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This Electronic Thesis Or Dissertation Has Been Downloaded from the King’S Research Portal At This electronic thesis or dissertation has been downloaded from the King’s Research Portal at https://kclpure.kcl.ac.uk/portal/ Nurses who smoke : the experience of attempting to quit. Rowe, Kathleen The copyright of this thesis rests with the author and no quotation from it or information derived from it may be published without proper acknowledgement. END USER LICENCE AGREEMENT Unless another licence is stated on the immediately following page this work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International licence. https://creativecommons.org/licenses/by-nc-nd/4.0/ You are free to copy, distribute and transmit the work Under the following conditions: Attribution: You must attribute the work in the manner specified by the author (but not in any way that suggests that they endorse you or your use of the work). Non Commercial: You may not use this work for commercial purposes. No Derivative Works - You may not alter, transform, or build upon this work. Any of these conditions can be waived if you receive permission from the author. Your fair dealings and other rights are in no way affected by the above. Take down policy If you believe that this document breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 07. Oct. 2021 NURSES WHO SMOKE: THE EXPERIENCE OF ATTEMPTING TO QUIT Kathleen Rowe BSc (Hons) RGN RNT DIpN AdvDipEd Thesis submifted for the degree of PhD King's College University of London LOKOl, us V. ACKNOWLEDGEMENTS First and foremost I would like to thank the nurses and students for participating in this research and for giving up their time to talk to me with frankness. Special thanks are due to my loving husband Malcolm and to Clare, Graham, Alison and Sam for their constant love, faith, patience and support during the course of the study. I 'am also grateful to my friends and colleagues for their help and encouragement. I would like to thank my supervisor Professor Jill Macleod Clark, without whose wisdom, understanding, and encouragement, this study would not have been possible. This study was made possible in part by the National Board for Nurses, Midwives and Health Visitors for Northern Ireland and their support is gratefully acknowledged. 2 ABSTRACT The aim of this study was to evaluate the impact of an individualised cessation intervention on the smoking behaviour of qualified nurses and student nurses and to explore the experiences of nurses who attempted to give up smoking. A comparison or reference group comprised qualified nurses and student nurses who wished to give up smoking but did not receive the intervention. In phase one, data were collected pre and post intervention and analysed using a combination of quantitative and qualitative methods. Self reports of smoking cessation were objectively verified by measuring carbon monoxide in expired alveolar air and cotinine in saliva. Twenty five per cent of nurses in the intervention group stopped smoking at one year compared with 8% in the reference group. This suggests that an individualised smoking cessation intervention is an appropriate method for helping nurses stop smoking and that Prochaska and DiClemente's (1982) transtheoretical model of behavioural change is a useful framework upon which to base smoking cessation interventions. In phase two semi-structured interviews were undertaken with qualified nurses and student nurses to explore the reasons why some stopped smoking and others continued. A qualitative approach to analysis revealed that nurses who successfully stopped experienced something akin to a 'Damascus Road' experience and had internalised the effects of smoking on their health and professional role. Specific barriers to stopping smoking were also identified particularly amongst the qualified nurses who described the powerful relationship they enjoyed with cigarettes. This relationship was linked to varying levels of stress incurred in their everyday lives. Student nurses described the impact of important peer relationships which were in turn nurtured by the smoking condoning culture within the College of Nursing. In examining the effect of smoking on the nurse's role the findings suggest that nurses who smoke are compromising their role as promoters of health in this area and that the students studied have little understanding of the meaning of health promotion. The implications of these findings for professional practice are discussed. 3 TABLE OF CONTENTS PageNo. TITLE 1 ACKNOWLEDGEMENTS 2 ABSTRACT 3 TABLE OF CONTENTS 4 LIST OF TABLES AND FIGURES 12 LIST OF APPENDICES 14 INTRODUCTION 16 CHAPTER ONE: THE PREVALENCE OF SMOKING Introduction 20 The Extent of Smoking in the General Population 21 Smoking and Gender 22 Smoking and Age 23 Smoking and Socio-Economic Status 24 The Prevalence of Smoking Among Nurses in General 26 Prevalence of Smoking in Different Sub-Groups of Qualified Nurses 34 The Prevalence of Smoking Among Student Nurses 41 Factors Influencing Student Nurses and Qualified Nurses' Smoking Behaviour 47 Stress 47 Young People's Peer/Social Influence on Smoking Behaviour 52 Level of Education and Type of Training 56 Smoking and Gender Issues 57 Summary 59 4 PaeNo. CHAPTER TWO: SMOKING CESSATION: THE PRACTICE THEORY GAP Introduction 61 Smoking Cessation Interventions 61 The Extent of Health Professionals' Smoking Cessation Interventions 62 Smoking Cessation Interventions Delivered by Doctors 62 Smoking Cessation Interventions Delivered by Dentists 64 Smoking Cessation Interventions Delivered by Pharmacists 65 Smoking Cessation Interventions Delivered by Nurses 67 Smoking Cessation Interventions For Nurses 69 Assisting Qualified Nurses to Stop Smoking 69 Assisting Student Nurses to Stop Smoking 71 Summary 74 CHAPTER THREE: THE LIMITATIONS OF SMOKING CESSATION INTERVENTIONS POSSIBLE THEORETICAL EXPLANATIONS Introduction 76 The Health Belief Model of Change 77 The Theory of Self Efficacy and Behavioural Change 78 The Transtheoretical Model of Change 80 Stages of Change 80 Processes of Change 83 Decisional Balance Theory 85 Sum mary 86 5 PageNo. CHAPTER FOUR: RESEARCH METHODS Purpose and Design 89 RESEARCH METHODS: PART A PHASE ONE OF THE STUDY: THE SMOKING CESSATION PROGRAMME 91 Collecting and Analysing Pre and Post Intervention Data 91 Exploratory Work and Feasibility Study 94 Access to Study Site 94 Recruitment of Sample 96 Data Collection Methods and Tools 96 (a) Pre-Test Self Administered Questionnaires 96 (b) The Intervention 97 (c) Carbon Monoxide Expired Alveolar Air Measurements 98 (d) Saliva Cotinine Concentration Data 99 (e) Post-Test Self Administered Questionnaires 100 Pilot Work: 101 Access to Pilot Site 101 Piloting the Instruments 101 MAIN STUDY 104 Data Collection Procedures 104 The Intervention 105 (a) Assessment of Health Beliefs and Motivation to Stop Smoking 105 (b) Planning the Approach to Stopping Smoking 106 (c) Implementation of the Smoking Cessation Plan 106 6 PageNo. Monitoring Smoking Behaviour 107 Objective Measurements 107 One Year Post-Test Semi-Structured Questionnaires 107 Problems Experienced with Data Collection 108 Data Analysis 109 Analysing the Pre-Test and Post-Test Questionnaire Data 109 Analysis of Objective Measurements 114 Ethical Issues 114 RESEARCH METHODS: PART B PHASE TWO OF THE STUDY: THE IN-DEPTH INTERVIEWS 117 Data Collection and Data Analysis of Taped Recorded Semi- Structured Interviews 117 The Relevance of a Qualitative Approach 118 Exploratory Work 121 Sample and Access 121 Data Collection 122 (a) Development of Semi-Structured Interview Schedule 122 (b) Tape Recording the Interviews 123 Pilot Work: Taped Recorded Semi-Structured Interviews 123 Revisions 125 MAIN STUDY 126 Data Collection 126 Semi-Structured Taped Recorded Interviews 126 Problems with Audio Recorded Data Collection 127 Data Analysis: 128 Analysing the Audio Recorded Data 128 7 PageNo. (i) Transcription of Taped Interviews 129 (ii) Phenomenological Reduction 129 (iii) Delineating Units of General Meaning 130 (iv) Delineating Units of Meaning Relevant to the Research Question 131 (v) Eliminating Redundancies 132 (vi) Clustering Units of Relevant Meaning 132 (vii) Determining Themes from Clusters of Meaning 133 (viii) Writing a Summary for each Individual Interview 133 (ix) Identifying General and Unique Themes for all the Interviews 134 Ethical Issues 135 CHAPTER FIVE: FINDINGS FROM PHASE ONE THE SMOKING CESSATION PROGRAMME Introduction 137 Findings From Qualified Nurses' And Student Nurses' Baseline Questionnaires 138 The Qualified Nurses' Data 139 Characteristics of Qualified Nurses 139 Smoking History of Qualified Nurses 140 Health Beliefs of Qualified Nurses 141 Qualified Nurses' Perceptions of their Role as Promoters of Health 143 The Motivation of Qualified Nurses to Stop Smoking 143 The Student Nurses' Data 147 Characteristics of Student Nurses 147 Smoking History of the Student Nurses 148 Health Beliefs of Student Nurses 149 Student Nurses' Perceptions of their Role as Promoters of Health 150 The Motivation of Student Nurses to Stop Smoking 151 Smoking Cessation Outcomes 154 8 PageNo. The Impact of the Intervention 154 The Importance of Objective Verification of Smoking Cessation 155 (a) Levels of Carbon Monoxide in Expired Alveolar Air 155 (b) Concentration of Cotinine in Saliva Samples 158 One Year Questionnaire Data From The Nurses Who Stopped Smoking 159 Responses From the Student Nurses and Qualified Nurses Who Stopped Smoking 159 Reasons Given
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