In response to publicising the study, staff, patients and carers volunteered to take part (See Table 1).
Key informants were all senior Trust managers. Frontline staff participants included a variety of healthcare professionals. Twenty staff were from Trust A and thirty-one from Trust B; this disparity can be accounted for in the size of the focus groups conducted with Level 2 Advisors (Trust A, n=4; Trust B, n=14). Participants from five organisations, who all sat on the steering group, were interviewed to explore partnership working. These included a member of the Strategic Clinical Network, the local tobacco control office and the service user group, respectively, plus the medical director from one Trust and deputy medical director from the other. Four service users were interviewed in a focus group (3, female; 1, male; all smokers). Interviewed individually were one service user who had been hospitalised previously (female, smoker) and 2 male, inpatient smokers; also one male and one female carer, both of whom were ex-smokers. The service users they cared for were not interviewed.
Coherence
The findings suggest that some staff were satisfied that introducing smokefree policies was in the patients’ best interest.
It was quite clear why we were going smokefree, it was to improve the health of the patients, and that patients were dying 15-20 years before the rest of the population, so I felt we had a duty of care for the patients.
Frontline Staff, Trust A
This is a NICE public health guideline and as an organisation we had a duty to implement it.
Key Informant, Trust A
Other staff, although they understood the motivation for smokefree policies, did not agree with the reasoning behind them. In particular, suggesting that they viewed smoking as just one factor amongst others, which contributes to the reduced life expectancy of MH services users.
I think there’s much more we can do and we can look at in terms of health promotion, in terms of alternatives to prescribing antipsychotics, in terms of polypharmacy, in terms of all those things that we do that have a part to play in people’s life expectancy being so much lower, it just feels like we’ve pinned everything on smoking and I think smoking’s part of a number of processes that are leading to people living less.
Key Informant, Trust A
Some staff thought it was unethical and contradictory, in terms of insisting patients quit, rather than waiting until they felt ready, as expressed in this focus group:
… I think part of it is you’re kind of taking the contemplative state away from people – even though we did try to prepare people as much as possible for the smoking ban coming in and did do a lot of work – but still that decision’s kind of being enforced on them.
… They haven’t chosen to start with…
…and the smoking cessation training again, a huge bit of it is around the contemplation stage.
Facilitator: Right that’s interesting isn’t it, so in some ways are you saying the policy doesn’t really…
… Reflect smoking cessation advice.
Facilitator: Yeah.
… Because a big part of it’s about behaviour change and being ready to change, we were trying to get people to stop smoking who weren’t ready to.
Frontline staff, Trust B
Cognitive participation
Buy-in
Preparation processes were often reported as good, especially regarding hearing experiences of introducing smokefree policies from other Trusts. Although there were mixed levels of buy-in, they were reported to have increased over time in both Trusts. Staff on secure units bought into the policy more than those on non-secure units.
I think we were so tuned into this coming in and happening that, I would say my practice hasn’t changed because we were already onto this before the policy was ever put in place.
Frontline Staff, Trust B
For staff involved in the short-term care of patients, they more frequently reported concerns that the policy would not achieve the long-term benefits it purported to.
Enrolment
Senior support
Fundamental to buy-in was seeing senior members of the organisation backing the policies; this gave the implementers the authority to act.
I think the other thing to say is we were, because the way the project was led and it was led by our medical director, there was buy-in from the beginning from senior members of the Trust really so […] our exec management team, everybody had kind of bought in at that level which then fed down, erm kind of through the Trust really.
Key Informant, Trust A
Where this was not done, there was anecdotal evidence of delays in progression. Critical to success was having a subgroup structure that was prioritised by members, tightly managed and well-focused, with key decision-makers round the table. This enabled implementation of the policies more effectively. Where delegation of responsibility occurred instead, it could lead to further delays, with decisions having to be referred back to the senior manager. Middle management support influenced the outcomes; buy-in at this level was not always translated to the frontline, who felt they lacked the authority to insist on the changes.
It has to come from senior management. I am new and young, it shouldn’t be on my shoulders … you don’t want to break down the relationships you have with colleagues.
Champion, Trust A
A lack of consequences for non-compliance by staff was also reported; for example, relating to disciplining staff who smoked in uniform. Enabling access to training was recognised as important in supporting the smokefree message and overall implementation, however this varied between Trusts.
Collective action
Planning
Communication of the reasoning behind the decision to bring in smokefree policies was seen as key in bringing all stakeholders on board. Many participants had found an early stakeholder event useful. Nevertheless, some participants thought that service users, carers and frontline staff were insufficiently consulted during implementation. They expected to be able to discuss the pros and cons of the process and were unhappy with decisions being made at a senior level and handed down rather than co-created.
Personally I think it would have been better if there was some consultation or at least early on a lot of transparency about why that decision had been made.
Partner Organisation Representative
Adequate time was thought to have been given to prepare for the going smokefree deadline, although there were a lot of hurdles to overcome to meet it. As well as planned communication strategies, informal communication routes were found to have been instrumental in disseminating the policy to patients and carers. Efforts were made to let patients in the community know about the introduction of the policy, however they were often ill-prepared on admission.
Implementation
Certain locations and units were reported as more successful than others in implementing smokefree policies. It was suggested that this was due to the length of stay or security level of the ward and differences in the contexts patients were admitted from e.g. community, prison; and the services available to them prior to admission. However, levels of preparation varied:
R1: We put in a lot of preparation.
R2: We put in very little preparation. It was just the posters went up and the next day, “You’re not smoking anymore”.
R1: I don’t know why [specialty] didn’t do what we did. But we made a decision as a directorate very early on.
Frontline staff focus group, Trust A
R3: You had it on bulletins and emails and the pharmacy talks. Maybe the preparation of the patients could have been better.
R4: I had a different experience, we had a big countdown, then on the day of it, we had a huge healthy living event.
Frontline staff focus group, Trust B
It was clear that careful use of language was required to encourage smokefree policies to be seen positively. Ambiguity in the policies over patients’ leave compounded any inconsistencies. Consistency of enforcement was another key to success.
If I was out with a patient and he or she lit up … I would ask them to put it out. And I know for a fact, a good half of the staff members on the ward that I work on, would just say, “Just hide behind that bush and do it [smoke a cigarette] quickly”. We need that continuity …
Frontline staff, Trust B
Patients’ leave from the ward was seen as a particularly difficult time to manage, when the policy was often likely to be challenged. Participants recognised the smoking culture and some talked about the importance of avoiding the need for enforcement by changing it.
[There has been a] culture of smoking in mental health. Smoking has been accepted. It has not been seen as problematic.
Visitors entering open sites and smoking in the grounds were a particular challenge. There were many details that needed to be worked out following the introduction of the policies; suggesting a requirement for ongoing review and response in a timely manner.
Community links
Communication from healthcare professionals to patients in the community about changes to Trust policy was reported as weak. Although it was recognised that preparing smokers pre-admission was preferable, broken communication channels resulted in staff having to tell patients upon admission that they could not smoke. Similarly, patients admitted from prison reportedly had smuggled in smoking materials. Communication on discharge back into the community was also reported as incomplete, with receipt of messages to healthcare professionals responsible for providing smoking cessation services unclear.
There's nothing on discharge yet, we did have a whole referral process in place - a simple form they complete and send it electronic - it's never been used so we know we've got a problem with our staff on the wards who don't refer.
Key Informant, Trust A
With variable smoking cessation services on offer in the community, staff expressed a concern that patients would simply be abstaining from smoking as opposed to making a long-term, lifestyle change.
Reflexive monitoring
Positive aspects
There was a view that staff had been more successful in quitting smoking since introducing the smokefree policies. Where the policy was successful, patients’ MH was seen to have improved as they were no longer experiencing nicotine withdrawal symptoms; this had led to a more relaxed atmosphere on the wards, less anxiety in patients, and more time for therapeutic activities.
Patients are more likely to engage with activities because they want to fill their time; which then progresses onto getting more leave.
We have one patient that goes to the gym, one that goes to the library. It [smokefree policy] improves the time they spend off the ward doing meaningful activities.
Champions, Trust A
In addition, patients felt a sense of achievement following their successful quit attempt, which was reported to improve their mental health.
I think for some of our patients, because it’s actually a learning disabilities hospital, but obviously a lot of them have mental health issues as well, it increased their confidence and self-esteem. A lot of our patients had poor self-esteem and they actually achieved something by stopping smoking, they achieved something that was extremely difficult and I think it made them think, if we can do that we can do other things as well.
Frontline Staff, Trust B
Negative aspects
Several, unintended, negative consequences of introducing smokefree policies in Trusts were expressed by participants, such as an increase in patients smoking indoors:
Because we’ve implemented a policy which is driving the smoking underground […] Now we’re having staff having to go into rooms that are filled with smoke and therefore it’s become a second-hand smoking issue.
Key Informant, Trust B
The hope that reduced smoking would increase patient engagement with activities was not always realised, some used it in other, less active ways:
We see patients are in bed longer …
Frontline staff, Trust A
In addition, consequences reported included raised staff stress levels, increased violence and aggression, concerns over ethics and interactions with medication, perceived concerns over the reaction from the external regulator (Care Quality Commission), divergence of opinion between staff and ‘workarounds’ to avoid compliance instigated by patients and staff. It is unclear if these are substantiated by Trust data from alternative sources.
Where patients had informal leave, there were concerns about them smoking off-site or of patients being exploited by local individuals. Although this falls outside the remit of the policies and this evaluation, it is important in terms of holistic care for patients and the impact on-site e.g. it undermines patients’ ability to abstain and staff’s attempts to support them, and it potentially increases difficulty in monitoring antipsychotic drug levels. Staff expressed uncertainty over what was acceptable in nudging patients toward changing their smoking behaviours.
Mixed aspects
Whilst in some wards the smokefree policy was introduced relatively easily, in others, staff participants thought there was an increase in challenging or aggressive incidents.
Where I work, everyone is on board. In forensics a lot of patients will never leave, so there wasn’t a choice.
Champion, Trust A
Talking to staff nurses they say violence has increased, and anxiety.
Frontline staff, Trust B
The therapeutic relationship was reported as being damaged in some cases by the smokefree policies.
Well it made me feel a bit horrible to one staff because he kept coming out and saying, “Not in here”.
Inpatient, Trust A
Enforcement
Enforcement was a key theme that arose organically from the data, it was both a major concern and a signifier of contradictory expectations and practices. For example policies were not always adhered to:
[There are] still [enforcement] issues as we have staff who disagree very strongly. I suspect some staff are allowing patients to smoke on escorted leave.
Frontline staff, Trust A
Although alcohol was prohibited, some staff viewed smoking differently, and therefore did not think it should be disallowed in similar ways:
I think drinking alcohol is different because it disinhibits people, and causes violence, so it’s right to prohibit alcohol.
Frontline staff, Trust B
However others challenged this view, stating buying cigarettes should be treated the same as alcohol:
Would you report them [a patient on escorted leave] buying a litre bottle of vodka? … you’d report it!
Frontline staff, Trust A
Staff participants discussed confusion and frustration regarding how the policy was to be enforced successfully. Where successful enforcement occurred, it tended to be in settings where patients were used to their behaviours being restricted.
Working in a forensic setting, I work in an environment where patients are used to not having things and smoking just became one of those.
Frontline staff, Trust A
Some frontline staff implementing the policy felt that it was at odds with their professional values of ensuring the patients’ best interests.
I think that we’re affecting choice, we’re just enforcing something that goes against the grain of what we do as nurse.
Frontline Staff, Trust A
Visitors to the Trust sites, who smoked, also created a challenge to staff implementing smokefree policies. They may be members of the public crossing the site or visitors accompanying outpatients or visiting inpatients. Many of them brought smoking equipment on-site with them.
Risk
Staff who reported the notion of risk noted that this applied to both staff and patients. Several staff noted concerns about how insisting a patient stop smoking could compromise their own safety (either from aggression or fire). However, some opposite views were also expressed, that there was no noticeable increase in risk from aggression or fire.
R2: I have also seen the side of, the violence it causes to staff.
R1: I have to pick up on that because there has been no increase in violence toward staff since [the smokefree policies came in].
R2: Maybe [not] on forensics, but on the adult ward.
Frontline staff focus group, Trust A
Staff talked about how they felt caught, weighing up the risks between compliance and non-compliance with the policies. Monitoring risk from the interaction between medication and smoking was seen by staff as necessary and concerning but the risk was rarely realised, in their experience. Electronic cigarettes were seen as a potential risk by Trusts, who imposed different and changing restrictions on their use and kept them under review. The wider public were also reported to be at risk e.g. from caches of smoking paraphernalia being found off-site.
Smoking cessation resources
Policies set out arrangements for provision of NRT to smokers shortly after admission, and were generally adhered to, but there was uncertainty sometimes about access and administration. NRT was not universally accepted by patients as an alternative to smoking, some of whom expressed dislike for NRT products. However, some inpatients who had the opportunity to try different products ahead of the deadline, tended to be more accepting. Smoking cessation behavioural support was reported as variable between Trusts and sites, partly due to challenges in delivering training.
Patient experience
Successful behaviour change
Patients with learning disabilities in secure settings reported quitting successfully, as did a carer, when retelling the experiences of a service user who also quit.
I smelt them smoking, that’s when it started again. Now that the ban’s in its perfect; saves money as well.
Inpatient, Trust B
I didn’t think it would be achievable, but they [staff] managed it [supported my daughter to quit] …. So for me it was a bit like a miracle.
Carer, Trust B
Fears and unsuccessful change
Conversely, patients admitted to an acute or informal setting felt pressure and judgement increased but enforcement carried specific challenges.
…there was people there [Psychiatric Intensive Care Unit (PICU)] who had serious problems who wanted to smoke and they were giving out vaping things but there was no safety net for those who just didn’t want them and they were psychotic …
… if they don’t get what they want they really start self-harming.
… in the PICU unit it [the smokefree policy] was very well adhered to.
Carer, Trust A
Quits begun on-site were not seen as well-supported in the community, with patients expecting a negative impact on sustainability. Patients and carers reported that short-term admission was seen as a time of abstinence rather than quitting altogether.
Coherence and cognitive participation
Both benefits and concerns were recognised. Overall patients and carers understood the policy and the practical implications. Some patients believed that previously they would have resisted the policy but now realised they had benefitted overall. However, there were doubts expressed by some with regard to the reasoning for going smokefree, as it was still seen by them as a negative experience for patients.
Planning and implementation
Positives of stopping smoking with regard to physical health, environmental improvement, social interaction and a personal sense of achievement were expressed by patients/carers. Negatives including psychological stress, impact on social interaction, lack of smoking cessation support in the community and the construction of smoking as deviant were all reported by patients/carers. There were anecdotal successes but also continued resistance to the policies and incidences of smoking by patients off-site.
Active ingredients
When approaching the data using NPT and logic modelling, active ingredients were identified in relation to implementation of the smokefree policies (Table 2). This analytical process has previously been explored and found to be useful (28).