Situating tobacco dependency education in health professional prelicensure curricula: An interprofessional learning opportunity.

The present commentary articulates several reasons to support integration of tobacco dependency treatment into health professional prelicensure education curricula. Evidence from the current literature suggests curriculum content specific to tobacco tends to address related health risks and advice to quit, with minimal knowledge or skill development to support prelicensure health professionals gaining self-efficacy and competence necessary to treat tobacco dependency within their emerging practice norm. Moreover, although the health effects of tobacco use and exposure to tobacco smoke reaches across ALL health professional practice areas, there is no evidence of interprofessional prelicensure education opportunities to address this health priority. We then highlight interprofessional education activities at the University of Manitoba (Winnipeg, Manitoba) with health and social service academic units, and briefly introduce an exciting new project specific to tobacco dependence treatment. We conclude by featuring involvement from the respiratory therapy community in addressing this health priority and in interprofessional endeavours.

SITUATING TOBACCO DEPENDENCE IN PRELICENSURE PROGRAMS

For decades, we have known that ongoing use of tobacco and exposure to second-hand smoke results in a wide variety of health conditions that span all ages and costs our health care system billions of dollars annually (1–3). At this point, it is safe to say, for tobacco-dependent individuals or those exposed to tobacco smoke regularly, that virtually any health condition being treated is either a result of tobacco use and/or ongoing use will interact with treatments, and/or ongoing use will diminish treatment outcomes (either short term or long term) (4,5). Moreover, the majority of tobacco users report an interest in quitting (6,7) and one-half will make an unaided quit attempt (7,8).

In 2003, Canada signed the then newly ratified World Health Organization Framework Convention on Tobacco Control, which included nine articles (strategies) designed to reduce demand for tobacco (9). Of these nine strategies, one focuses on the responsibility for comprehensive health professional education programs, and another addresses expectations of health and social service providers to treat tobacco dependency. Evidence suggests that health providers who receive training in tobacco dependency counselling are more likely to offer assistance, which improves the success of quit attempts (10). In 2011, seven Canadian health professional associations (Canadian Association of Occupational Therapists; Canadian Counselling and Psychotherapy Association; Canadian Dental Hygienists Association; Canadian Nurses Association; Canadian Physiotherapy Association; Canadian Pharmacists Association; and the Canadian Dental Association) updated a joint position statement – The Role of Health Professional in Tobacco Cessation – which included a renewed challenge for pre-license programs to include tobacco dependency treatment knowledge and skills (11). Given this context, it appears logical that our health care system would be responsive to addressing tobacco dependency, which includes enhanced education of prelicensure health and social service practitioners.

Despite the global and national endorsement of tobacco dependence as a well-documented health priority and the existence of clinical practice guidelines for health professionals for more than two decades, our health care system and prelicensure education programs are lagging behind. In 2006, the Canadian Public Health Association conducted a web-based environmental scan of medical, nursing, dental and pharmacy programs (12). The scan suggested that within Canada, very few of these programs offered tobacco cessation education. A recent PubMed search for current literature (2012 to 2015) resulted in 14 studies related to health professional prelicensure education and tobacco dependency; 13 specific to the United States and one from Canada. The Canadian study surveyed nursing educators in Quebec (n=278; response rate 20.8%). While respondents recognized the importance of treating tobacco dependency, the nursing programs, on average, offered approximately 1 h/year, which was primarily concerning risk factors. The educators suggested there was minimal attention devoted to treating tobacco dependence due to a lack of knowledge (13). Of the other 13 studies examining prelicensure programs, nursing (n=2), pharmacy (n=1), dental hygiene (n=1), physical therapy (n=1), social work (n=1) and respiratory therapy, all reported minimal attention to tobacco dependency treatment; the focus was mostly concerning tobacco-related diseases and to advise patients to quit (14–20). Alternatively, two medical school programs suggested residents’ practice related to treating tobacco dependency benefited from preceptors who modelled tobacco counselling behaviour (21,22). In addition, two dental programs and one dental hygiene program reported on the benefits of using simulation laboratory learning experiences and standardized patient scenarios; students who received lectures and simulation learning demonstrated more knowledge and stronger perceived self-efficacy (23–25). On a final note, while health professional regulatory authorities have adopted practice guidelines and position statements to guide practice expectations, the development of competency statements to guide prelicensure curriculum content supportive of students gaining the skills and knowledge needed to meet these practice expectations is missing.

INTRODUCING EDUCATION FOR INTERPROFESSIONAL COLLABORATION

Treatment of tobacco dependency is a priority that spans all health and social services, which is reflected by endorsements and areas of current research. Yet, inclusion of interprofessional education (IPE) to support practices embracing interprofessional collaboration (IPC) has been absent. IPE has been defined as “occasions when two or more professions learn with, from and about each other to improve collaboration and the quality of care” (26). And IPC was defined by Health Canada as “the active participation of each discipline in patient care. It enhances patient and family-centred goals and values, provides mechanisms for continuous communication among care givers, optimizes staff participation in clinical decision making within and across disciplines, and fosters respect for disciplinary contributions from all professionals” (27).

A growing body of literature indicates that IPC teamwork improves the quality, safety and cost-effectiveness of health care delivery. The impact of IPC teamwork on clinical outcomes has been studied in several diverse clinical settings, including primary health care practices, general medicine clinics, nursing homes, community-based programs, hospital emergency departments, intensive care units, operating rooms, labour and delivery units, and inpatient medical and surgical wards (28,29). In 2010, the WHO developed a Framework for Action to advance IPE and collaborative practice globally (30). Team-based practice has been identified as one of the five core competencies that all health professionals must possess for the 21st century (31) and IPE is a key strategy to transform health professional education (32). The Health Council of Canada identified improvement of teamwork as a critical catalyst of system change and improving human resource management (33).

INTERPROFESSIONAL LEARNING OPPORTUNITIES AT THE UNIVERSITY OF MANITOBA

The University of Manitoba has successfully delivered several Interprofessional Learning Opportunities (IPLOs), with such notable examples as: ‘Learning Health Promotion Interprofessionally’ (offered twice per year since 2012 to >2000 students from 13 different health professional groups), ‘Learning Patient Safety Interprofessionally’ (inaugural offering March 2015 to >250 students from six health professional groups), and the ‘IP Clinical Placement Project’ (there is a growing number of clinical practice environments that mentor inter-professional teams of senior students in their clinical placements/fieldwork/senior practicum/externships) (34). At this time, we are planning an IPE project to support health professional prelicensure learners to develop the necessary knowledge, skills, attitudes and behaviours in tobacco dependence treatment and IP collaboration. To achieve this, the proposed plan is to develop, implement and evaluate two IPLOs; each focusing at different points along the learning continuum. One will be a non-practice education IPLO targeting the ‘functional’ learner level and the other is a practice education IPLO targeting the ‘competent’ learner level. Furthermore, this project includes an integrated knowledge translation approach, which enhances project partners’ engagement throughout the life cycle of the project to obtain feedback, consensus and to improve uptake of project findings.

Through the integration of theoretically grounded IPE innovation with evidence-based learning in tobacco dependence and treatment, the proposed project promises to address a significant gap in prelicensure health profession education. Educating through IPLOs will build united health professions teams in the treatment of tobacco dependency and foster experiences of drawing on one another’s strengths to improve patient care. In our current project, we will develop nonpractice, case-based IPLOs that may involve simulation and/or standardized patients for functional learners and then real-world application with the help of clinical preceptors for competent learners. Most significantly, the implementation of IPLOs embedded along the prelicensure learning continuum will nurture these health professional learners to collectively hold responsibility for addressing tobacco dependency through learning ‘about, with and from one another’.

RESPIRATORY THERAPIST INVOLVEMENT

Our innovative tobacco dependence IPE project involves faculty from the Department of Respiratory Therapy. Collaborating in the early stages of planning with this IPE project are two enthusiastic respiratory therapy faculty members. Their interest is two-fold: they are eager to learn from other health professions involved in tobacco dependence curriculum development; and each brings a wealth of knowledge because they are in the process of developing curriculum content specific to this health priority. As the collective of health professionals move forward, refining practice expectations and increased understanding of the role each member of the health care team can play will foster a more responsive health care experience for patients who are addicted to tobacco products.