# Situation: The public health nurse and the school nurse plan health education on oral hygiene and tobacco use for Grade 6 pupils of a public elementary school. Before the tobacco lessons, the nurses survey the pupils and run a practice scenario in which a classmate, acting as a friend, keeps urging each pupil to take a cigarette. The results: Believe that smoking is harmful: 92% Intend never to smoke: 88% Took the cigarette when the classmate kept urging: 60% Which teaching method should the nurses MAINLY use?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627192  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: The public health nurse and the school nurse plan health education on oral hygiene and tobacco use for Grade 6 pupils of a public elementary school.

Before the tobacco lessons, the nurses survey the pupils and run a practice scenario in which a classmate, acting as a friend, keeps urging each pupil to take a cigarette. The results:
Believe that smoking is harmful: 92%
Intend never to smoke: 88%
Took the cigarette when the classmate kept urging: 60%
Which teaching method should the nurses MAINLY use?

## 보기

1. Values clarification on why pupils should avoid smoking
2. Role play of refusing repeated offers from a peer **✔ 정답**
3. A talk by a former smoker on how he started and quit
4. Group discussion on the harms of smoking to teenagers

**정답: 2**

## 해설

Knowledge and attitudes (92% believe smoking is harmful) and intention (88% intend never to smoke) are already high, yet 60% gave in under repeated pressure. The gap lies between intention and a skill: refusing under peer pressure. Role play lets pupils rehearse the words and actions of refusal in a safe setting until they can use them. Values clarification and group discussion work on attitudes that are already favorable, and a former smoker's talk offers a model but no practice.

## 심화 해설

The survey results reveal a classic intention–behavior gap: pupils already hold strong negative beliefs about smoking and most say they do not plan to smoke, yet a majority still accepted a cigarette when pressured repeatedly. This means the nurses should not spend more time trying to change knowledge or attitudes. Instead, the main teaching method must target the missing link—behavioral skill practice for refusing offers under social pressure.

Why role play is the priority

In this scenario, 92% believe smoking is harmful and 88% intend never to smoke. These are already high numbers. However, 60% took the cigarette when a peer kept urging them. The problem is not what pupils know or believe; it is what they can actually do in the moment. Role play directly rehearses the verbal and nonverbal refusal behaviors needed to resist repeated peer offers.

Refusal under pressure is a performance skill, not just a decision. A pupil may know smoking is bad and may want to say no, but without practiced responses, repeated urging can override intention. Role play provides a safe setting to practice words, tone, eye contact, body language, and alternative actions—such as walking away or changing the subject—until the response becomes automatic.

Key point! When knowledge and attitude scores are already high but behavior still fails, the educational gap is a skill deficit, not a knowledge deficit. Teach and rehearse the skill.

How the evidence supports skills-based refusal training

The provided studies consistently show that teaching refusal skills—often through role play, modeling, rehearsal, and feedback—is more effective than purely informational or attitude-focused approaches for adolescent substance use prevention.

One study compared peer pressure resistance training with a normative education approach and found that resistance skill training was the active strategy for reducing cigarette, alcohol, and marijuana use onset [1]. This aligns with the scenario: the pupils do not need more information about norms or harms; they need the actual skill to refuse when someone keeps offering.

Another study directly compared social skills training with didactic training and no training. The social skills training group showed significantly greater increases in assertiveness for resisting peer pressure related to risk behaviors . This supports choosing an active rehearsal method over a talk or discussion.

A third study described refusal skills training that used role-plays built from real situations, following a sequence of rationale, modeling, rehearsal, feedback, and reinforcement . The pupils in the scenario would benefit from exactly this structure: see a model refusal, practice it, receive feedback, and repeat.

A fourth study examined the mediating role of refusal skills in preventing adolescent alcohol misuse and found that refusal skills serve as a key mechanism through which prevention programs reduce substance use . This reinforces that the nurses should focus on building the skill itself, not just strengthening the intention.

Why the other options are less appropriate

| Option | What it targets | Why it is not the main method here |
| --- | --- | --- |
| 1. Values clarification | Attitudes and beliefs | Attitudes are already favorable; 92% believe smoking is harmful |
| 3. Talk by a former smoker | Modeling and motivation | Provides a model but no active practice of refusal behavior |
| 4. Group discussion on harms | Knowledge and perceived risk | Knowledge is already high; discussion does not rehearse the actual refusal skill |

Watch out! Do not confuse a good role model with skill rehearsal. A former smoker’s story may inspire, but it does not let pupils practice saying no under pressure. The gap shown by the 60% acceptance rate is behavioral, so the teaching method must involve active practice.

The most defensible choice is therefore role play of refusing repeated offers from a peer. It directly addresses the identified deficit—the inability to translate intention into refusal behavior when confronted with persistent social pressure—and is consistent with the evidence that refusal skills training improves adolescent resistance to substance use offers [1].References (research sources)

- [1]Preventing alcohol, marijuana, and cigarette use among adolescents: peer pressure resistance training versus establishing conservative norms.Research articleHansen WB, Graham JW (1991) · DOI: 10.1016/0091-7435(91)90039-7

## 임상 시나리오

Refusal Skills Training for Peer PressureClosing the intention-behavior gap in school tobacco education
When knowledge and attitude scores are already high but behavior still fails, the educational gap is a skill deficit, not a knowledge deficit. Teach and rehearse the refusal skill.

Use role play to practice verbal and nonverbal refusal behaviors: saying no firmly, maintaining eye contact, using confident body language, and alternative actions such as walking away or changing the subject.

Rehearse responses to repeated offers, not just a single refusal. The scenario showed 60% accepted under persistent urging, so practice escalating refusal strategies across multiple pressure attempts.

CautionDo not spend limited teaching time on values clarification or group discussion when 92% already believe smoking is harmful and 88% intend never to smoke. The priority is active behavioral rehearsal, not more information.

## 핵심 개념

- **intention-behavior gap** — Discrepancy between what a person intends to do and what they actually do, often due to lack of skills or environmental barriers.
- **refusal skills** — Learned verbal and nonverbal behaviors used to decline offers or pressure, such as saying no firmly, eye contact, and walking away.
- **role play** — A teaching method where learners act out scenarios to practice behaviors in a safe, simulated environment.
- **peer pressure** — Social influence from peers to adopt certain behaviors, attitudes, or actions, often tested in adolescence.
- **skill deficit** — A gap in the ability to perform a behavior, distinct from lack of knowledge or motivation.

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