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ABC Case Study Series: Hawke’s Bay Hospital
Education Fuels ABC Success in Perioperative Departments
Vivace Group Ltd
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Hawke’s Bay Hospital:
Education Fuels ABC Success in Perioperative Departments
Executive Summary
A recent focus on improving smokefree practice within Hawke’s Bay Hospital
Perioperative Unit has driven an increase in the number of patients being offered brief
advice, from 0% to 83% in just two months. Factors that have played a role in
contributing to this outcome are listed below:

A hospital-wide training target is fueling a sense of urgency for staff to complete
training: 80% of all doctors and nurses are to have completed ‘Ask about the
Elephant’ and ABC training by May 2010.

A flexible, innovative approach to training delivery is promoting greater staff
attendance and engagement, e.g. in the Emergency Department funding was
provided to back-fill staff attendance at the training session, and in Day Surgery,
the training was divided into three sections and staff were allowed to complete
the training in any order, allowing for staff to ‘drop in and out’ of the session as
was typical, without needing to repeat again.

A comprehensive train the trainer model was introduced, and to date 25 link
nurse champions have been trained to deliver in-ward ABC training and provide
on the ground support for staff. They also provide valuable input into the design
and modification of systems and training to suit each ward’s specific needs.

Trainers are given a full days training, receive a welcome pack and are supported
during the year with four follow up sessions and regular communication. Funding
is provided for staff to cover time spent on smokefree duties and their efforts are
recognised in terms of contribution to professional development.

Nurse managers are encouraged to play a supportive role for link nurse
champions and expectations about their role are formally agreed with the
smokefree team early on.

The ABC training places an emphasis on ‘shifting thinking’ around smokefree
practice, focusing on the role of the health professional and the impact that they
can make - ensuring each staff member understands the role they play in
supporting the patient to be smokefree on their wider hospital journey.

An incentive was introduced to encourage staff to take up the e-learning tool – a
$10 coffee card for use in the hospital café for staff who could not be released for
education sessions and who undertook completion of the e-learning tool in their
own time.

The introduction of a new patient smokefree form, prompting the ABC approach
is supporting health professionals to have ‘the conversation’ with new patients,
and its bright clear design is being well received by staff.
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
Resources are being revised to include changes to the Anaesthetic Record, so
that nicotine replacement therapy is included under post op medications and the
development of periop specific smokefree posters is underway for patient areas
that promote key messages around smokefree practice pre and post surgery.
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Background
Hawke’s Bay Hospital is the largest hospital in the Hawke’s Bay region, and provides
medical, surgical, specialist, assessment and rehabilitation services for the local
population. Based in Hastings, the hospital discharges approximately 125,000 patients
per year, and employs a staff of over 1,500 nurses to deliver its health services. Smoking
is a major issue for the local population, with the region reporting a higher than average
percentage of smokers: 24.8%, compared to 20% nationally (2006 census).
The hospital has been implementing a ‘Totally Smokefree’ project across the community
since 2007; a strategic framework of complementary strategies and workstreams
delivered through the hospital and across the community to build smokefree practice and
behaviours.
The introduction of the national health target ‘Better help for smokers to quit’ in July 2009
has seen additional focus being placed on the hospital setting, and has supported an
increased investment in training, systems innovation, and resource development for
hospital staff and patients, to promote better implementation of smokefree practice by
health professionals across the hospital . Smokefree practice involves the screening of
smoking status of all patients and the provision of brief advice and practical support to
be smokefree, (known as the ABC approach – Ask Smoking status, provide Brief advice,
provide Cessation advice or referral.)
A recent drive to boost smokefree practice across the perioperative departments has
had successful results, with one of the busiest departments in the hospital - the Hastings
Day Surgery - reporting an increase in the percentage of smokers being offered brief
advice, from 0% in December 09, to 83% by February 2010.
Interviews were conducted with staff across the DHB from within the smokefree
department and in perioperative to identify the contributing factors that have supported
the increased implementation of the ABC approach in these departments. The findings
are summarised below.
‘Shifting the Thinking’ about Smokefree Practice
The recent focus on improving smokefree practice across the perioperative departments
is part of an ongoing comprehensive approach to ‘shifting thinking’ amongst the wider
workforce at the Hawkes Bay DHB that has been taking place for the last few years.
The ‘shift’ was kick-started with the introduction of the DHB’s smokefree policy in 2007.
As well as addressing environmental issues, the policy committed staff to screening
patients on smoking behaviour and delivering brief advice, even before the ABC
approach was formally introduced. “It meant the organisation had to shift its thinking from
seeing smokefree as just being about the car park and grounds, to clinical practice and
how we can best encourage and support patients to be smokefree. It’s about making a
difference. This difference can be achieved through health care staff routinely asking
patients about tobacco use and providing advice and support to those patients that are
not smokefree,” (Smokefree Project Manager).
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Staff Education Drives a Shift in Staff Thinking
The smokefree team recognised early on that without a shift in thinking, efforts to
increase smokefree practice within the hospital would not be well supported by staff.
Education was identified as the key to delivering this ‘mind shift’ and this lead to the
development of the ABC training programme for staff.
Today the training is delivered in two parts; the first part is a 20 minute presentation
about the importance of smokefree practice, the systems that support it and the
provision of NRT. The training places particular emphasis on the role of the staff as
health professionals, encouraging staff to understand the important role they play and
building confidence in practicing the ABC approach. “It’s re-positioning the focus to be
positive… most people who smoke don’t actually want to smoke. It’s about
understanding that the ABC approach is about providing patient care rather than judging
patients,” (Smokefree Liaison Nurse).
The training is designed to support the staff to have a wide knowledge-base to draw
from when conducting the brief conversation with patients about the importance of being
smokefree. However if a patient is wanting more information and support, and time is
pressured, staff are encouraged to provide a referral to the internal smokefree service to
be followed up. “Staff were nervous at first because they thought they had to become
cessation experts. It’s about a brief and effective intervention and then referring on to the
smokefree service” (Smoking Liaison Nurse).
Once staff have completed the first part of the training they are directed to complete the
Ministry of Health’s online e-learning tool ‘Ask about the Elephant’
(www.smokingcessationabc.org.nz). On completion of the e-learning tool they qualify as
quit card providers. An incentive was introduced to encourage staff to take up the elearning tool – a $10 coffee card for use in the hospital café for staff who could not be
released for education sessions and who undertook completion of the e-learning tool in
their own time. “That was a nice touch….things like that all help,” (Anaesthetic
Technician Manager.)
‘Train the Trainer Model – Smokefree Link Champions
With over 1,500 nurses based at the hospital alone and only one dedicated trainer, a
train the trainer approach was identified as the most efficient and sustainable way of
delivering the ABC training quickly across the workforce and providing ongoing in-ward
support for staff.
.
A comprehensive train the trainer model was developed by the smokefree team and the
‘Smokefree Link Champion’ project was launched early in 2009. To date 25 nurses have
been recruited to deliver in-ward ABC training and support the consistent approach of
the ABC approach through the hospital wards. Potential champions were rallied via a
hospital-wide advertising campaign and a face to face in-ward recruitment drive, which
was successful in encouraging additional participation. At least one link nurse was
recruited from each department, ensuring that there is a ‘go to person’ in each ward to
manage any day-to-day matters that arise.
Link champions received a full day’s in-depth training on the importance of Smokefree
practice and the ABC approach, evidence of tobacco harm, nicotine addiction, provision
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of NRT and quit cards, internal processes and resources – including NRT Standing
Order and mandatory assessment of nicotine dependence (appendix 1). They were also
provided a ‘welcome pack’ which included a free month’s gym membership, as a thankyou for their efforts.
In addition to training staff, the champions can also provide valuable input into the
design of systems and resources for each department. “The nurses can see what is and
isn’t working in their area, and their input means that each department is able to fully
participate.” (Smokefree Liaison Nurse).
Whilst their role is voluntary, funding is provided by the smokefree programme to pay for
extra staff to back-fill time spent away from the ward on smokefree-related duties. This
has been identified as an important step in securing staff participation and support from
management: “This has really helped as it means we can free them (link champions) up
without putting extra burden on other staff members,” (Clinical Nurse Manager.) This has
also helped in gaining the active support of the nurse managers, who play an important
role in aiding the link champions to deliver training and reinforce smokefree practice
across the department. To assist this outcome the smokefree team has developed an
agreement for each link nurse’s manager that sets out the expectations of their role in
relation to smokefree practice.
The link nurses continue to meet four times per year to have ongoing training, remotivation and provide the opportunity to discuss any issues that arise. Additional
support is provided during the year via letters, emails and relevant research sent to
share with their staff from the Smokefree Liaison Nurse.
Comments from the staff identified that the link champion system appears to be working
well for the hospital, and nurses are becoming increasingly excited about their roles,
feeding back stories of staff and patient successes: “It’s working really well – its been
amazing the pockets of passion that have come out of these champions,” (Smokefree
Liaison Nurse). Steps are now underway to ensure that the link champion’s roles are
being recognised in the nurse portofolios, as a demonstration of leadership and other
key skills, forming part of their ongoing professional development.
Internal Target Fuels Training Drive
While the link champions provided a boost to capacity for training delivery, prior to the
health target training attendance was not being achieved at the desired levels. In
response, the smokefree team secured the support of senior management and
agreement was reached to set an internal training target for the DHB; 80% of all doctors
and nurses are to have completed the e-learning tool and attended the ABC training by
the end of May 2010.
This target has helped fuel a major effort to get clinical staff up-skilled: “We’ve delivered
a huge education drive across the hospital,” (Smokefree Liaison Nurse). It has also
helped communicate the message that everyone has a role to play in achieving the
target: “It’s about lots of small conversations taking place along the patient journey. “
(Smokefree Liaison Nurse.)
Training Tailored to Meet Department Needs
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In order to get the maximum attendance and ‘buy-in’ for the ABC training, the smokefree
team has tailored their training approach to meet the needs of different departments. In
terms of the emergency department (ED) this has meant extending the training to be one
and a half hours in length, delivered in small groups of just one to three staff. Funding
was also provided to back-fill staff attending training, so that they could commit to the
time off without distractions. This approach promoted better engagement by staff, who
had time to ask questions and become familiar with the material. “We didn’t have drop in
and outs – it was amazing!” (Smokefree Liaison Nurse). This approach has been
recognized as successful in building support for the ABC approach across ED. “Staff
there are telling me stories about patients giving up….we have seen a massive shift in
where people are at.” (Smokefree Liaison Nurse).
New Smokefree Screening and Intervention Form
Part of the training delivered to staff includes a focus on using the new smokefree
screening and intervention form - a patient administration form that is now included in all
patient administrative packs (appendix 2).
The form supports hospital staff to have a conversation with patients about smoking
behaviour and cessation options. It is completed by the pre-administration nurse, house
officer or anaesthetic technician: “who ever opens up the pack owns it and has to do it,”
(Smokefree Liaison Nurse). The focus in training is to ensure that this initial conversation
with the patient addresses smoking status and cessation options effectively. ”They are
encouraged to focus on how being smokefree is the best thing they can do for their
health, and to prepare for surgery.” (Smokefree Liaison Nurse).
The form has been designed to stand out in the pack, using a bright green design.
Feedback from nurses has shown this approach is working, with one nurse reported to
comment - “It sticks me in the eye.”
Driving Smokefree Practice across Perioperative
January 22 this year marked the ‘go live’ date for rolling out the new form across
perioperative. The day was supported by posters and communications and a large
morning tea provided by smokefree staff to help raise staff awareness of the new form’s
introduction.
This important day followed months of staff training activity, tailored to meet the needs of
this particular department. To accommodate staff needs, training was bought into the
department and was broken down into three sections – covering key themes relating to
smokefree practice, the ABC approach and NRT provision. Staff were able to drop in
and out of training sessions and this made training in this busy environment
manageable. “This was really important…. It meant attendees were able to drop in and
out of a session as their schedules required, and if they came into training late they
could just stay on after to complete the part which was missed” (Smokefree Liaison
Nurse).
Due to the large number of patient handovers typically taking place in perioperative, the
presentation was extended to 45 minutes to ensure that each stage of the patient
journey was addressed and a smooth ‘handover’ for patients was achieved. The training
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was delivered by the trainer wearing scrubs – to ‘fit in’ with the department, an approach
which was reported to be well received by staff.
Whilst only approximately half of all perioperative staff had received training by March
2010, results indicate that the training has had a major impact. In Hastings Day Surgery
there were 88 events recorded during February 2010, in which 14% of patients were
identified as smokers, and brief advice was given to 83%. This compares with 0% of
patients being offered brief advice in December 2009.
Team Approach Supports Practice in Perioperative
The appointment of a passionate and effective link champion for the perioperative
department, and the active support of her manager are both seen as key factors
supporting the successful implementation of smokefree practice across this area: “It’s a
‘team’ approach – otherwise it’s too big for one person.” (Clinical Nurse Manager).
Expectations about the role of the nurse manager and link champion were established
early on: “Right from the first instance – we had a contract with the project manager, like
a terms of reference, making it really clear what the expectations were, which was really
good.” (Clinical Nurse Manager).
The “team approach” involved a joint planning process, with the smokefree team, to
identify the priorities in terms of education, and patient focus. “We began by prioritising
patients who were staying over night, because they would be more vulnerable to nicotine
withdrawal.”(Link Champion)
The link champion’s roll was to also provide feedback into what was and wasn’t working
for her area. “For example we found that when we initially rolled it out, people wanted
NRT but this was often being missed by the recovery nurse,” (Link Nurse). The
documentation was not supporting a smooth transition and patients typically weren’t
getting a patch administered before they went to the ward. This issue has subsequently
been addressed, and a permanent change to the anesthetic record is now underway
(see below).
Having experience across all the department areas has been invaluable to supporting
the link nurse to deliver her role. “It has been really important for getting the buy-in
internally, using someone within the team. She is a familiar face for staff…part of our
family, and has a good relationship and rapport with people.” (Clinical Nurse Manager).
The clinical nurse manager’s role is described as one of “raising awareness to staff of
the need to value smokefree education and the benefits for the patients if they do that …
and the benefits for the organistion.”” (Clinical Nurse Manager). Her role is also about
providing opportunities on the roster for staff to have time to do the training and meet
with the link nurse, get feedback and work together to remove any departmental barriers.
The approach has helped build internal support and behaviour change, according to the
Link Champion: “Initially when we started this, there was a bit of negativity, it was seen
as ‘yet another thing we have to do,’ but with education and the way it has been rolled
out, everyone has taken it on board and sees the importance. Now we’ve got nurses that
can write quit cards, passion is filling. “Having confidence in an effective in-hospital
referral system is also seen as a factor contributing to the likelihood of referrals taking
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place. “The support is great. They usually will show up within 5 or 10 minutes of being
called,” (Link Champion).
ABC Training Drives Positive Change Among Anaesthetic Technicians
The anaesthetic technicians within the Hawkes Bay hospital are one of the most recent
staff groups to have received the ABC training, and according to the technician manager
its impact is already showing results.
Initially the technician manager did not see Smokefree Practice as being particularly
relevant to his department: “Our area was a bit ‘grey’ because we don’t have much time
with patients, and then after 10 minutes they are asleep! Also surgery is a big deal for
patients and we don’t want to put patients on edge. “
However, attending the internal training has changed this perception across the ward.
“The training was great. It helped me realise that actually is important to have the
conversation (about smoking status) with patients and often you actually do have time.”
The changes to the pre-administration form have helped support this conversation: “It
gives us an opening to discuss their smoking behavior, and discuss options for cessation
support moving forward.” The training has supported staff to get behind the smokefree
message and make changes in their personal lives too. “The talk around the
departments is quite positive … and we’ve had positive feedback from staff who smoke
too.” Approx. 50% of those who staff who smoke have started on NRT as a direct
response to the training.
The availability of NRT has been identified as a critical factor in supporting staff to
promote this to patients: “People have the opportunity if they want to, to give up smoking
for a minimal amount of money. So if people ask we can really help them.” The elearning tool has been completed by most staff, and the $10 coffee card was seen as a
positive incentive to getting staff to do the training.
The perception is that the anaesthetic technicians are there to reinforce the messages
patients have already received (in the hospital): “People tend to listen to you more when
you’re in scrubs, they really pay attention to what you say.” One barrier in place
however is that whilst technicians are increasingly offering brief advice to patients, they
are currently unable to provide quit cards through the quit care provider scheme, a
matter which is being looked into further.
Looking Ahead
The comprehensive approach to shifting thinking and supporting behavior change at
Hawkes Bay hospital appear to be having an increased impact on staff behaviour, with
hospital data and feedback from staff suggesting that change is very much taking place
in those departments that are being targeted.
In the immediate future the smokefree team, working with the Link Champion, will
continue to prioritise driving staff education across the perioperative department, and the
focus will be placed on rolling out training to outpatient departments later in the year. A
number of changes are taking place currently in terms of systems and resources:
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Changes to the Anaesthetic Record
The link champion for perioperative identified a ‘gap’ existed in terms of the
administering of NRT to post-operative patients. “Once a patient has come out of surgery
the recovery nurse wasn’t looking on the medication charts to identify NRT requirement,
which meant that patients could be waiting hours before any nicotine replacement was
offered,” (Link Champion). Changes are now underway to the Anaesthetic Record, to
have NRT included under post-operative medications. “This change will be fantastic – It
means that patients will be able to benefit from the effects of NRT more quickly and that
NRT is routinely on anaesthetists and recovery nurses minds. There has been huge
support for this right through the department” (Smokefree Liaison Nurse).
New Visual Aids Promote Pre-surgery Smokefree Practice to Patients
Two large new posters are being designed for display in patient areas that promote
going smokefree as “the best thing you can do to prepare for surgery.” The posters
highlight the risks and potential complications related to smoking and surgery, and the
negative impact on wound healing time. This approach is designed to both support
patients to be prepared for any discussions taking place in the ward, and encourage
patients to initiate action. “It encourages patients to talk to their nurse, doctor or any
health professional about the issue – who ever is close at hand,” (Link Champion).
A similar message is also going to be promoted on the hospitals public story boards and
perioperative will be leading this approach, putting information on there about smokefree
practice for patients, and celebrating the staff involved.
Appendices
Appendix 1: Training Day schedule for Link Nurse Champion Training Day
Appendix 2: Smokefree Screening and Intervention Form.
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