Smoke-Free Mental Health Facilities in NSW - Guidance for Implementing

Transcription

1 Guideline Department of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) Fax (02) Smoke-Free Mental Health Facilities in NSW - Guidance for Implementing Document Number GL2009_014 Publication date 30-Jul-2009 Functional Sub group Clinical/ Patient Services - Mental Health space space space Summary The Guideline provides practical guidance to Chief Executives and designated personnel in NSW Area Health Services who are planning to facilitate the implementation of the NSW Health Smokefree Workplace Policy in NSW public hospitals and residential mental health care facilities and drug and alcohol facilities (including step-down units) utilised by mental health consumers. This Guideline should be read in conjunction with NSW Health Security Manual 'Protecting People and Property: NSW Health Policy and Guidelines for Security Risk Management in Health Facilities' and PD 2005_315 Zero Tolerance Policy and Framework Guidelines. (addendum made 10/12/2009) Author Branch Health Advancement Branch contact Carlie Naylor Applies to Area Health Services/Chief Executive Governed Statutory Health Corporation, Board Governed Statutory Health Corporations, Public Hospitals Audience Chief Executives and designated personnel in Area Health Services Distributed to Public Health System Review date 30-Jul-2014 Policy Manual Patient Matters File No. 02/ Status Active Director-General

2 GUIDELINE SUMMARY GUIDANCE FOR IMPLEMENTING SMOKE-FREE MENTAL HEALTH FACILITIES IN NSW PURPOSE The purpose of this Guideline is to provide practical guidance to Chief Executives and designated personnel in NSW Area Health Services who are planning to facilitate the implementation of the NSW Health Smoke Free Workplace Policy in NSW public hospital and residential mental health care facilities and drug and alcohol facilities (including step-down units) utilised by mental health consumers. KEY PRINCIPLES This Guideline has been prepared by NSW Health s Centre for Health Advancement. The Guideline (see Section B) provides recommendations and practical guidance for Area Health Services for facilitating implementation of the NSW Health Smoke Free Workplace Policy in NSW public hospital and residential mental healthcare facilities including facilities located within drug and alcohol and justice healthcare settings. The Guideline draws on the current evidence base around implementing smoke-free policies for mental healthcare facilities and identifies eight core principles for implementation in these settings. They are: Organisational commitment to improving health. Consultative management approach. Planned and informed implementation. Communication and information. Education and training. Identification of nicotine dependence and the provision of support. Tobacco control and the environment. Monitoring and reviewing implementation. USE OF THE GUIDELINE This Guideline has been developed to support Area Health Services achieve Phase 4 of the NSW Smoke Free Workplace Policy and implement smoke-free mental health facilities. The Guideline promotes the active engagement of consumers, their families and carers and all staff of mental healthcare facilities and services in the implementation process. The Guideline also promotes the importance of evidence-based best practice advice and support for addressing nicotine dependency and for managing nicotine withdrawal symptoms in consumers and staff of mental healthcare facilities. GL2009_014 Issue date: July 2009 Page 1 of 2

3 GUIDELINE SUMMARY REVISION HISTORY Version Approved by Amendment notes July 2009 (GL2009_014) Chief Health Officer/Deputy Director-General Population Health Issue of guidance for implementing smoke-free mental health facilities in NSW ASSOCIATED DOCUMENTS Guidance for implementing smoke-free mental health facilities in NSW Section A: Background information Section B: Recommended strategies for Area Health Services Section C: Information and resources to support Area Health Services GL2009_014 Issue date: July 2009 Page 2 of 2

4 Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A: Background Information Section B: Recommended Strategies for Area Health Services

5 NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) Fax. (02) TTY. (02) This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the NSW Department of Health. NSW Department of Health 2009 SHPN (CCDPHA) ISBN For further copies of this document please contact: Resource Distribution Unit Locked Mail Bag 5003 Galdesville, NSW 2111 Tel. (02) Fax. (02) Further copies of this document can be downloaded from the NSW Health website June 2009

6 Contents Executive summary The implementation process The Guideline at a glance... 4 SECTION A: Background information Background About the Guideline Terminology Best practice actions for effective implementation of smoke-free policies in mental health facilities Issues for implementation in NSW Guiding principles for implementation Literacy issues for mental health consumers Support documents SECTION B: Recommended strategies for Area Health Services Principle 1: Organisational commitment Recommended strategies for Area Health Services Public announcement of intention Principle 2: Consultative management approach Recommended strategies for Area Health Services Establish Local Site Smoke Free Workplace Policy Working Groups Principle 3: Planned and informed implementation Recommended strategies for Area Health Services Development of a local site Smoke Free Policy implementation plan Principle 4: Communication and information Recommended strategies for Area Health Services Develop a comprehensive communications strategy Principle 5: Education and training Recommended strategies for Area Health Services Staff education and training sessions Consumer information sessions NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE i

7 6 Principle 6: Identification of nicotine dependence and provision of support Support for mental health consumers who are nicotine dependent Managing nicotine withdrawal for consumers of medium and long term stay mental health facilities Recommended strategies for Area Health Services Procedures for assessing nicotine dependence Procedures for supporting consumers and staff members to manage nicotine withdrawal Principle 7: Tobacco control and the environment Recommended strategies for Area Health Services Ensure clinical practices support implementation Smoke-free signage Environmental changes Leave arrangements if consumers wish to smoke off-site Principle 8: Monitoring and reviewing implementation Recommended strategies for Area Health Services Management and reporting of incidents The Incident Information Management System (IIMS) Regular monitoring and reviewing implementation progress Assessing the impact of implementation Acknowledgements References PAGE ii NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

8 Executive summary All NSW Health hospital campuses are in the process of implementing the NSW Health Smoke Free Workplace Policy. This Policy mandates that all hospital campuses under the control of NSW Health should be totally smoke-free. Currently in NSW some Area Health Services mental healthcare facilities have been granted exemption from the Policy with smoking permitted in outdoor designated smoking areas only. There are also a number of Area Health Services that have implemented or are in the process of implementing the NSW Health Smoke Free Workplace Policy to include mental health facilities. NSW Health has the aim of improving the health of all people in NSW and a responsibility to ensure the health, safety and welfare of all persons utilising its facilities and services. All healthcare consumers have the right to be treated in a smoke-free environment and all employees have the right to work in a smoke-free workplace. The implementation of Phase 4 of the NSW Smoke Free Workplace Policy to include mental healthcare facilities is therefore a step towards ensuring equity in the provision of our healthcare system. Implementation of smoke-free policies in mental healthcare facilities will provide support to address nicotine withdrawal symptoms for mental health consumers and for the staff that work in these facilities. As well, implementing the Policy in mental healthcare facilities will assist to discourage tobacco use and offer consumers and staff the opportunity to consider quitting. Implementing smoke-free mental healthcare facilities provides a safe environment where consumers can learn how smoking impacts on their lives, find resources and opportunities that will help them if they choose to quit and support their ability to manage their own physical wellness. This Guideline has been prepared by NSW Health s Centre for Health Advancement. Its purpose is to provide practical guidance to Chief Executives and designated personnel in NSW Area Health Services who are planning to facilitate the implementation of the NSW Health Smoke Free Workplace Policy in NSW public hospital and residential mental healthcare facilities and drug and alcohol facilities (including step-down units) utilised by mental health consumers. The Guideline draws on the current evidence base around implementing smoke-free policies for mental healthcare facilities and identifies eight core principles for implementation in these settings. They are: 1. Organisational commitment to improving health. 2. Consultative management approach. 3. Planned and informed implementation. 4. Communication and information. 5. Education and training. 6. Identification of nicotine dependence and the provision of support. 7. Tobacco control and the environment. 8. Monitoring and reviewing implementation. NSW Health has undertaken an examination of the current available evidence in NSW, Australia and in other countries and consulted with personnel in Area Health Services and other stakeholders about smokefree implementation issues for their local mental health facilities. The best practice actions for effective implementation identified by Lawn and Pols (2005) in their systematic review of published international studies of smoke-free policies in psychiatric settings have provided the foundations for the development of the Guideline s recommendations. These actions are presented in Table 1: NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 1

9 Table 1: Lawn, S and Pols, R. Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry 2005; 39: Availability of and effective use of NRT. Extensive consultation and collaboration, and co-ordination of efforts across the disciplines, in order to provide a consistent focus that will not be undermined by subgroups or individuals. Support at all levels, from direct care of consumers to hospital administration and policy. A preparation period, prior to the introduction of the policy, involving community agencies and groups and inpatient staff in education and advertising of the impending smoke-free status to consumers and carers i.e. communicate the intention to introduce the smoke-free policy to all stakeholders. Provision of alternative activities, dietary changes, clear protocols and family support for the bans. More effective measures to accommodate consumers who are unable to tolerate abrupt abstinence. Greater awareness of the policy prior to admission. This would involve co-ordination and partnership across the mental health sector between community and inpatient services. Greater support for and education of direct-care staff on distinguishing mental illness symptoms from nicotine withdrawal symptoms. Development of alternative supports to assist staff to manage their own nicotine withdrawal and associated stress levels whilst at work. Sensitivity to the potential for restrictions to be perceived as a further source of powerlessness and control, with implications for staff morale as agents of further social control and consumers as recipients. Clear policies and protocols for managing potential increases in trade and standover for cigarettes between consumers, black market use and sale of tobacco on hospital grounds. Improved understanding of nicotine s interaction with anti-psychotic drug metabolism so that consumers who are smokers receive appropriate medication prescription, review and coordination as they transition through the various stages of the service, inpatient and community. More co-ordinated efforts between hospital and community staff to help consumers who wish to stay quit as part of discharge planning. Development of clear policies with regard to smoking and occupational health and safety concerns for staff and consumers as part of the process of introducing the policy and maintaining compliance. This would include clearer clinical and ethical guidelines that address the issue of distress and withdrawal, patient autonomy and legal aspects of introducing the policy. Lawn and Campion (2008) 2 highlighted the importance of location variations and stressed the importance of considering these in conjunction with the abovementioned general principles. The authors also reported the importance of building the evidence for implementation of smoke-free policies in different settings, so that smoke-free policies have the greatest chance of success with least distress to mental health consumers. The Guideline is divided into three sections: Section A introduces the Guideline and provides background information about the Guideline. Section B provides recommendations and practical guidance for Area Health Services for facilitating implementation of the NSW Health Smoke Free Workplace Policy in NSW public hospital and residential mental healthcare facilities including facilities located within drug and alcohol and justice healthcare settings. Section C: Information and Resources to Support Area Health Services provides Area Health Services with additional information and examples of resources and procedures that will assist with implementation. The following diagram (Point 1. The implementation process) provides a summary of the stages of the implementation process. A summary of recommended actions and strategies for Area Health Services is provided in Point 2, The Guideline at a Glance. 2 Lawn S and Campion J. Smoke-free initiatives in psychiatric inpatient units: A National Survey of Australian Sites. An Independent Report. Flinders University Adelaide, Australia. August ISBN PAGE 2 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

10 1. The implementation process It is recommended that the implementation process is conducted over a minimum six-month period incorporating four key phases: preparatory, developmental, pre-implementation and implementation. Preparatory Developmental Pre-implementation Implementation 3 Establish implementation management & reporting structures. 3 Public announcement. 3 Form working group. 3 Agreement on terms of reference. 3 Undertake preimplementation surveys. 3 Develop implementation plan. 3 Design communication strategy. 3 Update staff. 3 Offer support (advice/ pharmacotherapies/referral) to staff who smoke. 3 Design publicity and promotional activities. 3 Develop education and training programs for staff. 3 Design education programs for consumers. 3 Develop information materials for staff, consumers, families, visitors and local community. 3 Hold discussions with staff regarding clinical management practices. 3 Develop procedures for assessing nicotine dependency for consumers at admission. 3 Develop procedures for monitoring nicotine withdrawal symptoms. 3 Develop procedures for recording smoking status, treatment, and intentions at discharge. 3 Undertake publicity and promotional activities. 3 Disseminate information to reach GPs regarding preadmission advice. 3 Update staff on progress. 3 Offer support to staff who smoke. 3 Commence education and training programs for staff. 3 Disseminate information to consumers, families and other visitors. 3 Produce/gather/disseminate information resources for staff, consumers, families and visitors and local community. 3 Finalise clinical management practices. 3 Finalise instructions for staff regarding new procedures. 3 Develop/commence schedule of consumer information/education sessions. 3 Review progress and make adjustments. 3 Undertake publicity and promotional activities. 3 Decommission designated current smoking areas. 3 Remove smoking paraphernalia. 3 Update staff. 3 Disseminate information to staff, consumers, families and visitors. 3 Commence new procedures for admissions, discharge, identifying nicotine withdrawal, offering NRT/support, reporting incidents. 3 Provide support for staff and consumers. 3 Commence consumer information sessions. 3 Review progress and make adjustments. 3 Assess performance at six-months. 3 Develop procedures for reporting breaches and incidents. 3 Develop procedures for safely storing ignition devices, eg lighters. 3 Design smoke-free signage. 3 Review progress and make adjustments. Ongoing commitment, visibility and communication from management to staff of facility, Area personnel and consumers. Regular training, information, support and updates for staff. Regular review, monitoring, adjustments, reporting and communication. NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 3

11 2. The Guideline at a glance Principle 1: Organisational commitment Recommended strategies 1. Public announcement of intention to go smoke-free. Actions 3 Use organisational communication processes as well as the local media to promote the intention of management of the facility to implement the Smoke Free Workplace Policy to staff, consumers and local community; 3 Provide accurate information about the Smoke Free Workplace Policy, its purpose, benefits, processes, timeframe and key contact person/s; 3 Provide information about the support that will be available for staff and consumers; 3 Provide information about new changes and processes that will be instigated. Principle 2: Consultative management approach Recommended strategies 1. Establish a local site Smoke Free Workplace Policy Working Group. Actions 3 Include a broad range of representatives; 3 Oversee the implementation process in each facility; 3 Report to the Area s Smoke Free Workplace Policy Implementation Working Committee; 3 Nominate a local contact person/s as project leader for implementation. Principle 3: Planned and informed implementation Recommended strategies 1. Development of a local site implementation plan. 2. Report regularly to the AHS Smoke Free Workplace Policy Implementation Working Committee. Actions 3 Surveys that targets consumers and staff are designed to explore current attitudes, concerns, smoking status of staff and consumers, support needs; 3 Risk management plans; 3 Promotional and publicity strategies; 3 Information, education and communication strategies for reaching staff, consumers, visitors and the local community; 3 Staff training programs; 3 Procedures for assessing nicotine dependence on admission; 3 Procedures for discharge and recording consumer smoking status; 3 Monitoring procedures for identifying issues associated with nicotine withdrawal, interactions with medications, the provision of brief interventions and cessation support; 3 New signage; 3 Procedures for monitoring compliance with the Policy. 3 Provide information about implementation progress, issues arising, further actions needed and any changes necessary to timelines. PAGE 4 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

12 Principle 4: Communication and information Recommended strategies 1. Development of a comprehensive communication strategy. 2. Translate information and provide non-written materials. Actions 3 Use routine communication systems, publicity, direct contact opportunities eg staff meetings and consumer forums; 3 Promote the theme Smoke-free Healthcare ; 3 Include information about ETS exposure, harm and risks for staff, consumers and visitors; 3 Address misconceptions/myths identified through surveys; 3 Encourage compliance and promote its importance. 3 Provide information in a range of formats to reach a broad cross section of people with varying literacy and learning skills and visual abilities; 3 Regularly assess reach and awareness of the communication strategy s activities and make adjustments as required. a. Target staff 3 Provide a letter to staff as soon as decision is made; 3 Provide regular information and updates to staff; 3 Provide a map of the facility showing boundaries and smoking areas off site; 3 Address communication needs through staff recruitment, induction programs, in-services, newsletters, internal communication systems including s, notices and intranet systems; 3 Provide support resources and materials and referral information about the Quitline; 3 Undertake discussions with staff about developing new clinical management practices; 3 Explore opportunities for health education sessions for staff and consumers. b. Target consumers 3 Inform about the Policy prior to admission; 3 Target Divisions of General Practice and other relevant primary healthcare providers; 3 Include information materials in a range of formats e.g. posters, brochures, signs and electronic; 3 Provide display materials in emergency and admissions settings; c. Target visitors, contractors and local community 3 Introduce procedures that permit regular communication between staff and consumers about managing nicotine withdrawal symptoms. 3 Develop a media kit and target local media with positive stories and local champions supporting implementation; 3 Inform and continually remind visitors about the Policy and importance of adherence and cooperation. NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 5

13 Principle 5: Education and training Recommended strategies 1. Conduct staff education and training programs. Actions 3 Target a range of staff members, especially opinion leaders; 3 Conduct sessions for at least 1 hour and away from ward areas or conduct regular half-hourly sessions at staff hand-over; 3 Target the majority of staff for training in brief interventions; 3 Target clinical care staff for training in more intensive interventions; 3 Evaluate all training sessions; 3 Provide different information and training sessions for different staff members; 2. Conduct consumer information sessions. 3 Provide information in various formats. 3 Target all consumers; 3 Discuss a range of tobacco and health issues; 3 Include a focus on healthy lifestyle, physical activity and diet; 3 Discuss not smoking after discharge and support available and strategies for staying quit; 3 Provide information in various formats. Principle 6: Identification of nicotine dependence and provision of support Recommended strategies 1. Assess nicotine dependency on admission. Actions 3 Develop protocols for assessing the level of nicotine dependence on admission; 3 Introduce protocols that are suitable for admissions during day, evening, emergency and public holidays; 3 Identify smoking status and include information on the overall consumer care plan; 3 Use the Fagerstrom test for Nicotine Dependence; 3 Provide the consumer and family/carers with information about the Quitline; 3 Enter information about pharmacotherapies provided for managing nicotine withdrawal; 2. Persist with offering NRT support to consumers. 3. Record smoking status information at discharge. 3 Advise about contraindications to treatment regimes if consumer intends leaving facility to smoke. 3 Introduce procedures for persisting with offers of NRT to those experiencing nicotine withdrawal symptoms. 3 Enter information about smoking status, intentions regarding smoking and use of pharmacotherapies for managing nicotine withdrawal on discharge plans; 3 Provide consumers at discharge and in consumer information sessions with information associated with resuming smoking after discharge and the need for close monitoring and possible adjustments to medications; 3 Provide smoking cessation support such as information about the Quitline and a minimum 3 day supply of NRT; 4. Support staff who smoke to manage not smoking whilst at work. 3 Instigate Quitline fax referral systems if requested by consumer on discharge. 3 Provide staff members who smoke with information about the Policy and support available prior to implementation; 3 Provide NRT to staff members as per procedures outlined in NSW Department of Health s Protocol for provision of NRT to staff of NSW public health facilities referred to in the Smoke Free Workplace Policy Progression of the NSW Health PD2005_375; 3 Develop a staff information package with assistance from pharmacy personnel and include information about nicotine withdrawal, products available to help fact sheets and Quitline services. PAGE 6 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

14 Principle 7: Tobacco control and the environment Recommended strategies 1. Ensure clinical care practices support implementation. 2. Provide appropriate new signage. 3. Undertake environmental changes. 4. Explore options for the development of procedures for leave arrangements. Actions 3 Introduce new practices and procedures that support the implementation of the Smoke Free Policy; 3 Develop a system for obtaining feedback from and for information exchange between facilities and other Area Health Services about the trialling of new practices. 3 Ensure new signage is consistent with existing smoke-free signage in other Areabased public healthcare facilities; 3 Place signage at all relevant locations including the site s entrances and exits, previous designated smoking areas, lifts and stairwells and places of congregation; 3 Ensure all signs and smoke-free notices are provided in a variety of written and nonwritten formats. 3 Introduce procedures for collection and safe storage of ignition devices and associated paraphernalia on admission; 3 Remove all ash trays from the site; 3 Provide external stubbing bins at boundary gates and entrances; 3 Provide consumers and visitors with a map showing boundaries and smoking areas off site; 3 Decommission all previous smoking rooms and areas by the removal of all smoking signs, ashtrays and lighters. 3 These should be consistent with those introduced at other Area-based public healthcare facilities; 3 Area Health Services should refer to procedures that are outlined in the Policy Directive Smoke Free Workplace Policy Progression of the NSW Health PD2005_ Principle 8: Monitoring and reviewing implementation Recommended strategies Actions 1. Report incidents. 3 Develop procedures for recording on IIMS information about smoking related incidents. This will require instructions for using key words such as smoking and cigarettes ; 2. Introduce monitoring and reviewing systems. 3. Measure progress and impact of implementation. 3 Develop new procedures in consultation with staff members, consumers and local community; 3 Disseminate information about the reporting of smoking-related incidents. 3 Regularly remind staff about the new procedures and the importance of recording incidents; 3 Use a range of opportunities and contact with staff to regularly remind and update staff on procedures and for gaining feedback on issues arising associated with implementation; 3 Provide for regular updating of progress of implementation to local site implementation working group and the Area Health Service s Smoke Free Workplace Policy Implementation Working Committee; 3 Regularly review all procedures, practices and new programs introduced as components of the implementation process. 3 Develop a set of performance indicators for monitoring the implementation plan; 3 A useful guide for developing performance indicators is provided by Cormac and McNally (2008) presented in section 8.13 of the Guideline, and Lawn and Pols (2005) best practice actions presented in Box 2 of the Guideline. NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 7

15 SECTION A Background information 1 Background The World Health Organization has identified tobacco as the second major cause of death in the world and the fourth most common risk factor for disease worldwide. There have been dramatic reductions in the number of people who smoke tobacco products and the number of people who are exposed to environmental tobacco smoke (ETS). However, tobacco smoking remains the leading single cause of mortality and morbidity and the main or a significant cause of many diseases. In 2006 the Australian Bureau of Statistics (ABS) indicated that 32% of adults who self reported mental or behavioural problems in the National Health Survey were current daily smokers, compared with 20% of those who self reported no mental or behavioural problems. Furthermore, adults who self reported having high/very high level of psychological distress were more likely to be current daily smokers (35%) than were those who self reported a moderate level (25%) or low level (17%) of psychological distress (1). of America and Australia has shown that a total smokefree policy can be implemented in these facilities when there is careful planning and consistency by all staff (2). As well, evidence shows that interventions designed to address nicotine dependency known to work for the general population (such as support and the use of smoking cessation pharmacotherapies) are also effective for mental health consumers (3). Implementation is a step towards ensuring equity in the provision of our healthcare system. It requires a planned and structured approach that includes a broad consultation program and the introduction of new practices and procedures. For some consumers and staff implementation may pose difficulties and for others it will be welcomed. Therefore, implementation should be handled sensitively particularly in its application in medium and long term mental healthcare facilities. Box 1 (page 9) summarises the reasons for implementing a smoke-free policy in mental healthcare facilities. NSW Health has the aim of improving the health of all people in NSW and a responsibility to display leadership and commitment to ensuring the health, safety and welfare of all persons utilising its facilities and services. All NSW Health hospital campuses are in the process of implementing the NSW Health Smoke Free Workplace Policy. This Policy mandates that all hospital campuses under the control of NSW Health should be totally smoke-free. Currently in NSW some Area Health Services mental health facilities have been granted exemption from the Policy with smoking permitted in outdoor designated smoking areas only. There are also a number of Area Health Services that have implemented or are in the process of implementing the NSW Health Smoke Free Workplace Policy to include mental health facilities. Implementation of Phase 4 NSW Health Smoke Free Workplace Policy to include mental healthcare facilities and services is a challenging task. However, research from the United Kingdom, Canada, the United States PAGE 8 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

16 Box 1: Why is implementation of smoke-free policy in mental healthcare facilities important? Smoking causes damage to the health of individuals, those around them and their unborn children. Mental health consumers have the right to be treated in a smoke-free environment. Employees have the right to work in a smoke-free workplace. The Occupational Health and Safety Act 2000 requires that employers provide their workers and visitors to their premises with a safe place of work. Healthcare organisations have a duty to provide a safe and healthy environment. NSW Health Smoke Free Workplace Policy mandates that all public health facilities and campuses under the control of NSW Health should be totally smoke-free. The implementation of Phase 4 of the NSW Smoke Free Workplace Policy to include mental healthcare facilities is a step towards ensuring equity in the provision of our healthcare system. People with a mental illness already experience high levels of social exclusion and health inequality. Implementation of smoke-free policies in mental health facilities will provide support to address nicotine withdrawal symptoms for mental health consumers and for the staff that work in these facilities. Implementing smoke-free mental healthcare facilities provides the opportunity to discourage tobacco use and help consumers and staff quit. Implementing smoke-free mental healthcare facilities provides a safe environment where consumers can learn how smoking impacts on their lives, find resources and opportunities that will help them if they choose to quit and support their ability to manage their own physical wellness. Smoking is a fire hazard. NSW Smoke-free Environment Act 2000 makes it an offence to smoke in an enclosed public place. A public place refers to a place or vehicle that is open to or being used by the public or a section of the public. An enclosed public place has a ceiling or roof and, except for doors and passageways, is completely or substantially enclosed on a permanent or temporary basis. This means that any indoor workplace that allows public access must also be smoke-free. Designated smoking areas in hospitals that are in enclosed public spaces are prohibited by the Act. 2 About the Guideline This Guideline has been developed to support Area Health Services achieve Phase 4 of the NSW Smoke Free Workplace Policy and implement smoke-free mental health facilities. The Guideline promotes the active engagement of consumers, their families and carers and all staff of mental healthcare facilities and services in the implementation process. The Guideline also promotes the importance of evidence-based best practice advice and support for addressing nicotine dependency and for managing nicotine withdrawal symptoms in consumers and staff of mental healthcare facilities. The Guideline is divided into three sections: Section A introduces the Guideline and provides Area Health Services with relevant background information. Section B provides recommendations and practical guidance for Area Health Services for facilitating implementation of the NSW Health Smoke Free Workplace Policy in NSW public hospital and residential mental healthcare facilities including facilities located within drug and alcohol and justice healthcare settings. Section C: Information and Resources to Support Area Health Services provides Area Health Services with additional information and examples of resources and procedures that will assist with implementation. 2.1 Terminology This Guideline uses the term consumer to define a person utilising mental healthcare facilities. However, different descriptors of people who use mental healthcare facilities may have been used in some information and examples of procedures that have been provided by stakeholders or sourced from literature and presented in the Guideline. 2.2 Best practice actions for effective implementation of smoke-free policies in mental health facilities NSW Health has undertaken an examination of the current available evidence in NSW, Australia and in other countries and consulted with Area Health Services personnel and other stakeholders about smoke-free implementation issues for mental health facilities. The best practice actions for effective implementation identified by Lawn and Pols in their 2005 systematic review of published international studies of smokefree policies in psychiatric settings (4) provided the foundations for the development of the Guideline s recommendations. NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 9

17 These actions are presented in Box 2: Box 2: Lawn S and Pols R. Smoking bans in psychiatric inpatient settings? A review of the research. Australian and New Zealand Journal of Psychiatry 2005; 39: Availability of and effective use of NRT. Extensive consultation and collaboration, and coordination of efforts across the disciplines, in order to provide a consistent focus that will not be undermined by subgroups or individuals. Support at all levels, from direct care of consumers to hospital administration and policy. A preparation period, prior to the introduction of the policy, involving community agencies and groups and inpatient staff in education and advertising of the impending smokefree status to consumers and carers i.e. communicate the intention to introduce the smoke-free policy to all stakeholders. Provision of alternative activities, dietary changes, clear protocols and family support for the bans. More effective measures to accommodate consumers who are unable to tolerate abrupt abstinence. Greater awareness of the policy prior to admission. This would involve coordination and partnership across the mental health sector between community and inpatient services. Greater support for and education of direct-care staff on distinguishing mental illness symptoms from nicotine withdrawal symptoms. Development of alternative supports to assist staff to manage their own nicotine withdrawal and associated stress levels whilst at work. Sensitivity to the potential for restrictions to be perceived as a further source of powerlessness and control, with implications for staff morale as agents of further social control and consumers as recipients. Clear policies and protocols for managing potential increases in trade and standover for cigarettes between consumers, black market use and sale of tobacco on hospital grounds. Improved understanding of nicotine s interaction with anti-psychotic drug metabolism so that consumers who are smokers receive appropriate medication prescription, review and coordination as they transition through the various stages of the service, inpatient and community. More coordinated efforts between hospital and community staff to help consumers who wish to stay quit as part of discharge planning. Development of clear policies with regard to smoking and occupational health and safety concerns for staff and consumers as part of the process of introducing the policy and maintaining compliance. This would include clearer clinical and ethical guidelines that address the issue of distress and withdrawal, patient autonomy and legal aspects of introducing the policy. Lawn and Campion (2008) (5) highlighted the importance of location variations and stressed the need to consider these in conjunction with the aforementioned general principles. The authors also reported the importance of building the evidence for implementation of smoke-free policies in different settings, so that smoke-free policies have the greatest chance of success with least distress to mental health consumers. Therefore the application of recommendations outlined in this Guideline by Area Health Services should be responsive to the cultural and structural context and environment of each individual facility. It is imperative that new procedures are sensitive to the issues and challenges of addressing smoking in mental health settings and address and resolve conflicts between service goals (that is, providing care to users) and the health and safety responsibilities to staff and public alike (that is, protecting them from ETS). It is also important that mental health facilities and Area Health Services disseminate information they collect that reports on implementation progress to others within the Area Health Service and to personnel within other Area Health Services. 2.3 Issues for implementation in NSW The Guideline s developmental processes identified the following implementation issues for NSW Area Health Services: Provide sufficient time (a minimum of six months is recommended) for: devising a planned and consultative approach to implementation that permits the opportunity for issues to be identified and discussed; and developing a structured implementation plan; Develop risk management plans in the preliminary stages of implementation and review regularly; Provide information for staff who smoke prior to implementation such as information about managing nicotine withdrawal and quit smoking support that is available for those seeking to quit smoking; Develop procedures for the effective diagnosis, treatment of nicotine dependence and monitoring of nicotine withdrawal symptoms (including making adjustments to medications as required) in combination with psychological and social support for consumers; Develop procedures for recording a consumer s smoking status and their smoking intentions at PAGE 10 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

18 discharge so that support can be provided to those seeking to remain quit and that any potential interactions with medication can be noted for those resuming smoking; Provide healthcare staff with information and training in brief interventions and the use of nicotine replacement therapies to prevent and manage nicotine withdrawal symptoms in consumers during their hospital stay; Provide staff education and information about behaviours that may be symptoms associated with nicotine withdrawal; Develop procedures that enable staff to regularly encourage consumers who have chosen not to take up the offer of nicotine replacement therapy (NRT) and who are experiencing nicotine withdrawal symptoms, to try NRT; Provide opportunities for all clinical care staff including GPs, psychiatrists and allied health professionals to work together to develop new clinical care management practices and consumer education programs that are consistent with and complement the Smoke Free Workplace Policy. Clinical care management practices should not include the use of NRT as a tool for negotiation between staff and consumers; and Develop appropriate tools for monitoring adherence to procedures by staff, consumers and visitors and for reviewing the implementation process. 2.4 Guiding principles for implementation The Guideline is divided into the following eight core principles: 1. Organisational commitment to improving health. 2. Consultative management approach. 3. Planned and informed implementation. 4. Communication and information. 5. Education and training. 6. Identification of nicotine dependence and the provision of support. 7. Tobacco control and the environment. 8. Monitoring and reviewing implementation. The Guideline recognises that change is best achieved when managers, staff and consumers work together in partnership and cooperatively. Consistency, coordination, consultation and full management support are essential for successful implementation of smoke-free policies in mental healthcare facilities. 2.5 Literacy issues for mental health consumers It is important that mental health service providers are aware of the prevalence of issues such as limited literacy, vision impairment through medication and the need for glasses. Consumers also have a wide variety of learning skills including visual learning, aural learning, and interactive learning. Area Health Services should therefore consider developing strategies for the management of these issues in their respective practice settings. The development of information and communication materials in various formats is recommended and provision should be made for levels of repeated information to manage different phases of a consumer s admission or state of wellness. NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 11

19 2.6 Support documents This Guideline should be considered by Area Health Services in conjunction with the following departmental documents: The Policy Directive Smoke Free Workplace Policy Progression of the NSW Health, PD2005_375; PD/2005/ PD2005_375.html The Guide to the Management of Nicotine Dependent Inpatients, GL2005_036; GL/2005/GL2005_036.html Let s take a moment, quit smoking brief intervention a guide for all health professionals ; take_a_moment.pdf The Protocol for provision of nicotine replacement therapy (NRT) to staff of NSW public health facilities ; and The NSW Tobacco Action Plan A vision for the future ; tobacco_ap_vision.pdf These resources are available on-line from the NSW Health web site NSW Health has recently released the policy directive Physical Health Care within Mental Health Services PD2009_027. Smoking cessation is covered in the policy directive and services are advised to provide support and encouragement for consumers to quit smoking. PAGE 12 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B

20 SECTION B Recommended strategies for Area Health Services Principle 1: Organisational commitment Organisational commitment to improving the health of the community, equity in the healthcare system and to the provision of a healthy, smokefree environment for consumers, staff and all other service users and visitors to mental healthcare facilities is important for successful implementation. Prominent leadership from management is essential at all stages of implementation. This includes supporting and promoting the need for organisational change. It is particularly important for medium and long term care facilities where implementation poses significant challenges. 1.1 Recommended strategies for Area Health Services Public announcement of intention Initial misconceptions about the Policy may cause concern for staff, consumers, families and the community. A strong united stance and clear information about implementation provided by management early in the process is important for easing these concerns. It is recommended that: a. The first step towards implementation of the Policy is positive and timely promotion of the intention of the facility to implement the Policy by senior management; b. Area Health Services utilise existing organisational communication processes as well as local media and communication outlets; and The purpose of the Smoke Free Workplace Policy; A focus on promoting the benefits for all including mental health consumers, staff and visitors to the facilities; The recognition of the sensitive nature of the issue of smoking and mental health consumers; Promoting the experiences of other Area Health Services in NSW, and in other countries such as the United Kingdom, Canada and the United States that have shown that a total smoke-free policy can be implemented in mental healthcare facilities including medium and long term care facilities when there is careful planning, coordination and consistency by all staff; Promoting the comprehensive nature of the implementation program and the need for a range of new practices and procedures to be introduced; Reassuring staff, consumers and families that support, information and referral will be provided for those seeking assistance with managing nicotine withdrawal during their stay in a mental healthcare facility; An outline of the implementation process that the Area Health Service will be undertaking; An explanation of what the Policy will mean for consumers and visitors in terms of not being permitted to smoke within the grounds of the facility; The timeframe for implementation; and Designated contact/s within the Area Health Service who can assist and provide further information. Box 3 (page 14) provides a sample media release. c. The following information should accompany the public announcement: The Area Health Service s commitment to protecting the community s health; NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B PAGE 13

21 Box 3: Media release for smoke-free mental health: sample Lights out for smokers at (Healthcare facility) On [date] [name of healthcare facility] will go totally smokefree. This means that previously designated smoking areas will be removed and smoking will be banned everywhere on campus including outdoors. Each year more than 15,000 Australian s die prematurely as a direct result of smoking. (Name of Spokesperson e.g. Executive Director, healthcare facility], says this initiative is an important step towards ensuring a truly smoke-free workplace, it will also help to protect staff, consumers and visitors from the harmful effects of environmental tobacco smoke (passive smoking). Evidence from other workplaces that have gone smokefree shows employees are more likely to quit or at least reduce the number of cigarettes they smoke. We understand that smoking is a personal choice but, as a healthcare facility, we want to support our staff by making the healthier choice the easier one. NSW Health has an ongoing commitment to helping our staff and consumers give up smoking, (Name of spokesperson said). Removing the designated smoking areas on campus will also assist people who have recently quit smoking from being tempted to smoke and therefore will support those people abstaining from smoking. [name of spokesperson] explains how the ban will also help consumers and visitors to [name of facility]. All [facility] staff, consumers and hospitalised patients will have access to fact sheets and Quitline referral forms. Nicotine replacement therapy and onsite counselling [if relevant for this facility] will also be available to staff. For anyone who smokes and would like to give up, Quitline provides support and practical encouragement on Around 40 Australians die every day from smoking-related illnesses this is more than the combined total killed by alcohol, illegal drugs, murder, suicide and road crashes. It is also estimated that 140 Australians die each year from lung cancer caused by breathing other people s smoke. For further information about the NSW Health Smoke Free Workplace Policy, please visit gov.au/policies/pd/2005/pd2005_375.html ~ ENDS ~ For more information please contact [name, Public Relations Manager, Area/Facility and contact number] PAGE 14 NSW HEALTH Guidance for Implementing Smoke-free Mental Health Facilities in NSW Section A&B