Smoking report

1. Introduction 1. 1. This Briefing Paper provides an analysis of the results of the survey of patients admitted to adult acute and PICU inpatient services. This is to understand their views following the implementation of a smoking ban in hospital environments through the Smoke Free policy in response to government legislation (Health Act 2006). The Care Quality Commission requires that all Trusts will promote good health for their service users, staff and visitors by providing a smoke free environment. The survey was conducted in April 2010 by a trained team of CNWL service users. 2. Background 2. 1 The Trust has successfully implemented no smoking in all inpatient buildings and various reports to the Board have been presented with the aim of providing assurance of this and also to highlight areas of risk. One of the recommendations of the latest Board report (December 2009) on the Update of the Smoke Free policy implementation within the Trust was to carry out an in – patient survey to establish their perspective on the smoking ban. 2. 2 The CNWL Smoking Survey was designed by Deputy Chief Pharmacist, Anshu Rayan, through close collaboration with the service user survey team, the Head of Patient & Public Involvement, Chris Bumstead, and Clinical Audit Specialist, Seraphim Patel. This is the first time since the smoke free legislation has been implemented that patients have been formally asked about their views. 2. 3 The aim of this pilot survey was to find out the understanding of patients about the no smoking rules and how this has affected the patients’ experience of being on the ward, and whether they had noticed any impact of the policy on the ward environment. 2. 4 The objectives of this audit were as follows: – To identify various aspects of patient experiences of implementing the no smoking rules on inpatient wards. – To use the results and feedback to improve the way the no smoking rules are managed on the wards. – To develop ways in which patients can be further supported with wishing to manage their smoking behaviour and promote improved smoking cessation outcomes. – To tailor the support provided to staff working on inpatient wards to address particular challenges, depending on local needs. – To use the results and feedback to review the training provided to CNWL staff across the trust with the aim of listening to patient needs. 3. Methodology 3. 1 Service users on all adult acute admission and PICU wards were given the opportunity to complete a questionnaire either by themselves or through an interview with the service user survey team members. 3. 2 The questionnaire provided opportunities to make direct answers to questions as well as giving space for additional comments. The team of service user interviewers visited the wards and offered the opportunity to all patients on the ward to take part in the survey. Completed questionnaires were returned to the Clinical Audit Department for analysis. A service user on work experience placement in the Patient & Public Involvement Team has also been involved in processing and analysing the data. 3. 3 A total of 142 patients completed the smoking questionnaire. Of these:  52% were White  20% Black  15% Asian  8% were of mixed ethnicity  45 came from other ethnic groups In addition, of the total number of patients surveyed: – 21% of these were between 18 – 25 years old – 22% between 26 — 35 years old – 31% between 36 – 50 years old – 27% were 50 years old and over – 64% of the total patients surveyed were male – 36% were female – 20% of patients considered themselves as having a mental disability – 17% a physical disability – 50% of patients that completed the questionnaire identified themselves as smokers (n= 70). 3. 4 The results of this survey were reported to the Trust Acute Care Forum in September and disseminated to the local Acute Care Forums with more detailed data on their local performance. 4. Overview of Results 4. 1 Of the total patients surveyed, 60% felt satisfied or very satisfied with the way the no smoking rule had been handled on the ward. 40% felt dissatisfied/very dissatisfied. This is not a surprise given the high percentage of inpatients who smoke. 4. 2 71% of patients were aware of why smoking was not allowed on the ward. Of those 31% patients thought this was due to health and safety protocol, examples included risk of fire and harm to others and 9% thought smoking was not allowed because it was illegal. 4. 3 When asked whether patients felt that the air quality had improved on the ward since the smoking ban, 50% agreed, and of the smokers surveyed, 55% also agreed. 4. 4 52% of patients that were surveyed expressed that they had experienced problems on the ward due to the no smoking rule. Of those, 13% had witnessed/experienced more aggressive behaviour from other patients and 8% witnessed people smoking on the ward. When asked whether they felt smoking ban had affected the level of violence and aggression on the ward, 46% of patients agreed that it had been affected. Of those, 53% thought it had increased. 4. 5 62% of smokers stated that they had received verbal information/ advice to help with cigarette cravings, and 27% reported to have received written information. In addition, 30% of smokers reported to have been offered or prescribed medicines to help with cigarette cravings to help give up smoking. 4. 6 21% of smokers stated that they had been offered the opportunity to participate in activities on the ward to help with cigarette cravings at times when they have been unable to smoke, of which 36% said this was helpful. 4. 7 22% of smokers reported that they have thought about giving up smoking as a result of the smoking ban and 28% of patients would like more help with cigarette cravings or assistance to give up smoking. 5% of these patients would like to give up smoking. 5. Conclusions from the survey 5. 1 The results indicate that the majority of in-patients that were surveyed felt satisfied/very satisfied with the way the smoking ban has been implemented on the wards, across all sites audited. This included sites (St Charles and Gordon) where there have been problems in accessing outside areas for smoking. 5. 2 There was a widespread awareness of the existence of the smoking ban, however a very small number of patients knew all the reasons why the ban was in place, including the legal requirement. Some patients were however aware of the health and safety implications. 5. 3 The Trust is committed to ensuring that staff, patients and visitors are not exposed to environmental tobacco smoke and to provide a safe, smoke free environment. It was therefore important to investigate whether patients felt that the air quality on the wards had improved since the ban. 50% of patients agreed with this and it is important to note that 55% of these were smokers. 5. 4 The Mental Heath Foundation publications, ‘ Death of the Smoking Den’ described the initial impact of no smoking legislation in psychiatric units in England in 2008. Within this, aggression or violence was cited as linked to the ban and an increase in incidents which were often triggered by staff not being able to escort patients outside or simply being told that they cannot smoke on the wards. The results of this survey indicated that 53% of patients felt that the level of violence and aggression on the ward had increased. This is also consistent with the latest Board report (December 2009) on the Update of the Smoke Free policy implementation which reported that the level of incidents have increased since the ban, and that some of these were due to violence and aggression towards ward staff due to the smoking restrictions in place. Staff have continued to use their expertise, knowledge and training to manage these situations. Counselling on behaviour, use of Nicotine Replacement Therapy (NRT) and support groups are amongst the interventions employed in such situations. In addition since this Smoke Free policy Board report, progress has been made to address some of the problems with certain sites not having access to outside areas. An updated report to the Trust Board will be provided early in the New Year. 5. 4 According to the Trust Smoke Free policy, all in-patients should be asked on admission if they smoke. Those patients that do smoke should receive a smoking history assessment, as soon as appropriate, giving relevant information about smoking and support to quit if desired. This survey revealed that 62% of smoking patients had received verbal information/advice and 27% had received written information. The Trust has a Trust smoke free leaflet and also a medicines information leaflet on Nicotine Replacement Therapy (NRT) available for all patients. 5. 5 30% of smokers reported they have been offered or prescribed medicines to help with cigarette cravings to help give up smoking. This is in line with Trust documents which include the Policy for Smoking Assessment and Interventions and also Guidelines on Nicotine Replacement Therapy and Buproprion, which are both available on Trust net as guidance for staff. It is important that Nicotine Replacement Therapies are offered to patients where appropriate during in-patient admissions in order to help patients with withdrawal cigarette cravings. In addition Trust-wide training is available for all healthcare staff: ‘ Managing smoking in a smoke free environment & supporting service users to quit smoking’, this aims to raise awareness of key issues linked to smoking and ensure practitioners are equipped to deliver smoking cessation interventions and cascade relevant training to colleagues. It is important to note that 22% patients reported that they had thought about giving up as a result of the smoking ban and that 28% would like more assistance and advice. It is important that advice is provided for smokers on giving up smoking and on how to manage cigarette cravings. There are also local Specialist Stop Smoking Services available who will provide specialist advice and support with such patients wishing to stop smoking. 6. Recommendations 6. 1 An action plan has been developed in response to this survey ACTION LEAD BY 6. 2 To provide more guidance to all staff including managers on managing the smoking ban. The Smoke Free Steering Group is to review and revise the Trust Smoke Free policy. Robyn Doran Dec 2010 6. 3 To review Trust Smoke Free training to add more information on managing violence and aggression that might be triggered by the smoking ban. Anshu Rayan Dec 2010 6. 4 To ensure inpatients have access to Stop Smoking specialist advice should they wish to stop smoking. Service managers (with support of Smoke Free leads) to contact local Stop Smoking services to enable patients to have access to specialist service. Audit to be undertaken to evaluate the uptake of the Stop Smoking Service and to measure the outcomes for CNWL inpatients. Anshu Rayan Inpatient service managers June 2011 6. 5 To ensure that each site locally is responsible for completion of smoking assessments and providing information to smokers on or soon after admission. Service Managers (with support of Smoke Free leads) to include smoking leaflets in In-patient admission packs and Ward In-patient packs. Service Managers and clinicians to ensure smoking assessments are completed for all smokers. This will be subject to an audit of patient records and linked to 6. 4 above. Anshu Rayan Inpatient service managers June 2011 6. 6 To carry out the Smoking Audit in Older Adults, Learning Disabilities, Eating Disorders and Addictions inpatient units in January 2010 to find out the views of patients about the no smoking policy and how this has affected their experiences within their particular services. Anshu Rayan / Chris Bumstead March 2011 7. Summary 7. 1 This survey has provided a unique opportunity to obtain a comprehensive picture of patients’ views of a policy which impacts directly on their freedoms on the adult acute care and PICU wards. It has provided a stimulus for further focused work to be done to ensure that service users are supported in their attempts to cease smoking and to manage their smoking behaviour in public spaces. The Board is therefore asked to support the recommendations for focused actions to improve these services.