CPEnhancing Patient Communication for the Psychiatric Nurse

December 2010 Volume 1, Number 3

Counseling Points™

Psychiatric Nurse

This activity is supported by an educational grant from Pfizer, Inc. A Publication of the

American Psychiatric Nurses Association

Breaking Barriers and Implementing Changes

Treating Tobacco Dependence in Persons with Mental Illness: Identifying Challenges and Opportunities

Part 3 in a 3-Part Series

Counseling Points™ 2

Chair:

Daryl Sharp, PhD, PMHCNS-BC, NPP

Director, Doctor of Nursing Practice Program

Associate Professor of Clinical Nursing and in the Center for Community Health

University of Rochester Medical Center

Rochester, New York

Faculty/Authors:

Madeline A. Naegle, APRN, BC, PhD, FAANProfessor and Coordinator, Advanced

Practice Nursing: Psychiatric-Mental HealthDirector, New York University College of

Nursing, International ProgramsDirector, New York University, World Health

Organization Collaborating Center for Geriatric Nursing Education

New York, New York

Victoria Palmer-Erbs, PhD, APRN, BCAssociate Professor of NursingCollege of Nursing and Health SciencesUniversity of Massachusetts BostonBoston, Massachusetts

Steven A. Schroeder, MDDepartment of Medicine and Smoking

Cessation Leadership CenterUniversity of California, San FranciscoSan Francisco, California

Georgia L. Stevens, PhD, APRN, PMHCNS, BCGeropsychiatric Nurse CoordinatorBaltimore Mental Health Systems & Maryland

Mental Hygiene AdminsitrationBaltimore, Maryland

APNA and Faculty/Authors Disclosure Statements:

Accredited status of an activity does not imply APNA or ANCC Commission on Accreditation endorsement of commercials products.

Georgia Stevens discloses that she has received honoraria and served on a Speakers’ Bureau for Janssen Pharmaceuticals.

Madeline Naegle, Victoria Palmer-Erbs, Steven Schroeder, and Daryl Sharp have no conflicts to disclose.

Publishing Information:

PublishersJoseph J. D’OnofrioFrank M. MarinoDelaware Media Group66 South Maple AvenueRidgewood, NJ 07450Tel: 201-612-7676Fax: 201-612-8282Websites: www.delmedgroup.com www.counselingpoints.com

Editorial DirectorNancy Monson

Art Director

James Ticchio

Cover photo credit: © Geo Martinez / Veer ©2010 Delaware Media Group, Inc. All rights reserved. None of the contents may be reproduced in any form without prior written permission from the publisher. The opinions expressed in this publication are those of the faculty and do not necessarily reflect the opinions or recommendations of their affiliated institutions, the publisher, APNA, or Pfizer, Inc.

Counseling Points™ Breaking Barriers and Implementing ChangesTreating Tobacco Dependence in Persons with Mental Illness: Identifying Challenges and Opportunities

Continuing Education Information Target AudienceThis educational activity is designed to meet the needs of psychiatric nurses with an inter-est in providing quality care to consumers with mental illness who smoke and/or use other tobacco products.

Learning ObjectivesUpon completion of this educational activity, the participant should be able to:

• Identify the barriers and challenges that nurses face in providing tobacco dependence interventions in healthcare delivery systems

• Describe nursing strategies to address the challenges that deter the delivery of evi-dence-based tobacco dependence interventions

• Describe nursing strategies to reduce the barriers to the delivery of evidence-based tobacco dependence interventions

Continuing Education CreditThe American Psychiatric Nurses Association is accredited as a provider of continu-ing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Successful completion of this activity will be achieved when a participant reads the issue, completes the posttest with 80% correct or better, and completes the evaluation. This can be done online or via mail or fax. See detailed information on pages 14-15.

1 contact hour may be earned for successful completion of this activity.

The contact hours for this continuing education activity will expire on December 31, 2012.

Disclosure of Unlabeled UseThis educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. The American Psychiatric Nurses Association, Delaware Media Group, and Pfizer, Inc. do not recommend the use of any agent outside of the FDA-approved labeled indications. The opinions expressed in this educational activity are those of the faculty/authors and do not necessarily represent the views of the American Psychiatric Nurses Association, Delaware Media Group, or Pfizer, Inc.

DisclaimerParticipants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clini-cians or other healthcare professionals without first evaluating their patients’ conditions, con-sidering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.

DeCember 20103

Dear Colleague,

As we reach the final of three issues of Psychiatric Nurse Counseling Points™ on tobacco cessation for persons with mental illnesses and/or substance abuse addictions, we turn our focus to identifying and overcoming the barriers and challenges nurses face in delivering tobacco dependence interventions.

This series has shown that individuals with mental and/or substance use disorders as well as mental health personnel have higher rates of smoking dependence than the general population. Little has been done, however, to address the barriers to tobacco reduction efforts and to integrate smoking cessation interventions into psychiatric treatment. The APNA has taken a strong position that we cannot talk about mental health transformation and recovery if we do not transform mental health settings and care delivery to address the health and wellness of whole persons, and include the reduction of tobacco dependence.

We would once again like to thank Pfizer, Inc. for providing an educational grant for this series of three issues. (You can access the previous two issues, by the way, from the APNA website.) We urge you to visit the APNA Tobacco Dependence Informa-tion Center at www.apna.org/TDInfoCenter, and to take the challenge of interven-ing with consumers, peers, and your organization in this important area of health and psychiatric-mental health nursing.

Best regards,

Carol Farley-Toombs, MS, RN, NEA-BC

President, APNA

welcome

Counseling Points™ 4

Introduction

N urses are essential care providers, and are required to assist organizations in meeting national practice standards for treating tobacco dependence, which

includes tracking and reporting tobacco dependence out-comes. Despite the availability of efficacious interventions, nurses and other clinicians do not consistently intervene with their patients who smoke.1 The competing demands of clinical practice can undermine nurses’ interest in and motivation to address tobacco dependence. Furthermore, healthcare organizations often lack the structures that sup-port efficient delivery of interventions.

How can nurses become more motivated, confident, and competent in assessing consumer needs, in facilitating change, and in delivering evidence-based tobacco depen-dence treatments? And how might we strengthen organi-zational care delivery systems so that consumers receiving mental healthcare can be assured of easy access to such interventions? This issue of Psychiatric Nurse Counseling Points™ is focused on identifying and addressing the barri-ers nurses face from their organizations, other clinicians, and consumers in promoting smoking cessation, and identifying strategies and interventions to overcome these barriers.

Organizational Barriers to Tobacco Dependence TreatmentHealthcare purchasers, payers, and insurers do not typically view tobacco dependence interventions as a priority, and covered services, medications, and copayments are costly.2

Challenging these fiscal barriers requires advocacy for acces-sible and affordable screening and treatment.

There is widespread agreement that psychiatric-mental health service organizations have been slow to address tobacco dependence among consumers and staff. Solway has described a central and ingrained culture of allowing, accepting, and even encouraging tobacco use in mental health settings.3 Cigarettes have been used as behavioral reinforcers and smoking breaks as a form of normalizing socialization, with staff and consumers smoking together. This has created a limiting and demeaning perception among consumers and clinicians that smoking is one of the last pleasures available to mental health consumers.4 In addition, Prochaska, Hall, and Bero report that the tobacco industry has not only promoted smoking in psychiatric set-

tings, but has supported efforts to block smoking bans in hospitals.5

When healthcare administrators fail to prioritize tobacco dependence treatment, barriers to cessation are reinforced or erected.6 Despite the fact that tobacco dependence is a DSM-IV-R Axis 1 diagnosis, interventions too often are not conceptualized as part of psychiatric-mental health treatment. Adequate supplies of educational materials and medications to aid cessation may not be available, and clinical proficiency in delivering evidence-based tobacco dependence interventions may not be identified by employ-ers as an essential component of nursing competencies. “No smoking” guidelines may not exist or be enforced. These barriers undermine institutional support for staff members who do promote smoking cessation treatment.

Culture change in mental health settings requires strong leadership and an organizational plan to achieve these goals. Solway describes four critical strategies for challenging the barriers to tobacco culture change: 1. reframing the lack of attention to tobacco cessation as

discriminatory and leading to further marginalization of mental health consumers;

2. identifying meaningful alternatives to smoking; 3. reframing tobacco cessation rather than tobacco use as a

choice; and 4. reducing tobacco use among mental health staff.3

Organizations that prioritize tobacco dependence treat-ment for consumers and staff can employ these strategies to facilitate staff interest in and motivation for helping con-sumers avoid the dire health consequences of tobacco use and dependence.1

Consumer Barriers to Tobacco Dependence TreatmentThe high prevalence rate of smoking and its related mor-bidity and mortality among persons with mental illness perhaps reflects an underestimation of the harmful effects of smoking and a lack of knowledge among consumers about effective ways to quit.7 In fact, research has consis-tently revealed that mental health consumers often have not been offered information about or opportunities to discon-tinue tobacco use.8-10 Given the chronic, relapsing nature of tobacco dependence, it is difficult to significantly impact nicotine addiction without providing information about the

Treating Tobacco Dependence in Persons with Mental Illness: Identifying Challenges and

Opportunities

DeCember 20105

harm associated with tobacco dependence and counseling consumers about effective quit strategies. Support also needs to be supplied using a variety of educational formats and motivational interventions over time.

Dissemination of information alone does not facilitate behavior change. The personal beliefs of consumers about tobacco and cigarettes must be understood if educational efforts are to be meaningful.11 Consumers often describe the beneficial effects of cigarettes in terms of helping them to calm down, think better, and relieve boredom.12 Many describe the negative effects of quitting as withdrawal symptoms, weight gain, social isolation from their smok-ing peers, and mental health instability (including symptoms of depression and anxiety).12 Addressing these perceived pros and cons is critical when assessing a consumer’s readi-ness to quit and his/her receptivity to information, sorting through and resolving potential ambivalence about stopping smoking, providing useful evidence-based information, and developing an effective quit plan.

Research guided by self-determination theory has dem-onstrated that an autonomy-supportive, intensive, evidence-based intervention yields better cessation outcomes than typical community care regardless of the readiness to quit.13 Nurses are most effective in aiding harm reduction and/or cessation when they strive to understand consumers’ health-related values and their relationships with nicotine, includ-ing their past quit attempts. Consumers respond best when nurses offer them treatment choices. Coercive interven-tions or pressuring people to stop smoking by threatening or shaming them are ineffective and harmful because they tend to strengthen resistance to health behavior change by undermining consumers’ sense of efficacy and autonomy.13

Clinician Barriers to Tobacco Dependence TreatmentIn addition to organizational barriers and consumers’ chal-lenges in stopping smoking, there are a number of clini-cian barriers that stand in the way of consistent delivery of tobacco dependence treatment. These include:

Knowledge gaps: Just as consumers and their families may underestimate the harm caused by the use of tobacco products to mental health consumers and those around them, so, too, may clinicians; clinicians may also lack up-to-date knowledge about advances in tobacco treatment interventions.14 Such evidence-based information is avail-able to nurses in the literature, even if it is not a current organizational priority.15

Competing demands: Resources for mental health staff are often limited, particularly in economically challeng-ing times. When competing demands are prioritized, the treatment of tobacco dependence may be deemed too com-

plex and time-consuming to be implemented by staff who feel undervalued and overworked.

Negative beliefs: A variety of commonly accepted myths contribute to the failure to intervene, such as the perception that tobacco cessation causes mayhem in the clinical setting or interferes with mental health treatment (e.g., consumers will become agitated or will stop com-ing to treatment groups). The literature that negates these misperceptions needs to be broadly disseminated.15-17

A clinician’s own smoking status: In addition to normalizing rather than denormalizing tobacco use, smok-ing by clinicians negatively impacts tobacco dependence treatment because clinicians who smoke are less likely to intervene with consumers who smoke than are clinicians who don’t smoke.18,19

Pessimism: Despite research indicating that many con-sumers with mental illness want to and can be successful in stopping smoking, many clinicians doubt their capacity to do so.20 By not addressing tobacco dependence actively, such pessimism is communicated to consumers—when the evidence shows that clinician advice can significantly strengthen smokers’ motivation to quit.1 Unfortunately, this pessimism further stigmatizes and marginalizes mental health consumers.21,22

It is no longer an option for nurses to dismiss the importance of assessing and offering tobacco

dependence treatment to all consumers.

Nursing Strategies for Implementing Tobacco Dependence Interventions on the Individual LevelAs healthcare delivery systems create smoke-free cam-puses, nurses and other employees will be called upon to role-model healthy lifestyle choices for consumers. This means that everyone will be required to develop appro-priate strategies to follow new workplace policies. Some will also need to manage personal tobacco use during work hours.23

The American Psychiatric Nurses Association’s (APNA) Tobacco Dependence Task Force notes that “Failure to act on tobacco dependence equals harm.”24 It is no longer an option for nurses to dismiss the importance of assessing and offering tobacco dependence treatment to all consum-ers. There is also a further requirement of documenting the outcomes of such approaches, even when the nurse thinks the mental health consumer will not be interested in or would not be successful in ending tobacco use at this time.25

Counseling Points™ 6

Implementing Changes in Nursing PracticeGiven the current nursing shortage and the nurse’s already well-documented, significant duties in clinical settings, many may wonder how nurses can effectively respond to requests for individual practice changes. These changes will be influenced by the individual’s educational prepara-tion, current licensure status and certification, as well as the current scope of role responsibilities within his/her organization.26-28

Practicing nurse generalists and advanced practice nurses know that the nursing profession expects all nurses to dem-onstrate commitment to the profession and professional competence as lifelong learners who will continue to grow and refine practice competencies (i.e., knowledge, attitudes, and skills) as required for current practice.28,29 The Ameri-can Nurses Association’s (ANA) Nursing’s Social Policy State-ment indicates that nurses “are responsible for practicing in accordance with recognized standards of professional nurs-ing practice and professional performance.”30 Nurses are also held individually accountable and responsible to develop their own continuing education plans to maintain core competencies in the areas in which they practice. Thus, these broad professional statements and standards would clearly include any new employer requirements to incor-porate evidence-based practices in working with consumers who are experiencing episodes of mental illness while strug-gling with tobacco dependence.24,31,32

If needed, nurses or other providers should offer a brief intervention, refer the person

to tobacco dependence treatment, and appropriately document the clinical encounter and any smoking or tobacco use behaviors.

Nurse generalists and advanced practice nurses also are expected to incorporate evidence-based public health approaches for health promotion, risk reduction, disease prevention, and relapse prevention into their clinical prac-tice.1 These areas include but are not limited to prevention and education of nonusers about the well-known dangers of tobacco dependence; the education and encouragement of smokers and nonsmokers to adopt healthy lifestyle habits; and the assessment of each mental healthcare consumer on every new hospitalization for current tobacco use or risk to resume tobacco use. If needed, nurses or other providers should offer a brief intervention, refer the person to tobacco dependence treatment, and appropriately document the clinical encounter and any smoking or tobacco use behaviors.33

Additionally, there is growing emphasis on screening and educating the psychiatric-mental health consumer who

may be a current nonsmoker, never-smoker, or a bystander about the negative health effects of environmental tobacco exposures, especially secondhand smoke (i.e., “side stream smoke released from the burning end of a cigarette and exhaled mainstream smoke by the smoker”).34 Rabin pro-vides a national newspaper account on risks of another important environmental exposure, labeled “third-hand smoke,” and describes it as “the invisible yet toxic brew of gases and particles clinging to smokers’ hair and cloth-ing, not to mention cushions and carpeting, that lingers long after second-hand smoke has cleared from a room.”35 Nurses may be asked about the risks of both direct use and indirect smoking exposures, and must be prepared to edu-cate and advise consumers and families about these hazards to everyone living with them.

Making the Commitment to Identify and Treat Tobacco Dependence In addition to following general guidelines for the scope and practice of nursing, psychiatric-mental health nurses also must understand and implement the ANA’s latest (2007) Psychiatric-Mental Health Nursing: Scope and Standards of Practice document into their practice.8,36,37 However, in order to treat tobacco dependence most effectively, nurses must integrate these standards with current evidence-based treatment guidelines.24,25 Postponing treatment delays the implementation of effective care and the health benefits associated with tobacco cessation at any stage of the con-sumer’s life.38 Eventually, consumers, family members, and insurers may view failure to assess and offer treatment for tobacco dependence as a form of neglect of an important life-threatening health condition.

The latest tobacco treatment guidelines are the Clini-cal Practice Guideline for Treating Tobacco Use and Dependence (Fiore et al., 2008).1 When reviewing this document, nurses should identify those aspects of the guidelines that are already operational in their workplace. Nurses should then note any new items among the guidelines and plan to acquire new knowledge and skills as dictated by these items.1 The goal is to use current clinical and research expertise and consumer preferences to customize tobacco intervention plans that are both engaging and likely to pro-mote individual successes in treatment outcomes. Using local program resources, nurses can work directly with con-sumers—individually or in small groups—to offer initial and longer-term treatment interventions and supports. In other settings, nurses can refer consumers to a tobacco treatment specialist who “helps tobacco dependent individuals elimi-nate or substantially reduce their tobacco use by assisting them in developing the motivation, confidence, knowledge and skills necessary to achieve cessation and maintain absti-nence.”32 The Choices Program in New Jersey is an exam-

DeCember 20107

ple of an extension of supports beyond traditional inpatient and outpatient treatment approaches.39 This innovative pro-gram employs a peer support network of Consumer Tobac-co Advocates who reach out to smokers with mental illness and provide community-based education and supports.

It is clear that the roles and responsibilities of the reg-istered nurse in psychiatric-mental health settings require the nurse to participate in identifying consumers at risk for tobacco-related illnesses and in treating tobacco dependence and nicotine addiction. Formerly, it was sufficient to know “a specific body of knowledge.” Currently, competent nurses need to know “how to access the ever-changing information needed to manage care.”29

Recently, the American College of Sports Medicine managed a similar practice challenge to the one currently facing psychiatric-mental heath nurses about identifying and treating tobacco dependence.40 With evidence mounting about the huge costs of inactivity and the value of regular daily exercise to assist clients in achieving and maintaining overall health goals, exercise and health science (EHS) pro-fessionals were called upon to actively prescribe and moni-tor daily exercise as a treatment to all of their client popula-tions. Just as with tobacco dependence, EHS professionals realized that the failure to identify a client’s current exercise requirements caused harm to his or her overall health status. How would a diverse membership of EHS professionals best communicate with each other and motivate the general public more effectively to act on this new, lifesaving infor-mation? EHS experts knew, just as nurses already know, that all practice changes must begin with necessary personal behavioral changes in each individual, before changes can be made in working with consumers in clinical settings.40

Many nurses will approach the task of building and refin-ing knowledge, attitudes, and skills in the area of tobacco dependence and nicotine addiction in the same way in which EHS professionals implemented practice changes in exercise prescription, by using an incremental steps strategy. This process begins with an individualized self-assessment to identify values and beliefs about nicotine addiction, as well as knowledge and skills regarding tobacco use and depen-dence (Table 1). The nurse can then set ongoing incre-mental goal(s) to become more skilled and proficient in this treatment area.

Nursing Strategies for Implementing Tobacco Dependence Interventions on the Organizational Level Despite the widespread adoption of federal guidelines on smoking cessation, most nurses do not include interventions for tobacco dependence in their provision of direct nursing care. In addition to the factors discussed previously, delays

by treatment facilities and schools of nursing in modifying policies or changing curricula contribute to this problem. Wewers and colleagues noted that content on techniques for smoking cessation was absent from 50% of baccalaureate programs surveyed.41 The expectation that nurses will col-laborate with colleagues and work with consumers toward smoking cessation is usually not clearly articulated in policy

Table 1. Nurse’s Reflections and Self-assessment: Identifying Personal Factors and Educational Gaps about Tobacco Dependence

• What experiences do I have with tobacco dependence and nicotine addiction (myself, family members, friends, col-leagues)?

• How do these personal experiences and organizational factors inform my beliefs about the importance of treating tobacco dependence and nicotine addiction in my current employment setting?

• Am I aware that the identification of current tobacco users is a part of a new national best practices standard of care?

• Am I confident that treating tobacco dependence and nico-tine addiction works and will make a difference in a con-sumer’s life?

• At this time, am I willing to take the necessary actions to acquire the new knowledge, attitudes, and skills to assist consumers in addressing the effects of addiction in their lives? If yes, where can I start and how soon can I begin?

• What do I already know about the best approaches to the treatment of tobacco dependence and nicotine addiction? Do I have a good understanding of the pathophysiology of tobacco dependence and nicotine addiction? How well can I communicate to the consumer the harmful effects of nicotine dependence on the successful treatment of their mental illness condition?

• How well can I describe to the consumer how pharmaco-logic interventions work to treat tobacco dependence and nicotine addiction, and why combinations of treatments are important to consider at any stage of a person’s life and health status? If not, where can I obtain this information?

• How can I engage and motivate the consumer to consider the important health risks associated with tobacco depen-dence and nicotine addiction? How do I collaborate with the consumer to take the necessary steps to end tobacco use while he/she is receiving care?

• Could I possibly become a champion in my clinical setting, taking the lead with others in addressing harmful effects of tobacco dependence and nicotine addiction in my organi-zation? What must I do to ready myself for this role? What resources and supports are needed?

Counseling Points™ 8

management support and resource availability, mediated by organization climate, policies, and practices.46 Another study found that health professionals who themselves participated in a smoking cessation program reported greater willingness to assess and advise consumers about smoking and provide behavioral counseling.51

Rogers’ Innovation Diffusion ModelEverett Rogers developed a model of innovation diffusion that links five factors having to do with the innovation itself and the responses of individuals or organizations to the change to the success of an innovation.44 The first fac-tor is relative advantage, or the perception that the new practice is better than the current practice. Some studies found that nurses in psychiatric hospitals report that they are unsure that smoking cessation is of benefit to mental health consumers, and hence, these nurses do not support policy changes.47,48,52 These findings suggest the absence of another factor essential to the adoption of an innovation, compat-ibility, or the extent to which there is a fit between pro-vider goals, experience, and values. For example, 68.5% of the nurses in a small study (N=156) reported that they believe that messages to consumers about smoking encroach on their rights and on nurses’ rights to smoke; the policy or innovation, in other words, clashes with the provider’s goals or values.47 In another study, nurses who smoked reported they felt “caught in the middle” by their own tobacco addiction and stated they would welcome offers of assis-tance to quit.53

Helfrich et al. labeled the same phenomenon as a lack of the “innovation-values fit” necessary to adopt an innova-tion.46 When values impede nurses’ willingness to encour-age smokers to quit, as when nurses themselves smoke, they are less likely to encourage consumers to quit.1 Simi-larly, faculty who smoke may be less likely to teach health implications of nicotine dependence and smoking cessation skills to students.54 The attributes (belief systems, educa-tion, experiences) of nurses employed in the facility can also be linked to barriers and facilitating factors. If nurses are influential in their institutions or on their units, their beliefs and practices can promote change or present barriers to it. The complexity or simplicity (the perceived ease) with which an innovation might be adopted is also a factor in the readiness of an organization to embrace innovation.45 While guidelines such as the 5 As (Ask, Advise, Assess, Assist, Arrange) for initiation and support of smoking cessation are straightforward, changes such as education and training and strategies for dealing with resistance are required for staff to implement the changes. These may be viewed as costly and complicated.1 The triability, or the extent to which

or educational standards or supported by management and employees.

A key factor noted by Miller et al. is the particularly wide gap between scientific discoveries and the treatment models employed for substance/nicotine dependence.42 These authors emphasize the lag in the implementation of evidence-based practices in substance abuse facilities, with the result that best clinical practices are slow to influence healthcare outcomes.43 This situation is paralleled in mental health treatment facilities.

Research is limited regarding the reasons for delays in the adoption of guidelines for best clinical practices proposed by government and professional organizations. Findings sug-gest more reasons are documented for individual providers` failure to implement changes (lack of time, training, and/or belief in efficacy) than for the failure of organizations, insti-tutions, and facilities to bring about change. The writings of Flynn and Simpson as well as Everett Rogers elucidate barriers and facilitators to change at organizational levels.44,45 In addition, research by Helfrich et al. explores the appli-cation of change models in the healthcare sector and pro-vides some important “lessons learned.”46 Not surprisingly, multiple factors influence the readiness to change clinical practices within organizations, be they private practices, community care centers, schools of nursing, or healthcare institutions.45

A major variable influencing the failure to change nurs-ing practices for tobacco cessation may be the attitude that as employees, despite individual licensure, nurses have little capacity to influence policies and practices within the larger organization.45 While they may believe that it is important to discuss smoking with consumers, nurses may not do so because it is not in their job descriptions or the nursing role as practiced in the workplace. Research findings suggest that a lack of unity among nurses about the personal need to quit smoking to promote consumer health and their own health is another factor that may impede organizational change, especially when nursing staff report beliefs that nonsmoking policies increase the stress on smoking nurses or increase the likelihood of con-sumer behavioral disturbances.47-49

Links between the structure and climate of an organiza-tion and significant change-related factors are documented. Early on, Hocking et al. demonstrated the importance of the managerial hierarchy when they reported that smoking bans in studied hospital sites were more acceptable when managers who possessed good negotiating skills consulted nurses about impending policy changes.50 Similarly, compli-ance with total smoking bans was more acceptable when institutions recognized their smoking employees and offered support to those nurses. This reinforces the observation that effective innovation implementation is a function of

DeCember 20109

staff learning and readiness to comply with, support, or use new procedures and new policies. The educational out-comes of learning and perceived mastery of new knowledge and skills have been shown to correlate with the adoption of an innovation.55,56

A number of study findings support the idea that a posi-tive organizational climate, (shared perception of the rela-tive priority of specific roles or tasks) and a general readi-ness to embrace innovations, attributes, and resources are present when successful, change-oriented learning takes place.46 These studies emphasize that the characteristics of the organization into which change is introduced is equal

an innovation can be tested, and operability, how read-ily the benefits of an innovation can be perceived by others, are the fourth and fifth of Rogers’ factors.44 These factors necessarily build on organizational readiness to change and to educate others in new practices. In order to explore tri-ability, policy changes must allow at least a “pilot testing” of the innovation by a small group in a potential frame-work. Flynn and Simpson identify 1) exposure (training and workshops); 2) adoption; 3) implementation; and 4) practice of the newly adopted innovation as essential steps.45 This model is compatible with continuing education approaches in nursing and healthcare delivery systems with the goals of

In the last issue of Counseling Points™ for the Psychiatric Nurse you stated that some mental health providers believe that smoking cessation is unrealistic for their clients because they think consumers don’t want to quit, won’t be able to quit, or their symptoms will get worse—but these are all misconceptions. So let’s tackle the latter part of this question in more detail: Will smoking cessation exacerbate an underlying mental illness?

The medical literature is really conflicted on this point. Early on, it said smoking cessation did worsen an underlying illness and now it says it doesn’t. The truth is probably somewhere in between: Smoking cessation probably does exacerbate symptoms of mental illness in some consumers but not in others.

Also, we now recognize that many people with mental illness drink large quantities of caffeinated coffee, and there are ele-ments in cigarette smoke that cause caffeine to have a short-er half-life in the blood. That means if you stop smoking, caf-feine hangs around longer in your system and you may get jittery and anxious from the coffee and from the withdrawal of the nicotine, not from the underlying psychiatric illness.

Are there particular illnesses where the literature suggests smoking cessation may have worse effects—in people with schizophrenia, bipolar disorder, etc.?I don’t think the literature is strong on that. We’re still exam-ining this issue, but in some instances—say, alcohol depen-dence—it appears that people who are able to stop smoking are better able to get sober and stay sober.

Why are people with mental illnesses more susceptible to tobacco dependence than those in the general population? It’s because they smoke at higher rates, anywhere from 2-3-4 times higher, depending on the study, year, and diagnosis. Probably the highest rates are seen in people with substance abuse disorders/addictions or alcoholism.

Does smoking cessation counseling for those with mental illnesses differ from cessation counseling for those in the general population? Not greatly, but there are a couple of things that are dif-ferent. One is that people with mental illness have regular encounters with therapists and other health professionals, so there’s the opportunity there to bring it up. Two is that it may take these people a little longer to quit than others, because of the intensity with which they smoke. Basically, though, we use the same tools—counseling plus pharma-cotherapy plus peer support—that we use for people in the general population.

Since this publication is for psychiatric nurses, are there specific strategies that nurses are particularly well positioned to use to help consumers with psychiatric illnesses to stop smoking?Nurses are very respected among health professionals, and are seen as the consumer’s advocate, so clients may be espe-cially trusting of them. If nurses mention smoking cessation, it may carry more weight than if another health professional brings it up. I hope nurses will lead the way.

An Interview with Steven A. Schroeder, MDDirector

Smoking Cessation Leadership CenterUniversity of California, San Francisco

San Francisco, Californiahttp://smokingcessationleadership.ucsf.edu/

In this final issue of Counseling Points™ for the Psychiatric Nurse, we wrap up our interview with Dr. Schroeder…

Counseling Points™ 10

Table 2. Strategies to Support Tobacco Dependence Interventions on the Organizational Level: Recognize, Assess, Design, Provide, Implement43-47,52,57-60

RECOGNIZE and work within the structure of the organiza-

tion, whether it is a unit, treatment facility, or school of nursing:

1) Articulate how smoking cessation practices and policies fit with the organizational mission and strategic goals of the organiza-tion. Rationale: Demonstrate an “innovation-values fit.”

2) Plan a smoking cessation program and related policies con-gruent with the mission of the organization, nursing traditions and innovations, and other professional leadership, and the organization’s community and organizational prominence. An example is the national nursing agenda, which includes an employee-friendly policy and efforts to increase safety in the work environment. Rationale: Innovations in the healthcare sector require coordinated use of an innovation by multiple organization members in order to see benefits.

3) Introduce all levels of managers to approaches to policy development and ways to introduce it to personnel and con-sumers in order to achieve maximum “buy in.” Involve nurs-ing staff in planning proposed policy changes and education for policy implementation. Rationale: Facilitating early “buy in” enhances a positive organizational climate.

ASSESS the climate of the organization, including attitudes and

openness to change in groups of employees and management. 1) Identify and include “thought leaders” (charismatic individu-

als who are influential in shaping their colleagues’ ideas and can help overcome resistance). Invite them to champion the innovation or project as role models and teachers, and take ideas forward both in policy and by modeling the desired clinical behaviors.

2) Recognize that the organization is a social system in which informal communication is as influential as formal policy and/or part of a larger system. Use assessment questions, such as:

• What is the culture of the organization? • What are its norms and traditions? • What place does smoking have in the culture?

If smoking is perceived as part of the culture of a psychiatric hos-pital, consumers and staff will be less open to change. Rationale: When the climate is one of openness, ease of communication, flexibility, and reward for change, adoption of innovations hap-pens more readily. Changes that can be embraced with positive cultural meaning will be more acceptable.

DESIGN training/education which is specific to employees and

the organization’s readiness for change and learning needs:

1) Address motivational issues—strive to understand employ-ees’ perspectives and include problem-solving for perceived barriers in training/education.

2) Design training/education which is specific to health profes-

sionals as learners:

a) Address attitudes.

b) Identify knowledge of smoking and tobacco dependence

(i.e., the nature, reward systems, and levels of addiction),

comprehensive care that emphasizes psychosocial as well

as pharmacologic interventions, prevalence of smoking in

health professionals, etc.

c) Educate all staff, but identify selected (senior or more

knowledgeable or enthusiastic) staff as champions.

• Provide supervision during practice and learning.

• Use workshop, feedback, and coaching models.

• Develop evidence-based protocols on smoking cessa-

tion tailored to consumers’ varied levels of dependence.

Rationale: Training relevance predicts use of materials and

training materials are adopted more readily when organi-

zational climate factors are positive.

PROVIDE access to resources so that employees can be treated

for tobacco dependence:

1) Encourage smoking employees to seek help; be compassion-

ate when this is difficult.

2) Acknowledge the role of peer influence when nurses are

smokers themselves (approximately 13% of nurses smoke, with

higher prevalence rates among psychiatric nurses) and cannot

come to terms with a clash with their beliefs.

3) Develop protocols for referring and using employee assistance

for smoking cessation counseling and support.

4) Provide access or referral to smoking cessation treatment

programs.

IMPLEMENT changes:

1) Recognize implementation as a transition period and allow

adequate time for change to occur.

2) Allow at least a pilot testing of the innovation by a small

group or a unit.

3) Provide positive reinforcement and feedback when users

engage in sustained changed practices. Rationale: The

operability and ease of use of the innovative change being

introduced must be reinforced over time and with positive

outcome data. By documenting the positive outcomes in

consumer and employee smoking cessation in program fol-

low-up, as well as documenting changes in nursing practice

over time, the relative advantages of changes in practice will

be more evident.

DeCember 201011

References

1. Fiore MS, Jaen RC, Baker TB, et al. Treating Tobacco Use and Depen-dence: 2008 Update. Clinical Practice Guidelines. Rockville, Md: US Department of Health and Human Services, Public Health Service. May 2008. Accessed October 13, 2010 at: www.ahrq.gov/path/tobacco.htm.

2. Gollust SE, Schroeder SA, Warner KE. Helping smokers quit: Understand-ing the barriers to utilization of smoking cessation services. Milbank Quart. 2008;86;601-627.

3. Solway E. Windows of opportunity for culture change around tobacco use in mental health settings. J Am Psychiatr Nurs Assoc. 2009;15:41-49.

4. Sharp DL, Blaakman SW, Cole RE, et al. Report from a national tobacco dependence survey of psychiatric nurses. J Am Psychiatr Nurs Assoc. 2009;15: 172-181.

5. Prochaska JJ, Hall SM, Bero LA. Tobacco use among individuals with schizophrenia: What role has the tobacco industry played. Schizophr Bull. 2008;34;555-567.

6. Ratschen E, Britton J, Doody GA, et al. Smoke free policy in acute men-tal health wards: Managing the pitfalls. Gen Hosp Psychiatry. 2009;31;131-136.

7. Ziedonis D, Williams JM, Smelson D. Serious mental illness and tobacco addiction: A model program to address this common but neglected issue. Am J Med Sci. 2003;326:223-230.

8. Diaz FJ, Rendon DM, Velasquez DM, et al. Smoking and smoking cessation among persons with severe mental illness. Psychiatr Serv. 2006;57:462.

9. Goldberg JO. Successful change in tobacco use in schizophrenia. J Am Psychiatr Nurs Assoc. 2010;16:21-29.

10. Williams JM, Foulds J. Successful tobacco dependence treatment in schizophrenia. Am J Psychiatry. 2007;164, 222-227.

11. Sharp DL, Bellush NK, Evinger JS, et al. Intensive Tobacco Dependence Intervention with Persons Challenged by Mental Illness: Manual for Nurs-es. 2009. Accessed October 13, 2010 at: www.apna.org/i4a/pages/index.cfm?pageid=3643.

12. Williams JM, Zeidonis DM. Snuffing out tobacco dependence: Ten rea-sons behavioral health providers need to be involved. Behav Healthcare. 2006;26:27-31.

13. Williams GC, McGregor HA, Sharp D, et al. Testing a self-determination theory intervention for motivating tobacco cessation: Supporting autono-my and competence in a clinical trial. Health Psychol. 2006;25:91-101.

14. Williams JM, Steinberg ML, Zimmermann MH, et al. Training psychiatrists and advanced practice nurses to treat tobacco dependence. J Am Psychi-atr Nurs Assoc. 2009;15:50-58.

in importance to the change itself. Planning to influence the climate can increase facilitating factors and/or decrease bar-riers. For example, making information available to nurses, a consumer group, an institution, or a treatment program that spells out the relative advantages of including protocols for consumer smoking cessation has the potential to influ-ence the climate.

Communication changes the climate when the percep-tion of the positive outcomes of a smoke-free environment are both formally and informally discussed and time is allot-ted to building consensus among staff members and manag-ers. When consensus can be reached, for example, about the role of nurses in conducting the 5 As intervention and making referrals to treatment, the role is more likely to be adopted. Communication is a powerful means of obtaining “buy in” from individuals, but it can also be used to form alliances with influential groups. If, for example, nurses or patient care technician/assistants are union members, obtaining support from the union or employing federation can help to increase a positive disposition to change within the climate.

The theories and research examples briefly described above provide the rationale for the strategies outlined in Table 2.

By taking on the role of a champion for tobacco depen-dence intervention, psychiatric nurses can be instrumental in affecting change in their organizations. As the mental health consumer’s greatest ally and advocate, psychiatric nurses can and should use the principles addressed in this and the previous section to consistently provide high-qual-ity tobacco dependence treatments throughout the health-care delivery system. If tobacco dependence interventions are not working well where you practice, it is important to strategize with your colleagues and leaders about how to improve their delivery.

ConclusionOrganizational, consumer, and clinician barriers to provid-ing timely, evidence-based tobacco dependence treatment do harm and must be overcome.17,61 The Surgeon Gen-eral’s 1999 Report on Mental Health identified the concept of recovery as the most important aim of mental health services; the concept was reaffirmed by the 2003 Presi-dent’s New Freedom Commission and mostly recently by the Substance Abuse and Mental Health Services Admin-istration (SAMHSA).62 If this model is to be meaningful, psychiatric-mental health nurses must help consumers in strengthening their physical and mental health and well-ness. We have an ethical imperative to assist mental health consumers to be survivors by working holistically, includ-ing aggressively and compassionately treating tobacco dependence in all settings (Table 3).

Table 3. We Know What We Need to Do15,17,21,63,64

• Train ourselves and other staff members in brief and inten-sive interventions

• Standardize assessments of smoking status and interest in stopping smoking

• Include nicotine dependence and withdrawal on Axis 1 diagnosis list and treatment plan

• Develop protocols for and access to pharmacotherapy• Offer treatments for staff who smoke• Denormalize tobacco use• Facilitate culture change

– Spread the intervention message person to person– Marginalize smokers (but not too much)

• Advocate for public health strategies– Taxes on tobacco products– Countermarketing– Smoke-free policies (e.g., in workplaces, bars, etc.)

Counseling Points™ 12

40. Jonas S. On oganizing the practice. In: Jonas S, Phillips EM, eds. ACSM’s Exercise is Medicine: A Clinician’s Guide to Exercise Prescription. Phila-delphia, Pa: Lippincott Williams & Wilkins. 2009. PP 20-30.

41. Wewers ME, Kidd K, Armbruster D, et al. Tobacco dependence curri-cula in U.S. Baccalaureate and graduate nursing education. Nurs Outlook. 2004;52:95-101.

42. Miller WR, Sorenson JL, Selzer JA, et al. Dissemination evidence-based treatment practices in substance abuse treatment: A review with sugges-tions. J Subst Abuse Treat. 2002;31:25-39.

43. Miller WR, Sorenson JL, Selzer JA, et al. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions. J Subst Abuse Treat. 2006;31:25-39.

44. Rogers EM. Diffusion of Innovations. New York, NY: The Free Press. 2003. 45. Flynn PM, Simpson DD. Adoption and implementation of evidence-based

treatment. In: Miller PM, ed. Evidence-based Addiction Treatment. San Diego, Ca: Elsevier. 2009, pp 419-437.

46. Helfrich CD, Weiner BJ, McKinney, MM, et al. Determinants of implemen-tation effectiveness: Adapting a framework for complex innovations. Med Care Res Rev. 2007;64:279-303.

47. Bloor RN, Meeson L, Crome IB. The effects of non-smoking policy on nursing staff smoking behavior and attitudes in a psychiatric hospital. J Psychiatr Ment Health Nurs. 2006;13:188-196.

48. Crockford D, Kerfoot K, Currie S. The impact of opening a smoking room on psychiatric inpatient behavior following implementation of a hospital-wide smoking ban. J Am Psychiatr Nurs Assoc. 2010;15:393-400.

49. Chou K, Lu R, Mao W. Factors relevant to patient assaultive behaviors and assault in acute inpatient psychiatric units in Taiwan. Arch Psychiatr Nurs. 2002;16:187-195.

50. Hocking B, Borland R, Owen N, et al. A total ban on workplace smoking is acceptable and effective. J Occup Med. 1991;33:163-167.

51. Puska PMJ, Barrueco M, Roussos C, et al. The participation of health pro-The participation of health pro-fessionals in a smoking-cessation program positively influences the smok-ing cessation advice given to patients. Int J Clin Pract. 2005;59:447-452.

52. Stubbs J, Haw C, Garner L. Survey of staff attitudes to smoking in a large psychiatric hospital. Psychiatr Bull. 2004;28:204-207.

53. Heath J, Andrews J, Kelley FJ, et al. Caught in the middle: Experi-ence of tobacco-dependent nurse practitioners. J Am Acad Nurs Pract. 2004;16:396-401.

54. Sarna L, Bialous SA, Rice VH, et al. Promoting tobacco dependence treat-Sarna L, Bialous SA, Rice VH, et al. Promoting tobacco dependence treat-Promoting tobacco dependence treat-ment in nursing education. Drug Alcohol Rev. 2009;28:507-516.

55. Terrell F, Zatsick DF, Jurkovich GJ, et al.. Nationwide survey of alcohol screening and brief intervention practices at US Level I trauma centers. J Am Coll Surg. 2008;207:630-638.

56. Strauss S, Twerell JM, Munoz-Plaza C, et al. Correlated of drug treatment program staff`s self-efficacy to support their client`s Hepatitis C virus (HCV) related needs. Am J Drug Alcohol Abuse. 2007. 33:245-251.

57. Garner B. Research on the diffusion of evidence-based treatments within substance abuse treatment: A systematic review. J Subst Abuse Treat. 2009;36: 376-399.

58. Liddle HA, Rowe CL, Quille TJ, et al. Transporting a research-based adolescent drug treatment program into practice. J Subst Abuse Treat. 2002;22:231-243.

59. Bartholomew NG, Joe GW, Rowan-Sal GA, et al. Counselor assessments of training and adoption barriers. J Subst Abuse Treat. 2007;33:193-199.

60. Tong EK, Strouse R, Hall T, et al. National survey of US health profession-als’ smoking prevalence, cessation practices, and beliefs. Nicotine Tob Res. 2010;epub doi:10.1093/ntr/ntq071.

61. Lawn S, Condon J. Psychiatric nurses’ ethical stance on cigarette smoking by patients: Determinants and dilemmas in their role in supporting cessa-tion. Int J Ment Health Nurs. 2006;15:111-118.

62. Substance Abuse and Mental Health Services Administration (SAMHSA). Recovery to practice: Project overview. Accessed October 8, 2010 at www.dsgonline.com/rtp/resources.html.

63. Ziedonis DM, Zammarelli L, Seward G, et al. Addressing tobacco use through organizational change: A case study of an addiction treatment organization. J Psychoactive Drugs. 2007;39:451-459.

64. Schroeder SA, Morris CD. Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse prob-lems. Annu Rev Public Health. 2010;31:297-314.

15. Prochaska JJ. Ten critical reasons for treating tobacco dependence in inpatient psychiatry. J Am Psychiatr Nurs Assoc. 2009;15:404-409.

16. Williams JM. Eliminating tobacco use in mental health facilities: Patients’ rights, public health, and policy issues. JAMA. 2008;299:571-573.

17. Schroeder S. Moving forward in smoking cessation: Issues for psychiatric nurses. J Am Psychiatr Nurs Assoc. 2009;15:68-72.

18. Sarna L, Bialous SA, Wells MJ, et al. Smoking among psychiatric nurses: Does it hinder tobacco dependence treatment? J Am Psychiatr Nurs Assoc. 2009;15:59-67.

19. Slater P, McElwee G, Fleming P, et al. Nurses’ smoking behaviour related to cessation practice. Nurs Times. 2006;102:32-37.

20. el-Guebaly N, Cathcart J, Currie S, et al. Smoking cessation approaches for persons with mental illness or addictive disorders. Psychiatr Serv. 2002;53:1166-1170.

21. Christakis NA, Fowler JH. The collective dynamics of smoking in a large social network. N Engl J Med. 2008;358:2249-2258.

22. Schroeder S. Stranded in the periphery-the increasing marginalization of smokers. N Engl J Med. 2008;358:2284-2286.

23. Massachusetts Bureau of Substance Abuse Services (BSAS). Tobacco-free Policy Guidelines. 2010. Accessed October 13, 2010 at: www.mass.gov/?pageID=eohhs2terminal&L=6&L0=Home&L1=Provider&L2=Certification,+Licensure,+and+Registration&L3=Programs&L4=Substance+Abuse+ Treatment&L5=Guidelines+for+Funded+Providers&sid=Eeohhs2&b=t erminalcontent&f=dph_substance_abuse_p_guidelinh.

24. American Psychiatric Nurses Association Tobacco Dependence Task Force.Psychiatric Nurses as Champions for Smoking Cessation. Accessed October 13, 2010 at: www.apna.org/i4a/pages/index.cfm?pageid=3827.

25. Sharp DL, Blaakman SW. Report from the Tobacco Dependence Council. J Am Psychiatr Nurs Assoc. 2009;15:412-414.

26. American Nurses Association. Code of Ethics for Nurses with Interpretive Statements. Washington, DC: American Nurses Association. 2001.

27. American Nurses Association. Nursing’s Social Policy Statement: The Essence of the Profession. Silver Spring, Md: American Nurses Associa-tion. 2010.

28. American Nurses Association. Nursing: Scope and Standards of Practice, 2nd ed. Silver Spring, Md: American Nurses Association. 2010.

29. Massachusetts Department of Higher Education Nurse of the Future Competency Committee. Nurse of the Future Nursing Core Competen-cies, version 2. Boston: Massachusetts Department of Higher Education. 2007. Accessed October 13, 2010 at: www.mass.edu/currentinit/current initNursingPublications.asp.

30. American Nurses Association. Nursing’s Social Policy Statement. Wash-ington, DC: American Nurses Association. 2003.

31. Zillich AJ, Corelli RL, Hudmon KS. Smoking cessation for the busy clini-cian. The Rx Consultant. 2007;16:1-11.

32. Center for Tobacco Treatment Research and Training (CTTRT).Certifica-tion Steering Committee: Role Definition Study. Worcester, Ma: University of Massachusetts Medical School Division of Preventive and Behavioral Medicine. 1998. Accessed October 13, 2010 at: www.umassmed.edu/tobacco/training/index.aspx.

33. The Joint Commission. Screening and Treating Tobacco and Alcohol Use. Oakbrook Terrace, Il: The Joint Commission. 2010. Accessed Octo-ber 13, 2010 at: www.jointcommission.org/PerformanceMeasurement/ PerformanceMeasurement/Screening+and+Treating+Tobacco+and+ Alcohol+Use.htm.

34. Office of the Surgeon General. The Health Consequences of Involun-tary Exposure to Tobacco Smoke: A Report of the Surgeon General, US Department of Health and Human Services. What Is Secondhand Smoke? 2007. Accessed October 13, 2010 at: www.surgeongeneral.gov/library/secondhandsmoke/factsheets/factsheet1.html

35. Rabin RC. A new cigarette hazard: ‘Third-hand smoke.’ NY Times. 2009. Accessed October 13, 2010 at: www.nytimes.com/2009/01/03/health/research/03smoke.html.

36. American Nurses Association. Nursing: Scope and Standards of Practice. Washington, DC: American Nurses Association. 2004.

37. American Nurses Association. Psychiatric-Mental Health Nursing: Scope and Standards of Practice. Washington, DC: American Nurses Associa-tion. 2007.

38. Lee C, Kahende J. Factors associated with successful smoking cessation in the United States, 2000. Am J Public Health. 2007;97:1503-1509.

39. Choices. Consumers Helping Others Improve their Condition by Ending Smoking. New Brunswick, NJ: Choices. 2010. Accessed October 13, 2010 at: www.njchoices.org/.

DeCember 201013

• Tobacco use has historically been a part of the mental health treatment milieu, and psychiatric-mental health service organizations have been slow to address tobacco dependence among consumers and staff.

• Healthcare purchasers, payers, and insurers do not typically view tobacco dependence interventions as a priority, and covered services, medications, and copayments are often costly.

• Tobacco dependence interventions are often not formalized as a part of psychiatric-mental health treatment. • Clinician barriers to tobacco dependence treatment include gaps in current knowledge, competing clinical

demands, and negative beliefs and pessimism about the ability of mental health consumers to quit.• Treatment-specific guidelines provide valuable information about effective treatment. While review-

ing the latest tobacco treatment guidelines, nurses should identify those aspects of the guidelines that are already operational in their workplaces and note any new items among the guidelines. They should assess their own knowledge level and plan to acquire new knowledge and skills as dictated by changes in the guidelines.

• Rogers has developed a diffusion of innovation model comprised of five factors having to do with the inno-vation itself and the responses of individuals or organizations to making the change: relative advantage, compatibility, complexity or simplicity, triability, and operability.

• A number of studies support the idea that a positive organizational climate and a general readiness to embrace innovations, attributes, and resources are present when successful, change-oriented learning takes place.

• Failure by nurses to identify current tobacco users causes harm.

Treating Tobacco Dependence in Persons with Mental Illness: Identifying Challenges and Opportunities

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