De Ruijter, D., Candel, M.J.J.M., Smit, E.S., de Vries, H., Hoving, C. (2018). The effectiveness of a computer-tailored e-learning program for practice nurses to improve their adherence to smoking cessation counseling guidelines: randomized controlled trial, Journal of Medical Internet Research, 20(5):e193, DOI:10.2196/jmir.9276


Background: Improving practice nurses’ (PN) adherence to smoking cessation counseling guidelines will benefit the quality of smoking cessation care and will potentially lead to higher smoking abstinence rates. However, support programs to aid PNs in improving their guideline uptake and adherence do not exist yet.

Objective: The aim of this study was to assess the effects of a novel computer-tailored electronic learning (e-learning) program on PNs’ smoking cessation guideline adherence.

Methods: A Web-based randomized controlled trial (RCT) was conducted in which an intervention group (N=147) with full access to the e-learning program for 6 months was compared with a control group (N=122) without access. Data collection was fully automated at baseline and 6-month follow-up via online questionnaires, assessing PNs’ demographics, work-related factors, potential behavioral predictors based on the I-Change model, and guideline adherence. PNs also completed counseling checklists to retrieve self-reported counseling activities for each consultation with a smoker (N=1175). To assess the program’s effectiveness in improving PNs’ guideline adherence (ie, overall adherence and adherence to individual counseling guideline steps), mixed linear and logistic regression analyses were conducted, thus accommodating for the smokers being nested within PNs. Potential effect moderation by work-related factors and behavioral predictors was also examined.

Results: After 6 months, 121 PNs in the intervention group (82.3%, 121/147) and 103 in the control group (84.4%, 103/122) completed the follow-up questionnaire. Mixed linear regression analysis revealed that counseling experience moderated the program’s effect on PNs’ overall guideline adherence (beta=.589; 95% CI 0.111-1.068; PHolm-Bonferroni =.048), indicating a positive program effect on adherence for PNs with a more than average level of counseling experience. Mixed logistic regression analyses regarding adherence to individual guideline steps revealed a trend toward moderating effects of baseline levels of behavioral predictors and counseling experience. More specifically, for PNs with less favorable scores on behavioral predictors (eg, low baseline self-efficacy) and high levels of counseling experience, the program significantly increased adherence.

Conclusions: Results from our RCT showed that among PNs with more than average counseling experience, the e-learning program resulted in significantly better smoking cessation guideline adherence. Experienced PNs might have been better able to translate the content of our e-learning program into practically applicable counseling strategies compared with less experienced colleagues. Less favorable baseline levels of behavioral predictors among PNs possibly contributed to this effect, as there was more room for improvement by consulting the tailored content of the e-learning program. To further substantiate the effectiveness of e-learning programs on guideline adherence by health care professionals (HCPs), it is important to assess how to support a wider range of HCPs.

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