Predictions and experiences regarding the implementation of the Smoke Free
Initiative on a specialist NHS locked Rehabilitation Unit
Nadia E Cox BSc
Assistant Psychologist, Rotherham
Doncaster and South Humber NHS Foundation Trust
Dr Victoria Nithsdale, DclinPsy
, Senior Clinical Psychologist
Rotherham, Doncaster and South Humber NHS Foundation Trust
Cox N.E. & Nithsdale V. (2017) Predictions and
experiences regarding the implementation
of the Smoke Free Initiative
on a specialist NHS locked Rehabilitation Unit.
International Journal of Psychosocial Rehabilitation. Vol 21 (1) 17-31
smoking in secondary care stated that all mental health settings should
be smoke-free and provide smoking cessation support. The current study
explored the concerns of staff and service users prior to the
implementation of a smoke-free policy within locked rehabilitation. It
aimed to capture people’s reflections on the actual experience of
introducing a smoke-free environment. The study was conducted using
four focus groups; with thematic analysis to analyse the data and
produce themes. The findings indicated that there had been an increase
in unsettled behaviour, increase in rule breaking and a lack of clarity
of the rules and procedures. A complete ban would be the most
constructive way to implement a smoke-free initiative, allowing service
users and staff unambiguous guidelines. Least restrictive practice and
client centred approaches are at the heart of mental health care;
however a smoke-free policy appears to contradict these philosophies
within a rehabilitation setting.
Keywords: Smoking ban, Rehabilitation, Mental Health, Inpatient, Smoke-free policy
In the USA, UK and Australia, over 40% of all tobacco is consumed by
people with mental health disorders (Lawn and Campion, 2013). Smoking has been
part of the cultural fabric in mental health care for many decades. In mental
health settings, cigarettes have often been used informally as a service user
management tool by staff, mediating exchanges and relationships between staff
and service users, and between peers. Cigarettes have sometimes been used
inappropriately; examples of this are staff using control over cigarettes in
order to encourage service users to comply with requests such as taking
medication, getting dressed, or to settle their adverse behaviour. Additionally, tobacco use can directly impact the
treatment some psychiatric service users may be having, by increasing the
metabolism of many psychotropic medications. This can therefore result in the
need for higher medication doses (Royal College of Psychiatrists, 2013).
Within systems of care for service users with mental health problems,
especially where the culture of smoking is dominant, several myths exist. This
includes the belief, that failure to supply service users with tobacco will
lead to increased service user aggression, that service users are not
interested in quitting, and that they are unable to quit (Lawn and Campion,
2013). Another belief held by many service users and staff members is that
smoking is helpful to service users and the management of their symptoms and
that smoking is used by them as a means of coping with stress, to alleviate
cognitive problems and side effects of psychiatric medications, and to relieve
boredom and loneliness. This is unfounded and research demonstrates that
continued smoking drives the continuing cycles of the instability of symptoms.
In addition, research into smoking and mental health has shown that instead
of helping people to relax, smoking actually increases anxiety and tension
(Mental Health Foundation, 2007).
Another concern of mental health staff
is that smoke-free mental health settings will damage their therapeutic
relationship with service users, increase service user distress and agitation,
and increase the number of adverse incidents among the service user population.
However, this is not borne out by the evidence and staff generally had more
concerns than the service users. Australian research demonstrated decreased
service user aggression and decreased staff injuries when tobacco was removed
from an inpatient psychiatric setting (Smith et al 2013). A UK study in a medium secure unit found
that, although 64% of the staff supported a smoke-free policy, 43% reported
experiencing service user management issues. These included increased verbal
aggression and increased use of staff time in supervising service users smoking
(Garg et al 2009). However, several studies have found that these concerns are
unfounded. This suggests that greater success may relate to how staff attitudes
are addressed and the comprehensiveness with which clinical management of
nicotine withdrawal occurs (Lawn and Pols, 2005).
There is also a
perceived negative connotation surrounding the implementation of smoking bans
within an inpatient setting. Smith et al (2013) conducted research to investigate
service user views on a complete smoking ban within an intermediate to
long-term psychiatric facility. They established that the overall approval rate
for the ban was slightly higher than was found in previous inpatient surveys.
In addition, approval was lowest among current smokers. Participants appeared
to underestimate the level of approval of the policy among their peers,
regardless of smoking status. For example, only 8 % of non-smokers and 10 % of
those that stopped smoking reported that others were happy about the ban, when
it was established from the research that 44% of the participants were in
support of the implementation of the ban. Other findings also strongly suggest
that anticipated negative effects of smoking bans are worse than the actual
outcomes resulting from implementation (Lawn and Pols, 2005).
Background to the Current Study
The Mental Health Foundation (2007) has suggested that various factors
have been shown to be beneficial for the successful implementation of
smoke-free policies. These include adequate consultation with staff and service
users to alleviate their fears, sufficient staff training, and supporting staff
to quit smoking or abstain while at work and clear leadership and management
support. It has
also been suggested that the type of ban, that is, whether partial or complete
has an extensive impact on the success of the smoke-free policy (Ballbe
et al 2013).
In particular, Lawn and Campion (2013) discovered that partial bans have been
shown to create more difficulties and discrepancies in enforcing the policy
than complete bans. Which can also be inferred from Sohal, Huddlestone and
Ratschen’s (2016) research, their findings suggests that a contributing factor
in the escalation of reported incidents were a result of service users having
to wait until staff had made arrangements around the scheduling of smoke breaks
and deciding who would be the escorts. In several occurrences, service users were described as displaying
frustration as a result of being unable to smoke, perceiving the smoke breaks
as restrictive. Negotiating the management of urges to smoke in the context of
scheduled breaks presented as a key source of conflict, sometimes triggering
verbal and physical hostility towards staff. Therefore, making units completely
smoke free, would eliminate the triggers that were identified by this research
(Sohal et al, 2016). Sohal et al’s (2016) findings demonstrate that the
successful implementation of a smoke free policy is likely to depend on the
consistency of suitable smoking-related information, and the provision of
training and resources to enable staff to support smokers adequately. Cheshire and Wirral NHS
Partnerships implemented smoke free across their hospitals and grounds in 2014.
They employed a nicotine replacement policy with the aim of being able to
provide a safe smoke free environment for all service users and staff who wish
to stop smoking by offering suitable therapies and support and help people who
do not wish to stop smoking to manage their nicotine dependency symptoms whilst
on Trust premises/grounds.
2013 guidance on smoking in secondary care provided by the National Institute
for Health and Care Excellence (NICE) states that all mental health settings
should be entirely smoke-free and provide comprehensive smoking cessation
support. Therefore, Rotherham, Doncaster and South Humber NHS Trust implemented their Smoke
free initiative on the 1st March 2016. The locked rehabilitation
unit in the current study took on board lessons learnt from other services and
introduced a gradual reduction in smoking on the ward. Reducing the number of
cigarettes and times that service users were able to go out for a cigarette was
introduced initially in preparation for a total ban on site. Nicotine
replacement therapies were available for service users and a number of staff
members were trained to become ‘smoking champions’, to offer personalised
support for the service users.
The current study took place on a male
only locked rehabilitation unit in a central location within a large campus of
hospital buildings. The smoke free initiative extended to the entirety of the
hospital campus. Prior smoking had been permitted on site and in a fenced off
area of the garden available to all service users. The present study evaluated
the service users’ and staffs’ assumptions, attitudes, predictions and worries
prior to the smoking initiative being enforced and reflections on the actual
experience of the event three months afterwards. The service users were males
of working age, all of whom had experienced psychosis and were currently or
previously regarded as presenting a risk to themselves or others.
To explore the concerns of staff and service users prior to the hospital
becoming smoke free.
Develop a better understanding of how people cope with a situation where
a smoke free environment is introduced.
Capture people’s reflections on the actual experience of introducing a
smoke free environment in a locked setting.
staff and smoking service users were invited to attend a focus group prior to
the smoke free initiative being implemented. Informed consent was gained from
each participant prior to the focus group commencing, by them signing a
participant information sheet. There were a total of four focus groups; two
prior to the initiative (one group was service users only and one staff only),
then two focus groups three months after the implementation of the policy
(again one service users only and one staff only). The sample size for the
first focus groups consisted of four service users and five staff members and
the second focus group consisted of two service users and five staff members,
unfortunately due to the circumstances of the unit only one service user and
two staff members were involved in both groups.
interview schedule was utilised throughout the first focus groups and prompts
were devised to ensure leading questions were avoided. Each focus group was
recorded and then later transcribed into a script. Thematic analysis was used
to analyse the data gathered and produce themes helping to capture the intricacies of meaning within the information
The second focus groups were held three months after the
policy had been in place, and enabled the views and reflections of the service
users and staff involved to be gathered. A second interview schedule was used
throughout the sessions. The focus groups were again recorded and transcribed
into a script and analysed using thematic analysis.
was gathered from each group and using thematic analysis the transcription was
interpreted into a number of reoccurring themes.
to the implementation of the Smoke Free Initiative
themes were derived from the focus groups prior to the smoke free initiative
being put in place; behavioural management, empathy/choice, optimism,
proactive/alternative strategies and policy. All five themes were identified by
both the staff and the service user groups.
theme was established from the transcription of the group, as being a very
prominent and perpetuating factor. The participants recognised that this can be
split into a number of sub-themes including; staff skills, violence, demand on
staff time/staffing levels and rebellious behaviour.
some of the sub themes could be interpreted as negative towards the initiative,
there was a perception that it could be a chance for staff to change the way in
which service users were approached when they were anxious or agitated. The
staff group identified that it could help them utilise and develop their verbal
People will probably shine out with how they deal with situations.’ -
groups felt that the smoke free initiative may have an impact on the level of
incidents that occur on the ward, and could lead to an increase in violence and
aggression. Comments from the service user participants included:
‘… (There will be an) Increase in incidents and things, like maybe assaults…’ – Service
thoughts were also shared by the staff participants; they felt that service
users could become more agitated resulting in increased aggression, more
incidents and causing a greater demand on staff time.
think it’s putting us (staff) in a really vulnerable position initially, definitely because tempers
are going to be raised.’ – Staff
common sub theme that was indicated within the groups was that of service users
rebelling against the initiative and smoking in their rooms. The service user
group identified that this is something that happens occasionally at the moment
and therefore there is a strong possibility that this will continue to occur.
Both focus groups identified that bringing cigarettes and lighters on to the
ward may become a problem, especially in the initial stages, as the service
users will be still getting used to the policy and therefore cravings for
cigarettes will be strong.
‘… We might have an issue with lighters; you know smoking in rooms,
obviously bringing lighters onto the wards and cigarettes…’ -
focus groups acknowledged that they felt the smoke free initiative took away
the service users right to choose whether they wanted to smoke or not. This
theme was very prominent within the staff group, it was recognised that this
would be an extremely difficult task for some, especially when a lot of the
service users on the unit have been smoking for the majority of their adult
lives. Staff believed that the service users on the unit live there and, even
though it is a hospital, while they are detained it is their home.
think it’s wrong (stopping smoking) but that’s just
me, I do I don’t like it I really don’t. I can really sympathise, empathise
with the lads and how they are going to feel. It’s awful.’ - Staff
identified that service users use the time to have a cigarette to socialise
with each other and talk in a less invasive environment.
Everybody seems to interact a lot more (when outside in the smoke pod).’ - Staff
it was recognised that the health benefits for both staff and service users is
a positive thing to come from the initiative it was felt that this was just
another thing that will be taken away from them. This could have a detrimental
effect on a service user’s mental health and recovery.
‘…It’s their choice, they’re adults, they’ve
made that decision that they want to smoke…’ - Staff
feelings were also shared by the service user group; they agreed that they were
having the choice to make an informed decision taken away from them.
can they stop you smoking though, everyone’s an adult, we are all adults here.’
– Service users
groups emphasised how difficult it is going to be for service users to stop
smoking although it was highlighted that it was not a smoking ban, and the
service users were not being told they have to quit. They are being told that
they will no longer be able to smoke on the hospital grounds. However for some
of the service users on the unit this does mean that they will have to quit
smoking due to them not having sufficient leave to go off the grounds
there were a number of negative opinions regarding the implementation of the
smoke free initiative, both staff and service users did highlight a number of
possible benefits that may come from it and were hopeful that the policy may
bring about some changes.
staff and service users identified that they believed it will have an impact on
the health of both staff and service users. It was identified that this will be
in both terms of not actually smoking and if the service user wants a cigarette
then they will have to walk off the grounds and therefore will result in
additional exercise for them. Staff believed that not having to light
cigarettes, the reduction in second hand smoking, and not spending most of
their time looking for lighters will free up staff to focus on therapeutic
Spending the whole shift looking for lighters…’ -
groups outlined that there would be a financial gain from the smoke free
initiative. The service user group, expressed hopefulness around the prospect
of saving money and this enabled them to look to the future and at what they
can buy for when they move on from the unit. It was also acknowledged that even
if a service user just cuts down the amount they smoke then this will also have
a positive impact on them financially.
that staff outlined had helped them feel optimistic about the impending
initiative was learning about the success that other trusts had when
implementing it. Staff that competed the ‘Smoke Free Champions’ training
expressed how helpful it was that they were informed about other places where
the ban had been implemented and could then use lessons learnt and best
practice to aid in implementing the restrictions on ward.
was given confidence by people saying oh well they’ve done it at Wathwood and
they expected loads of hassle and it went smoothly…’ -
identified that the ward had taken a very proactive approach to implementing
the initiative, and it was analysed into sub themes; training, reduction in
smoke breaks, leave, more activities and nicotine replacement therapy (NRT).
acknowledged by staff that the training offered was beneficial in raising
awareness around the different types of NRT available and also in providing
learning materials to the wards to educate both staff and service users in the
negative consequences of smoking. There were, however, concerns that the
training did not focus enough on the behavioural support that the service users
may need and focused more on NRT.
I do feel like we don’t really have many tools for like how to implement
behavioural support…’ - Staff
lead up to the policy being implemented, the ward began to gradually cut down
the amount of times the service users were able to utilise the smoking area.
The staff group recognised that this had been very successful and service users
have dealt with the gradual reductions well.
17 leave was another big talking point for both focus groups. The service users
spoke about not wanting to use all their leave going for cigarettes and this
would not help as they did not have enough leave to continue smoking throughout
I won’t be using my leave just to go for a smoke…’ – Service users
spoke more about their concerns with regards to leave. It was discussed that
staff felt that there would be a lot more requests from service users for
leave, putting extra strain on staff as it is not always possible to
facilitate. There was also a worry that service users would use their leave for
smoke breaks rather than engaging in therapeutic activities. As service users
are only given limited leave to begin with this could interrupt engagement and
hinder their rehabilitation and recovery.
prominent theme that emerged from the focus groups was surrounding the use of
NRT. Both staff and service users had strong views on this subject. Service
users were very disappointed at the range of NRT available to them, for example
they were unable to utilise the Nicotine spray.
I’ve got the spray stuff (NRT) but
they won’t let me have that…’ – Service users
was also frustration from the service users at not being able to use E-Cigarettes.
They were understanding of the reasons why they were contraband items on wards,
however believed that other forms of approved NRT was insufficient and was not
sufficient for them.
I’ve tried patches, inhalators, and didn’t get nowhere…’ – Service users Policy
theme that emerged from the staff group was issues regarding policy. The
service user group only briefly mentioned policy and this was to express that
they felt they had no choice or control in the matter. However with the staff
group, policy was a very prominent theme; they raised apprehensions regarding
the clarity and consistency of the initiative.
staff team brought about concerns around the clarity of the policy and how it
was communicated to both staff and service users. Staff expressed confusion as
to what the policy actually consisted of, and how it would be implemented on a
locked rehabilitation unit. It was identified that there was no clear message
sent out to staff about what would happen to smoking paraphernalia on the ward.
When the policy was looked at there was no reference to certain aspects that
appeared to be important to running of a locked rehabilitation unit.
‘… There seems to be confusion over what we
are actually going to try and do (when the policy begins) …’ - Staff
were also concerned that there may be mixed messages given to service users
from staff and as a result this may cause problems with keeping consistency on
What’s been told by one staff member and what they’re told by another (is
different) …’ – Staff
were a lot of concerns prior to the policy being implemented regarding how it
would impact the dynamics of the ward and how it would work on a locked
rehabilitation unit. Service users were most concerned with the fact that they
were given no choice in the matter and that it was another thing that they were
having taken away from them. The staff group appeared apprehensive around not
knowing the details of the policy and the inconsistencies that could cause.
the implementation of the Smoke Free Initiative
second focus groups were held three months after the implementation of the
policy. The groups did consist of some different participants than were in the
initial focus groups, however all participants either worked or resided on the
unit for the duration of the study, implying that they had experienced the unit
prior to and after the policy being in place.
groups highlighted some consistent themes, with both groups concurring on NRT,
fairness and the issue of smoking within the building, which was identified
within the theme of rule breaking/health and safety. There were some differing
themes emerging from the groups this time. The service users additionally
identified the theme of stress. The three differing themes identified by the
staff group were; conflicts with rehabilitation, inconsistencies and positives.
Nicotine Replacement Therapy (NRT)
service user focus group spoke about the availability and effectiveness of NRT.
The consensus of the group was that NRT did not work for them. They were
appreciative of being allowed the disposable e-cigarettes however explained
that they were too expensive, and due to being able to smoke them whenever they
liked they were using them much more quickly than if they were actual
cigarettes. They discussed that the inhalators that are available on the ward,
are not sufficient in lessening their cravings.
They (NRT lozenges) don’t do anything;
you just get the nasty nicotine taste…’ – Service users
The service users believed that it would be better if they were able to
have rechargeable e-cigarettes; they knew the reason why this had not been
allowed due to the fire risk of the chargers. However the group stated that the
chargers were the same as mobile phone chargers which they are allowed and
therefore did not agree with the rationale for this.
it’s the same charger as a phone (e-cig charger). But were allowed phones, it doesn’t make sense does it…’ –
users suggested that a compromise should have been made with them before the
policy was put in place. They suggested that the policy makers should be
expected to work with the service users to reach a compromise with regards to
the policy, and they felt that this compromise would be to allow service users
to use re-chargeable cigarettes.
makers should have) You know compromised,
like I say enabled people to have the e-cigarettes. That would have been a lot
better…’ – Service users
staff group acknowledged that some service users were using the disposable e-cigarettes
that were authorised, however it was suggested that they are more expensive
than tobacco and therefore others are reluctant to try them. As with the
service user focus group the staff also spoke about the lack of variety for NRT
and not being able to use instant sprays. They felt that service users may have
more success if they had access to these types of NRT, even though they
recognised the rationale given for not prescribing the sprays. It would be
difficult to regulate, due to it needing to be prescribed like medication and
this could not be facilitated sufficiently often. Some did feel that it would
be the same as the lozenges and the inhalators.
sprays would be) Just the same as the lozenges and inhalator cartridges
which they still have to come and get anyway…’ – Staff
staff group emphasised that the number of service users utilising NRT has
reduced, they felt that this was due to service users smoking within the ward
environment and therefore not requiring it. Correlations between people being
caught smoking in their rooms and those who have recently discontinued NRT were
ones that have stopped using the patch (NRT) then you realise that it’s because they’re actually smoking on the
ward…’ - Staff
Rule Breaking/Health and Safety
issue of smoking on the ward was also identified within the theme of rule
breaking/health safety. The service users acknowledged the danger of smoking in
their rooms and that this could potentially lead to a fire, however they spoke
of how people did it out of necessity. It was highlighted that as people were
not being able to access designated smoking areas frequently due to
restrictions in section 17 leave, they had taken to smoking on the ward. The
focus group acknowledged that they knew this was not acceptable, however
justified it with explaining that sometimes people cannot get out for a
They (service users) can’t go without
cigarettes; they don’t like to face the fact that they have to go without
them…’ – Service users
users spoke of the dangers of having multiple lighters on the ward. They
recognised that prior to the ban there was just one lighter on the ward that
was easily monitored by staff. However, since the ban people had to smuggle
lighters and tobacco onto the ward in order to fulfil their cravings. Although
the focus group did highlight that service users were smoking in their rooms,
they did acknowledge that this is not something that they enjoyed doing or
wanted to do, they did it because they do not feel that they have any other
users illustrated that they understood that smoking on the ward and breaking
the rules of the policy was wrong, they felt that they had no alternate choice.
The staff group recognised that this is one of the biggest problems that has
emerged from the policy. They stated that there is only so much that can be
done on a rehabilitation ward to prevent this and are limited with what
ethically appropriate consequences can be applied. The staff focus group
highlighted the same difficulties; and a sub theme of Hopelessness was identified.
Obviously it (the policy) has contributed to smoking in rooms and
smoking in the old smoke pod… Those who haven’t got leave are smoking in their
rooms and those who have got their leave must be bringing it and again we can’t
search, we can only do so much searching…’ - Staff
group suggested that there was a lack of respect for the policy, and due to
staff utilising a least restrictive approach there were few ethically
acceptable consequences that could be given to service users that brought
contraband items on the ward or were found to be smoking with the ward
environment. The group explained that bedroom doors had been locked off when a
service user had been smoking in their room due the potential risk of fire;
however some had then utilised the old smoking area. Staff gave the sense that
enforcing the policy was futile and hopeless and conflicts with the purpose of
know nothing’s happening about it really (smoking on the
ward) and I think what can we do…’ -
idea of compromise was considered within the theme of fairness. Service users
and staff identified that utilising the garden again for smoking would help
solve the problems regarding people bringing contraband items on to the ward.
They felt that they were at a disadvantage to other wards such as the acute
units, as at times they may have no leave or only escorted leave, while
patients on open units could walk out of the front door if they wished.
However, in a locked unit there can be a very limited amount of section 17
leave available to some and therefore participants felt that there should be a
designated smoking area that is accessible irrespective of leave status.
only been since this ban has come into place that everybody’s been smoking in
the building cos they can’t actually get out for a cigarette. And if they want
to go out for a cigarette then they have to wait like half an hour to an hour
depending on how the staff are feeling at that time if there is even, you can’t
go for a smoke’ - Service Users
Service users were also disapproving of
the policy as they felt it took away their choice. Believing that they have the
right to choose whether they smoked or not.
People are mentally ill they deserve to have a cig break it’s something that
they want to do, it’s their choice…’ - Staff
issue of choice was also raised with regards to the service users impressions
that they had lost the right choose and make their own decisions. Service users
suggested that smoking was not only beneficial for relaxing and aiding with
stress, it was also good as a method of socialising. The previous smoking area
was a space where staff did not spend time and therefore gave service users a quiet
place to interact with each other. It was highlighted in the group that they
had lost this aspect of socialisation when the policy was implemented.
(Smoking) good for socialising,
cos you have a cup of tea and a fag in the garden, talk about stuff and it’s
just nice…’ – Service users
users spoke of an increase in incidents and believed that other service users’
mental health had declined due to the policy being implemented, implying that
some were ‘deteriorating slowly’.
They also acknowledged that they were more frustrated and experiencing higher
levels of stress and anxiety.
‘…I find that more people are getting more
stressed out when the smoking ban came in...’ –
spoke of how they felt that incidents were becoming worse resulting in people
being placed on 1:1 observation levels and an increase in violence. They
believed that it was an injustice to other service users, as the people that
were really unwell and not handling the smoke free initiative well were causing
extra stressors on the ward.
it’s a problem (not smoking) for one it’s making
more problems for others, waking up like when someone needs a fag and shouting
and that waking us up and it’s not fair…’ – Service users.
service user focus group also discussed their frustrations around utilising
leave for a cigarette. They suggested that the amount of leave available is
inadequate and unfair to service users.
hard getting out 2 or 3 times a day for a smoke. You know it’s not good enough.
It’s not good enough…’ – Service users
suggested that there had not been a reduction in the amount of cigarettes
smoked since the policy was initiated. The focus group highlighted that even
though they are not getting out smoking as much; when they do they will smoke
as much as possible in that time as they do not know when they will get their
next one. This has resulted in some service users feeling physically unwell.
It’s only since the ban has come into place that everybody’s been smoking in
the building, cos they can’t actually get out for a cigarette…’ –
Conflicts with Rehabilitation
staff group indicated that they believed service users had lost the option to
choose whether they wanted to smoke or not. Although choice has already been
highlighted within the theme of Fairness,
the staff group additionally felt that the smoking initiative opposes a person
centred approach and determined that it is in conflict with rehabilitation. The
focus group identified that the policy had and has the potential to put
stressors on the relationships between both staff and service users and between
staff themselves. The group discussed
the aspect of the policy whereby it says that service users cannot smoke on
escorted leave, staff were apprehensive that implementing this when escorting a
service user would damage the therapeutic relationship and cause conflicts when
in the community.
That can affect our relationship (Stopping smoking on escorted leave)…’ - Staff
staff team were also conscious that there had been staff conflicts, due to
deciding who would escort service users off the grounds for a cigarette. Some
members of staff were reluctant to do this as they did not want to expose
themselves to passive smoking and used the policy to enforce this. They also
spoke about the extra strain put on staff that had to persuade service users to
attend therapeutic activities and not use their leave just to go for a
cigarette. A concern among the staff group was that service users would opt to
use their limited section 17 leave to go to the perimeter of the grounds to
have a cigarette instead of using their leave for therapeutic activities, as
they would feel that they would be sacrificing a cigarette.
they’ve (service users) only got 3 leaves
a day then they’re not going to use one to go do therapeutic activity cos its
gona, …they look at it as missing out on a smoke break…’ - Staff
large discussion was held regarding this policy conflicting with a person
centred approach. As well as the concerns staff raised regarding the service
users’ choice; the group also introduced issues with whether staff should have
the right to tell people they cannot smoke, and what alternatives they should
‘… But who are we to tell them (service
users) what should and shouldn’t make
them happy…’ - Staff
locked, the unit in the study was a rehabilitation unit. Staff felt their
duties were to promote independence within the service users, and they felt
that the policy has taken away some of that independence.
are supposed to be getting (service users) back into the community, back into self-responsibility. We are taking
something away from them… budgeting money managing money and they are going to
be spending half of it on fags that they have not had to do whilst they’ve been
here…’ - Staff
nature of the unit was discussed with regards to the extent to which staff
could search service users when they returned from section 17 leave. Staff stated
that the unit did not have the search facilities to ensure that cigarettes and
lighters were not brought on to the ward. They suggested that more thorough
searches would be required to implement this properly, although that would then
represent a low secure environment and not rehabilitation.
we are going to try and impose it (the policy) then it will be a lot more room searches, a lot more strip pat downs…’
We will be getting into secure territory…’ - Staff
preparation for the smoke free initiative was reflected on positively, with
cutting down the amount of smoke breaks the service users had. However, this
was regarded as insufficient when it came to aiding them in quitting or
educating service users about the negative consequences of smoking. The group
explained that staff from a learning disability ward had used visual aids and
also made it very clear to their service users that they were initiating a
complete ban including on escorted leave. However, the staff focus group did
recognise that they have very different clientele to a locked rehabilitation
unit and a very different environment. It was felt by the staff team that if
the locked rehabilitation unit had used a visual approach then the service
users could have perceived this as patronising, and would not have responded to
it. Staff expressed the uncertainty they felt when they were told that service
users could not smoke on escorted leave.
‘… Cos we’re like this less restricted
environment it’s very difficult to put that in place (the
policy) you know we can’t be so strict as
to say if we’re taking you to the shop don’t think you’re smoking with us cos
you’re not, if you’ve only got escorted leave then you’re not having a fag…’ -
had suggested that they felt the nature of the unit poses contradictions to the
policy. They believed that it was in conflict with rehabilitation and it is
almost impossible to police unless adopting the levels of restrictions
associated with a secure unit.
‘… I just think it’s (the
policy) a bit unrealistic for the group…’
‘… It (the
policy) is in conflict with rehab…’ -
staff focus group stated that there were a lot of inconsistencies in how the
policy was policed and implemented and also in people’s opinions of the policy.
There’s been no clarity or consistency (with the policy)…’ - Staff
felt that the way in which they dealt with service users that do break the
policy had not been clarified. Some had been locking their rooms off, or
locking the smoke pod and others believed that section 17 leave should be
stopped if they were found smoking on the ward. They felt that because the
policy did not work for a locked rehabilitation unit, loop holes had to be
found, and then this was where the problems stemmed from.
Then that (finding ways around the policy)
leads to vagary, and uncertainty and double standards…’ - Staff
addition, it was discussed about when service users were smoking on the large
grounds of the hospital campus. Some staff members expressed that they would
not feel comfortable approaching someone and asking them to put their cigarette
out, due to the risk of repercussions that could transpire. However, a staff
member stated that they had seen this occur on the grounds by another member of
the trust, and the service user responded well and put his cigarette out. The group
expressed that there is no continuity in this, as some staff will tell people
not to smoke and others will not, and if some service users continued to smoke
on the grounds, the consequences for this were uncertain. They believed that
this was also contributing to excess litter on the grounds as there are
cigarette ends everywhere.
Littering is adding to littering, we are even getting complaints from across
the way cos our service users are being seen to be having cigarettes sat on one
of the benches outside their unit…’
staff had been raising concerns with regards to the clarity of the policy, it
was discussed that the person who wrote the policy had left the trust as her
contract had finished. The staff focus group were very concerned that the
person in that role, which could have offered clarity, was no longer working
for the trust.
Provide some kind of continuity or some development for I guess life after the
smoking ban…’ - Staff
group identified that they felt it would be useful for a trust wide team to get
together and look at the policy, discuss problems that had emerged and re-think
certain aspects of the policy that were not working.
I think it will be useful to get some heads together (to discuss the policy)…’ - Staff
service user group did not indicate any positives to transpire from the policy;
nevertheless the staff group did argue that there were benefits that emerged.
The sub-themes were positive outcomes
and the success of the preparations
for implementing the policy. The staff focus group highlighted numerous
benefits that they felt had come out of the policy being implemented. It was
noted that the amount of cigarettes being smoked had reduced due to the
restrictions being put in place. This had in turn had an effect on the health
of the service users.
(The initiative has had a) Positive
effect on some individual’s health…’ - Staff
also noted that this had also impacted the amount of exercise that some service
users were now getting. Prior to the policy being brought in a number of
service users declined to go out of the unit unless it was to go to the local
shop, however now they are having to walk off the grounds more frequently and
even though this is to have a cigarette the positive side of it is that they
are gaining more exercise. Also due to restrictions service users are also
saving money as they do not have to buy as many cigarettes.
staff focus group also stated some positives for the staff team themselves;
they acknowledged that the amount of passive smoking had reduced. They are no
longer in the direct line of the service users smoking or having to light their
cigarettes in the smoke pod.
and other service users aren’t inhaling it (smoke) passively anymore…’ - Staff
staff team identified that the way verbal de-escalation was used had changed.
Prior to the implementation of the policy a common tool used to help
de-escalate a service user was to let them go for a cigarette, however now this
is no longer possible, staff are utilising their skills to help reduce
lot of it (de-escalation) is more
distraction with some sort of activity that like doing, a cup of tea, a hot
drink or something or a chat…’ - Staff
preparation that was completed on the unit prior to the smoke free initiative
was considered to have been a positive step to implementing the policy. The
service users responded well to the gradual reduction in time allocated for
smoking. However, it was felt that maybe more could have been done in terms of
educating them around the health implications and utilising visual aids to
purpose of this service evaluation was to see how the current NHS smoke free
initiative had impacted the service users and staff on a mental health locked
rehabilitation unit; and also to establish their predictions prior to
implementation of the policy. The current findings suggested that both staff
and service users were very apprehensive about the policy being implemented and
had a lot concerns regarding how it would work on a locked rehabilitation unit.
Research from Garg et al (2009); suggested there was an increase in service
user verbal aggression and an increase in staff time having to supervise service
users smoking. It also implied that there had been difficulties with
facilitating section 17 leave and tensions that this caused between some of the
staff. Both groups in the current research concurred with Garg et al’s (2009)
findings and proposed that there may be difficulties with behavioural
management and a possible increase in violence and aggression, which would in
turn mean a higher demand on staff time. It was agreed across both groups that
the policy could put everyone in a vulnerable position due to the increase in
stress and agitation that may be felt by the service users unable to smoke. The
service user group confirmed these predictions had been correct in the session
after the policy had been in place. They suggested that there has been an increase in incidents and they attributed
this increase to the policy making people more stressed and not having the
outlet to help reduce anxieties. However this does contradict the
findings of Smith et al (2011) as they suggested that in their research service
user aggression decreased. In addition, the concerns and belief in an increase
of incidents from the groups could be a result of the participant’s
anticipation that there would be an increase in challenging behaviour and their
negative perceptions of the initiative rather than an actual increase in these
behaviours as Lawn and Pols (2005) suggested in their research. Prior to the
implementation of the policy a common tool used to help de-escalate challenging
behaviour was to facilitate service users going for a cigarette, however now
this was no longer possible, staff reported utilising their skills such as
distraction techniques to help reduce agitation, and the staff group felt that
this was something very positive to come out of the policy.
The mental health foundation (2007) proposed that for the successful
implementation of the policy there should be adequate consultation with staff
and service users to alleviate their fears and sufficient staff training should
be available. The staff focus group acknowledged that they had received very
good and informative training on the smoking cessation course, however the
service user group felt that there was not enough consultation between the
policy makers and themselves. Research shows that having supportive smoking
cessation advisors is an important factor in the implementation of a smoke free
policy within a mental health setting (NICE, 2013). Although the staff group
did acknowledge that they had received adequate and beneficial smoking
cessation training they were concerned that the person who was in charge of
writing the policy was no longer employed within the trust due to her contract
ending shortly after the policy came into place. This led to concerns that
there was no longer anyone that could give clarity on the policy, or develop
the policy so that it encompassed the values of all the wards.
the implementation of the policy the staff group spoke about the
appropriateness of implementing this policy within a rehabilitation setting.
They acknowledged that it was a locked setting however due to the nature of the
unit, in terms of helping service users gain back their independence and to
integrate back into society, the group felt that as staff members they did not
have the protocols and security policies in place to ensure a complete smoking
ban. The staff group believed that the inability to thoroughly search service
users after unescorted leave and utilising a least restrictive approach
contributed to service users breaking the rules of the policy and smoking on
the wards. They suggested that there were few consequences that could be given for
this and therefore service users repeatedly smoked inside the building and in
the previous smoking area. Staff members questioned whether implementing this
sort of policy was person centred or a good use of their time. They also
expressed that enforcing a smoking ban was not the reason why they went into
this job role and felt that it removed independence from the service users and
contradicted the holistic way of working that is used with service users.
Although, the service user group acknowledged that they understood that smoking
on the ward was going against the policy and in addition breaking the law, they
felt that they had no choice. They explained that they did not enjoy smoking in
their rooms and spoke of not wanting to cause an accidental fire, suggesting
that sometimes the urge for a cigarette is so strong and they just have to have
one regardless of consequences. Both groups discussed the issue of smuggling
lighters and contraband smoking paraphernalia onto the ward, staff believed
this was due to not being able to implement stricter security procedures, such
as more thorough searches due the unit being a rehabilitation unit and not a
low secure hospital. These findings are in line with that of Zabeen,
Tsourtos, Campion and Lawn’s (2015). They suggested that open and semi-locked
units were more likely to experience policy breaches compared to locked
settings, and even though this is a locked setting, the majority of service
users have unescorted leave and lot more independence than those on other
locked units. This also agrees with Eadie et al (2012), their study showed that
the enforcement of a smoke-free policy was ‘easier’ in, locked units compared
to open units. Literature suggests that the nature of the ban,
whether it be a partial or complete ban has extensive impact on the success of
a smoke-free policy (Ballbe et al, 2013). Specifically, partial bans have been
shown to be more problematic and have more inconsistencies when enforcing the
policy (Lawn and Campion, 2013, p. 4228). The current study demonstrated some
of the ways in which a partial ban in a semi-open setting can be problematic.
service evaluation has a number of limitations; the analysis of the focus
groups was completed by two researchers and therefore could be subject to the
researcher’s bias. To eliminate this limitation it would have been beneficial
to have more than two people developing the themes from the transcriptions so
that findings would not be subjective to two people. Due to time constraints,
the period between the focus groups was only three months; giving services
users and staff a longer time frame between groups may have resulted in
substantially different outcomes, as the policy would have been more
established within the trust. The sample size of the groups was very limited to
staff on shift and service users willing to participate, there were only two service
users that attended the second focus group and therefore to ensure a more
representative range of opinions a larger sample size would have been
recommended that further research investigate whether an increase in incidents
after the implementation of the smoke free initiative in similar settings is
present, and would either endorse or discredit the views of the service users
on this issue. In addition, the evaluation was only conducted on one locked
rehabilitation unit, future research should utilise a wider representative
sample using a number of similar units to establish whether there is a
fundamental problem with implementing a smoke free policy within a
be drawn from this service evaluation that the best and most beneficial way to
implement a smoke free policy would be to introduce a complete smoking ban.
Research has suggested that more incidents and confusion occurs when service
users have a lack of clarity and predictable management with regards to when
and if they will be able to smoke. It can also be inferred that the policy
needs to be clear and consistent, and there needs to be clear management
accountability regarding the policy that can also lead the implementation at
every stage. The staff group spoke about the need for evaluation of the policy
and to address any problems that have emerged. In addition to this, there needs
to be procedures established for policing a smoking ban within a large hospital
campus, verification of the consequences for individuals breaking the policy
within the campus and who would take responsibility for the policing of this.
The smoke free policy was seen with optimism and anticipation, both staff and
service users believed that there could be positive changes made to their lives
from it. However, it does seem there are considerably more negatives to the
policy than people predicted. More consideration needs to be accounted to the
client group that will be affected by the policy and deciding whether this is
the least restrictive and most client centred approach to take due to it being
in direct conflict with rehabilitation.
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