Toward a Smoke Free Mental Health Workplace

Midas Tobacco Project: Mental Health Goes Smoke Free

This project was funded by a SWSAHS Health Promotion Unit through the Tobacco Control Grants programme.

Contents of this page:

Introduction
Project Summary
Rationale
Target Group
Partnerships
Objectives and Strategies
Evaluation
Participation Rates
Cessation Rates
Table 1: Uptake by Staff
Table 2: Uptake by Clients
Unexpected Outcomes
Barriers and Difficulties
Adverse Effects
Significant Findings
Costing Estimates
Recommendations

This report describes the Mental Health Goes Smoke Free project recently conducted within the inpatient units of Liverpool and Bankstown Hospitals, including factors that helped achieve project outcomes, barriers encountered and strategies implemented during the project. It journals the successes, failures and lessons learned from the project and concludes with recommendations for others who wish to undertake work in this field.

Coordinators

David Rich: Midas Dual Disorders Programme (Area Mental Health); Dr. Sheila Knowlden (Fairfield Department of General Practice)

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Project Summary

Goals:

• To trial a mechanism by which Mental Health Inpatient Units can implement the NSW Department of Health Smokefree Workplace Policy
• To equip staff to provide support and appropriate interventions for people abstaining from smoking tobacco
• To support staff who are smokers and wish to reduce or quit
• To promote good physical health care for consumers

Rationale

The project was aimed at facilitating the NSW Department of Health's Smokefree Workplace Policy, which will have the effect of removing the special right to maintain smoking areas previously granted to mental health inpatient units.

It was hoped to improve our understanding of problems in implementing the Policy while lowering smoking rates, reinforcing non-smokers to remain non-smokers and encouraging reduction and cessation in present smokers. It sought a coordinated approach to smoking cessation in the workplace for staff and for patients.

While many hospital and community health care staff believe they have a role in tobacco intervention, many still smoke and others believe they are not adequately equipped to deliver smoking cessation interventions (Feeney, Kelley, Griffin, & Young, 1997). Nursing and other staff acknowledge a need for further training to support their patients in a tobacco free environment but also recognise their own support needs.

People with mental health problems are amongst the heaviest smokers and suffer disproportionate morbidity as a result. Mental Health unit policies and staff attitudes have tended to reinforce continued smoking.

Target Group

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Clients and staff of the inpatient mental health wards of Fairfield/Liverpool and Bankstown Hospitals.

Partnerships

• Area Tobacco Cessation (Joanne Karcz)
• Fairfield Department of General Practice (Dr. Nicholas Zwar)
• Banks House (Bankstown Mental Health Service)
• Liverpool MHU (Fairfield/Liverpool Mental Health Service)

Objectives and Strategies:

1. To support the smooth implementation NSW Department of Health Smokefree Workplace Policy Policy timetables were included in the education projects and administrators have been encouraged to use the project to monitor their progress towards it implementation Staff involved in the project at Bankstown provided expertise to the main hospital's Smokefree Workplace programme

2. To develop a core of mental health staff who are thoroughly trained in issues to do with smoking, smoking withdrawal and the use of Nicotine Replacement Therapy (NRT)

3. To support those who have ceased smoking during this project and following their discharge from hospital

4. To build capacity of staff to assist with cessation services for other employees and clients

• Eight members of the mental health teams (5 mental health nurses, 1 occupational therapist, 1 nurse educator, 1 clinical nurse consultant) and 2 consumer advocates successfully completed a 3 days training course provided by the University of Sydney
• As a condition of entry into the course, which was funded by the project, the successful trainees undertook to develop inservice and other training for all ward staff. This training is ongoing. To date, about ¼ of the nonmedical clinical staff in each unit have received individual or group education on Smoking and Mental Health. In addition, medical staff at each unit received inservice training on the project protocols and rationale
• Trained staff conducted Inservice and provided personalised training programmes for other staff

5. To develop a better picture of tobacco use amongst people admitted to inpatient psychiatric care in SWSAHS

• Assessment of smoking status and a measure of dependency were made standard parts of the ward admission procedure, although compliance with this procedure was variable and medical compliance very poor

6. To increase knowledge and awareness of tobacco related harm amongst Mental Health Staff

• Current research has been delivered to staff on a regular basis throughout the programme
• Inservice programmes and training has been delivered to clinical staff and administrative staff by the programme coordinators and trained staff
• Medical staff were offered information sessions by the Academic Department of General Practice, although attendance was poor and the time available very limited
• Pharmacy staff at Liverpool and Bankstown Hospitals attended inservice training on tobacco and mental health

7. To reduce the risk of tobacco related harm amongst staff and clients of the Mental Health Teams

• Counselling, support and education, together with subsidized Nicotine Replacement Therapy was used to (a) reduce the actual incidence of smoking and exposure to tobacco smoke in the wards, (b) minimise the likelihood of ex-smokers and non-smokers taking up cigarettes and (c) to increase motivation among smokers to quit
• any inpatient who was a smoker was offered the opportunity to try NRT as a replacement therapy discharge for up to 8 weeks during their admission and after at no cost to the individual and with no requirement to eventually quit smoking
• every staff member who was a smoker had the opportunity to try NRT at a reduced cost

Evaluation

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Consumer Advocates in both participating services, strongly opposed to the project at the outset, became the most effective and consistent members of the teams. Two were heavy smokers; both successfully completed the University training, took up the NRT programme, and proved to be outstanding role models, effective trainers and excellent counsellors. They also proved to be effective in recruiting clients to the programme and providing post discharge support.

Participation rates:

Based on bed occupancy rates and smoking prevalence statistics, it was estimated that up to 55 clients would try NRT for at least part of their admission. It was expected that 12 staff would also try NRT.

Actual participation rates were:

• 12 clients at Liverpool and 4 at Bankstown tried NRT during the programme (N=16);
• 9 members of the staff and 4 Consumer Representatives used NRT

Cessation Rates:

It was explicit in the programme design that participants did not have to commit to stop smoking in order to receive NRT or other support. Nevertheless, a significant number of participants chose to quit smoking (see tables 1 & 2.)

The Consumer Representatives and staff members generally elected to use NRT to give up cigarettes. Most substantially reduced their tobacco intake or quit, with the Consumer Representatives being the most successful, 3 out of 4 not having smoked for periods between 3 and 7 months at the time of this report (see tables 1 & 2). Compared with typical smoking cessation programme success rates, the staff and consumer representatives have done extremely well.

Placebo interventions achieve about 10% cessation rates at 3 months. Therefore, to be considered effective, a programme must result in more than 10% of participants giving up tobacco.

Two of the consumer representatives who began NRT at the start of the programme have given up cigarettes and have been tobacco free for longer than 3 months. One quit but relapsed to 10 cigarettes per day at 2 months, and a fourth, who commenced the programme in the last month and has been tobacco free for 9 weeks as at November 2000). This is a remarkable achievement. Two out of 3 non-clinical staff also achieved non-smoker status, while one of four clinical staff managed to become a non-smoker. This equates to an overall 80% quit rate for staff and consumer representatives, on the criteria of 3 months tobacco free. Two of these participants are still using some NRT. Two others achieved substantial reductions, and are able to meet the Smokefree Workplace requirements. A higher 3 month quit rate could have been claimed: a second staff member relapsed at the beginning of the 4^th. month and has not been counted amongst the non-smokers.

Inpatients fared less well and it was suggested that many were taking up the offer of NRT to improve their budgets rather than their health. This is quite acceptable within the project parameters, which was more concerned with a smoke free workplace than quitting. Nevertheless, one successfully quit and a number reduced their intake while on the ward; others reported an increase in motivation to quit and increased confidence that they might be able to succeed. NRT proved to be acceptable and effective in reducing craving and few adverse psychological or physical effects were reported.

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Table 1: Uptake of NRT by Staff (*=attempted to quit)

Consumer Representative

Nursing

Other

Clinical

An important feature of the project has been to differentiate between tobacco and nicotine as the targets for intervention. Much of the friction which occurs in an inpatient unit seems to revolve around cigarettes ... borrowing, "botting", stealing, demanding, menacing and protecting a supply if you have one, are major sources of discord. Some of these eventually develop into aggressive incidents, especially so for people who have to cope with nicotine because they can't beg, borrow or steal enough smokes. This project has given staff a new perspective on these issues and new set of tools for managing them.

The absence of adverse impacts amongst the clients who have tried to do without tobacco, and anecdotal evidence of reduced discord between staff and clients and between clients has been beneficial, as has the strong support of the Consumer Representatives.

Funding has been sought to extend and enhance the current programme, and, with the return of staff from sick leave, both units are continuing to train staff and set up Tobacco Groups in the wards.

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Table 2: Uptake of NRT by clients

m/f

Unit

f

MW

f

CF

f

DC

f

7

IT

f

7

JH

m

14

KM

m

7

TM

m

7

TW

m

PH

m

14

TN

m

14

WT

m

7