the 98 nurses with prestudy and post-study
data, all were
female, mean age was 43 years, 33% were current smokers, and
64% worked
in a medical or surgical or oncology settings. At 3 months,
compared to baseline,
significantly (p < .05) more nurses assessed patients’ interest in

quitting,
assisted with quit attempts, and recommended the use of the
quitline for cessation.
At 3 months after the program, nurses who smoked were less
likely to
ask about smoking status (odds ratio [OR] = 4.24, 95%
confidence interval
[CI; 1.71, 10.53]), advise smokers to quit (OR = 3.03, 95% CI
[1.24,7.45]),
and refer patients to a quitline (OR = 2.92, 95% CI [0.99, 8.63])
compared to
nonsmokers, despite no differences in delivery of interventions
at baseline.
Conclusions: Three months after attendance at an educational
program focused
on the nurses’ role in supporting smoking cessation efforts,
more nurses
engaged in interventions to help smokers quit. However, the
program was less
effective for nurses who smoked.
Clinical Relevance: This program demonstrated promise in
building capacity
among Czech nurses to assist with smoking cessation, but
nurses’ smoking
poses a challenge.
314 Journal of Nursing Scholarship, 2014; 46:5, 314–321.
C
2014 Sigma Theta Tau International
Sarna et al. Nurses and Smoking Sessation
The World Health Organization Framework Convention
on Tobacco Control (WHO FCTC), the first global health
treaty, focuses on reducing the health consequences of
tobacco use worldwide (WHO, 2013). Article 14 of the
treaty addresses the need for treatment of tobacco dependence
and recommends capacity building of all healthcare
professionals to meet this need (WHO, 2013). In order

for the goals of the WHO FCTC to be realized, nurses, the
largest group of healthcare professionals worldwide, need
to be educated about tobacco dependence treatment.
Similar to statistics about preventable death worldwide,
tobacco use is the main cause of preventable disease
and death in the Czech Republic. Approximately 16,000
deaths a year are attributed to tobacco (Peto, Lopez,
Boreham, & Thun, 2012); 36.9% of the population ages
15 to 64 years use tobacco (41.3% of men and 32.3%
of women), and 24.5% of the population over the age
of 15 years are daily smokers (WHO, 2013). This study
describes the impact of efforts to educate nurses in the
Czech Republic about implementing smoking cessation
interventions in clinical practice using a train-the-trainer
approach.
Background
Relatively few of the over 1 billion smokers worldwide
receive evidence-based assistance with quitting (WHO,
2013). The majority of smokers in the Czech Republic
(60%) express a desire to quit, but few healthcare
providers are adequately prepared to assist (Sovinova,
2013; Sovinova, Sadilek, & Csemy, 2012). Involving
the over 100,000 Czech nurses (Czech Nurses Association,
2013) in delivering smoking cessation interventions
could accelerate national efforts to address
this major health risk. The importance of the role of
nurses in addressing tobacco dependence to reduce
noncommunicable
diseases is supported by policy statements
from the 2012 WHO Global Forum for Government
Chief Nursing and Midwifery Officers and the
fourth triad meeting of the International Council of
Nurses, WHO, and the International Confederation of
Midwives (WHO, 2012). Nursing intervention to help
smokers quit can be effective. A review of 49 randomized
trials (Rice, Hartmann-Boyce, & Stead, 2013)

found that smokers who receive even minimal intervention
from nurses are more likely to quit smoking
than those who receive no assistance (relative risk [RR]
1.29, 95% confidence interval [CI] 1.20, 1.39). Similar
to the United States (Fiore et al., 2008), a guideline for
addressing tobacco dependence treatment in the Czech
Republic recommends a five A’s approach (i.e., asking
about a patient’s smoking status, advising smokers to
quit, assessing interest in quitting, assisting with cessation,
arranging follow-up) for smoking cessation interventions
utilizing social support and pharmacotherapy
(Kr´ al´ıkov´a et al., 2005).
Additionally, Czech nurses have a guideline supporting
their role and responsibilities in smoking cessation
(Mala´ , Felbrova´ , Kulovana´ , Kra´ l´ıkova´ , & Sˇ
teˇpa´nkova´ ,
2009). Nurses are involved in interventions at the 40
cessation centers in the country (www.slzt.cz/centralecby),
a website is available to support quit efforts
(www.stop-koureni.cz, www.odvykanikoureni.cz), and
smokers have access to a national telephone quitline
(paying half-tariff) that provides counseling and support
during quit attempts. Nonetheless, support for smoking
cessation is still unusual in hospital settings, and nurses
are rarely involved, even in providing a brief intervention
and referring smokers to the quitline.
Over 70% of third-year nursing students in the Czech
Republic believed that health professionals have a role in
providing cessation intervention, but only 7.4% received
training in nursing school (Warren, Sinha, Lee, Lea, &
Jones, 2009). Healthcare providers who receive training
about tobacco cessation are more likely to intervene with
patients who smoke than those who do not. A metaanalysis
of eight studies confirmed that educational programs
for healthcare professionals had a positive impact
on patients’ quitting as assessed by 7-day point prevalence

and continuous abstinence (odds ratio [OR] = 1.60,
95% CI [1.26, 2.03]; Hartmann-Boyce, Stead, Cahill,
& Lancaster, 2013). The majority of these studies were
conducted in the United States, with three in Europe
(Scotland, United Kingdom, and Germany), and none in
Eastern Europe. None were conducted in hospital-based
settings. The analysis did not consider the impact of the
healthcare providers’ smoking status on outcomes.
A review of 17 randomized trials (three studies
included nurses but none focused solely on nurses) evaluating
training of health professionals in smoking cessation
on patient smoking outcomes at least 6 months after
intervention found that those who received education
were significantly more likely to intervene with smokers
(Carson et al., 2012). Several other studies provide
a foundation for educational programs to foster capacity
building with nurses. After hospital-based nurses’ receipt
of a 1-hr educational session based on the five A’s, more
patients who smoked reported receiving an intervention
and quitting 30 days after discharge (Vick, Duffy, Ewing,
Rugen, & Zak, 2012). A study targeting hospital-based
nurses (Matten et al., 2011) using a 3-hr course based
on the Rx for ChangeC program (Corelli et al., 2005)
reported improvement in attitudes, knowledge, cessation
counseling, and referrals up to 1 year after the program.
Nurse-initiated interventions with patients who smoked
and received care in an emergency room increased
Journal of Nursing Scholarship, 2014; 46:5, 314–321. 315
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Nurses and Smoking Sessation Sarna et al.
after an educational program involving 20-min face-toface
training and a 45-min online tutorial focused on brief
interventions (Katz et al., 2012).
Smoking among nurses is a barrier to delivery of
smoking cessation interventions (WHO, 2012). Smoking

among nurses varies worldwide (Smith, 2007), and it is
estimated that 40% of female nurses in the Czech Republic
smoke, a prevalence that is higher than the female
population (E. Kr ´ al´ıkov´ a, personal communication, June
23, 2011, regarding unpublished data from Kr´ al´ıkov´ a,
Kmetova, & Rames). The prevalence of smoking among
nursing students in the Czech Republic is 33.2%, similar
to rates in the region (e.g., Lithuania, 36.6%; Slovakia,
41.8%), and is a serious concern that must be addressed
as part of capacity-building efforts to address patients’
smoking cessation needs (Warren et al., 2009). Smoking
among nurses has been associated with more negative
attitudes and decreased involvement in smoking cessation
(Lenz, 2008). However, there areminimal data about
the impact of healthcare providers’ smoking on the outcomes
of educational programs on tobacco dependence
treatment.
Purpose
The aim of this study was to evaluate a brief hospitalbased
educational program focused on increasing nurses’
delivery of smoking cessation interventions according to
the five A’s and referral to a quitline, and promoting positive
attitudes about their involvement in smoking cessation.
We also examined the impact of the nurses’ smoking
status on program outcomes.
Methods
Design
A prospective design was used to assess changes in selfreported
frequency of nursing interventions to support
patients’ quit efforts in their nursing practice, prestudy
and 3 months after a brief educational program. The
study was approved by the institutional review board
of the principal investigator’s institution and the Charles
Hospital in Prague, which served as the ethics approval
body for all participating hospitals in the country.
Participants and Recruitment

Participants in this study included a convenience sample
of nurses from the Czech Republic who attended 1 of
10 educational programs about brief smoking cessation
interventions for hospitalized smokers. Nurses at each
hospital were invited to attend the educational program
and were recruited to participate in this study by the
nurse faculty member who had received special education
through a train-the-trainer program. Attending the
educational program was not contingent on participation
in the study, which was voluntary.
Measures
A survey administered before and after the educational
intervention, which included items based on a previously
developed and validated questionnaire, “Helping
Smokers Quit” (Sarna, Bialous, Ong, Wells, & Kotlerman,
2012a), was used to assess nursing interventions in
smoking cessation. Native speakers translated the Czech
Republic Helping Smokers Quit (CR-HSQ) survey. Reliability
was reestablished by test-retest (93% of the K values
were in the acceptable range, i.e., >.7). A nine-item
subscale evaluated nurses’ frequency (“always, usually,
sometimes, rarely, or never”) of self-reported delivery of
smoking cessation interventions using the five A’s, plus
items about recommending use of a telephone quitline
for cessation, recommending tobacco cessation medications,
reviewing barriers to quitting for patients unwilling
to make a quit attempt, and recommending a smokefree
home. A three-item subscale assessed attitudes about
nurses’ smoking, involvement in helping patients stop
smoking, and need for additional skills or training (rated
on a 5-point scale from strongly agree to strongly disagree).
A 13-item subscale evaluated attitudes and confidence in
counseling patients to quit smoking (responses on a 5-
point scale ranged from strongly disagree to strongly agree),
and a six-item subscale evaluated level of counseling
proficiency

(responses on a 5-point scale ranged from poor
to excellent) (Corelli et al., 2005). Additional items asked
about nurses’ sex, age, and smoking status. Nurses were
asked if they ever smoked 100 or more cigarettes in their
lifetime, and if they smoked now and were classified as
current, former, or never smokers. Professional characteristics
included work setting and years since their basic
nursing educational program. The survey administered
before and after the educational program contained the
same items.
Educational Program
The 1-hr educational program on the nurses’ role
in smoking cessation was based on the abbreviated Rx
for ChangeC program (Corelli et al., 2005) tailored to
nurses in the Czech Republic. The program was delivered
by nurses who participated in a 1-day train-the-trainer
workshop, developed by the authors, using PowerPoint
slides (Microsoft, Inc., Redmond, WA, USA). Content included
tobacco epidemiology; principles of dependence;
C
assessing tobacco dependence and withdrawal symptoms;
treatment of tobacco dependence using the five A’s; role
of the nurse in tobacco dependence treatment; community
resources, including the tobacco cessation centers
and the telephone quitline; role playing with motivated
and unmotivated smokers; and practical steps for implementing
the educational program for hospital-based
nurses. Subsequently, each workshop attendee received a
46-slide PowerPoint set with a script for each slide based
on the content described in the preceding sentence, educational
materials such as pamphlets, and informed consent
and pre- and postevaluation questionnaires. Trained
nurse faculty in eight hospitals throughout the Czech

Republic delivered educational programs to their staff
nurses (two hospitals ran two programs).
Data Collection
The nurse faculty collected the pretests of the nurses
who agreed to participate in the evaluation at each facility.
At the time of the 3-month post-test, the nurse faculty
sent notices to participants about the need to complete
the survey and provided a secure location for submitting
the anonymous surveys. After completion, the surveys
were sent to a central data collection address in Prague
and then to the investigators in the United States.
Data Analysis
Data entry was performed at the University of California
at Los Angeles by one of the authors (Brook).
All analyses used SAS 9.2 (SAS Institute, Inc., Cary,
NC, USA). Descriptive statistics were used to characterize
study variables. The primary outcome used to evaluate
the program was the change in the nurses’ self
-reported frequency of cessation interventions and referral
of patients to the quitline. Differences between
responses about clinical practice before and after the
educational
intervention were examined using nonparametric
sign tests. We used the McNemar test to examine the
increase, from baseline to 3 months, in the proportion
of nurses who consistently (“always” or “usually”) intervened
using the five A’s and referral to the quitline. Additionally,
we compared the frequency of those who consistently
(“always” or “usually”) intervened with smokers
using the five A’s, and referred smokers to a quitline by
the nurses’ smoking status (dichotomized as current vs.
former/never smoker). Baseline and 3-month data were
analyzed separately for smokers versus nonsmokers using
chi-square tests. Subsequently, proportional differences
of pre-post change in frequency of use of the various elements
of the intervention by smoking status were examined

with nested analysis of participants within hos-
Table 1. Demographic and Professional Characteristics of the
Nurses
(N = 98)
M (SD)
Age (years) 42.78 (11.49)
Years since graduated from nursing school 24.11 (11.62)
n (%)
Sex
Female 98 (100)
Smoking status
Never 44 (45.36)
Former 21 (21.65)
Current 32 (32.99)
Clinical practice setting
Medical 27 (27.55)
Oncology 28 (28.57)
Urgent care 14 (14.29)
Intensive care/emergency room 15 (15.31)
Surgical 8 (8.16)
Psychiatric 1 (1.02)
Rehabilitation 3 (3.06)
Obstetrics 2 (2.04)
pitals using generalized estimating equation modeling for
dichotomous outcomes.We calculated the OR for the difference
in performance between the smokers and nonsmokers
at baseline and 3 months.
Results
One hundred fifty-seven nurses completed the baseline
survey and 106 completed the 3-month survey. Of these,
98 (62.4% of 157) had both pre- and posttest data and
are the subject of this analysis. Table 1 displays the
demographics
of the sample. Participants were female, average
43 years of age, and had over 20 years of practice.
Almost a third were current smokers. There were

no significant differences in demographic characteristics
between nurses who completed the 3-month survey and
those who dropped out after the baseline.
Three months after the educational program, there was
significant improvement in the overall frequency of assessment
of a smoker’s readiness to quit, the provision
of assistance with quitting, recommendations for use of
the quitline, and recommendations about medications
for cessation. Additionally, significantly more nurses reported
reviewing patients’ barriers to quitting and recommending
a smoke-free home after discharge (Table 2).
An analysis showed that after the educational program,
there was an increase in the percentage of nurses who
consistently (“always/usually”) assessed smoking status
(22.68%, p = .02) and referred smokers to the telephone
quitline (15.63%, p = .04). Nurses reported improved
confidence in their overall ability to help smokers
C
Table 2. Changes in Nurses’ Delivery of Smoking Cessation
Interventions
Before and 3 Months After Attendance of an Educational
Workshop
Nurses’ tobacco Baseline 3 months Sign
dependence interventions n (%) n (%) test
Ask a patient’s smoking status
Always 49 (50.00) 46 (47.42) .57
Usually 12 (12.24) 16 (16.49)
Sometimes 22 (22.45) 19 (19.59)
Rarely 9 (9.18) 9 (9.28)
Never 6 (6.12) 7 (7.22)
Advise a patient to quit smoking .21
Always 17 (17.71) 27 (27.55)
Usually 26 (27.08) 22 (22.45)

Sometimes 33 (34.38) 33 (33.67)
Rarely 16 (16.77) 12 (12.24)
Never 4 (4.17) 4 (4.08)
Assess patients interest in quit smoking .002
Always 12 (12.24) 22 (22.68)
Usually 23 (23.47) 26 (26.80)
Sometimes 34 (34.69) 28 (28.87)
Rarely 17 (17.35) 15 (15.46)
Never 12 (12.24) 6 (6.19)
Assist a patient quit smoking .007
Always 13 (13.27) 15 (15.79)
Usually 13 (13.27) 21 (22.11)
Sometimes 19 (19.39) 14 (14.74)
Rarely 26 (26.53) 29 (30.53)
Never 27 (27.55) 16 (16.84)
Arrange smoking cessation follow-up .10
Always 8 (8.16) 5 (5.26)
Usually 4 (4.08) 6 (6.32)
Sometimes 6 (6.12) 13 (13.68)
Rarely 8 (8.16) 11 (11.58)
Never 72 (73.47) 60 (63.16)
Recommend the telephone quitline .03
Always 8 (8.16) 7 (7.29)
Usually 11 (11.22) 22 (22.92)
Sometimes 20 (20.41) 23 (23.96)
Rarely 20 (20.41) 16 (16.67)
Never 39 (39.80) 28 (29.17)
Refer to community resources .03
Always 14 (14.29) 15 (15.96)
Usually 14 (14.29) 16 (17.02)
Sometimes 19 (19.39) 26 (27.66)
Rarely 22 (22.45) 16 (17.02)
Never 29 (29.59) 21 (22.34)
Provide medication recommendations .0007
Always 4 (4.08) 11 (11.96)
Usually 8 (8.16) 13(14.13)

Sometimes 26 (26.53) 24 (26.09)
Rarely 19 (19.39) 19 (20.65)
Never 41 (41.84) 25 (27.17)
Review barriers to quitting .005
Always 6 (6.12) 8 (8.42)
Usually 15 (15.31) 22 (23.16)
Sometimes 29 (29.59) 29 (30.53)
Rarely 25 (25.51) 21 (22.11)
Never 23 (23.47) 15 (15.79)
Continued
Table 2. Continued
Nurses’ tobacco Baseline 3 months Sign
dependence interventions n (%) n (%) test
Recommend smoke-free home .02
Always 9 (9.18) 10 (10.31)
Usually 16 (16.33) 22 (22.68)
Sometimes 22 (22.45) 23 (23.71)
Rarely 22 (22.45) 21 (21.65)
Never 29 (29.59) 21 (21.65)
quit after the program and assisting patients with quitting
(Table 3).
The nurses’ smoking status made a difference in
the impact of the educational program on delivery
of smoking cessation interventions. There were
no statistically significant differences in the consistent
(“always/usually”) delivery of the five A’s prior to the
educational program between nurses who were current
smokers and those who were not. When comparing
changes in consistent intervention between smokers and
nonsmokers at 3 months, we see significant differences
(Table 4). Four times more nonsmokers reported consistently
asking about a patient’s smoking status. Three
times as many nurses who were nonsmokers consistently
advised smokers to quit. None of the nurses who smoked
consistently arranged for follow-up. Almost three times
as many nurses who were nonsmokers consistently

recommended
use of the telephone quitline as compared to
current smokers.
Discussion
This study demonstrates that a brief educational program
about nurses’ role in smoking cessation can have a
positive impact on nursing practice in the Czech Republic.
Three months after the program, nurses’ self-reported
frequency of interventions to help smokers quit and confidence
to assist smokers significantly increased. To our
knowledge, this is the first study to report the efficacy of
such a program for nurses in the Czech Republic. There
is over a decade of evidence to support the positive impact
of educational programs on clinical practice (Carson
et al., 2012), and more recently, on patient outcomes
(Hartmann-Boyce et al., 2013). However, few studies
have addressed the impact on nursing practice.
In order for tobacco dependence treatment to increase
in Eastern Europe, the expansion of educational programs
for healthcare professionals is essential. One third
of the parties to the WHO FCTC reported that they had
no specialized services to assist smokers to quit (Pin´ e-
Abata et al., 2013; WHO, 2013). Even a small increase in
C
Table 3. Changes in Attitudes About Nurses’ Ability to Assist
Patients
With Smoking Cessation Before and 3 Months After an
Educational
Program on Smoking Cessation
Baseline 3 months
n (%) n (%) Sign test
Overall ability to help patients quit smoking .02
Poor 35 (36.08) 28 (29.17)

Fair 28 (28.87) 21 (21.88)
Good 30 (30.93) 39 (40.63)
Very good 4 (4.12) 6 (6.25)
Excellent 0 (0) 2 (2.08)
Ability to ask about smoking .13
Poor 16 (16.49) 15 (15.46)
Fair 25 (25.77) 22 (22.68)
Good 30 (30.93) 30 (30.93)
Very good 17 (17.53) 18 (18.56)
Excellent 9 (9.28) 12 (12.37)
Ability to advise patients to quit smoking .32
Poor 16 (16.49) 17 (17.71)
Fair 32 (32.99) 29 (30.21)
Good 37(38.14) 32(33.33)
Very good 9 (9.28) 12 (12.50)
Excellent 3 (3.09) 6 (6.25)
Ability to assess patients’ readiness to quit .14
Poor 38 (39.58) 31 (32.98)
Fair 24 (25.00) 19 (20.21)
Good 25 (26.04) 38 (40.43)
Very good 9 (9.38) 3 (3.19)
Excellent 0 (0) 3 (3.19)
Ability to assist patients in quitting .01
Poor 42 (43.30) 28 (29.79)
Fair 23 (23.71) 22 (23.40)
Good 23 (23.71) 35 (37.23)
Very good 7 (7.22) 6 (6.38)
Excellent 2 (2.06) 3(3.19)
Ability to arrange for follow-up 0.86
Poor 62 (63.92) 55 (59.78)
Fair 13 (13.40) 17 (18.48)
Good 14 (14.43) 12 (13.04)
Very good 2 (2.06) 2 (2.17)
Excellent 6 (6.19) 6 (6.52)
nursing intervention following attendance at a brief educational
program could have a profound impact on

helping smokers quit. For example, the over 10% improvement
in nurses consistently referring patients to
the telephone quitline for cessation support could result
in 10 additional smokers out of 100 receiving
treatment.
In this study, the cost of the educational program was
relatively low, but depended on the support of the hospital
administration to release time for the nurses. With
rapidly advancing technology, web-based programs focused
on smoking cessation may provide nurses easier
access to educational programs. A quasi-experimental
study of nurses in the United States demonstrated the
efficacy of a webinar in significantly improving referral
to the quitlines compared to print materials alone
6 months after participation in the program (Sarna
et al., 2012b). A randomized clinical trial of a webbased
program tailored for pediatric nurses and respiratory
therapists also demonstrated efficacy in improving
interventions and attitudes 3 months after the program
(Gordon, Mahabee-Gittens, Andrews, Christiansen, &
Byron, 2013).
Smoking status of healthcare providers is rarely reported,
or considered, in evaluations of educational programs
focused on smoking cessation interventions, but
it was an important factor in this study. As recommended
by the WHO (2012), these data should be collected
and analyzed in future studies. Future educational
programs could also include support for quitting among
healthcare providers. Our findings are similar to findings
reporting the negative impact of smoking among
nurses on their clinical practice (e.g., Raupach et al.,
2012). In countries where smoking prevalence among
nurses is high, smoking status should be given special
attention.
Limitations
In addition to the convenience sample and the small

sample size, there are a number of factors that should be
considered in the interpretation of these findings. Without
a comparison group, we are unable to confirm if
the improvement in the frequency of nurses’ interventions
was due to attendance at the educational program
or other factors. The nurses who attended these programs
and completed the surveys may have been more
interested in tobacco control than nurses who did not
participate, and thus provided more positive responses.
The sample size did not allow for subgroup analysis such
as the comparison of never, former, and current smokers.
Although each nurse faculty who led the workshop
was provided with a packet of educational materials, we
were not able to guarantee the fidelity of the delivery
of the program at each of the hospitals. This study did
not assess increases in knowledge per se, or link nurses’
self-reported frequency of cessation interventions with
changes in the number of smokers who received interventions.
Similar to the protocol by Katz et al. (2012),
future studies might consider providing a direct feedback
loop to nurses about their performance.
Including smoking cessation interventions as a core
part of day-to-day nursing care may be a role change for
nurses in the Czech Republic, with competing demands
on nurses’ time. In order to attend the program, nurses
C
Table 4. Differences in Consistent Interventionsa by the Nurses’
Smoking Status Before and After an Educational Program on
Smoking Cessation
(N = 98)
Prestudy Prestudy Post-study Post-study
rate rate OR rate among rate among nonsmokers OR
among smokers among nonsmokers [95% smokers nonsmokers

[95%
n (%) n (%) CI] p n(%) n (%) CI] p
Ask 16 (50.00) 44 (67.69) 2.10 [0.88, 4.98] .09 13 (41.94) 49
(75.38) 4.24 [1.71, 10.53] .002
Advise 9 (30.00) 33 (50.77) 2.41 [0.96, 6.04] .06 10 (32.26) 39
(59.09) 3.03 [1.24, 7.45] .02
Assess 8 (25.00) 26 (40.00) 2.00 [0.78, 5.13] .15 11 (35.48) 36
(55.38) 2.26 [0.93, 5.46] .08
Assist 8 (25.00) 17 (26.15) 1.06 [0.40, 2.81] .90 11 (35.48) 25
(39.06) 1.17 [0.48, 2.84] .74
Arrange 1 (3.13) 11 (16.92) 6.32 [0.78, 51.30] .08 1 (3.33) 10
(15.63) 5.37 [0.66, 44.06] .12
Quitline 3 (9.38) 16 (24.62) 3.16 [0.85, 11.80] .09 5 (16.13) 23
(35.94) 2.92 [0.99, 8.63] .05
Note. OR = odds ratio; CI = confidence interval. aNested
analysis of participants within hospitals using generalized
estimating equation modelings for
dichotomous outcomes for frequency of interventions:
“always/usually” versus “sometimes, rarely, never.”
needed to be released from patient care, which might
have limited the reach of the program. Additionally, although
reported in other studies, validation of the nursing
education on patient outcomes in terms of actual quit
attempts and abstinence with biochemical verification is
warranted.
Conclusions
This positive evaluation of an educational program
about smoking cessation for nurses in the Czech Republic
is encouraging and enhances our understanding of the
potential of brief programs to address this critical health
issue. Further study is needed to determine if this or other
educational programs should be disseminated to nurses
throughout the country and the region. Future research
might examine the value added of more comprehensive
programs as well as the impact of web-based programs on
changing clinical practice. The fact that there was a significant

difference in outcomes by nurses’ smoking status
suggests that educational programs about how to help patients
quit smoking implies the need to include efforts to
support cessation among healthcare providers as part of
capacity-building efforts.
Acknowledgments
This project was supported by a grant to the International
Society of Nurses in Cancer Care (ISNCC) from
the Bristol-Myers Squibb Foundation, Bridging Cancer
Care; the Lulu Wolf Hassenplug Endowed Chair fund
provided additional funding to support the analysis. We
thank the nurses in the participating hospitals in the
Czech Republic and Sarah McCarthy, MSc, MBA, Executive
Director, ISNCC, for her support throughout the
project.
Clinical Resources
Tobacco Free Nurses:
http://www.tobaccofreenurses.org/
Smoking Cessation Leadership Center:
http://smokingcessationleadership.ucsf.edu/
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and discuss briefly according to information found in Chapter 3
(Adams, 2012) of the Schmidt and Brown (2012) text book.
Provide the name of the article with an in text citation so that
the instructor knows which article is being reviewed. The in text
citation for the article must be included in each
section/paragraph below.
Study Design
In this section identify whether the study is quantitative or
qualitative. Then discuss the specific design. Information is
found in Chapters 6, 7 and 8.
Sample Size and Representativeness
Identify the size of the sample and whether is it
representative of the population.
Results of Data Analysis

Present the results of the data analysis and discuss the
analysis procedures. Be specific about the procedures used and
actual findings. Identify the statistical test used in the research
study.List the statistical results of the test used in the research
study. This will include all of the statistical results, not just the
p value. Identify whether the results of the statistical analysis
were significant. Include the p value for the tests that are
statistically significant.
Summary of Strengths and Weaknesses --45 points
Identify the strengths and weaknesses of the study.
Remember to use the textbook for supporting citation and
reference when making this evaluation so that quantitative
studies are evaluated for reliability and validity.
Overview of Qualitative Article --45 points
Research Question In this section of the paper, identify
the research question and discuss briefly according to
information found in Chapter 3 of the Schmidt and Brown
(2012) text book. Provide the name of the article with an in text
citation so that the instructor knows which article is being
reviewed. The in text citation for the article must be included in
each section/paragraph below.
Study Design
In this section identify whether the study is quantitative or
qualitative. Then discuss the specific design. Information is
found in Chapters 6, 7 and 8.
Sample Size and Representativeness
Identify the size of the sample and whether is it
representative of the population. Remember that the criteria for
evaluating a qualitative sample are different from evaluating a
quantitative sample.
Results of Data Analysis Procedures
Present the results of the data analysis and the themes
identified. Be certain to describe the data analysis procedures
used.
Summary of Strengths and Weaknesses --45 points
Identify the strengths and weaknesses of the study.

Remember to use the textbook for supporting citation and
reference when making this evaluation. Qualitative studies are
evaluated for trustworthiness (credibility, transferability,
dependability and confirmability).
Summary of the Main Points of the Paper
Always summarize the main points of a paper. A brief summary
of the articles reviewed is sufficient. On a separate page add
the references which are the citations for each of the articles
reviewed and any other sources that you used for the paper.
References
Adams, S. (2012). Identifying research questions. In N.A.
Schmidt & J.M. Brown. (Eds.). Evidence-based practice for
nurses: Appraisal and application of research. (2nd ed., pp. 66-
87). Sudbury, MA: Jones & Bartlett Learning.
The correct citation of each article is worth 15 points so the
citation of the two articles reviewed is worth 30 points.
NOTE: Format/style
Proofread the paper as described in the tips for success in this
course and correct any typos, grammar, spelling, punctuation,
syntax, or APA format errors before submitting your paper to
Turnitin. Up to 40 points can be deducted from the grade for
this assignment for these types of errors, or for not using at
least the minimum number of required references.
Total possible points for assignment = 210 points

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