The International Journal of Psychosocial Rehabilitation
 
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




Citation:
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



Abstract
Guidance on 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 



Introduction:
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.

The 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.

Aims

         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.


Method
All 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.

An 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 gathered.

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.

Interpretation/Analysis
Data was gathered from each group and using thematic analysis the transcription was interpreted into a number of reoccurring themes.

Prior to the implementation of the Smoke Free Initiative
Five 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.

Behavioural Management
This 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.

Whilst 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 de-escalation skills.

            ‘… People will probably shine out with how they deal with situations.’ - Staff

Both 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 users

These 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.

‘… I think it’s putting us (staff) in a really vulnerable position initially, definitely because tempers are going to be raised.’ – Staff

Another 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…’ - Staff

Empathy/Choice
Both 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.

‘… I 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
It was 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
 
Although 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

These 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.

‘… How can they stop you smoking though, everyone’s an adult, we are all adults here.’ – Service users

Both 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 unescorted.

Optimism
While 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.

Both 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 activities.

            ‘… Spending the whole shift looking for lighters…’ - Staff

Both 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.
 
Something 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.

‘… I was given confidence by people saying oh well they’ve done it at Wathwood and they expected loads of hassle and it went smoothly…’ - Staff

Proactive/Alternative Strategies
Staff 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).

It was 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

In the 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.

Section 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 a day.
 
            ‘… I won’t be using my leave just to go for a smoke…’ – Service users

Staff 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.

A 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

There 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
Another 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.

The 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

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 the ward.

‘… What’s been told by one staff member and what they’re told by another (is different) …’ – Staff

There 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.

After the implementation of the Smoke Free Initiative
The 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.

The 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)
The 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.

‘… But it’s the same charger as a phone (e-cig charger). But were allowed phones, it doesn’t make sense does it…’ – Service users
Service 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.

‘… (Policy 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

The 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.

‘… (NRT sprays would be) Just the same as the lozenges and inhalator cartridges which they still have to come and get anyway…’ – Staff

The 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 discovered.

‘… The 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

The 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 cigarette.

‘… 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

Service 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 choice.
 
Service 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

The 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 rehabilitation.

‘… You know nothing’s happening about it really (smoking on the ward) and I think what can we do…’ - Staff

Fairness
The 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.

‘…it’s 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

The 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.

‘…It’s (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

Stress
Service 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...’ – Service users

They 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.

‘… Cos 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.

The 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.

 … It’s 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

It was 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…’ – Service users

Conflicts with Rehabilitation
The 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

The 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.

‘… If 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
A 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 use instead.

 ‘… But who are we to tell them (service users) what should and shouldn’t make them happy…’ - Staff
Although 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.

‘…We 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

The 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.

‘… If 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…’ - Staff

            ‘… We will be getting into secure territory…’ - Staff

The 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…’ - Staff

Staff 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…’ – Staff
‘… It (the policy) is in conflict with rehab…’ - Staff

Inconsistencies
The 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

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

In 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
Although 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

The 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

Positives
The 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

It was 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.

The 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.

            ‘…Staff and other service users aren’t inhaling it (smoke) passively anymore…’ - Staff

The 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 agitation.

‘… A 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

The 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 represent this.

Discussion
The 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.

After 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.

Limitations
This 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 beneficial.

Recommendations

It is 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 rehabilitation environment.

 Conclusion
It can 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.

References
Ballbe, M., Sureda, X., Martinez-Sanchez, J.M., Salto, E., Gual, A., & Fernandez, E. (2013). Second-hand smoke in mental healthcare settings: Time to implement total smoke-free bans? International Journal of Epidemiology. 42 (3), 886–893.

Cheshire and Wirral Partnership NHS Foundation Trust (2014) Nicotine Management Policy Leaflet code: G-NMP-13-599

Eadie, D., MacDonald, L., Angus, K., Murray, R., O’Mara-Eves, A., Stansfield, C., & Leonardi-Bee, J. (2012). Review 7: A review of the barriers to and facilitators for implementing smoke free strategies and interventions in secondary care settings. NICE evidence reviews: Smoking cessation acute, maternity and mental health services (Draft 3.0). Retrieved from http://guidance.nice.org.uk/PHG/51/Consultation/

Lawn, S. & Pols, R. (2005). Smoking bans in psychiatric in service user settings? A review of the research. Australian and New Zealand Journal of Psychiatry, 39(10), 866-885.
 
Lawn, S. & Campion, J. (2013). Achieving smoke-free mental health services: lessons from the past decade of implementation research. International journal of environmental research and public health, 10(9), 4224-4244.
 
Lawn, S., Feng, Y., Tsourtos, G. and Campion, J. (2015). Mental health professionals’ perspectives on the implementation of smoke-free policies in psychiatric units across England. International Journal of Social Psychiatry, 61(5), 465-474.

Garg, S., Shenoy, S., Badee, M., Varghese, J., Quinn, P. and Kent, J. (2009). Survey of staff attitudes to the smoking ban in a medium secure unit. Journal of forensic and legal medicine, 16(7), 378-380.
 
Mental Health Foundation Smoking and Mental Health: Why people smoke and how to quit (2007)
National Institute for Health and Care Excellence. Smoking Cessation in Secondary Care: Acute, Maternity and Mental Health Services. Available online: https://www.nice.org.uk/guidance/ph48 (accessed on 11 April 2016).

Royal College of Physicians; Royal College of Psychiatrists. Smoking and Mental Health; RCP: London, UK, 2013.

Smith, P.H., Homish, G.G., Kozlowski, L.T., Spacone, C., Trigoboff, E., & Joffe, S. (2013). Effects of a complete smoking ban on in service users at an intermediate to long-term psychiatric facility. Community mental health journal, 49(2), 193-198.

Sohal, H., Huddlestone, L. and Ratschen, E. (2016). Preparing for Completely Smoke-Free Mental Health Settings: Findings on Service user Smoking, Resources Spent Facilitating Smoking Breaks, and the Role of Smoking in Reported Incidents from a Large Mental Health Trust in England. International journal of environmental research and public health, 13(3), 256.

Zabeen, S., Tsourtos, G., Campion, J. and Lawn, S. (2015). Type of unit and population served matters when implementing a smoke-free policy in mental health settings: Perceptions of unit managers across England. International Journal of Social Psychiatry, 61(7) 700-710.
 



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