Teachable moments and missed opportunities for smoking cessation counseling in a hospital emergency department: a mixed-methods study of patient-provider communication

Abstract

BackgroundWhile primary care medical clinics have been the most common setting for the delivery of advice about smoking cessation, the hospital emergency department (ED) is a valuable context for counseling medically underserved tobacco users. We conducted a secondary analysis based on a larger audio-recorded study of patient-provider communication about pain and analgesics in the ED. Within a sample of ED patients with back pain, the purpose of this mixed-methods study was to examine how physicians and nurse practitioners capitalize on “teachable moments” for health education to offer spontaneous smoking cessation counseling in the ED.MethodsPatients presenting to an academic ED with a primary complaint of back pain were invited to participate in a study of patient-provider communication. Audio-recorded encounters were transcribed verbatim. Two coders reviewed each transcript to determine whether smoking was discussed and to build a corpus of smoking-related discussions. We then developed inductively generated coding categories to characterize how providers responded when patients endorsed smoking behavior. Categories were refined iteratively to accommodate discrepancies.ResultsOf 52 patient-provider encounters during which smoking was discussed, two-thirds of the patients indicated that they were smokers. Providers missed opportunities for smoking cessation counseling 70% of the time. Eleven encounters contained teachable moments for smoking cessation. We identified four primary strategies for creating teachable moments: 1) positive reinforcement, 2) encouragement, 3) assessing readiness, and 4) offering concrete motivating reasons.ConclusionsMost providers missed opportunities to offer teachable moments for smoking cessation. In encounters that contained teachable moments, providers employed multiple strategies, combining general advice with motivation tailored to the patient’s particular circumstances. Creating motivational links to enhance smoking cessation efforts may be possible with a minimal investment of ED resources.

Knowledge as enablement: additional perspectives influenced by complexity

“…For example, smoking cessation messaging is typically the domain of primary healthcare, yet it has been argued that hospital emergency departments provide unique and unexpected low-cost opportunities to promote awareness about the risks of cigarette smoking (Buchbinder et al, 2014). There is a consensus within the literature that has been reviewed that teachable moments are best identified in a top-down manner by the healthcare professionals (Cohen et al, 2011;Phelan, 2010).…”

“…However, if new attractors do emerge, the likelihood is that they will reflect local nuances-including local knowledge systems, norms, values, metaphors, and idioms (Cameron & Deignan, 2006)-because they develop through cognitive processes such as selective attention (Klein, 2008) and sensemaking ( Dervin, 1998;Weick, 1995) during experiential learning processes (Wals, 2007). From the perspective of the intervention design, attractor sites also represent potential teachable moments (Buchbinder, Wilbur, Zuskov, McLean, & Sleath, 2014).…”

Mental Health Hospital Admissions: a Teachable Moment and Window of Opportunity To Promote Change in Drug and Alcohol Misuse

“…A Cochrane review of 14 randomised controlled trials (RCTs) involving brief motivational interventions for alcohol use delivered during non-alcohol-related general hospital admissions concluded patients receiving brief interventions reduced their alcohol use more than control groups (McQueen et al 2011). However, Buchbinder et al (2014) found these Bteachable moments^are often not recognised during hospital admissions and thus represent missed opportunities for interventions. More importantly, the effectiveness of utilising this Bmomentd uring an acute psychiatric hospital admission has not been explored.…”

“…Substance misuse A hospital admission may represent a Bteachable moment^for health-related behaviours (e.g. Lau et al 2010;Buchbinder et al 2014), that is, a time when health-related behaviours (e.g. substance use) that may have indirectly contributed to the admission potentially become more open to change.…”

“…There is a growing literature demonstrating the effectiveness of screening and brief interventions in general hospitals that seek to capitalise on this moment (e.g. Buchbinder et al 2014;Cobain et al 2011;Désy et al 2010;Lai and Sitharthan 2012). A Cochrane review of 14 randomised controlled trials (RCTs) involving brief motivational interventions for alcohol use delivered during non-alcohol-related general hospital admissions concluded patients receiving brief interventions reduced their alcohol use more than control groups (McQueen et al 2011).…”