Mental health professionals’ perspectives on the implementation of smoke-free policies in psychiatric units across England

Abstract

Background:

The original audit on which this 2013 secondary analysis is based, was conducted in 2010. It explored implementation of smoke-free policies from the perspective of unit managers in 147 psychiatric units across England comprising a randomly selected sample of nine different unit types.

Material:

Two main themes are presented: positive perspectives of smoke-free policy implementation, and barriers and problems with smoke-free policy implementation. Analysis of unit managers’ experiences and perspectives found that 96% of participants thought smoke-free policy had achieved positive outcomes for staff, patients, services and care.

Discussion:

Consistency of response was the most prominent factor associated with policy success. Quality of the physical environment and care delivery were clear positive outcomes which enabled the environment to be more conducive to supporting staffs’ and patients’ quit attempts. Lack of consistency and a prevailing culture of acceptance of smoking were identified as some of the most reported perceived continuing problems. Solutions included the need to acknowledge that this type of complex systems change takes time and ongoing staff education and training.

Conclusion:

Our results demonstrate the importance of taking into account the experiences and attitudes of staff responsible for enacting smoke-free policy.

Keywords

Smoke-free policy mental health psychiatric inpatient implementation

Introduction

Tobacco smoking is a major preventable risk factor for several chronic physical health conditions, accounting for nearly 6 million deaths worldwide each year (World Health Organization (WHO), 2012). Indirect exposure, or environmental tobacco smoking, is a significant public health problem (United States Department of Health and Human Services, 2006; WHO, 2009). In England, smoking is the largest cause of preventable illness, responsible for almost one in five deaths (Health and Social Care Information Centre, 2012).

Smoking rates in people with mental disorder range from 32% to 88% (Lawrence, Mitrou, & Zubrick, 2009; McManus, Meltzer, & Campion, 2010; Shetty, Alex, & Bloye, 2010) compared to 20% in the general adult population (McManus et al., 2010) (Table 1). A total of 42% of adult tobacco consumption in England is by people with mental disorder (McManus et al., 2010). While general population smoking prevalence has decreased, this has not occurred for people with mental disorder (Royal College of Physicians and Royal College of Psychiatrists, 2013).

Table 1.

Proportion of population in England with different mental disorder and rates of smoking (McManus et al., 2010).

	National prevalence of disorder	Proportion who are regular smokers
Any mental disorder	23%	33%
Common mental disorder	16%	32%
Depressive episode	3%	37%
Phobias	2%	37%
Generalised anxiety disorder	4%	36%
PTSD screen	3%	37%
ADHD screen	1%	31%
Psychosis	1%	40%
Suicide attempt in past year	1%	57%
Drug dependence	3%	69%
Alcohol dependence	6%	46%
Alcohol problems	24%	30%

ADHD: attention deficit hyperactivity disorder; PTSD: posttraumatic stress disorder.

Higher levels of smoking are responsible for the largest proportion of health inequality and excess mortality experienced by this population (Her Majesty’s Government (HMG), 2011). Although smokers with mental disorder are just as motivated to stop as the general population (Ashton, Miller, Bowden, & Bertossa, 2010; Ashton, Rigby, & Galletly, 2013), they are less likely to be offered cessation support (Wye et al., 2010). Smoking cessation results in improved mental health and life expectancy, reduced risk of developing physical illness, and may play a role in preventing mental disorder (HMG, 2011).

Implementing smoke-free policy in treatment and care settings can help address this health inequity. However, it can be challenging. England’s mental health facilities implemented smoke-free policy in July 2008. Prior to this, a survey in one English inpatient unit found that 60% of staff believed they should smoke with patients (as did 78% of patients). A total of 54% of staff (and 79% of staff who smoke) believed that smoking had a therapeutic role for patients including within staff/patient interactions, and 93% believed that patients’ mental health would deteriorate without access to cigarettes (Dickens, Stubbs, & Haw, 2004; Stubbs, Haw, & Gamer, 2004). A 2005 survey of 151 mental health units (Jochelson & Majrowski, 2006) revealed that most staff and patients perceived smoking as a normal aspect of patients’ care and doubted that comprehensive smoke-free policy would succeed. In a 2007 survey of 86 English Trusts human resource directors (Ratschen, Britton, Doody, Leonardi-Bee, & McNeill, 2009; Ratschen, Britton, & McNeill, 2008, 2009), participants held particular concerns about safety and clinician/patient relationships.

Understanding attitudes and concerns of staff towards smoke-free policy is important for successful implementation (Eadie et al., 2012; Leonardi-Bee et al., 2012). Smoke-free policy can be successfully implemented in mental health settings (Eadie et al., 2012; Lawn & Pols, 2005). However, few studies explore issues across the spectrum of unit types (Lawn & Campion, 2010). Without such exploration, our understanding about smoke-free policy, making predictions about overall policy effectiveness and planning next steps is limited.

Study aims

This audit was conducted on behalf of England’s Department of Health and included feedback about smoke-free policy from mental health unit managers with frontline responsibility for policy enactment. Aims were to determine what they perceive as facilitators and benefits to implementing smoke-free policy in their units and to identify possible problems and barriers arising from the policy.

Methods

The audit was informed by systems theory which is well suited to interpreting policy and practice change, involving system rules and processes, in complex and dynamic systems such as mental health treatment settings (Laszlo & Krippner, 1998). It is particularly useful for understanding how stakeholders interact and develop beliefs and attitudes about their roles, and how policy is enacted within organisations. It is useful here because the culture of smoking has been a recognised part of mental health service systems for decades, with staff playing an important role in perpetuating that culture (Lawn, 2004).

Sampling, recruitment and data collection

Drawing on the Australian national survey conducted by Lawn and Campion (2010), two of the co-authors developed a similar survey with experts from the Department of Health. Between January and May 2010, the survey was sent to 220 unit managers of a random sample of different types of mental health units across England. This was undertaken by staff at the Tobacco Control Collaborating Centre who identified potential services from available listings within each Trust, followed by a letter from the head of the Department of Health to chief executives of mental health Trusts asking them to encourage their unit managers to respond. At the time, there were approximately 15,200 adult public mental health beds across the 58 Trusts in England, which represents approximately 300 units. Nine different adult mental health unit types were approached, reflecting diverse units and patient acuity. These included high, medium and low secure units; acute inpatient, inpatient alcohol/opiate detoxification and psychiatric intensive units; and day care and residential rehabilitation units (Table 2). Unit managers were chosen because of their routine contact within the unit environment and their role in overseeing the practice of staff teams (and therefore thorough knowledge of those practice and any staff issues) in operationalising service policies. The sampling frame included all mental health units in England (n = ~300), with surveys sent to approximately 73% (n = 220) of this total sample. Unit managers in 147 units responded (response rate = 67%).

Table 2.

Participant response rate by type of unit.

Name of unit	Response rate
Residential rehabilitation	n = 34 (23.13%)
Day care	n = 10 (6.80%)
Acute inpatient	n = 44 (29.93%)
Low secure	n = 21 (14.29%)
Medium secure	n = 16 (10.88%)
High secure	n = 3 (2.04%)
Psychiatric intensive care unit (PICU)	n = 13 (8.84%)
Inpatient alcohol/opiate detoxification unit	n = 5 (3.40%)
Other	n = 1 (0.68%)
Total	N = 147 (100%)

The survey included 52 questions comprising Likert-rated, yes/no or multiple choice questions, complemented by site visits to help verify what was reported, the results of which are reported elsewhere (Wareing & Gray, 2010, 2012). In addition, the survey included five unstructured questions, allowing open responses about perceived enablers and barriers to implementation of smoke-free policy. Results from these five questions are reported in the following:

Describe what the positive consequences of the smoke-free policy/legislation are in your view for patients and staff?

What do you think are the main things important for successful smoke-free policy/legislation?

Describe successful approaches that have been taken by your unit to ensure compliance with smoke-free policy/legislation?

Describe the problems which your unit experienced with smoke-free policy/legislation and what you think the reasons for this are?

What do you think are the main reasons for unsuccessful smoke-free policy/legislation?

The original audit was deemed an audit, with approval provided by the Department of Health. This analysis was approved by the University ethics committee.

Data analysis

Responses were analysed using Summative Content Analysis which involves subjective interpretation of text data through systematic classification, coding and identifying themes or patterns (Hsieh & Shannon, 2005). It goes beyond manifest (visible) content analysis processes of counting frequency of different words within responses (Hsieh & Shannon, 2005), to examining language and its meaning intensely. Using Latent Content Analysis (Graneheim & Lundman, 2004), the researchers interpreted the content, to discover and understand underlying or implied meaning of responses (Kondracki, Wellman, & Amundson, 2002; Morse & Field, 1995).

The first (S.L.) and second authors (Y.F.) undertook data analysis by reading and re-reading responses to each question, word by word, then undertaking formal analytic memo-writing to begin formulating general impressions about participants’ responses. They checked back and forth within responses and across questions, highlighting words and phrases with similarities and differences in perspectives as part of preliminary coding to identify tentative themes and sub-themes. Memos were also used to record decision making steps, to compare and contrast responses, to verify and finalise themes. Discussions were recorded and final groupings checked against audio-recordings and memos to ensure accuracy. Specific examples of responses that exemplified each theme were discussed and agreed upon.

Before proceeding, it is important to alert the reader to ambiguity concerns about the term ‘smoke-free’. Across mental health settings, arrangements relating to smoking facilitation and smoke-free policy enforcement are manifold and extremely heterogeneous. We encourage the reader to view smoke-free policy within clinical practice settings as a process that involves ongoing and routine enforcement, rather than viewing it as a finite event, when considering these findings (for a more comprehensive discussion of this issue, see Lawn & Campion, 2013, pp. 4226–4227). Further discussion is provided in the ‘Limitations’ section.

Findings

Findings are presented in two parts. Part A describes participants’ positive perspectives within three sub-themes: (1) positive consequences of smoke-free policy for patients and staff, (2) successful approaches taken to ensure compliance with the policy and (3) main factors for successful smoke-free policy. Part A results are summarised in Table 3. Part B describes perceived barriers and problems with implementation within two sub-themes: (1) problems experienced with smoke-free policy and (2) main reasons for unsuccessful smoke-free policy. Part B results are summarised in Table 4. Between 95 and 122 responses were received for each question.

Table 3.

Part A: unit managers’ positive perspectives of implementation of smoke-free policy.

Sub-theme	Summary findings	Sample details
1. Positive consequences of the smoke-free policy for patients and staff	A range of positives	115 (94%) of total, n = 122
	No positives	7 (6%) of total, n = 122
	Improved quality of the physical, caring/working and cultural environment	88 (72%) of total, n = 122
	Improved quality in provision of care to patients, feeling more empowered to address patients’ smoking, and reduced ambiguity and clinical tensions within their care role	28 (32%) of total, n = 88
	Staff and patients more able to quit as a result of the policy	66 (54%) of total, n = 122
	Created a more health promoting structure for staff to provide care	30 (46%) of total, n = 66
	Patients who attempted to quit during their admission were more likely to use NRT and staff more likely to want to quit and support patients to quit	36 (55%) of total, n = 66
2. Successful approaches taken to ensure compliance with the policy	Enhanced clinical processes to ensure consistent cessation support (e.g. referral to the smoking cessation nurse, dedicated smoking care plans, care planning for persistent policy non-compliance, pharmacist present in ward reviews)	27 (25%) of total, n = 107
	Comprehensive communication by Trusts to staff and patients during planning and implementation, through community meetings and consultations	31 (29%) of total, n = 107
	Clear and consistent ongoing communication of the policy to educate staff and patients	38 (36%) of total, n = 107
	Existence of designated smoking areas	38 (36%) of total, n = 107
3. Main factors for successful smoke-free policy	Consistency in how information and education about the policy and support was provided to patients and staff, how adverse incidents related to smoking were managed, the use of NRT, and awareness of the need for unity shown by staff teams towards the policy	40 (37%) of total, n = 109
	Clear information and clear surrounding legislation, to guide staff and patients to better understand the policy and be compliant	20 (18%) of total, n = 109
	Existence of the policy itself	4 (3.7%) of total, n = 109

NRT: nicotine replacement therapy.

Table 4.

Part B: unit managers’ perceived barriers and problems with implementation of smoke-free policy.

Sub-theme	Summary findings	Sample details
1. Problems experienced with smoke-free policy	No problems with implementation of smoke-free policy	26 (26%) of total, n = 100
	Inclement weather	13 (13%) of total, n = 100
	Layout of the unit, the establishment of undesirable smoking zones near entrances and walkways outside the hospital precincts	15 (15%) of total, n = 100
	Staff culture of ignoring patients’ smoking	10 (10%) of total, n = 100
	Staff belief that patients disagreed with the policy and that long-stay patients perceive the unit as like their home and should be allowed to smoke inside	12 (12%) of total, n = 100
	General problems with staffing levels which adversely affected staff capacity to respond to infringements to the policy	23 (23%) of total, n = 100
	Difficulty with managing patients’ behaviour, especially agitated patients	15 (15%) of total, n = 100
2. Main reasons for unsuccessful smoke-free policy	Patients’ beliefs and attitudes towards the policy and towards smoking	13 (14%) of total, n = 95
	Smoking as an important coping mechanism for patients to deal with stress and boredom	12 (13%) of total, n = 95
	Lack of motivation by patients to quit smoking and inpatient admission as not the right time to impose smoking restrictions on patients	12 (13%) of total, n = 95
	Lack of staff and system support, coordination and consistency to carry out appropriate interventions to maintain the implementation of the policy	39 (41%) of total, n = 95
	Lack of a clear supportive introduction to policy when they started their role in the smoke-free unit	16 (43%) of total, n = 37
	Inconsistent staff approaches to the enforcement of the policy	21 (57%) of total, n = 37

Part A.1: Staff perceptions of the positive consequences of smoke-free policy

Seven of 122 participants (6%) saw no positives; 115 (94%) reported a range of positives. A total of 88 participants (72%) reported improved quality of the physical environment (cleaner, less smoke smells), caring/working environment and cultural environment, with perceived benefits for staff and patient health. Of these 88 participants, 28 (32%) perceived that smoke-free policy had improved overall quality in patient care; feeling more empowered to address patients’ smoking now that it was an acknowledged part of care. They also reported that it reduced ambiguity and clinical tensions within their health professional role (managing cigarette supply as part of that role) which had been apparent previously when patients’ smoking was condoned:

The smoke-free environment creates a safe, healthy workplace/environment; it has reduced the health hazards and discomfort, and there is no longer any shared health risks to non-smokers in terms of passive smoking; it has eliminated debate on whether nurses undertake level one observation and have to sit in the smoking room with patients. (Acute, ex-smoker)

A total of 66 participants (54%) reported that staff and patients had been more able to quit as a result of the policy. Of these 66 participants, 30 (46%) said the policy created more health promoting structures for staff to provide care. A total of 36 participants (55%) perceived that patients who attempted to quit during their admission were more likely to ‘avail themselves of Nicotine Replacement Therapy (NRT) when they are motivated to quit smoking’ (acute, ex-smoker). They also perceived that it ‘increased staff quitting and drive to support people who wish to stop smoking’ (medium secure, ex-smoker) and enabled staff to be ‘more therapeutically involved’ (acute, never smoker) with patients:

We have been able to convert the smoking room into a ‘quiet room’ which is utilised by both patients and staff … Non-smoking patients feel less obliged to sit with smokers, therefore reducing risk of passive smoking related health issues.

Part A.2: Successful approaches taken to ensure compliance with the policy

A total of 107 participants provided information about successful approaches taken to ensure policy compliance. These involved training and education for staff and patients, improving communication strategies and ward processes and procedures, removing smoking rooms and restricting patients’ access to cigarettes and designated smoking areas. Collaborative approaches were stressed, but blanket approaches with consistent application were equally emphasised:

Discussion in the house meetings, asking clients to think of ways in which we can comply with the legislation – for example, a client offered to find out about smoking cessation aids … so they could share the information with other clients. Having bedrooms redecorated to give clients a pleasant living environment which they want to keep fresh and clean. (Residential rehab, ex-smoker)

A total of 27 participants (25%) reported introducing enhanced consistent clinical processes as part of improving policy success. Processes included referral to the smoking cessation nurse, brief interventions training, dedicated smoking cessation care plans, care planning for persistent policy non-compliance and having a pharmacist present in ward reviews to address patients’ smoking withdrawal needs.

Additionally, 38 (36%) participants emphasised the importance of skilled communication of policy, to educate staff and patients. Responses of 31 participants (29%) suggest that Trusts had communicated the policy comprehensively to staff and patients during planning and implementation, through community meetings and consultations:

Just good staff tolerance and therapeutic relationships with patients help enable them to understand why this is necessary. (Psychiatric intensive care unit (PICU), Smoker)

Despite perceived success of these approaches, 38 (36%) participants acknowledged designated smoking areas as part of this success. They held that it was better to assign designated smoking areas across extensive grounds and know where smokers went than to not know where to find them:

We have an outside space for service users to smoke, which is open 24 hours a day. It is near to the staff office and good for observation and supports other patients and staff who are able to maintain a smoke-free environment. (Acute, never smoker)

Part A.3: Factors associated with successful smoke-free policies

A total of 109 participants identified factors perceived as responsible for successful smoke-free policy. A total of 40 participants (37%) reported consistency as central to policy success; how information and education about the policy and support was provided to patients and staff, how adverse incidents related to smoking were managed, use of NRT and the need for unity shown by staff teams towards the policy. Inclusive communication, discussion and negotiation with patients were also perceived as important for policy success:

The Unit held patient meetings and meetings with advocacy to work towards enforcement of the smoke-free legislation. The timings of smoking were agreed within those meetings and have now been implemented successfully since the changes were made by patients. (Low secure, smoker)

A total of 20 participants (18%) said information and surrounding legislation had to be clear, to guide staff and patient understanding and compliance with policy; to ‘give people a choice; not just enforce policy’ (acute, Ex-smoker). Four participants said the policy’s existence itself was key to implementation success because a total ban on smoking enabled a ‘zero tolerance approach’ (acute, Smoker); ‘we just got on and embraced it and introduced it because we had to’ (acute, never smoker).

Part B.1: Problems experienced with smoke-free policy

Of 100 participants, 26 (26%) reported no problems with implementation of smoke-free policy. However, 13 participants (13%) highlighted the crucial role that unfavourable weather played, making patients reluctant to go out to smoke. Additionally, 10 participants (10%) stated that the culture of ignoring smoking helped support resistance to the policy. However, 12 other participants (12%) stated that long-stay patients perceive the unit as like their home and so should be allowed to smoke inside.

A total of 23 participants (23%) reported problems with staffing levels which adversely affected their capacity to respond to policy infringements. This included patients who smoked in their rooms late at night and lack of staff to monitor patients’ behaviour at these times. It also included the need for staff to escort some patients off the unit to smoke due to perceived safety concerns.

A total of 15 participants (15%) stated that smoke-free policy implementation was hindered by perceived difficulty with managing patients’ behaviour, especially agitated patients who wished to continue smoking while hospitalised. They stated that patients who were severely ill and/or under the influence of illicit substances were not responsive to requests not to smoke on premises and that violent and verbally abusive incidents between patients and staff would increase dramatically as a result of the policy, despite also seeing the value of a smoke-free environment to overall health of staff and patients. This ambivalence suggests that staff struggled with a range of internal value conflicts as part of their policy enforcement role. Perceived problems reported in units where a partial policy existed (allowing smoking in designated areas) included ambiguity in how to respond to and manage patients’ smoking:

The Unit had problems with getting the timings of smoking correct as these had to fit in sensibly around other activities. Due to us having set times for smoking, there can be issues if staff are not readily available at those times. (Low secure, smoker)

Part B.2: Main perceived reasons for unsuccessful smoke-free policy

Of 95 participants, 13 (14%) reported the main reason for unsuccessful smoke-free policy as patients’ beliefs and attitudes towards the policy and smoking, generally; that patients either did not want to stop smoking or did not feel they could. Participants stated that patients were aware of health risks related to smoking, but they believed that patients voiced strong disapproval with the smoke-free policy and perceived it as interfering with their personal rights. A total of 12 participants (13%) also perceived that smoking was an important coping mechanism for patients to deal with stress and boredom; that patients would be unhappy with restrictions on their ‘liberties’ and a policy that ‘undermined patient choice’. Additionally, 12 participants (13%) perceived lack of motivation by patients to quit smoking and that inpatient admission was not the right time to impose smoking restrictions on patients:

Some patients, who are often all detained in their facilities against their will, will always try to find ways around the policy and controls; mental health problems are the main focus and stopping smoking is not a priority when people are unwell or vulnerable to further stress. (Medium secure, ex-smoker)

A total of 39 participants (41%) perceived lack of staff and system support, coordination and consistency as important reasons for unsuccessful smoke-free policy implementation:

The main reasons are inconsistent staff approaches to the enforcement of the policy; also poor/inconsistent management of breaches of policy regarding smoking. (Low secure, smoker)

Responses of 37 participants (39%) provide clues to why staff held these beliefs. Of these participants, 16 (43%) said they did not have a clear supportive introduction to the policy when they started their role in the unit. A total of 21 participants (57%) reported inconsistent staff approaches to policy enforcement; that some professionals do not believe in smoking cessation’ (acute, never smoker). Two participants stressed that more staff need to be trained to support the policy. None reported that they had received or were offered comprehensive training or support to help them implement the policy.

Discussion

The findings reveal many positive staff perceptions about smoke-free policy since its introduction in English mental health units. These included the belief that it facilitated staff and patients’ smoking cessation, reduced ambiguity about smoking as a patient right and choice, and that policy implementation was relatively straightforward to implement. However, findings also show prevailing concerns that mirror those previously reported (Lawn, 2004; Ratschen, Britton, Doody, et al., 2009; Ratschen, Britton, & McNeill, 2009; Ratschen, Doody, Britton, & McNeill, 2010; Schultz, Finegan, Nykiforuk, & Kvern, 2011). These include the perception that most patients are resistant to the policy and that greater consistency of communication, system support and staff response is still needed for policy success.

Positive impacts of smoke-free policy

Overall, findings showed that the policy was rated positively by most participants. Health benefits related to improved air quality and reduced exposure to second-hand smoke (Jochelson & Majrowski, 2006; McNeill, Craig, Willemsen, & Fong, 2012) as well as improvements in the working and cultural environment. These are all important elements to consider within a system theory perspective because they signify how environmental factors, interactions between groups and rules are interpreted and influence how those systems implement change (Laszlo & Krippner, 1998; Lawn, 2004; Millet, 1998). They indicate that smoke-free policy offers an opportunity to improve health through improving a range of structures and relationships within systems of care, and help reduce social acceptability of smoking (Bogdanovica, Godfrey, McNeill, & Britton, 2011; Fong et al., 2006). Smoke-free policy can therefore constitute an important component of health promotion and staff clearly recognised its health benefits.

Continuing barriers and problems with implementing smoke-free policy

Behaviour change

Many participants reported behavioural changes in staff and patients following policy implementation; they smoked less or were more likely to make quit attempts. However, smoking cessation was generally not perceived by staff as a treatment priority and some staff still perceived smoking as an acceptable cultural norm for patients (Dickens et al., 2004; Green & Hawranik, 2007; Lawn & Condon, 2006). Therefore, how mental health professionals deliver their own beliefs, values and knowledge to patients is important. These results suggest that more education, training and practical support for staff are needed. Systems theory holds that shifting cultural norms takes time and involves continuous and coordinated effort, experiment and reflection to learn new ways of responding (Millet, 1998). Many participants perceived difficulties with managing patients’ behaviour change and patients’ capacity to remain quit, so they did not enforce the policy (Kerr, Woods, Knussen, Watson, & Hunter, 2013). These myths (Prochaska, 2011) need to be challenged through more consistent identification of smokers and provision of evidence-based tobacco treatment delivered as standard care to all hospitalised smokers, as well as more training for staff in practical cessation treatment.

Consistency

Participants perceived consistency as central to policy success, holding clear perceptions of problems with inconsistent policy enforcement, communication and education support, and fragmented administrative and clinical processes; concerns noted by several studies (Eadie et al., 2012; Lawn & Campion, 2010; Lawn & Pols, 2005; Leonardi-Bee et al., 2012; Moss et al., 2010).

Education and training

Studies of smoke-free mental health policy suggest that implementation success depends on consistent and widespread education of staff and patients (Moss et al., 2010). A concern raised by some participants was that they could not provide adequate patient smoking cessation care, either because they lacked competencies to manage patients’ immediate tobacco withdrawal needs (Ballbe et al., 2012; McNally & Ratschen, 2010), or because they lacked necessary organisation supports (Ballbe et al., 2012; Ratschen, Britton, & McNeill, 2009; Wye et al., 2010).

In this audit, staff knowledge and skill levels related to smoking cessation were perceived to be generally low and only two participants reported that they had received smoking cessation training. Kerr, Wilson, Soundararajan, Meldrum and Lockie (2011) found that only 7% of mental health professionals had undertaken smoking cessation training. Ratschen et al. (2008, 2009) found that 36% of doctors did not know that doses of several mental health medications must be lowered when patients stop smoking. Compulsory training, revisited at regular intervals, linked to core competencies or annual performance reviews might be a solution.

Mental health staff’s ethical dilemmas

Many staff held positive beliefs about the policy and its benefits of supporting smoking cessation, improving health, reducing harm and protecting non-smoking staff, patients and visitors (McNally et al., 2006). However, findings suggested that the smoking culture prevailed for many participants. Prominent within this were perceptions that patients remained resigned to smoking because of established relations with tobacco, smoking identity and the ‘need to smoke’ to self-medicate and cope with their mental illness, as well as assumptions about patients being opposed to the policy. Such perceptions suggest that staff might continue to face many personal and professional dilemmas, internal value conflicts and ambivalence when attempting to implement smoke-free policy and to manage patients’ behaviour, especially agitated patients (Lawn & Condon, 2006). Such conflicts can have a strong emotional impact on staff, highlighting that smoke-free policy enactment occurs within a complex system involving many competing issues. More practical and ongoing routine clinical support for staff is needed.

In addition, the latent consequence of this ambivalence was that smoking in designated areas was strongly supported, condoned and relied upon in many units. More work is needed to build more meaningful care options for patients and more productive clinical care alternatives for staff. Total smoke-free policy was perceived as restrictive by almost half the participants. However, partial bans have been shown to lead to the need to negotiate smoking privileges, which can undermine effective delivery of care and create unintended power differences between patients and staff (Campion et al., 2008; Eadie et al., 2012; Jochelson & Majrowski, 2006; Keizer, Descloux, & Eytan, 2009). They can also be more difficult for staff who are then able to smoke during breaks, thereby continuing their own cycle of addiction and withdrawal (Etter, Khan, & Etter, 2008; Jochelson & Majrowski, 2006).

Limitations

Several limitations are acknowledged. The audit involved secondary analysis of a dataset with only five questions. Also, 33% of units approached did not respond to the survey; therefore, potential alternate experiences were not captured. Inherent ambiguities in the definition of ‘smoke-free’ and its practice application, as ‘a process’ rather than ‘an event’ (Lawn & Campion, 2013), are also recognised as a potential limitation for research purposes. The findings reported here are based on real-world practice perspectives of policy implementation. To help overcome this issue, future surveys could provide clear definitions of total and partial smoke-free policy and ask respondents to identify their setting’s status accordingly.

This audit only sought the views of one individual from each setting and not those of other parties impacted by the policy, such as patients, patients’ family, other nurses, psychiatrists and allied health staff, policy-makers and administrators. Some participants might have given more favourable reports than was actually the case, as a consequence of their clinical leadership role. Also, the original survey did not contain specific questions asking about respondents’ age, gender, level of experience of other variables that might have been of interest. In addition, staff reports of their perspectives and patients’ perspectives are subjective. These limitations were minimised by drawing ideas from a large sample and by allowing anonymous return of surveys. Research that contrasts and compares non-smoking and smoking staff and experiences of different unit types would be useful. This might help reveal unique factors and differing emphases and clinical priorities about smoke-free policy to help tailor implementation efforts according to unit type and purpose, and patients’ needs and circumstances. We are currently undertaking this analysis. Finally, since the original survey occurred in 2010, there has been further embedding of smoke-free policy in mental health settings and the wider community. Therefore, views and practices may have changed; however, the finding may well still be of value in other countries where smoke-free policies are yet to be implemented.

Conclusion

This audit reports staff experiences and perspectives related to implementation of smoke-free policy in inpatient mental health settings since its full enactment across England. Findings improve our understanding of cultural and practical challenges that clinical staff continue to face, and progress made in implementing smoke-free policy in these units. The need for greater consultation and collaboration, education and support for clinical staff suggests that further study and time is needed to improve smoke-free policy success. These results inform policy-makers about important values, beliefs and contexts that can be used to refine implementation strategies and guide where further efforts are needed.

Footnotes

Acknowledgements

We thank staff from the Tobacco Control Collaborating Centre for assisting with data collection and unit managers who participated in the audit.

Funding

This research was made possible from a Department of Health grant to the Tobacco Control Collaborating Centre and Chartered Institute of Environment Health, UK.

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