Background
Methods
Participants
Participant characteristics (n = 36) | Mean (SD) |
---|---|
Age (years) | 38.3 (13.8)* |
Years in current role | 6.9 (8.1)* |
Gender | n (%) |
Male | 9 (25) |
Female | 27 (75) |
Service type | n (%) |
Secondary care inpatient wards | 1 (20) |
Secondary care community services | 3 (60) |
Primary care community services (IAPTS) | 1 (20) |
Participants in each service | n (%) |
Secondary care inpatient wards | 4 (11.1) |
Secondary care community services | 15 (41.7) |
Primary care community services (IAPTS) | 17 (47.2) |
Professional discipline | n (%) |
Occupational Therapist** | 1 (2.8) |
Psychiatrist | 4 (11.1) |
Clinical Psychologist** | 4 (11.1) |
Trainee Clinical Psychologist | 2 (5.6) |
Health Psychologist | 1 (2.8) |
Assistant Psychologist | 1 (2.8) |
Psychological Wellbeing Practitioner (PWP) | 5 (13.9) |
Trainee PWP | 2 (5.6) |
IAPTS placement student | 1 (2.8) |
Cognitive Behavioural Therapy (SBT) Therapist | 1 (2.8) |
Nurse** | 6 (16.7) |
Student Nurse | 1 (2.8) |
Social worker | 3 (8.3) |
Forensic Mental Health Practitioner | 1 (2.8) |
Support worker | 1 (2.8) |
Administrator/assistant | 2 (5.6) |
Self-reported smoking status | n (%) |
Non-Smoker | 17 (47.2) |
Ex-Smoker | 13 (36.1) |
Occasional/social smoker | 6 (16.7) |
Interview protocol and data collection
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Experiences of addressing smoking with mental health patients
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Attitudes toward smoking cessation and harm reduction in the mental health context
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Attitudes and adherence to the smoke-free policy and mandatory training
Data analysis
Results
Themes
Psychological capability: Having the knowledge and skills to address smoking with patients
“I didn’t understand that the policy was around helping people to change their behaviour. I just thought it was the logistics and practicalities of don’t smoke in the hospital grounds. In the same way as you wouldn’t expect people sitting out there drinking bottles of vodka. But that doesn’t necessarily mean you are there trying to change those people’s problems with alcohol. So if that is the policy then that is news to me.” (Male, ex-smoker, Clinical Psychologist, community based).[…]
“Even in inpatient setting, when you speak to them about smoking cessation, it’s not because of stop smoking. It’s because they are not allowed to smoke in hospitals. So you don’t prescribe something based on someone wanting to stop smoking. You prescribe to keep them on nicotine whilst they are on the ward… So you talk about it, but you prescribe it in the end just to pull them through until their next cigarette.” (Male, occasional smoker, Psychiatrist, community & inpatient based).
“I think almost too much information, and the part that’s more relevant to me was right at the end, like how you have those conversations with people, and I think if the training was just that in a more experiential way, like role plays. But it does help you practice to have those conversations with people and how to bring it up, because its uncomfortable, and that felt more relevant. But because it was right at the end, I was fed up by then. I noticed that I had that temptation to skip through it.” (Female, non-smoker, Clinical Psychologist, IAPTS). […]
“Practically speaking as a clinician and a manager as well, I think that it’s too long. I think there is way too much science in there for the majority of clinical staff in the trust. Hardly any clinical staff need to know about the neuro pathways that affect nicotine addiction and its interaction with antipsychotic drugs. It’s kind of overshot the mark massively. I think it’s good that we should all have some training, but I think it’s too much and pitched at the wrong level” – (Male, Ex-Smoker, Clinical Psychologist and service manager, IAPTS).
“The more it goes on the more upset I am about prescribing all these extras because sometimes people use more nicotine than if they were allowed to smoke every two hours.” (Female, ex-smoker, Psychiatrist, Community & inpatient based). […].
“I’ve got limited knowledge, but I think realistically if you’re able to just stop, then possibly you’re going to more likely have stayed stop without having to rely on something else. Like some people get addicted to the patches and the tablets; all these different things that they are trying to do to help them stop. But it’s just transferring that addiction to another area.” (Female, ex-smoker, PWP, community based).
Physical opportunity: Environmental factors that influence MHPs practice relating to addressing smoking with patients
“I have talked to people who felt smoking was a major problem for them and quitting smoking was a major goal. I have done some problem solving around that in terms of if they are using it, what else can they be doing. But that’s usually if they have brought it to me with something that they need help with. As opposed to me saying let’s sit and talk about smoking.” (Female, non-smoker, PWP, IAPTS). […]
“If they tick on the form that actually I’m happy with the level that I’m smoking, that’s not something I’m looking to make changes in, then it feels a bit uncomfortable to bring it up in the context of having a lot of things to do in that assessment anyway.” (Female, non-smoker, clinical psychologist, IAPTS).
“I think our time out of the ward is a very good opportunity to talk about quitting smoking, and plus the fact that when they are on escorted leave, town leave not ground leave, they are not really supposed to smoke when they are on their leave. But of course, you can’t actually physically stop them” (Female, ex-smoker, Nurse & ward manager, inpatient based).
“The problem with enforcement I think is coming from inpatient to community. Our patients don’t give a monkey about smoking outside the door, next to the no smoking sign. Whereas I think inpatient is able to enforce it a little bit differently, particularly you know they have to go outside the grounds of the unit or whatever. But yeah it’s hard to see how it’s possible or how that problem to getting people to take it seriously. Do you man handle people off the grounds? I don’t really understand.” (Male, ex-smoker, Clinical Psychologist, community based).
“My best experience of trying to address people's smoking has been with the use of a spirometer that gives you a measurement of lung age, which in the previous service where I worked we had one… I was looking after people in their 40s and most of them had lung ages of a very heavy smoking population and a lot of them had lung ages between 80-110, and that was a really great motivational tool. The other advantage about this particular service is that there was a dedicated smoking cessation team and dedicated clinic and groups, so it was very easy to slot people in, and it was very clear who was going to see them and where they were going to go. Those people were very accessible, so it all worked really well.” (Female, ex-smoker, Psychiatrist, community & inpatient based).
Social opportunity: Social factors that influence MHPs practice relating to addressing smoking with patients
“I think one of the other things you find is they hide their cigarettes and come back to them a few hours later. I’ve seen people do that here… And it becomes like an Easter egg hunt and I think it’s because people might go and they know where their friends are hiding them. I think there has got to be more of a policy around how you handle that”. (Male, occasional smoker, Forensic Mental Health Practitioner, community based).
“People are under pressure to bring cigarettes and lighters in onto the ward whereas before you didn’t have that pressure to bring cigarettes.” (Female, ex-smoker, Psychiatrist, community & inpatient based). […]
“Yes, and you have this double bubble called debts. So everything is one hundred percent. So if you borrow one cigarette, you may as well bring two cigarettes back” (Male, ex-smoker, Psychiatrist, community & inpatient based).
“It’s good if it gets implemented and followed through properly, but it doesn’t. Patients keep on smoking on the wards and staff are scared to confront patients, so they don’t do anything about it. I regularly go on the ward and being an ex or occasional smoker, I go on and immediately smell it, and I say ugh who’s smoking? I walk straight to the room of the patient smoking and I say this patient is smoking, and the response is, oh no he’s not! Which is ridiculous! So I don’t think it’s getting used as it should”. (Male, occasional smoker, Psychiatrist, community and inpatient based).
Automatic motivation: Biases that affect MHPs practice relating to addressing smoking with patients
“I think it’s common knowledge and everyone knows the consequences of smoking, so why do I have to state the obvious every time I see the clients, because they are not stupid. They’ve got the knowledge but they made the choice they want to make.” (Female, occasional smoker, Nurse, community based).
“From experience I have not really met many who would ever want to give up. That seems to be the one thing they like about their life.” (Male, ex-smoker, Clinical Psychologist, community based). […].
“I think overall they are locked up and banged up in a secure environment, so what can they do? So obviously when they go on their escorted or unescorted leave, invariably they do smoke.” (Female, ex-smoker, Nurse & Ward Manager, inpatient based).
“They can’t see it as a psychiatric problem, so they can’t see why you’re asking. It’s none of your business kind of thing.” (Male, ex-smoker, Psychiatrist, community & inpatient based). […]
“Some patients interpret it as part of control. Because of the dynamics it’s why are you telling me what to do. Can I tell you to stop smoking? It’s my life…” (Male, non-smoker, Social Worker, community Based).
Reflective motivation: Self-conscious decision making and reasoning that influence MHPs practice relating to addressing smoking with patients
“We have got a responsibility to provide them with some information about health promotion and smoking comes into that. But I think in the community that’s probably where our role ends. You know, we can offer them where to find some more information or give some advice, but Erm… yeah. I think that’s it really”. (Female, Occasional Smoker, Nurse & Team leader, Community based).
“I think that it has been made a part of my job, more than I would do it as part of my job, with the smoking. It’s an unhealthy habit, there are lots of unhealthy habits. But its more something I’ve kind of been told to do.” (Female, ex-smoker, Social Worker, community based).
“I don’t think I’ve ever offered. It just never comes to mind. I don’t know why. But maybe the number of problems people tend to come to me with, that doesn’t seem to ever factor in their list of… well it’s not even a problem for them, but even if it is then its way down the list behind other drugs or other problems that they are having.” (Male, ex-smoker, Clinical Psychologist, community based).
“I think sometimes because people have got issues with their medication as well, if they are mixing the two together, you might be more likely to focus on discussing their issues about their medication with them and that you can’t mix two difficult issues together and you’re unlikely to be successful in discussing both so unless there is an obvious physical health problem that was becoming a major concern, I would probably choose the medication.”(Male, ex-smoker, Social Worker, community based). […]
“I often ask about it if they are a smoker and just say, is that something you’re looking to give up or not? Especially if there are financial issues or health issues or maybe if they are smoking a lot of marijuana or something like that.” (Female, non-smoker, Clinical Psychologist, IAPTS).
“It isn’t our role as clinicians to police smoking. If it were illegal which cannabis is, we take a different approach on that obviously. But with smoking as of yet not illegal, we can’t stop them. Literally. When they go out on their leave, which isn’t every minute of every day, they may smoke. But while they are in the building, they are not smoking.” (Female, ex-smoker, Nurse & Ward Manager, inpatient based). […]
“I don’t allow them to smoke that much so they are only allowed two cigarettes when they go out on leave. It causes a lot of problems with negotiations.” (Female, ex-smoker, Psychiatrist, community & inpatient based).
“In all honesty, I’d worry about being thumped! You don’t know what the patient’s history is. You don’t know what the risk history is. I think that’s tricky.” (Female, ex-smoker, Psychiatrist, community & inpatient based). […]
“I’ve seen people smoking, just near our office actually, and I feel a bit conflicted and there is some dissonance. Because I think it probably is my role as a senior clinician to enforce the policy, it’s probably all of our role to do that really. But at the same time I have other conflicting ideas which get in the way of me doing that. Like… I don’t want to get into conflict with someone and they are not a patient being seen in our team, they are clearly inpatients. And… I’m really busy and I’ve got other things I could be doing with my time, so there are always excuses that I think I could make for myself to not get into a conflict situation about it” (Male, Ex-Smoker, Clinical Psychologist and service manager, IAPTS).
Discussion
Barriers identified | COM-B | TDF | Intervention function | Possible intervention |
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Poor comprehension of harm reduction approaches, smoke-free policy and its purpose. Unable to recall training content MHPs lack the confidence to address smoking with patients who do not initially indicate willingness to quit. | Psychological capability | Knowledge Memory, attention and decision Cognitive and interpersonal skills | Education Training Environmental restructuring Enablement | Brief, face-to-face or online smoking cessation training tailored specifically to MHPs roles [35]. Training which allows MHPs to practice the skills required to address smoking with patients (e.g. role play group training), thus improving capability as well as confidence and motivation [24] |
Inability to monitor patients’ smoking in community services. Lack of time and resources to provide smoking cessation interventions (only ask about smoking at initial assessment). | Physical opportunity | Environmental context and resources | Training Restriction Environmental restructuring Enablement | Improve communications/referral process between mental healthcare (non-smoking specialists) services and stop smoking services (smoking specialists) [36]. |
Tobacco has become a prominent contraband item in the community and inpatient settings. Lack of support from colleagues to enforce smoke-free policy. | Social opportunity | Social influences | Restriction Environmental restructuring Modelling Enablement | Group training to encourage team work and shared learning across different care teams [24]. Videos of positive attitudes of fellow healthcare providers and colleagues. Increased vigilance to prevent anti-social behaviour (i.e. hiding tobacco in bushes and units) that is sensitive to mental healthcare contexts (e.g. ‘watchful eyes’ intervention [37] has been found to be effective in other contexts, but may not be appropriate in settings whereby patients experience paranoia). |
Intrinsic biases regarding mental health and smoking. | Automatic motivation | Reinforcement Emotion | Training Incentivisation Persuasion Coercion | Improve clinical reasoning and decision making skills, such as through reflective practice and active metacognitive review [23]. Use of emotive videos of patients who want to quit, but cannot due to their mental health. |
Smoke-free policy and training lacks relevance to non-inpatient services. Prioritise alcohol and other substances over tobacco. Only intervene with tobacco use in light of financial or physical health issue. Belief that addressing smoking with patients could provoke retaliation from some patients. | Reflective motivation | Professional role and identity Beliefs about capabilities Beliefs about consequences Intentions Goals | Education Persuasion Modelling Incentivisation Coercion Enablement | Tailoring training to clinical setting/role, and manuals to aid MHPs [23]. Incorporate smoking cessation into other treatments [34]. Improving awareness that ‘preventing’ is more beneficial compared with ‘treating’. Improved dissemination of findings that show violence has decreased in inpatient setting following smoke-free policy implementation [31]. |