Mental Health Acute Wards

wnoise · Apr 24, 2008

Thanks a lot, psychmeup,

Your information is very useful for me. I am working hardly to change my ward into a non smoking place, but it is difficult. You have given to me a good point of view to justify my study. :up:

Chaoticdreams33, MSN, RN · May 1, 2008

We are smoke free. We offer patients the patch and the gum if they cannot tolerate the patch. It usually isn't a problem, mostly just when a new patient is told that they will be able to smoke as soon as they get to us! I always ask the nurse giving me report if the patient knows they are coming to us and if they know that there will be no smoking allowed. At least don't promise something that is not going to happen!

StuPer · May 6, 2008

I'm afraid I have some experience of this as we recently enforced a no-smoking policy across the area in all health care facilities.

Now don't get me wrong I understand the reasoning behind non-smoking policies, both for the health of staff and that of clients, however I do believe mental health settings have an arguement to be considered different.

Firstly the ethical issue, we often lock people up in hospital due to mental illness, they do not have a choice in the matter. To then impose our standards on patient regardless of history (eg having smoked for decades with no intention of stopping) smacks of big brother and we are supposed to be advocating for greater autonomy and inclusivness in mental health care for patients.

Secondly, how do you think your attempts to form a theraputic relationship with someone is going to go when you have deliberately denied a drug of addiction, that outside of the hospital grounds is a legal entity.

Thirdly I dont know about other areas, but here, staff have been told that they cannot visit the home of a patient in the community unless that person has agreed to not smoke while staff are present.... even if they are on a Community Treatment Order (compulsory MH care in the community). Now imagine the not unlikely scenario where a CTO client (who does not want our care or treatment) refuses not to smoke when staff are present... are we really going to breach that person and force them into hospital because they wont stop smoking?? The 'educator' who came to explain the policy to us had a real hard time with that one.

How many PRN's/sedation/restraint actions are going to occur as a result of patient agitation due to lack of access to 'smokes'. Well as I said I have some experience via the local staff in the Acute Unit, the answer is many many incidents. None of which can be attributed to anything other than the smoking policy. The Area managment seem to have adopted a wonderful strategy in order to implement this and keep the State Health service happy. Staff initially religiously reported incidents via the online incident system.

However over a course of weeks and months staff simply stopped reporting as there was absolutely no action taken by management to reduce the level of incidents or review the policy. This pattern was perfect to evidence to State Health that while there were some inital problems, things seem to have settled down

(using the reporting stats).

All I can say, is please think very, very, carefully about implementing such blanket policies into health care, especially MH facilities. Patients who smoke do so often for a theraputic reason associated with their illness, it may not be the healthiest or best strategy, but who the hell are we to tell people how to live their lives on something like smoking, when we have forced them into the facility in the first place.

I would hope that even non-mental health workers can see the potential for violence that this can lead to, and which is a reality in this area.

StuPer

wnoise · May 8, 2008

This is very important. We have many patients that in the last 6 years have more than 20 incomes. They can feel themselves betrayed if next income we change into a freesmoke unit.

wnoise · May 8, 2008

dear stuper,

thanks a lot for your help. it is a very interesting point of view.

it is incredible how many people have very different experiences about the same matter: no smoking policies.

your message is really nice. to be honest i am just studying acute mental health units where patients are enforcing to stay. at other levels, in spain, patients can go out and smoke freely.

about the ethical issue i agree with you, but i think that the hospital has to provide to staff and no smoker patients a secure place free of smoke. i think the right of health must be “first” that the right to smoke.

i am not sure about if the health authority has to impose no smoking policies but in case that they do it, maybe to exclude mental patient could be a case of discrimination, based at prejudices and not clinical evidence. for example, about alcohol there is no dilemma and it is a legal drug as well. and cannabis that it is legal to smoke in my country.

about your second item i agree with you but it is the same with many other things like: maniac behaviors, other drugs (alcohol and coffee are forbidden at my ward) and the professional has to overcome these problems.

along my study i contact many wards with no smoking policy that have no problems at all (sedations, restrains,…) and they guarantee that staff and patients are much better after the stop smoking.

anyway, every day i feel i am far from a conclusion. i am considering culture, staff relationship with smoking, economics, etc.

thanks a lot indeed for your help and i am sorry for my english.

elkpark · May 8, 2008

I recognize that every facility is different and has its own experience. However, I'll just add that I worked for several years as a psych hospital surveyor/inspector for my state and the Feds, and, in that capacity, went into every psych unit in our state on a regular basis. Many of these units were going "smoke-free" during the period I worked as a surveyor, so I would hear from the staff about (and observe, to some extent) how the process was going. Many of the staff on many of the units were v. apprehensive about the change and expecting things to work out badly, but, as it was actually implemented in the hospitals, most of the units of which I had first-hand knowledge had very few problems, and very little increase in violence or other kinds of problems. I think a lot of it has to do with the attitudes of the staff and how this is presented to the clients, and the alternatives (patches, gum) that are made available. Most of the units in our state were very pleased with the outcome of the change, and I'm not aware of any unit that has even considered switching back. Even our state hospitals went smoke-free, without any serious problems (more problems with the staff than with the clients! :chuckle)

As wnoise notes (and I've made this argument myself before), there are lots of things that it's legal for adults to do "outside" that we don't allow them to do in hospitals for safety and health reasons. Heck, in every psych unit I've ever worked on we don't even let them have caffeinated coffee!!

(And, wnoise, you have no need to apologize for your English -- it's great!)

kiwipsychnurse · May 8, 2008

We are gearing up for non smoking in 2010. Glad I dont work in the acute side of the service, thats going to be a rough 3 months.

RN2begin · May 9, 2008

I'm afraid I have some experience of this as we recently enforced a no-smoking policy across the area in all health care facilities.
Now don't get me wrong I understand the reasoning behind non-smoking policies, both for the health of staff and that of clients, however I do believe mental health settings have an arguement to be considered different.
Firstly the ethical issue, we often lock people up in hospital due to mental illness, they do not have a choice in the matter. To then impose our standards on patient regardless of history (eg having smoked for decades with no intention of stopping) smacks of big brother and we are supposed to be advocating for greater autonomy and inclusivness in mental health care for patients.
Secondly, how do you think your attempts to form a theraputic relationship with someone is going to go when you have deliberately denied a drug of addiction, that outside of the hospital grounds is a legal entity.
Thirdly I dont know about other areas, but here, staff have been told that they cannot visit the home of a patient in the community unless that person has agreed to not smoke while staff are present.... even if they are on a Community Treatment Order (compulsory MH care in the community). Now imagine the not unlikely scenario where a CTO client (who does not want our care or treatment) refuses not to smoke when staff are present... are we really going to breach that person and force them into hospital because they wont stop smoking?? The 'educator' who came to explain the policy to us had a real hard time with that one.
How many PRN's/sedation/restraint actions are going to occur as a result of patient agitation due to lack of access to 'smokes'. Well as I said I have some experience via the local staff in the Acute Unit, the answer is many many incidents. None of which can be attributed to anything other than the smoking policy. The Area managment seem to have adopted a wonderful strategy in order to implement this and keep the State Health service happy. Staff initially religiously reported incidents via the online incident system.
However over a course of weeks and months staff simply stopped reporting as there was absolutely no action taken by management to reduce the level of incidents or review the policy. This pattern was perfect to evidence to State Health that while there were some inital problems, things seem to have settled down
(using the reporting stats).
All I can say, is please think very, very, carefully about implementing such blanket policies into health care, especially MH facilities. Patients who smoke do so often for a theraputic reason associated with their illness, it may not be the healthiest or best strategy, but who the hell are we to tell people how to live their lives on something like smoking, when we have forced them into the facility in the first place.
I would hope that even non-mental health workers can see the potential for violence that this can lead to, and which is a reality in this area.
StuPer

Right On StuPer :up: Also, I think it is important to take into account WHY the person in smoking...there are new studies that show nicotine reducing anhedonia, avolition and other neg sxs in people with mental illness that include psychotic features...it explains why so many people with mental illness smoke, and sometimes quite a bit. It is a cheap (compared to the patch, gum or antipsychotics) and seemingly "self controlled" way to contain their illness. Also, why the sudden focus on smoking? ...we seem to be able to rationalize type II diabetes as a side effect of atypicals and yet put no regulations on diet...it's hypocritical and decreed by people completely disconnected from the "trenches" of treatment...

I am very much aware that smoking is deadly. I am also very much aware that patients are allowed to make educated choices and refuse their medication...I am not sure how we get away with regulating smoking (outside) for consenting adults...especially if it helps in any way, shape or form. Most often these people have lost an immeasurable amount, physically, emotionally, financially due to their mental illness. If they want to have a cigarette...we can at least give them the choice.

"Nicotine's stimulation of dopamine could help explain the high use of

nicotine by patients with schizophrenia as a form of self-medication to

reduce negative symptoms"

http://psychservices.psychiatryonline.org/cgi/reprint/50/10/1346

"Nicotine Helps Schizophrenia Patients with Attention and Memory Problems"

http://www.medicalnewstoday.com/articles/26516.php

"Nicotine restores the disorders observed in schizophrenics on early evoked potentials."

http://www.medscape.com/viewarticle/483888_4

etc., etc., etc.,

wnoise · May 10, 2008

Dear RN2begin,

Thanks for your message. I agree with you partially.

About the right of autonomy to decide to smoke or not to smoke I think the patient (like any other) has the right to choose. But I would like to remember the initial conditions I asked:

- Patient at acute mental health wards.

I am happy to know that nicotine has these nice effects but I am sure that smoking cigarettes is not the best way to have nicotine (at least meanwhile the patient is at ward). I cannot forget staff and no smoking patients’ safety.

I agree with you that patients are allowed to choose or refuse any kind of treatment, but my discussion is based in the Spanish Non-smoking Law. This law forbids smoking at any public center with the exception of mental health wards and penitentiary centers. So I disagree about the discrimination of mental patients. About the diabetic example I agree as well, but if a diabetic patient refuses a diet or insulin he/she damages him/herself, nobody else is in risk.

Thanks for your links, they are very interesting.

rotary · May 12, 2008

We do not allow smoking, patients have to leave hospital property to light up and must sign a waiver to do so (i think that's unsafe).

We do however have Nicotine Replacement Therapy where free gum, patches and inhalers are provided for them to use while staying in hospital.

catcoon · May 12, 2008

i work in an acute mental health hospital and we allow patients to smoke.

one of the reasons is because if you give meds to psych patients and they are not smoking while on the unit and the med is successful one gets the impression that the dose of med is effective. in all reality most patients start smoking as soon as they are discharged [often lighting up while walking out the door]. nicotine effects drug metabolism and the dose that was effective while in the hosp is no longer effective on the outside because the pt is smoking. often times the pt then discontinues the med because it's not working like it did in the hosp which in actuality is due to the false impression from the non-smoking policy.

i have worked in both smoking and non-smoking facilities and find that there is less relapse due to noncompliance with ineffective meds when the pts are allowed to smoke.

just my two cents worth.

bikie · May 18, 2008

I work in a an acute mental ward in Queensland Australia. The staff are not allowed to smoke, but the patients are. We have a huge back yard area to use. We find if the patients run out of smokes they get quite agitated.I don't think they want to try no smoking . The rest of the hospital is smoke free. :nurse: