Public Health Project- Aspects of Youth Vaping
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Graduate Theses, Dissertations, and Problem Reports
2020
Evaluation of the Impact of an Educational Intervention Focused Evaluation of the Impact of an Educational Intervention Focused on Adolescent Vaping Among Rural Middle School Students on Adolescent Vaping Among Rural Middle School Students
Holly F. Fitzwater West Virginia University, [email protected]
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Recommended Citation Recommended Citation Fitzwater, Holly F., "Evaluation of the Impact of an Educational Intervention Focused on Adolescent Vaping Among Rural Middle School Students" (2020). Graduate Theses, Dissertations, and Problem Reports. 7592. https://researchrepository.wvu.edu/etd/7592
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Evaluation of the Impact of an Educational Intervention Focused on Adolescent
Vaping Among Rural Middle School Students
Holly Fain Fitzwater, MSN, APRN, FNP-C
Capstone submitted
to the School of Nursing
at West Virginia University
in partial fulfillment of the requirements for the degree of
Doctorate in Nursing Practice
Teresa Ritchie, DNP, APRN, FNP-BC, Faculty of Record
Jill Cochran, PhD, APRN, FNP-BC, FAANP
Kesheng Wang, PhD, MA, BS
Gene Collins, MS
Morgantown, WV
2020
Keywords: Vaping, electronic cigarette, e-cigarette, adolescents, students, knowledge, attitudes
Copyright 2020, Holly Fain Fitzwater
ABSTRACT
Evaluation of the Impact of an Educational Intervention Focused on Adolescent
Vaping Among Rural Middle School Students
Holly Fain Fitzwater
According to the Centers for Disease Control (CDC), sixty deaths due to the use of electronic
cigarettes or other vaping products have been reported to date. Vaping has become viewed as a
safe alternative to traditional cigarette smoking, particularly in the adolescent population. The
U.S. Preventive Services Task Force (USPSTF) recommends education by primary care
clinicians to prevent initiation of tobacco products among adolescents. In order to combat this
health disparity in America’s youth, intervention by the nursing profession is necessary. An
educational session and interactive game were implemented by a school-based family nurse
practitioner in order to change the knowledge and attitudes of students regarding vaping in a
rural West Virginia middle school. Data analysis revealed a statistically significant 15.8%
decrease in adolescents who believe vaping is safer than smoking following intervention by the
nurse practitioner. Results also determined a statistically significant 27.9% increase in students’
knowledge following the educational session and interactive game. Ongoing education by
healthcare professionals is necessary to decrease the morbidity and mortality related to
adolescent vaping.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL iii
This project is dedicated to my late grandfather, Harold Fain.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL iv
Acknowledgments
First and foremost, I praise my Savior, Jesus Christ. I humbly thank Him for blessing me with
perseverance and strength to achieve this milestone in my education. I also thank Him for
blessing me with wonderful family, friends, faculty members, and colleagues.
My husband, Chris – Thank you for the sacrifices that you made for me to continue my
education and reach my goal. On the days that I wanted to give up, you pushed me. You always
had faith in me, even in the moments when I didn’t have faith in myself. I could not have
accomplished this without you. We finally did it! I love you.
My parents, sister, and Aunt Martha – Words cannot express how grateful I am to have had you
in my cheering section. Thank you for listening to years of complaints, anxieties, and fears.
Each one of you have contributed to my success in some way. I love you all and I am so
thankful for each one of you.
Dr. Teresa Ritchie – Thank you for the countless hours that you dedicated to my project. I am
grateful to have had you as my Faculty of Record. I truly appreciate the time and support that
you have dedicated to my education and nursing career.
Capstone Committee Members – Thank you for the time and efforts that you contributed to my
project. I feel very fortunate to have worked with each one of you and look forward to future
collaborations.
I can do all things through Christ who strengthens me. Philippians 4:13
EVALUATION OF THE IMPACT OF AN EDUCATIONAL v
Table of Contents
Title and Abstract
Title ......................................................................................................................................... i
Abstract ....................................................................................................................... ii
Dedication ................................................................................................................... iii
Acknowledgements ..................................................................................................... iv
Table of Contents ........................................................................................................ v
Index of Appendices .............................................................................................................. vii
Introduction ........................................................................................................................... 1
Background ................................................................................................................. 1
Problem Statement ...................................................................................................... 3
Purpose and Significance of Problem ......................................................................... 3
Review of the Literature ....................................................................................................... 4
Synthesis of the Literature .......................................................................................... 11
Theoretical Framework .............................................................................................. 13
Project .................................................................................................................................... 14
Description and Design of Evidence-Based Project/Intervention Plan ...................... 14
Instruments ................................................................................................................. 17
Applicability of Framework ....................................................................................... 18
Feasibility Analysis .................................................................................................... 21
Needs Assessment .......................................................................................... 21
Market Analysis ............................................................................................. 22
Strategic Analysis ........................................................................................... 22
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Sustainability .................................................................................................. 23
Congruence of Organization’s Strategic Plan. ............................................... 23
Evidence of Key Site Support ........................................................................ 23
Measurable Project Objectives ................................................................................... 24
Results ........................................................................................................................ 25
Discussion .............................................................................................................................. 27
Limitations ................................................................................................................. 27
Recommendations ...................................................................................................... 28
Attainment of DNP Essentials ............................................................................................. 29
Bibliography ......................................................................................................................... 33
Appendices ............................................................................................................................ 39
EVALUATION OF THE IMPACT OF AN EDUCATIONAL vii
Index of Appendices
Appendix A: Demographic Questionnaire ................................................................................... 39
Appendix B: Pre-Intervention Questionnaire .............................................................................. 40
Appendix C: Post-Intervention Questionnaire ............................................................................. 41
Appendix D: Content Outline ...................................................................................................... 42
Appendix E: Budget...................................................................................................................... 43
Appendix F: Site Support Verification ........................................................................................ 44
Appendix G: Table 1.Wilcoxon Rank Test Results ..................................................................... 45
Appendix H: Table 2. McNemar Chi-Square Test Results .......................................................... 46
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1
Technology evolves at a quick pace in today’s world, which has allowed for safer, more
efficient healthcare. However, not all technology has contributed to health promotion and
disease prevention. The first electronic cigarette, also referred to as a vape or e-cigarette, was
introduced to the United States circa 2006 (Consumer Advocates for Smoke Free Alternatives
Association [CASAA], 2019). Many individuals view vapes as safe alternatives to traditional
cigarette smoking, resulting in a higher rate of tobacco-associated morbidity and mortality.
The prevalence of adolescent vaping is on the rise, becoming the most popular tobacco product
among eighth, tenth, and twelfth grade students (Giovacchini, Pacek, McClernon, & Que, 2017).
During the 2018 academic year, multiple vaping devices were confiscated at a middle school in
rural West Virginia; therefore, intervention by a school-based family nurse practitioner (FNP)
was enlisted to assist in educating the students on the dangers of vaping. This paper discusses an
evidence-based intervention directed at changing the knowledge and attitudes of adolescents
regarding the dangers of vaping.
Background
As of January 21, 2020, there were 2,711 reported lung injury cases confirmed nationally
due to e-cigarette, or vaping, product use-associated lung injury (EVALI) (Centers for Disease
Control and Prevention [CDC], 2020). There have been 60 vaping-related deaths throughout 27
states confirmed thus far (CDC, 2020). Between 2017 and 2018, the number of adolescent
students who reported actively using tobacco products increased from 3.6 million to 4.9 million,
respectively (Walton et al., 2019). Vaping products are often perceived as being tobacco-free or
a safe alternative to traditional tobacco products, but this is a false perception. E-cigarettes have
dramatically gained popularity and have been the most popular tobacco product used by youth
since 2014 (Walton et al., 2019). Teens are attracted to electronic cigarettes because of their
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2
appealing technology, sleek designs, and numerous flavorings. As of 2017, more than 15,000 e-
cigarette flavors were available from online manufacturers (Walton et al., 2019). These factors,
as well as targeted marketing to adolescents, have significantly contributed to this growing health
concern.
Intervention by FNPs is vital to combat the increasing prevalence of vaping in
adolescents. Education by primary care clinicians is recommended to prevent initiation of
tobacco products among adolescents (U.S. Preventive Services Task Force [USPSTF], 2019).
Results from a systematic review revealed that fewer youth initiate use of tobacco products,
including e-cigarettes, when they are recipients of behavioral counseling interventions (USPSTF,
2019). A variety of behavioral counseling interventions, including face-to-face counseling, are
deemed effective (USPSTF, 2019). Most research conducted has focused on prevention of
cigarette smoking; however, the interventions are applicable for the prevention of vaping
because of the similar context and cultural considerations among e-cigarette and traditional
cigarette use (USPSTF, 2019).
According to Milicic, DeCicca, Pierard, and Leatherdale (2018), implementing an e-
cigarette control policy is essential to decrease the prevalence of vaping in school-aged youth.
Schools with established policies banning vapes on the facility’s property reported less e-
cigarette use among students compared to schools without policies (Milicic et al., 2018). These
policies have the potential to be effective in reducing e-cigarette use in students, indicating the
importance for statewide implementation (Milicic et al., 2018). In addition to changing
knowledge and attitudes regarding vaping, this quality improvement project will ultimately lead
to creation of a vaping-specific policy at the middle school. The project also supported the
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3
evidence behind the recent legislation to increase the age from 18 to 21 in order to purchase
tobacco products.
Problem Statement
Despite popular belief, most vapes contain nicotine (USPSTF, 2019). Nicotine use
during adolescence interferes with brain development, which continues until age 25, and may
increase risk for substance abuse during adulthood (CDC, 2019c). According to the National
Institute of Health (2018), 10.9%, or one in ten, eighth grade students reported vaping nicotine-
containing substances within the last year. Intervention within the middle school age group is
necessary to target this population and prevent initiation of electronic cigarette use, both now and
later, in adolescence or early adulthood. Evidence supports clinician-based education in the
adolescent population in order to combat this growing health disparity (USPSTF, 2019).
Purpose and Significance of Project
A quality improvement project was implemented at a middle school in rural West
Virginia. The overarching goal of this project was to educate middle school students on the
dangers associated with e-cigarette use, ultimately resulting in a change of knowledge and
attitudes. The project consisted of an educational session including a demographic survey, pre-
and post-questionnaires, a 15 minute educational presentation, and an interactive educational
game. Prior to the session, students were given the option to complete a pre-test to evaluate their
baseline knowledge and attitudes regarding vaping. A post-test was administered after the
educational presentation and interactive game. Data was analyzed to determine if students’
knowledge and attitudes were impacted by clinician-based education.
This quality improvement project impacted adolescent health by educating middle school
students on the dangers of vaping. The goals of the project were to change knowledge and
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4
attitudes on the severity of e-cigarettes; therefore, preventing and/or reducing the prevalence of
adolescent vaping. Future benefits from this educational session include decreasing the
prevalence of adolescent vaping, ultimately resulting in decreased morbidity and mortality.
Educating adolescents on the dangers of vaping is essential in order to reduce associated health
risks. For example, there is an increased risk of myocardial infarction and irreversible lung
damage associated with daily e-cigarette use, despite adolescents’ perceptions of less associated
harm (Lechner et al., 2018; Walton et al., 2019). Universal education will combat this health
disparity and work to achieve the Healthy People 2020 goal to “reduce illness, disability, and
death related to tobacco use and secondhand smoke exposure” (Office of Disease Prevention and
Health Promotion [ODPHP], 2019).
Review of the Literature
Two comprehensive literature searches were conducted to obtain the best evidence-based
information for the design of this project. The initial literature search was conducted on May 15,
2019 and included the following databases: Academic Search Complete, Cumulative Index to
Nursing and Allied Health (CINAHL), Health Source, MEDLINE, Science Direct, and Cochrane
Library. The key terms that were utilized for the advanced search included: vaping, electronic
cigarette, e-cigarette, middle school students, attitudes, beliefs, and views. Before the
application of inclusion and exclusion criteria, 304 articles were yielded. Inclusion criteria
included: middle school students, English language, publication between 2013 to 2019, peer-
reviewed, and nicotine use. Exclusion criteria included: high school students, foreign languages
and countries, published before 2013, and cannabis use.
A second literature search was conducted on August 4, 2019 and included the following
databases: Academic Search Complete, CINAHL, Health and Psychosocial Instruments, Health
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5
Source: Nursing/Academic Edition, and MEDLINE. The second literature search was expanded
to include the Health and Psychosocial Instruments database. Key search terms included:
vaping, electronic cigarette, e-cigarette, teenagers, adolescents, middle school students,
education, beliefs, interventions. With this search, there were 18,660 hits. This search was more
generalized and included high school students, which resulted in a numerous amount of articles
for review. Criteria for inclusion of studies included: children and adolescents under the age of
18, English language, publication between 2013 to 2019, peer-reviewed, and nicotine use.
Exclusion criteria included: foreign languages, published before 2013, and cannabis use. A total
of 185 articles were yielded after application of the inclusion and exclusion criteria. After
critical evaluation, 12 articles were included in the literature review.
Literature consistently supports that electronic cigarette use in the teen population is a
health concern and intervention is necessary. Research conducted by Fulton, Gokal, Griffiths,
and Wild (2018) recommended vaping-specific education in schools. The cross-sectional
experiment revealed that approximately 40% of students, ages 11 to 16 years, were unaware that
e-cigarettes contain nicotine and are addictive (Fulton et al., 2018). Of the nearly 500
participants, 7% identified as current e-cigarette users in addition to 11.4% who reported
experimenting with vapes in the past (Fulton et al., 2018). An additional longitudinal study
conducted in the United Kingdom reported a strong association between vaping and smoking
initiation within 12 months among 13 and 14-year-old students (Fulton et al., 2018). According
to Fulton et al. (2018), education is necessary to reduce and prevent the incidence of vaping
among adolescents.
Statistics obtained from a cross-sectional study in North Carolina students emphasized
the prevalence of adolescent vaping and the likelihood of traditional cigarette smoking in the
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6
future (Kowitt et al., 2019). The purpose of this study was to determine which tobacco products
adolescents use first, leading to specific interventions and policies (Kowitt et al., 2019). Per the
data collected from the 2017 North Carolina Youth Tobacco Survey (NCYTS) in sixth through
twelfth grade students, 33.7% of adolescents reported that e-cigarettes were their first tried
tobacco product (Kowitt et al., 2019). Many adolescents reported experimenting with new
tobacco products, such as electronic cigarettes, in addition to traditional cigarettes (Kowitt et al.,
2019). According to Kowitt et al. (2019), adolescents exposed to Internet advertisements were
more likely to initiate tobacco use with e-cigarettes (0.57 adjusted odds ratios [aORs] and 95%
confidence interval [CI]). Prevention strategies aimed at new and emerging tobacco products are
likely to successfully combat the growing epidemic of adolescent vaping.
A 4-year randomized control trial was conducted to determine if the subjects’ behavior
was impacted by school-based interventions conducted over a 24-month period (Conner et al.,
2019). The intervention included biannual education on how to refuse smoking via billboards
and handouts (Conner et al., 2019). Homework-based interventions were utilized among the
control schools (Conner et al., 2019). According to Conner et al. (2019), adolescents who
reported “ever smoked” cigarettes at follow-up was only 15% for those not currently using
cigarettes compared to 42% who used e-cigarettes at baseline. Cigarette smoking at follow-up
was impacted by e-cigarette use at baseline (p<0.001) (Conner et al., 2019). This study
supported the correlation between adolescent e-cigarette use and future cigarette smoking, as
well as vaping use in adolescents who have friends who vape (Conner et al., 2019).
According to Bast et al. (2017), successful school-based smoking prevention initiatives
were dependent upon implementation strategies. The purpose of the X:IT school-based
intervention by Bast et al. (2017) was to prevent adolescent smoking. The cluster-randomized
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controlled trial revealed that the odds for adolescent smoking in intervention school were less
than control schools (aORs 0.45-0.81; 95% CI) (Bast et al., 2017). Schools with higher levels of
implementation success were associated with strong administrative leadership, alignment with
the mission statement, and an accepting school culture (Bast et al., 2017). According to Bast et
al. (2017), interventions that align with a school’s mission statement are easier to implement.
Bast et al. (2017) also recommended engagement from school leadership and faculty, as well as
open, effective communication. Overall, the study supported the need for properly implemented,
school-based interventions designed to prevent adolescent smoking.
The need for vaping-specific education in schools is further supported in a study
conducted by Anand et al. (2015). The purpose of the cross-sectional, nonexperimental study
was to explore the “prevalence, attitudes, and risk factors” associated with e-cigarettes in high
school students (Anand et al., 2015, p. 46). Similar to other studies conducted, most respondents
reported that vaping was a safe alternative to traditional cigarette smoking (Anand et al., 2015).
A total of 61% of students stated that they were unaware that e-cigarettes contain nicotine
(Anand et al., 2015). Unfortunately, 89.7% of students reported never receiving any information
during health education class on the dangers of e-cigarettes (Anand et al., 2015).
Recommendations from this study included identification of e-cigarette users and involvement
from school faculty and care providers (Anand et al., 2015). Identifying students at risk for e-
cigarette use is necessary for targeted interventions for prevention and cessation of adolescent
vaping (Anand et al., 2015).
Kristjansson, Mann, Smith, and Sigfusdottir (2017) and Owusu et al. (2019) conducted
cross-sectional research projects in middle school students within West Virginia and Tennessee,
respectively. The purpose of the study by Kristjansson et al. (2017) was to determine the social
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profiles of West Virginia adolescents who use electronic cigarettes due to the alarming rate of
adolescent vaping. Middle school students in 15 public West Virginia schools participated in the
survey which evaluated the following: smoking status, familial support, academic performance,
peer influences, and leisure time (Kristjansson et al., 2017). Non-smoking students reported
stronger familial support compared to e-cigarettes users (aOR 1.033, 95% CI 1.14-1.55)
(Kristjansson et al., 2017). Parental supervision was higher among the non-smokers than the
students who used vapes (aOR 0.95, p 0.456) (Kristjansson et al., 2017).
Owusu et al. (2019) examined the use of alternative tobacco products among adolescents
in Central Appalachia. Middle school students participated in a school-based tobacco survey
answering questions regarding use of tobacco products, peer pressure, and risks of tobacco use
(Owusu et al., 2019). According to Owusu et al. (2019), adolescents who believe that alternative
tobacco products increase popularity are more likely to use e-cigarettes (aOR 6.93, 95% CI 2.75-
17.44). Additionally, adolescents who believe that all tobacco products are dangerous were
nearly 70% less likely to use an alternative tobacco product compared to students who did not
report that all tobacco products are dangerous (aOR 0.31, 95% CI 0.11-0.88) (Owusu et al.,
2019). Findings from both studies concluded that the use of alternative tobacco products,
specifically electronic cigarettes, are appealing to the adolescent population and intervention is
necessary.
A pilot study conducted by Pentz et al. (2019) encouraged engaging adolescents with
videogames for the prevention of tobacco use. Videogames are more appealing and time-
efficient than other educational programs (Pentz et al., 2019). The purpose of the study was to
determine the effects of an interactive videogame on adolescents’ knowledge, beliefs, and
likelihood to engage in future vaping (Pentz et al., 2019). Results from the statistical analysis
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revealed that gameplay changed adolescents’ knowledge and perceptions as well as negative
health beliefs regarding tobacco use at the evaluation (p <0.001, p<0.05, respectively) (Pentz et
al., 2019). According to Pentz et al. (2019), further research on the use of adolescent
videogames should be conducted. The interactive video game for tobacco prevention guided the
life-size board game that was implemented in this quality improvement project.
A systematic review performed by Duncan, Pearson, and Maddison (2018) included 16
studies administered in a variety of settings, including healthcare facilities, schools, homes, and
family or peer-lead settings. The focus of this review was to determine successful interventions
to prevent smoking initiation in participants under the age of 18 years (Duncan et al., 2018).
Criteria for studies included in the systematic review were: children and adolescents aged 7 to 18
years; application of a smoking prevention strategy; experimental study design; and a post-
intervention outcome (Duncan et al., 2018). While school-based programs, healthcare settings,
and community events were successful in reducing adolescent smoking, there were challenging
limitations for effective outcomes (Duncan et al., 2018).
Healthcare providers are viewed as a credible source of information and their medical
opinions are often valued by patients (Duncan et al., 2018). While primary healthcare settings,
such as well-child visits, are optimal for discussing smoking prevention, time is often a limiting
factor (Duncan et al., 2018). Community settings are ideal because there is an attentive audience
and an established time frame; however, staff may not be educated or trained to deliver smoking-
prevention education (Duncan et al., 2018). Duncan et al. (2018) recommended utilizing
positive interpersonal communications for prevention of smoking. The information obtained
from this systematic review was applicable to vaping prevention and intervention to decrease the
number of adolescents who currently use e-cigarettes.
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Case et al. (2017) sought to determine the association between sensation-seeking
adolescents and e-cigarette use through the Texas Adolescent Tobacco and Marketing
Surveillance System (TATAMS). The three year, longitudinal study measured participants in
sixth, eighth, and tenth grades baseline and evaluated the use of tobacco products, personal
factors, and exposure to marketing of tobacco products (Case et al., 2017). According to Case et
al. (2017), adolescents who exhibited higher sensation-seeking scores had greater odds of
susceptibility to e-cigarettes (aOR 1.25; 95% CI) and higher odds of ever using an e-cigarette
(aOR 1.24; 95% CI). This study supported the need for early intervention to prevent initiation of
e-cigarette use in adolescents (Case et al., 2017). The recommendation for future studies was
communication to sensation-seeking adolescents to discourage and prevent the initiation of
vaping (Case et al., 2017).
Westling, Rusby, Crowley, and Light’s (2016) study to examine the use of e-cigarettes
over time revealed that adolescent vaping is highly associated with substance abuse. Online
survey responses were obtained from 1,130 eighth grade students and continued every 3 months
until the students began ninth grade (Westling et al., 2016). A total of 1,091 students completed
the survey at the beginning of their freshman year of high school (Westling et al., 2016).
According to Westling et al. (2016), 27.7% of eighth grade students followed by 31.4% of ninth
grade students reported lifetime use of an e-cigarette. Sixteen percent of eighth grade students
who reported never engaging in vaping had experimented with e-cigarettes by spring of ninth
grade (Westling et al., 2016). Eighth grade use of e-cigarettes had significant association with
lifetime use of other substances, particularly marijuana (phi 0.63) (Westling et al., 2016).
Westling et al. (2016) recognized that adolescents typically engage in vaping prior to initiating
traditional cigarette smoking or using other substances.
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Further research on the influences of adolescent vaping was conducted by Pentz et al.
(2015). Examples of influences include: demographics, social, and executive function deficits
(Pentz et al., 2015). This cross-sectional study revealed that students who qualify for free school
lunch; parental ownership of e-cigarettes; and executive functioning deficits were at greater risk
for adolescent vaping (aOR 1.96, 95% CI 0.92-4.15; aOR 2.29, 95% CI 1.01-5.15; aOR 4.99
95% CI 1.80-13.86, respectively) (Pentz et al., 2015). Predictors for adolescent e-cigarette use
included parental ownership of e-cigarette and peers who vape (aOR 3.21, 95% CI 1.66-6.20;
aOR 3.48, 95% CI 1.27-9.54, respectively) (Pentz et al., 2015). Pentz et al. (2015) recommended
educational programs that emphasize executive functioning skills such as goal setting and
planned decision-making.
According to Giovacchini et al. (2017), e-cigarette use increases with advancing age.
Data was obtained from the North Carolina Youth Risk Behavior Survey (NCYRBS) which is a
school-based survey design (Giovacchini et al., 2017). Approximately 19% of ninth grade
students reported lifetime use of e-cigarettes compared to nearly 33% of twelfth grade students
(p<0.001) (Giovacchini et al., 2017). Lifetime use of e-cigarettes was significantly higher than
lifetime use of traditional cigarettes, marijuana, cocaine, or other inhalants (Giovacchini et al.,
2017). Only 3% of adolescent e-cigarette users perceived the substances as having “great risk,”
compared to nearly 17% of non-vape users (Giovacchini et al., 2017). Giovacchini et al. (2017)
recommended educating adolescents on the dangers of e-cigarette use prior to beginning high
school. Healthcare providers should be aware of the growing adolescent vaping epidemic and
work to address the issue (Giovacchini et al., 2017).
Synthesis of the Literature
The studies included in this comprehensive literature synthesis supported the need for
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education directed at the middle school population. Two of the analyzed studies, both of which
were randomized control trials, discussed the correlation between adolescent e-cigarette use and
the need for educational intervention (Bast et al., 2017; Conner et al., 2019). School-based
interventions were deemed successful in the research, especially those which align closely with
the school’s mission statement (Bast et al., 2017). Evidence from the systematic review
concluded that education directed at tobacco prevention is most successful in the community
setting due to the willingness and acceptance to participate (Duncan et al., 2018). The
recommendation of the systematic review was interpersonal communication in order to prevent
tobacco use among adolescents (Duncan et al., 2018).
The remaining nine articles were cross-sectional or longitudinal studies and further
supported the need for adolescent education regarding tobacco prevention. The need for
prevention strategies aimed at new tobacco products, specifically electronic cigarettes, were
recommended by most studies (Fulton et al., 2018; Kowitt et al., 2019; Pentz et al., 2015). Three
studies identified social profiles common among adolescent e-cigarettes users which include the
following characteristics: low parental supervision, belief that e-cigarettes increase popularity,
free school lunch, parental smoking or e-cigarette use, and peer smoking or e-cigarette use
(Kristjansson et al., 2017; Owusu et al., 2019; Pentz et al., 2015). Lack of education was
commonly reported among subjects. For example, students reported lack of e-cigarette
education in health education classes and unawareness that vaping devices contain nicotine
(Anand et al., 2015; Fulton et al., 2018).
Middle school students are vulnerable to initiating e-cigarette use, which can lead to
future cigarette smoking, alcohol, and substance use. Adolescent education was recommended
by nearly all the studies synthesized. Most researchers recognized the limitations of
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generalizability due to limited population size, indicating a need for additional educational
interventions to be implemented. According to the USPSTF (2019), education by primary care
clinicians is preferred to reduce the use of tobacco among adolescents. Additional studies
directed at adolescent vaping are needed to determine additional evidence-based interventions to
combat teen vaping.
Theoretical Framework
Two theories were utilized to guide the quality improvement project. The first theory,
Kotter’s 8-Step Change Model, involves overlapping steps, beginning with creating a climate for
change (Weber & Weber, 2019). The framework continued to guide this project through
engaging and enabling the organization, followed by implementing and sustaining change
(Weber & Weber, 2019). The primary assumption of Kotter’s 8-Step Change Model is that the
organization is accepting of change (Barlow, 2015). According to Clarizen (2015), the three
building blocks of this framework are teamwork, transparency, and communication. The 8 steps
of Kotter’s Change Model include: create a sense of urgency, build a guiding coalition, create a
strategic vision with initiatives, enlist a volunteer army, remove barriers, sustain acceleration,
and institute change (Kotter International, 2019).
The theory of planned behavior was also used to guide the project. According to the
theory of planned behavior, behavior is a combination of intentions and perceptions of control
(Ajzen, 2019b). Intention is the person’s readiness to engage in a certain behavior (Ajzen,
2019b). Actual behavioral control describes the resources the person possesses, which controls
their behavior (Ajzen, 2019b). When behavioral control is strong, favorable intentions produce
the specific behavior (Ajzen, 2019b). This theory posits that there are three concepts guiding
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human behavior including behavioral beliefs, normative beliefs, and control beliefs (Ajzen,
2019a).
Project
Description and Design of Evidence-Based Project/Intervention Plan
This quality improvement project worked to answer the following question: Does an
educational program focused on the dangers of vaping, presented by a school-based nurse
practitioner, affect vaping knowledge and attitudes in middle school students? A quality
improvement project is an interdisciplinary effort to change a problem within the healthcare
system (Silver et al., 2016). Collaboration between the project leader, middle school principal,
and health education teacher was necessary for the implementation of the quality improvement
project. To determine change over time, a pre-test/post-test design was used.
The quality improvement project was conducted on January 14, 2020 at 8 a.m. in
school’s band room. Total enrollment at the middle school is 248 students, which differs from
the actual sample size due to attendance on the day of implementation. Each grade level entered
the band room separately. The session began with the eighth grade class, followed by the
seventh grade, then sixth grade class. Participation in the educational session and interactive
game, as well as completion and submission of the pre- and post-tests, were voluntary.
Upon entrance into the school’s band room, each student received a packet containing a
demographic survey on orange paper, a pre-educational questionnaire on green paper, and a post-
educational questionnaire on red paper. The purpose of the various paper colors was to de-
identify the participants. The questionnaires were randomly numbered beginning with 001 and it
was not possible to associate the random numbers with the students. The questionnaires were
designed for a 5th grade literacy level. By completing the questionnaires and returning them to
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
15
the project leader at the end of the session, students provided assent for participation. The
demographic survey and pre- and post-tests are disclosed in Appendices A, B, and C,
respectively.
Once seated in the band room, students were asked to anonymously complete the 3-item
demographic survey printed on the orange paper and the 8-item pre-test printed on the green
paper. Students were given approximately 10 minutes to complete the two questionnaires.
Then, students were asked to store their questionnaire packets within their bookbags or personal
items during the presentation and game. Next, the school-based FNP presented a 15-minute
educational session on the dangers of vaping. Educational content materials included
components from Tar Wars, a youth tobacco prevention program developed in 1988 (American
Academy of Family Physicians [AAFP], 2019). The program guidelines are consistent with
recommendations from the CDC and there have been statistical improvements in students’
knowledge and attitudes toward tobacco use on evaluations (AAFP, 2019). A detailed
educational presentation outline is provided in Appendix D.
After the brief educational presentation, an interactive game allowed students to put their
knowledge into practice. The nurse practitioner created a life-size board game which was guided
by an evidence-based pilot study conducted by Pentz et al. (2019). The pilot study utilized a
video game, smokeSCREEN, to increase middle school students’ knowledge about tobacco use
(Pentz et al., 2019). Each student’s virtual character navigated through the game by answering
tobacco-related scenario questions (Pentz et al., 2019). Results found that students’ risk
perceptions and negative health beliefs toward tobacco increased following the videogame
(Pentz et al., 2019). Following promising results from the pilot study conducted by Pentz et al.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
16
(2019), Hieftje, Fernandes, and Fiellin (2019) conducted a comprehensive research study to
analyze tobacco prevention following videogame intervention.
Hieftje et al. (2019) implemented smokeSCREEN in school or afterschool programs
throughout California, Rhode Island, Massachusetts, and Arizona. The final sample size
included 560 participants between the ages of 10 to 14 years; however, inclusion criteria was 10
to 16 years (Hieftje et al., 2019). The implementation of smokeSCREEN was successful in
changing the knowledge and beliefs of adolescents regarding tobacco use. Following videogame
play, there was an 8.2% increase (p-value < .0001) in the amount of students who believed that
e-cigarettes were dangerous (Hieftje et al., 2019). The study recommended further research on
school-based interventions, which was the purpose of this quality improvement project (Hieftje
et al., 2019).
Due to the rural location, limited funding, and minimal resources, providing students with
electronic devices to play a videogame was unrealistic. The FNP implemented a life-sized board
game following the educational presentation. Eight volunteers were chosen to serve as team
leaders as well as the life-size piece for the board game. Students were then randomly placed
into teams of approximately nine students. Each team was asked a scenario-style question, which
required application of their vaping knowledge and perceptions. The team leaders received input
from their group members before answering the question. If the team provided a healthy
response to the question, the team leader rolled the large die and advanced on the game board.
The life-size game took approximately 25 minutes to complete and provided students
with an entertaining, interactive application of their knowledge. Students were required to
communicate with their peers and recall information discussed during the presentation. Unlike
the studies conducted by Pentz et al. (2019) and Hieftje et al. (2019), this activity only involved
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
17
situations pertaining to electronic cigarettes. The educational session and interactive nature of
the game implemented by the FNP grasped the attention of the middle school students, leading to
a change in knowledge and attitudes. The quality improvement project was implemented in the
following order: demographic survey/pre-test, educational presentation, interactive game, post-
test. Each session was approximately 1 hour per class.
The health education teacher and school-based FNP were present and involved in the
implementation of the project. Following the completion of the life-size board game, students
were given 10 minutes to voluntarily complete the 8 question post-test on red paper. Students
were given the option to return the packet for data analysis by placing it into a locked drop-box
or into a locked shred box, both located at the exit of the band room. The locked drop-box was
orange and the locked shred box was black. Students were not allowed to exit the cafeteria with
the packets to prevent other students from having access to questions prior to the educational
session. Pre- and post-tests will remain locked in the project leader’s file for a 5-year period,
then all data will be shredded.
Instruments.
The pre- and post-test questions were modeled from two studies. The first study was a
cross-sectional, nonexperimental design conducted by Anand et al. (2015). The purpose of the
Anand et al. (2005) study was to examine prevalence and risk factors of e-cigarette use in high
school students (Anand et al., 2015). Questions utilized by the authors were modified after
“Monitoring the Future,” an ongoing research and reporting project of America’s youth (Anand
et al., 2015; University of Michigan, 2019). The second study was a cross-sectional study of
nurses’ knowledge, attitudes, subjective norms, and practices regarding e-cigarettes (Mbe,
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
18
Ayodele, & Doss, 2017). The study concluded a lack of knowledge among nurses regarding e-
cigarette use as well as a variety of beliefs regarding vaping safety (Mbe et al., 2017).
Due to the limited number of valid, reliable vaping questionnaires directed at the middle
school population, the project leader created pre- and post-tests guided by the questionnaires
utilized by Anand et al. (2015) and Mbe et al. (2017). Questions applicable to the project’s goals
and objectives were required to accurately evaluate the change in adolescents’ knowledge and
attitudes. The questions were also created to ensure literacy and comprehension within the target
population. Authors of both studies were contacted and informed of the quality improvement
project (V. Anand, personal communication, August 26, 2019; O. Ayodele, personal
communication, October 28, 2019).
Applicability of Theoretical Framework
Kotter’s 8-Step Change Model guided the changes occurring at the system level.
Step One is to create a sense of urgency within the organization (Kotter International, 2019). A
sense of urgency existed at the middle school due to the overwhelming number of vaping devices
that were confiscated throughout the previous academic year. Numerous middle school students
were disciplined for actively engaging in the use of tobacco on school property, particularly
vapes. The next step of Kotter’s Change Model is to build a guiding coalition to achieve team
cohesion and confront the issue of adolescent vaping (Clarizen, 2015; Kotter International, 2019;
Weber & Weber, 2019). The guiding coalition of this project was led by the school-based FNP
and included the principal, health education teacher, and school nurse.
Step Three is the creation of a strategic vision with initiatives (Kotter International,
2019). This step incorporated the goals of the project which were to change the beliefs and
attitudes among middle school students regarding vaping. The first vision of this project was to
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
19
decrease the number of students who believe vaping is safer than traditional cigarette smoking.
The second vision was for students to change their attitudes by recognizing e-cigarettes as a
health hazard. The initiative of a brief educational presentation and interactive game achieved
the visions of the project.
Enlisting a volunteer army or communicating the vision is the next step of the theoretical
framework (Clarizen, 2015; Kotter International, 2019). This group was comprised of similar
individuals from the guiding coalition group listed in Step Two; however, additional community
involvement at this point in the project was desired. Achievement of this step will continue
through implementation of this project at various school-based sites throughout two counties in
rural West Virginia. Step Five is the removal of barriers to enable action (Kotter International,
2019). The most anticipated barrier for this project was reserved time for the educational session
and activity. The barrier was eliminated with effective communication and planning between the
project leader and school administration.
Step Six is to generate short-term wins, which are vital to sustain momentum and achieve
long-term goals (Clarizen, 2015; Kotter International, 2019). The short-term wins of this project
are to decrease the prevalence of vaping; change knowledge and attitudes regarding vaping; and
prevent initiation of vaping. Achievement of the short-term goals will demonstrate decreased
risks among students at the middle school. The short-term wins of this project were measured by
data analysis; however, short-term wins will continue to be measured throughout the academic
year. Comparison of the number of vaping devices confiscated following the implementation of
this project will be compared to previous academic years.
The next step is to sustain acceleration to improve systems and policies (Kotter
International, 2019). Sustaining acceleration is an ongoing step following the implementation of
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
20
the project. Following achievement of the short-term goals, stakeholders are likely to be
optimistic and engaged in the next challenge, which is vital for sustainability of the project.
Working toward changing statewide health education curriculum to include vaping education
and vaping policies have begun and will continue through dissemination of knowledge. Step
Eight of Kotter’s 8-Step Change Model is to institute change (Kotter International, 2019). This
step is essential for the maintenance and sustainability of the project. Ideally, educational
sessions informing students on the dangers of vaping will be continued indefinitely in middle
schools across the state as a result of policy change. A goal of this project is to lead West
Virginia schools to the development of a specific vaping policy, preventing the presence of any
type of electronic cigarette on school property.
The theory of planned behavior was applied to the individual behaviors of the
adolescents. The first concept, behavioral belief, describes the belief about potential
consequences of the behavior (Ajzen, 2019a). The goal of the quality improvement project was
to change the behavioral belief that vaping is safer than traditional cigarette smoking. The
second concept of normative beliefs is the belief of what others view as normal (Ajzen, 2019a).
These beliefs lead to a subjective norm or social pressure (Ajzen, 2019a). This concept is an
issue with many health risks in the adolescent population because peer pressure greatly impacts
the decisions of adolescents.
The final concept of this theory, control beliefs, is how an individual perceives factors
that could facilitate or impede the behavior (Ajzen, 2019a). The educational presentation and
interactive game informed the middle school students that help is available for those who desire
vaping or smoking cessation. The FNP also discussed how the stakeholders will support
students who desire to quit using tobacco. The education implemented during the quality
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
21
improvement project encouraged students to change their behavioral, normative, and control
beliefs. By changing their beliefs on the dangers of vaping, the middle school students are more
likely to refuse or stop using e-cigarettes. The change in attitude was evaluated on the students’
pre- and post-tests.
Feasibility Analysis
The following sections provide details regarding the need and justification for this quality
improvement project. The necessity and feasibility of this project was supported through a
detailed needs assessment; strengths, weaknesses, opportunities, and threats (SWOT) analysis;
and market analysis. The overall health benefit of the project exceeded the weaknesses.
Needs assessment.
The key stakeholders of the project included the students, parents, teachers, school nurse,
and school-based nurse practitioner in addition to the school’s principal and health education
teacher. Communication and planning between the stakeholders, specifically the principal, were
essential for the project’s success. Content for the quality improvement project was derived
from multiple sites including Healthy People 2020, Centers for Disease Control and Prevention,
and the U.S. Preventative Services Task Force. Education for students was obtained from Tar
Wars, a program directed at preventing tobacco use among youth (AAFP, 2019).
Responses remained confidential and anonymous, preventing extraneous privacy
concerns. The project was welcomed due to the notable prevalence of vaping among students
and the faculty’s desire for student-provider interaction. A slight interference in the faculty’s
workflow occurred due to the need for dedicated educational session time. Faculty members
were permitted to attend and observe the educational session, which many vocalized as
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
22
informative and interesting. Technical issues were not of concern because the questionnaires
were not electronic.
Market analysis.
The project was less costly than other educational interventions which increased the ease
of implementation and support from the site. The project did not require administrative,
marketing, hospitality, or traveling expenses. The total cost for educational materials, incentives,
and project supplies was approximately 250 dollars. Approximately 220 dollars were utilized for
the project gameboard and incentives, including supplies for hands-on activities, treats for
student participation, and rewards for winning the interactive game. The remaining cost was
associated with the project supplies such as ink and paper for the questionnaires. The actual
project costs were lower than the projected project budget. While this project was both
economical and practical, the potential long-term outcomes for adolescent health are tremendous.
A detailed budget plan is listed in Appendix E.
Strategic analysis.
The strengths and opportunities of this project were numerous. Foremost, this project has
the potential to reduce morbidity and mortality related to tobacco use. It addressed the current
health issue of adolescent vaping at the local middle school and worked to achieve a Healthy
People 2020 goal. The project was cost-effective and required minimal resources. Most
stakeholders were employees at the project site and were eager about changing the students’
attitudes and beliefs on vaping. The opportunity for the FNP to educate the students on the
dangers of vaping was invaluable. The project has an opportunity for future health education
curriculum changes at the county and state levels. Adolescents will likely disseminate the
information learned during the educational sessions to peers and relatives, which will also assist
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
23
in achieving the Healthy People 2020 goal to “reduce illness, disability, and death related to
tobacco use and secondhand smoke exposure” (USPSTF, 2019).
There were few potential weaknesses and threats for the proposed project. Weaknesses
included interrupted classroom time; however, this was managed with communication and
planning between the FNP, principal, and health education teacher. The implementation site was
in rural West Virginia, which resulted in a homogeneous sample. With effective communication,
planning, and interprofessional collaboration, the controllable weaknesses of the proposed
project were minimized.
Sustainability.
The educational component and interactive game of the quality improvement project are
sustainable and will likely continue in the following academic years. Other schools in the
surrounding areas are likely to implement the content to educate their students on the dangers of
vaping. Vaping has gained popularity and is now a national health concern being addressed by
the President of the United States; therefore, current and future education will be necessary. The
quality improvement project also has the potential to be replicated in the future in order to obtain
more data.
Congruence of organization’s strategic plan to project.
The mission of Nicholas County Schools is to educate students for success in life
(Nicholas County Schools, 2019). The project aligned with Nicholas County Schools’ mission
statement because it provided education to students which will help them reach their full
potential and live successful, healthy lives. Regulations promoted the project because adolescent
vaping and tobacco use on school property are illegal and can result in criminal penalties.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
24
Evidence of key site support.
The middle school principal fully supported the project, as evidenced by Appendix F.
Due to the overwhelming number of adolescents who have been disciplined for vaping, the
principal encouraged the educational intervention. Additional school staff such as the school
nurse, health education teacher, and secretary also supported the proposed quality improvement
project. The principal altered scheduled class time on the day of implementation.
Measurable Project Objectives
• Goal: Change the attitudes regarding the severity of vaping among middle school students.
o Objective: Compare responses on pre- and post-tests to determine if the educational
session implemented by the nurse practitioner changed the students’ attitudes.
o Measurable Outcome: Demonstrate a 10% increase in the number of middle school
students who report e-cigarettes as a health problem in America by the post-test.
o Statistical Analysis: McNemar chi-square
• Goal: Increase knowledge of middle school students regarding the dangers of vaping.
o Objective: Compare responses on pre- and post-tests to determine if the educational
session implemented by the nurse practitioner increased the students’ knowledge.
o Measurable Outcome: Demonstrate a 15% decrease in the number of middle school
students who report that vaping is safer than traditional cigarette smoking by the post-
test.
o Statistical Analysis: McNemar chi-square
Data from returned demographic surveys and pre- and post-tests was manually entered
into Statistical Package for the Social Sciences (SPSS) software. A descriptive analysis was
utilized to explain the demographic data obtained from participants. The method of statistical
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
25
analysis used for questions 1 and 3 on the pre- and post-tests was the Wilcoxon signed-rank test,
which compares two answers from the same participants (Laerd Statistics, 2018b). The
remaining six variables were statistically analyzed utilizing the McNemar chi-square test, which
determines if there is a difference between dichotomous dependent variables (Laerd Statistics,
2018a).
Results
Total enrollment at the middle school during the time of implementation was 248
students. On the day of implementation, 212 students were present. All students chose to attend
the vaping session implemented by the school-based nurse practitioner. The sample size for data
analysis was 174 participants, which was an 82% response rate. Students’ ages ranged from 11
years to 15 years, with a mean of 12.64 years and included grades six through eight. The
majority of participants were females, indicated by 48.9% of students. Male students
encompassed 47.7% of participants, while the remaining 3.4% of students chose not to disclose
their gender. Results were considered statistically significant if p-value was <.05.
The measurable outcomes of this quality improvement project were analyzed utilizing the
McNemar chi-square test conducted through the SPSS application. The purpose of the
McNemar chi-square test is to determine the difference between a repeated dichotomous variable
(Laerd Statistics, 2018a). The first goal of this quality improvement project was to change
attitudes regarding the severity of vaping among middle school students. The measurable
outcome, demonstrate a 10% increase in the number of middle school students who report e-
cigarettes as a health problem in America by the post-test, was not achieved. According to the
pre-survey, 87.6% percent of students viewed vaping as a health problem in the United States.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
26
On the post-survey, 89.1% of students indicated that vaping is a national health problem,
increasing by 1.5%. This result was determined statistically insignificant with a p-value of .815.
The second measured outcome, demonstrate a 15% decrease in the number of middle
school students who believe that vaping is safer than traditional cigarette smoking by the post-
test, was successful. Prior to the educational intervention, 25.9% of participants reported
electronic cigarettes as a safe alternative to cigarette smoking. Post-test responses revealed that
10.1% of students view vaping as a safe alternative to cigarette smoking, The 15.8% decrease in
adolescents who believe vaping is a safer than smoking was statistically significant with a p-
value of .000.
Two unintended variables were also found to be statistically significant during data
analysis. Responses from the pre- and post-test question “How much do you know about
electronic cigarettes/e-cigarettes/vapes?” were analyzed by the Wilcoxon signed-rank test. The
Wilcoxon signed-rank test compares changes in two responses from the same participant over
time (Laerd Statistics, 2018b). This statistical analysis was applied due to ordinal variables (i.e.,
Likert-style responses) (Laerd Statistics, 2018b). Initially, 21.8% of students reported knowing
“a lot” about vaping. The post-test responses revealed that 49.7% of students reported knowing
“a lot” about vaping, indicating 27.9% increase in students’ knowledge. This value was
statistically significant with a p-value of .000.
The second unintended variable that was statistically significant was “How did you learn
about the electronic cigarettes/e-cigarettes/vapes?” This variable was also analyzed with the
Wilcoxon-signed rank test because more than one option was allowed to be chosen by the
respondents. Approximately 56% of students reported the media as their source of information
on vaping on pre-surveys. According to post-survey responses, 62.3% of students reported
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
27
media as their source of vaping information. The 6.2% increase in media as the primary source
of vaping information for adolescents was statistically significant with a p-value of .012.
The remaining five variables were not statistically significant. Refer to Appendices G and H for
continued results.
Discussion
Overall, this quality improvement project was deemed successful. Statistical results
demonstrated a 15.8% decrease in adolescents who believe vaping is safer than smoking
following the educational intervention by the school-based nurse practitioner. Data also revealed
a 27.9% increase in students’ knowledge regarding vaping after the educational session and
game. The project was feasible, practical, and welcomed by school faculty and staff.
Limitations
The project was implemented in the month of January, which is a common time for
illnesses. On the day of implementation, only 85% of students were present which negatively
impacted the sample size. Due to staffing conflicts, the school nurse was unable to be involved
in the implementation of this project. Involvement from the school nurse would be beneficial in
the future and assist with sustainability and daily application of the knowledge obtained. The
school does not have a gymnasium due to pending construction; therefore, the session took place
in the school’s band room.
While all students chose to attend the educational presentation and interactive game, only
174 surveys were submitted to the project leader for inclusion in the quality improvement
project. It is likely that students were concerned regarding anonymity due to numbering of
survey packets and possible grading of pre- and post-test responses. This resulted in 18% of
packets being placed in the shred box.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Responses from the question “How did you learn about the electronic cigarettes/e-
cigarettes/vapes?” were statistically significant with a 6.2% increase from pre-test to post-test.
However, it is unclear why this increase was noted. The assumption is that students referred to
the school-based nurse practitioner’s presentation as a form of media, prompting participants to
select “media” as their source of vaping education.
Recommendations
The project was implemented between the hours of 8 a.m. and 11 a.m. to avoid conflict
with lunch schedules, which is recommended for future implementation. The session began with
eighth grade, continued with seventh grade, and concluded with sixth grade. This sequence was
most practical due to the scheduling of lunches; however, scheduling is modifiable based on
individual schools’ preferences. Avoidance of core class interruptions is also recommended for
future implementation sites. Involvement and support from the school principal and health
education teacher were vital for the success of this project and is necessary for success at other
sites.
Modification of the responses for the question “How did you learn about the electronic
cigarettes/e-cigarettes/vapes?” is recommended. Pre-survey response options should include “I
have not learned about e-cigarettes.” This potential response would allow the project leader to
highlight the deficit of vaping education throughout our counties, state, or nation. Responses on
the post-survey should include an option to select the vaping presentation. This would help
eliminate confusion and provide clearer results during data analysis.
In other settings, administration may not be as flexible with the time requirement;
therefore, decreased time for the educational session and game may be necessary. A future
recommendation to promote completion of pre- and post-surveys is an incentive, such as a gift
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
29
card or small reward. Also, eliminating the random numbering of survey packets is
recommended to provide reassurance of anonymity. Implementation of the project within the
school’s gymnasium would be ideal for future sites. This would allow for a larger life-size game
board as well as more space for students’ teams. The project should be continued in the
upcoming academic years due to the potential to greatly reduce morbidity and mortality among
youth.
Attainment of DNP Essentials
Essential I
Essential I: Scientific Underpinnings for Practice provides FNPs with the ability to
translate knowledge into practice for patient benefit (American Association of Colleges of
Nursing [AACN], 2006). Upon discovery of alarming statistics from a detailed literature search,
the project allowed the school-based nurse practitioner to utilize extensive medical knowledge to
implement a program directed at educating adolescents on the dangers of vaping. The use of
two, scientific-based theories were utilized to guide the design and implementation of this
project. The project also has potential to greatly benefit adolescent health throughout West
Virginia.
Essential II
Essential II: Organizational and Systems Leadership for Quality Improvement and
Systems Thinking encourages focusing on the needs of a target population or community
(AACN, 2006). The project coincided with this Essential by directing an educational
intervention to a middle school population. Essential II also emphasizes organizational and
systems leadership (AACN, 2006). The school-based FNP was viewed as a leader and content
expert by school faculty and students.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
30
Essential III
Essential III: Clinical Scholarship and Analytical Methods for Evidence-Based Practice
promotes translating research into practice as well as disseminating new knowledge (AACN,
2006). Translation of research into practice was achieved by creating an interactive game,
guided by an evidence-based tobacco education program, to address the needs of a specific target
population. The project leader will disseminate the knowledge obtained through a variety of
methods. This project was presented at the West Virginia Nurses Association Policy Summit in
February 2020 in the form of an educational poster. The project leader is also presenting this
project at the inaugural West Virginia School of Osteopathic Medicine Pediatric Primary Care
Poster Symposium, which will occur in 2020. Additional dissemination of the obtained
knowledge is planned by seeking inclusion of standardized vaping education and vaping-
specific policies into statewide curricula.
Essential IV
Essential IV: Information Systems/Technology and Patient Care Technology for the
Improvement and Transformation of Health Care requires the use of information systems or
technology to evaluate the outcomes of care (AACN, 2006). Also, application of budgeting tools
and management of information are components of this Essential (AACN, 2006). The project
utilized technology to analyze data and conduct statistical testing. All data was manually entered
into the SPSS application, followed by electronic statistically analyses. A detailed budget was
also created for the project.
Essential V
Essential V: Health Care Policy for Advocacy in Health Care promotes involvement in
designing, influencing, and implementing health care policies (AACN, 2006). This Essential
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
31
aligns closely with a long-term goal of the project, which is statewide health education
curriculum change and specific vaping policies. The pilot program at the project site has focused
on the immediate policies at the middle school and advocacy within the local community. To
change health education curriculum and policies for West Virginia middle schools, the school-
based nurse practitioner will continue to be engaged with the state legislature and advocate for a
program directed at improving adolescent health.
Essential VI
Essential VI: Interprofessional Collaboration for Improving Patient and Population
Health Outcomes requires effective team leadership from the doctorally-prepared nurse
practitioner in addition to interprofessional communication (AACN, 2006). Essential VI was
portrayed throughout the project through communication between the project leader, school
principal, health education teacher, and other faculty members. Effective communication and
interprofessional collaboration was essential for the successful implementation of the project.
The school-based nurse practitioner continues to lead the interprofessional team dedicated to the
health of the school’s students.
Essential VII
Essential VII: Clinical Prevention and Population Health for Improving the Nation’s
Health is vital to improve the health of United States’ citizens (AACN, 2006). Essential VII was
the underlying framework for the proposed project. The doctorally-prepared nurse practitioner
possesses the knowledge necessary to achieve the goals of health promotion and disease
prevention (AACN, 2006). The overarching goal of this project was to educate middle school
students on the dangers of vaping, ultimately promoting health and preventing disease. This
project also worked to address the Healthy People 2020 goal related to tobacco use.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Essential VIII
Essential VIII: Advanced Nursing Practice refers to the competencies that are necessary
for advanced practice (AACN, 2006). Doctorate of Nursing Practice (DNP) degrees prepare
advanced practice registered nurses for various roles in the healthcare system (AACN, 2006).
The project strengthened the leadership and communication skills of the project leader as well
promoted credibility throughout the field of primary care and school-based healthcare. The
project leader exhibited critical thinking throughout the duration of the project. A professional
relationship was developed between the project leader, school administration, and students.
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix A
Demographic Questionnaire
1. What is your age?
2. What grade are you in?
3. What is your gender?
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix B
Pre-Intervention Questionnaire
Please DO NOT write your name or any information on this paper. Circle your answer.
1. Have you ever heard of electronic cigarettes, e-cigarettes, or vapes?
YES NO
2. How did you learn about the electronic cigarettes/e-cigarettes/vapes? (Choose all that apply)
MEDIA NEWSPAPER ROADSIDE POSTER (BILLBOARD)
FRIEND FAMILY OTHER
3. How much do you know about electronic cigarettes/e-cigarettes/vapes?
NOTHING AT ALL A LITTLE A LOT
4. Have you ever used an e-cigarette/vape/JUUL ®?
YES NO NOT SURE
5. Are electronic cigarettes/e-cigarettes/vapes safer to use than regular cigarettes?
YES NO
6. Electronic cigarettes/e-cigarettes/vapes may lead to “regular” cigarette smoking.
YES NO
7. Is vaping a health problem in America?
YES NO
8. Should electronic cigarettes/e-cigarettes/vapes be allowed in schools and public places?
YES NO
Questions modeled from Anand et al. (2015) and Mbe et al. (2017)
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix C
Post-Intervention Questionnaire
Please DO NOT write your name or any information on this paper. Circle your answer.
1. Have you ever heard of electronic cigarettes, e-cigarettes, or vapes?
YES NO
2. How did you learn about the electronic cigarettes/e-cigarettes/vapes? (Choose all that apply)
MEDIA NEWSPAPER ROADSIDE POSTER (BILLBOARD)
FRIEND FAMILY OTHER
3. How much do you know about electronic cigarettes/e-cigarettes/vapes?
NOTHING AT ALL A LITTLE A LOT
4. Have you ever used an e-cigarette/vape/JUUL ®?
YES NO
5. Are electronic cigarettes/e-cigarettes/vapes safer to use than regular cigarettes?
YES NO
6. Electronic cigarettes/e-cigarettes/vapes may lead to “regular” cigarette smoking.
YES NO
7. Is vaping a health problem in America?
YES NO
8. Should electronic cigarettes/e-cigarettes/vapes be allowed in schools and public places?
YES NO
Questions modeled from Anand et al. (2015) and Mbe (2017).
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix D
Content Outline
A. Activity 8 : Electronic Cigarettes
• Will discuss how electronic cigarettes are not safe alternative to traditional
cigarettes
• Information will provide description of electronic cigarette, toxic ingredients, and
brain effects
• Approximately 5 minutes duration
B. Activity 9: What is a JUUL ®?
• Will discuss the dangers associated with JUULs ®
• Will describe the function of a JUUL®
• Information will explain how JUULs ® negatively affect health
• Approximately 5 minutes duration
C. Activity 12: Reasons People Use Tobacco
• Will discuss the reasons that people use tobacco products
• Will discuss the impact of peer pressure and image
• Will educate students on the potential for addiction
• Approximately 5 minutes duration
Activities are derived from the Tar Wars Program Guide 2019-2020 School Year (AAFP, 2019).
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix E
Budget
Budget Categories
Personal
Funds
Organizational
Contributions
Projected Costs Actual Costs
ADMINISTRATIVE COSTS $0 $0 $0
Administrative Justification: N/A
Marketing $0 $0 $0
Marketing Justification: N/A
EDUCATIONAL MATERIALS/
INCENTIVES
$100 $100 $220
Educational Materials/Incentives Justification: Supplies for activities, candy
for participation, etc.
HOSPITALITY (food, room rentals,
etc.)
$0 $0 $0
Hospitality Justification: N/A
PROJECT SUPPLIES (office
supplies, postage, printing, etc.)
$0 $100 $30
Project Supplies Justification: Printing/copying costs for pre- and post-tests
TRAVEL EXPENSES $0 $0 $0
Travel Expenses Justification: N/A
OTHER $180 $0 $180
Other Justification: Nurse practitioner expense – donated
TOTALS $100 $200 $250
Appendix F
Site Support Verification
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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EVALUATION OF THE IMPACT OF AN EDUCATIONAL
45
Appendix G
Results
Table 1.
Wilcoxon Rank Test Results
Variable Response Pre-Test
Post-Test p-value
n Valid Percent n Valid Percent
Q3
How much do you
know about electronic
cigarettes/e-
cigarettes/vapes?
Nothing at all 8 4.7 4 2.4 .000
A little 125 73.5 79 47.9
A lot 37 21.8 82 49.7
Q4
Have you ever used an
e-cigarette/vape/JUUL
®?
No 116 67.1 113 68.5 .062
Yes 47 27.2 52 31.5
Not sure 9 5.2
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
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Appendix H
Results
Table 2.
McNemar Chi-Square Test Results
Variable Response Pre-Test
Post-Test p-value
n Valid Percent n Valid Percent
Q1
Have you ever heard of
electronic cigarettes/ e-
cigarettes/vapes?
No 3 1.7 1 0.6 .500
Yes 171 98.3 166 99.4
Q2
How did you learn about
the electronic
cigarettes/e-
cigarettes/vapes?
Media 97 56.1 104 62.3 .012
Other 76 43.9 63 37.7
Q5
Are electronic
cigarettes/e-cigarettes/
vapes safer to use than
regular cigarettes?
No 126 74.1 151 89.9 .000
Yes 44 25.9 17 10.1
EVALUATION OF THE IMPACT OF AN EDUCATIONAL
47
Variable Response Pre-Test
Post-Test p-value
n Valid Percent n Valid Percent
Q6
Electronic cigarettes/e-
cigarettes/vapes may
lead to “regular”
cigarette smoking.
No 39 22.8 29 17.4 .286
Yes 132 77.2 138 82.6
Q7
Is vaping a health
problem in America?
No 21 12.4 18 10.9 .815
Yes 149 87.6 147 89.1
Q8
Should electronic
cigarettes/e-
cigarettes/vapes be
allowed in schools and
public places?
No 133 78.2 134 80.7 .727
Yes 37 21.8 32 19.3
- Evaluation of the Impact of an Educational Intervention Focused on Adolescent Vaping Among Rural Middle School Students
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