Addressing the arguments against implementation of smoke-free policies in psychiatric facilities

Staff attitudes to completely smoke-free policies and smoking cessation practices in a mental health setting

BACKGROUND

Mental health trusts in England were expected to become completely smoke-free and embed smoking cessation practices by 2018. Such policies are fraught with concerns and have received mixed support from mental health staff. Understanding staff attitudes to these practices prior to enforcement of the policy could help design an effective implementation strategy.

METHODS

A cross-sectional survey was conducted with clinical and non-clinical staff in a Mental Health Trust to understand smoking cessation practices and attitudes to the implementation of a completely smoke-free policy.

RESULTS

There were 631 responses. Most participants disagreed with the policy on wards (59.6%) and throughout all mental health settings (57.4%). Clinicians expressed significantly lower organizational policy support (P = 0.001) than non-clinicians (P = 0.001). Psychiatrists were more supportive of the organizational items than nurses and allied health professionals. Clinicians' attitudes towards smoking cessation practices were less positive for those who were current smokers (P < 0.001), but more positive for clinicians who had received or were interested in attending smoking cessation training (P < 0.001).

CONCLUSIONS

Partial and completely smoke-free policies remain unsupported by staff in mental health settings. Smoking cessation training appears to reinforce rather than alter attitudes towards smoking cessation.

The impact of a social norms approach on reducing levels of misperceptions around smokefree hospital entrances amongst patients, staff, and visitors of a NHS hospital: a repeated cross-sectional survey study

BACKGROUND

Smoking is a cause of avoidable morbidity and mortality. In the United Kingdom (UK) the national smoking ban inside hospital buildings is widely adhered to. There is a perception it has led to smokers congregating around hospital entrances (Selbie D. 2016, It's time for a truly smokefree NHS. Public Health Matters Blog. Public Health England). Efforts to shift social norms and create positive smokefree environments might be strengthened by delivering social norms messages. This study explored the impact of a social norms approach campaign to reduce levels of misperceptions surrounding support for smokefree hospital entrances.

METHOD

Repeated cross sectional study design. Staff, patients, and hospital visitors at Pinderfields National Health Service (NHS) Hospital (Wakefield, United Kingdom (UK)) completed a survey before and after implementation of a public health social norms campaign (n = 481 surveyed before; n = 459 surveyed after). The main outcome measure was difference between perceived and reported levels of support for smokefree hospital entrances.

RESULTS

There were high levels of support for smokefree hospital entrances. The majority of participants agreed that patients (n = 849, 90% agreed), staff (n = 863, 92% agreed), and visitors (n = 850, 90% agreed) should not smoke in the hospital entrance. Participants underestimated the proportion of others who self-reported keeping the entrance smokefree. Over 90% of respondents reported not smoking in the hospital entrance, but the perception was that between 50 to 75% of hospital staff, patients, and visitors did not smoke in the hospital entrance. The mean percentage of hospital staff, patients, and visitors who respondents thought did not smoke in entrances was higher for respondents responding after, compared to those responding before, the campaign. There was an overall significant effect of time on attitudes towards smoking in the entrances; in all instances the mean percentage of hospital staff, patients, and visitors the participants believed agreed that hospital entrances should be smokefree was higher for those responding after, compared with before, the campaign.

CONCLUSIONS

People hold misperceptions of the proportion of people who choose to smoke in the hospital entrance. The social norms approach campaign was associated with a strengthening of positive social norms. Such campaigns should be considered by Trusts as one evidence-based based tactic to denormalise smoking, increase support for smokefree policies.

Improving patient education about tobacco withdrawal and nicotine gum use by registered nurses in inpatient psychiatry: A feasibility study

WHAT IS KNOWN ON THE SUBJECT?: Many psychiatric inpatients use tobacco, but most psychiatric hospital units prohibit tobacco use. Psychiatric nurses do not receive adequate education about how to teach patients to best manage tobacco withdrawal symptoms. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Psychiatric nurses who receive a brief educational intervention about tobacco withdrawal symptoms and best practices for using nicotine gum may be more prepared to teach patients about these topics. In turn, patients may use nicotine gum more often during their hospitalization, leading to improved outcomes for them as well as for staff. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: A simple educational intervention aimed at psychiatric nurses can result in positive outcomes for psychiatric inpatients who use tobacco. Patients who have a positive experience with stopping tobacco use while hospitalized may be more likely to commit to lifelong tobacco cessation afterwards. The results of this feasibility study demonstrate that additional research that builds on the work presented here is warranted.

ABSTRACT

Introduction Tobacco use is prohibited in most psychiatric facilities in the United States, yet many psychiatric inpatients are tobacco users. Psychiatric nurses have reported inadequate education about best practices for managing tobacco dependence. Aim To explore the feasibility of an educational intervention for psychiatric nurses designed to improve their ability to educate patients about best practices for managing tobacco dependence, as well as effective use of nicotine gum. Method Fourteen nurses on a psychiatric inpatient unit at a community hospital were educated about the targeted topics. Chart reviews of nonequivalent pre-intervention and post-intervention patient groups were conducted to explore the outcomes of the intervention. Results Patients received more teaching, and used nicotine gum more often, following the intervention. However, no statistically significant differences between the pre-intervention and post-intervention patient groups were found. Discussion Educating nurses about best practices for managing tobacco withdrawal symptoms may have positive outcomes. Existing research suggests that such interventions may be most effective when support and structure are provided to ensure long-term practice changes. Implications for practice This feasibility study demonstrates that a brief nurse education intervention has the potential to improve the experience of tobacco withdrawal for psychiatric inpatients. Future research that expands upon the current project is warranted.

A retrospective analysis of the association between providing nicotine replacement therapy at admission and motivation to quit and nicotine withdrawal symptoms during an inpatient psychiatric hospitalization

BACKGROUND

Psychiatric patients have high tobacco use prevalence, dependence, and withdrawal severity. A tobacco-free psychiatric hospitalization necessitates the management of nicotine withdrawal (NW) for tobacco using patients. NW management often requires the provision of approved nicotine replacement therapy (NRT) to patients, which may also motivate tobacco users towards cessation. However, few studies have examined the associations between providing NRT, motivation to quit, and NW among psychiatric patients.

OBJECTIVE(S)

To examine the associations between providing NRT at admission and motivation to quit smoking and severity of NW symptoms.

DESIGN

A retrospective review of the medical records of 255 tobacco using patients on whom NW was assessed during their hospital stay. The time when NRT was provided (i.e., at admission vs. not provided vs. on the unit), motivation to quit smoking, and 8-item Minnesota Nicotine Withdrawal Scale were assessed.

RESULTS

The primary NW symptom was 'craving' (65.1%); reporting of 'anxiety' varied by psychiatric diagnosis. Providing NRT at admission was not associated with motivation to quit. Patients receiving NRT on the unit (i.e., delayed receipt) had significantly higher NW than those who received NRT at admission. In multivariate analyses, receiving NRT on the unit was significantly associated with greater NW severity (β = .19, p = .002).

CONCLUSIONS

Among psychiatric patients, providing NRT at admission is associated with greater severity of NW. The provision of NRT for NW management may be considered as standard practice during tobacco-free psychiatric stays. Future studies may consider the effect of other tobacco treatment medications (such as varenicline, bupropion) on managing NW.

“Resisting the Ban”

Purpose

The purpose of this paper is to present an evocative story “Resisting the Ban” which illustrates the ethical and pragmatic issues that nurses face when contending with smoking ban policies in inpatient psychiatric settings.

Design/methodology/approach

The creative story “Resisting the Ban” was developed based on an organisational auto-ethnographic approach. The story was crafted through employing creative writing techniques and through framing and critiquing memories via several theoretical frames.

Findings

The story illustrates how smoking ban policies have created pragmatic and ethical issues on wards. The work practices of nurses have changed as have their relationships with patients. The liberties of involuntary patients have also been infringed.

Research limitations/implications

This approach can illuminate links between acts of resistance and issues associated with public policies.

Practical implications

The effects of smoking bans need to be considered more carefully particularly in relation to their effects on workers and patients. The social meaning of the smoking bans needs closer investigation. Policy needs to be recrafted so that it better addresses the liberties of involuntary patients. Also ward nurses need to be able to carry out their roles in a manner which is consistent with their values.

Social implications

Public policies, such as smoking bans, can produce negative consequences maligning relationships, practices and cultures. Critical auto-ethnography provides a means of understanding issues that have resulted from problematic policies.

Originality/value

Scholarly work conducted on the relationship between everyday resistance in workplaces and public policies is rare. This study offers new “insider” insights into the negative effects of a smoking ban policy in psychiatric inpatient settings.

Implementing National Institute for Health and Care Excellence smoke-free guidance in a secure facility: an evaluation of the prescribing costs in clozapine users

Aims and method The increased rates of smoking in people with mental illness is well documented, and establishing smoke-free mental health environments has been emphasised over recent years. This article examines the financial costs of implementing smoke free guidance and assesses the cost associated with patients who were prescribed clozapine and who committed to stopping smoking cigarettes for the duration of the study period.

RESULTS

Patients (38) who were prescribed clozapine were included in the study. A moderate reduction in dose was noted with a moderate reduction in prescribing costs. The total increase in cost for the whole group, however, was £17 624, largely due to the use of nicotine replacement therapy and an increase in the number of clozapine assay tests. Clinical implications Further studies on implementing this important policy change are needed. The positive effects must be balanced with increased financial pressure on Mental Health Trusts. Declarations of interest None.