Staff representations and tobacco‐related practices in a psychiatric hospital with an indoor smoking ban

The present study describes representations about smoking and practices related to patient smoking among staff of a large public psychiatric hospital. A survey was performed using a specially designed questionnaire. The return rate was 72.4% (n = 155). A large proportion of staff recognized the importance of both smoking status and mental health for patient's well‐being (46.9%), and believed that smoking cessation was possible for psychiatric patients (58.6%). However, the role of the psychiatric hospital was perceived as providing information (85.3%) and helping to diminish cigarette consumption (51%), rather than proposing smoking cessation (29.5%). Staff daily practice included reminding patients of smoking restrictions (43.9%), managing cigarettes (46.5%), and nicotine replacement therapy (24.3%). A principal component analysis of tobacco‐related practices revealed two main factors (59.8% of variance): basic hospital actions (factor 1) and more specialized interventions (factor 2), which were significantly associated with higher worries about personally developing smoke‐related illnesses (Spearman r = 0.38, P < 0.0001). Compared with non‐smokers, smokers reported higher perceived vulnerability to develop an illness due to tobacco and a higher level of worry about this. The discussion highlights the need to redefine roles and expectancies of mental health staff, and improve training and collaboration with experts, in order to improve efficiency concerning tobacco issues.     

Transition to a smoke‐free culture within mental health and drug and alcohol services: A survey of key stakeholders

Tobacco smoking is common among people with mental illnesses, and they carry a higher burden of smoking‐related illnesses. Despite this, smoke‐free policies and systems for supporting cessation have proved difficult to introduce in mental health and drug and alcohol services (MHDAS). This paper examines the barriers to becoming smoke free within New Zealand services. Key informants, including staff, smoke‐free coordinators, and cessation specialists were interviewed. Of the 142 invited informants 61 agreed (42%) to participate in a telephone interview, and 56 provided useable data. Organizations had a permissive or transitioning smoking culture, or were smoke free, defined by smoke‐free environments, smoke‐free‐promoting attitudes and behaviours of management and staff, and cessation support. Most organizations were on a continuum between permissive and transitional cultures. Only eight services had a fully smoke‐free culture. MHDAS face many challenges in the transition to a smoke‐free culture. They are not helped by exemptions in smoke‐free policies for mental health services, staff smoking, negative staff attitudes to becoming smoke free, poor knowledge of nicotine dependence, smoking‐related harm and comorbidities, and poor knowledge and skills regarding cessation‐support options. Health inequalities will continue across both service and socioeconomic divides without a concerted effort to address smoking.     

Smoking‐related violence in a mental health setting following the implementation of a comprehensive smoke‐free policy: A content analysis of incident reports

Smoke‐free policies in mental health settings are important to protect health but are often impeded by staff concerns that physical violence may increase. We aimed to address the literature gap about the frequency, nature, and management of physical violence in relation to smoking. We compared the antecedents and containment of smoking‐related incidents of physical violence over a two‐year period, (12 months when an indoor‐only smoke‐free policy was in place, followed by 12 months after a new comprehensive smoke‐free policy was introduced) using incident reports completed by staff in a large mental health organization in London, UK. Sixty‐one smoking‐related incidents occurred during the indoor‐only smoke‐free policy period; 32 smoking‐related incidents occurred during the comprehensive smoke‐free policy. We identified four antecedent categories for physical violence: i) patient request to smoke denied by staff; ii) during a supervised smoking break; iii) staff response to a patient breach of the smoke‐free policy iv) asking for, trading or stealing smoking materials. The antecedent pattern changed across the two policy periods, with fewer incidents of denying a patient's request to smoke and a greater number of incidents involving staff responding to breaches occurring after the introduction of the comprehensive smoke‐free policy. The prohibition of smoking breaks removed this source of violence. Timeout and PRN medication were the most common containment interventions. Understanding the context of smoking‐related violence may inform clinical guidelines about its prevention and management.     

Inpatient views and experiences before and after implementing a totally smoke‐free policy in the acute psychiatry hospital setting

In the present study, we examined the views and experiences of patients admitted to an acute psychiatry unit before and after the implementation of a totally smoke‐free policy. Forty‐six inpatients completed a questionnaire assessing their views before the smoking ban. Another 52 inpatients completed a questionnaire assessing their views and experiences after the smoking ban. Before the totally smoke‐free policy, 69.6% smoked, with 67.7% smoking more when admitted to the psychiatry ward. Before the smoking ban, 54.4% reported that the totally smoke‐free policy would be ‘negative’ or ‘very negative,’ and 30.5% said it would be ‘positive’ or ‘very positive.’ After the totally smoke‐free policy, 57.7% smoked heavily before hospital (mean cigarettes/day = 24.9), with consumption dramatically reducing following admission to a totally smoke‐free psychiatric unit (mean cigarettes/day = 8.3). After the totally smoke‐free policy, 36.5% reported that it was ‘negative’ or ‘very negative,’ and 50% reported that it was ‘positive’ or ‘very positive.’ Overall, inpatients reported improved acceptance of the policy following implementation. Inpatients stated that the most difficult thing about the smoking ban was experiencing increased negative emotions, while the most positive aspect was the improved physical environment of the ward. Inpatients who smoke must be appropriately supported using a range of strategies, and in the present study, we suggest relevant clinical implications.     

Self‐efficacy in providing smoking‐cessation services among psychiatric nurses in central and southern Taiwan: An exploratory study

Smoking by psychiatric patients remains prevalent. The purpose of this cross‐sectional study was to understand the influence of self‐efficacy and its correlates among psychiatric nurses when providing smoking‐cessation services (SCS). A convenience sample of 193 nurses from psychiatric institutions was obtained. Surveys were conducted using self‐report measures regarding SCS provided by psychiatric nurses. The survey questions focused on self‐efficacy, attitude, practical experience, and smoke‐free policies, and their implementation in the workplace. The participants reported low self‐efficacy for providing SCS in their self‐assessment, as demonstrated by their scores of 55.3 ± 20.4, on a scale of 0 (low confidence) to 100 (high confidence). Using multiple linear regressions, statistically‐significant, relevant factors included perceived provider‐related barriers in providing SCS, environmental tobacco smoke exposure, the nurse's attitude towards a patient smoking, and the nurse's frequency and practical experience in providing SCS. The correlates of this self‐efficacy can serve as a reference for in‐service curriculum planning of SCS by psychiatric nurses. In addition, policies to limit exposure to second‐hand tobacco smoke should be explored.     

Information technology-based standardized patient education in psychiatric inpatient care

Title. Information technology‐based standardized patient education in psychiatric inpatient care Aim. This paper is a report of a study to describe nurses’ experiences of information technology‐based standardized patient education in inpatient psychiatric care. Background. Serious mental health problems are an increasing global concern. Emerging evidence supports the implementation of practices that are conducive to patient self‐management and improved patient outcomes among chronically ill patients with mental health problems. In contrast, the attitude of staff towards information technology has been reported to be contradictory in mental health care. Method. After 1 year of using an Internet‐based portal (Mieli.Net) developed for patients with schizophrenia spectrum psychosis, all 89 participating nurses were asked to complete questionnaires about their experiences. The data were collected in 2006. Fifty‐six participants (63%) returned completed questionnaires and the data were analysed using content analysis. Findings. Nurses’ experiences of the information technology‐based standardized patient education were categorized into two major categories describing the advantages and obstacles in using information technology. Nurses thought that it brought the patients and nurses closer to each other and helped nurses to provide individual support for their patients. However, the education was time‐consuming. Conclusion. Systematic patient education using information technology is a promising method of patient‐centred care which supports nurses in their daily work. However, it must fit in with clinical activities, and nurses need some guidance in understanding its benefits. The study data can be used in policy‐making when developing methods to improve the transparency of information provision in psychiatric nursing.     

Interrater reliability of the Observer Rating of Medication Taking scale in an inpatient mental health facility

Non‐adherence to medication remains a major barrier to recovery from mental illnesses. Identification of those patients likely to experience adherence difficulties is best undertaken during inpatient treatment, prior to discharge into the community. More objective assessments of adherence behaviours might assist staff to more effectively target support to those patients most in need. This study investigated the interrater reliability of an inpatient behavioural observation scale of patient engagement with medication: the Observer Rating of Medication Taking (ORMT) scale. Eight mental health nurses working in a psychiatric hospital inpatient setting were trained in the use of the ORMT using video‐based vignettes. Working in pairs, staff then independently rated adherence behaviours of 13 inpatients in a rehabilitation unit (total of 160 ratings) over a 1‐week period. Concurrently, two expert raters also undertook independent ratings of patient medication‐taking behaviour using the ORMT. Interrater reliability was assessed across both staff and expert raters. The results indicated that the ORMT has satisfactory interrater reliability, and can be appropriately used in an inpatient setting. The observational location of raters on the ward influenced the range of medication‐taking behaviours observed, and thus the extent of concordance between raters. Further research to determine if the ORMT predicts adherence in the community is warranted.     

Impact of the implementation of the safewards model on the social climate on adolescent psychiatric wards

The Safewards model was created to reduce conflict and containment in psychiatric inpatient units. The model suggests alternative methods for containment and aims to create a safer hospital experience for both patients and staff. The evaluation of this model has provided evidence that it might be implemented on adolescent psychiatric wards. This study evaluated the impact of the implementation process of the Safewards model on the social climate of adolescent psychiatric inpatient wards by using the Essen Climate Evaluation Schema questionnaire. The study was carried out on six closed wards of one Finnish hospital district. Data were collected at baseline (42 adolescent inpatients and 134 staff members) and after the implementation of the model (39 inpatients and 115 staff members). The data were analysed using the Mann–Whitney U‐test. The findings of this preliminary study indicate that inpatients' experience of patient cohesion and therapeutic hold and staff members' experience of safety on adolescent psychiatric wards might be improved by the implementation of the Safewards model on adolescent psychiatric wards.     

Qualitative exploration of family perspectives of smoke‐free mental health and addiction services

The significant health disparities experienced by people with mental illness indicate the need for mental health service improvement. This qualitative study explored family and whānau (Māori family group) perspectives of smoke‐free mental health services. Thematic analysis found that family and whānau identified a number of barriers to the implementation of successful smoke‐free policy, including lack of coordination and consistency, and limited, if any, family and whānau inclusion. Family and whānau discussed smoking as a strategy for coping with anxiety and boredom; therefore, the need for other activities and strategies to replace smoking was identified as necessary in effective service delivery. The attitude that mental health service policy should be different from general health policy, due to the experience of mental distress, was also identified. In this paper, we argue that the development and implementation of quality mental health services would be strengthened by involving family and whānau in smoke‐free initiatives. Furthermore, the provision of relevant information to family, whānau, and service users would help dispel myths and stigma associated with tobacco and mental health.     

Effects of the implementation of the web‐based patient support system on staff’s attitudes towards computers and IT use: a randomised controlled trial

Scand J Caring Sci; 2010; 24; 592–599
Effects of the implementation of the web‐based patient support system on staff’s attitudes towards computers and IT use: a randomised controlled trial Utilisation of information technology (IT) in the treatment of people with severe mental health problems is an unknown area in Europe. Use of IT and guiding patients to relevant sources of health information requires that nursing staff have positive attitudes toward computers and accept IT use as a part of daily practises. The aim of the study was to assess the effects of the implementation of a web‐based patient support system on staff’s attitudes towards computers and IT use on psychiatric wards. Hundred and forty‐nine nurses in two psychiatric hospitals in Finland were randomised to two groups to deliver patient education for patients with schizophrenia and psychosis with a web‐based system (n = 76) or leaflets (n = 73). After baseline nurses were followed‐up for 18 months after the introduction of the system. The primary outcome was nurses’ motivation to utilise computers, and the secondary outcomes were nurses’ beliefs in and satisfaction with computers, and use of computer and internet. There were no statistically significant differences between study groups in attitudes towards computers (motivation p = 0.936, beliefs p = 0.270, satisfaction p = 0.462) and internet use (p = 0.276). However, nurses’ general computer use (p = 0.029) increased more in the leaflet group than in the IT intervention group. We can conclude that IT has promise as an alternative method in patient education, as the implementation of the web‐based patient support system in daily basis did not have a negative effect on nurses’ attitudes towards IT.     

Nicotine dependence criteria and nicotine withdrawal symptoms in relation to pain among an adult general population sample

Background: Evidence has shown that people who have smoked at any point in life have a higher probability of pain than those who have never smoked. The goal of this study was to analyze whether there are associations between nicotine dependence including nicotine withdrawal with pain and the number of pain locations. Methods: Data stems from a cross‐sectional survey study with a probability sample of residents of a northern German area with 4075 study participants, aged 18–64 years (participation rate 70.2%). Face‐to‐face in‐home computer‐aided interviews (Composite International Diagnostic Interview) were used to assess single pain locations, the diagnostic criteria of nicotine dependence, alcohol dependence, depressive, and anxiety disorders according to the Diagnostic and Statistical manual of the American Psychiatric Association (DSM‐IV). Results: Ever smokers with three or more nicotine dependence criteria after controlling for alcohol dependence, depressive, anxiety disorders, age and gender revealed an odds ratio (OR) of 4.2 (95% confidence interval, CI, 2.0–9.0) compared to ever smokers without nicotine dependence criteria, and ever smokers with four or more nicotine withdrawal symptoms displayed an OR of 3.6 (CI 1.5–8.7) compared to ever smokers who had not experienced withdrawal symptoms. Current smokers who used 20 or more cigarettes per day had an OR of 0.5 (CI 0.3–0.8) of experiencing pain in three or more locations compared to former smokers. Conclusion: Nicotine dependence criteria are associated with a higher probability of pain than having no nicotine dependence criteria in this general population sample.     

Evaluation of an alternative model for the management of clinical risk in an adult acute psychiatric inpatient unit

Despite their widespread use, typical visual observation practices are not evidence‐based and adverse events – such as self‐harm and absconding – still occur even under the most intense forms of observation. This study aimed to (i) develop and implement an engagement‐focused systematized model of clinical risk management in an adult acute psychiatric inpatient unit; and (ii) prospectively evaluate its effect on rates of violence, self‐harm, absconding, sexually inappropriate behaviour, and seclusion. A new model of engagement‐focused clinical risk management was developed using a participatory action research framework and implemented in an adult acute psychiatric inpatient unit. Using a mirror‐image design, rates of violence/aggression, self‐harm, absconding, sexually inappropriate behaviour, and seclusion were compared before and after implementation, and staff satisfaction levels were measured. The clinical engagement‐based model was introduced, and 1087 admissions before implementation (24 months) were compared with 965 admissions post‐implementation (18 months). The new model was associated with significantly reduced rates of absconding (pre: 10.5/1000 occupied bed days, 95% CI [9.0, 12.1] compared with post: 6.5/1000 occupied bed days [5.2, 8.1], P < 0.001) and seclusion (pre: 43.7/1000 occupied bed days, 95% CI [40.6, 46.9] compared with post: 30.9/1000 occupied bed days [27.9, 34.1], P < 0.0001). Rates of aggression, deliberate self‐harm, and sexually inappropriate behaviour were non‐significantly decreased. Findings suggest that this engagement‐focused model of clinical risk management in an adult psychiatric inpatient unit significantly reduced adverse patient events and was preferred by staff over current practice. Other psychiatric inpatient facilities may see a reduction in adverse events following the introduction of this well‐tolerated risk management model.     

Evaluation of a computer‐based intervention to enhance metabolic monitoring in psychiatry inpatients treated with second‐generation antipsychotics

What is known and Objective: Second‐generation antipsychotics (SGAs) play an important role in the pharmacologic management of various psychiatric conditions. Use of these medications has been associated with metabolic complications. Adherence to guideline‐recommended monitoring is suboptimal. We evaluated the effect of a computerized physician order entry (CPOE) pop‐up alert designed to improve rates of laboratory metabolic monitoring of patients treated with SGAs on a University Hospital inpatient psychiatry unit. Methods: A single‐centre, retrospective chart review was performed in which patient demographics and SGA drug and laboratory data were extracted from the CPOE database. We assessed the number of orders for appropriate metabolic monitoring data for patients admitted within a 6‐month period before or after the alert implementation. Results and Discussion: Pre‐alert (n = 171) and post‐alert (n = 157) groups were similar with respect to age, length of stay, sex, race and comorbidities. Following alert implementation, significant increases in monitoring both random (92·4% vs. 100%) and fasting (46·8% vs. 70%) glucose levels as well as random (28·7% vs. 74·5%) and fasting (18·7% vs. 59·9%) lipid panels (all P ≤ 0·001) were observed. The number of patients with both a fasting glucose level and fasting lipid panel available for monitoring increased from 12·9% to 47·8% (P < 0·0001). Significantly more post‐alert laboratory orders were submitted at the same time as the SGA drug order (P < 0·0001), suggesting that the alert itself had a direct influence on the ordering of metabolic monitoring labs. What is new and Conclusions: Implementation and use of an electronic pop‐up alert in an inpatient psychiatric unit significantly improved rates of ordering fasting blood glucose and lipid levels for inpatients treated with SGAs. Overall rates remain suboptimal, suggesting a need for additional strategies to further improve metabolic monitoring.     

Patient safety on psychiatric wards: A cross‐sectional,multilevel study of factors influencing nurses' willingness to share power and responsibility with patients

The World Health Organization highlights the need for more patient participation in patient safety. In mental health care, psychiatric nurses are in a frontline position to support this evolution. The aim of the present study was to investigate the demographic and contextual factors that influence the willingness of psychiatric nurses to share power and responsibility with patients concerning patient safety. The patient participation culture tool for inpatient psychiatric wards was completed by 705 nurses employed in 173 psychiatric wards within 37 hospitals. Multilevel modelling was used to analyse the self‐reported data. The acceptance of a role wherein nurses share power and responsibility with patients concerning patient safety is influenced by the nurses' sex, age, perceived competence, perceived support, and type of ward. To support nurses in fulfilling their role in patient participation, patient participation‐specific basic and continuing education should be provided. Managers and supervisors should recognize and fulfil their facilitating role in patient participation by offering support to nurses. Special attention is needed for young nurses and nurses on closed psychiatric wards, because these particular groups report being less willing to accept a new role. Ward characteristics that restrict patient participation should be challenged so that these become more patient participation stimulating. More research is needed to explore the willingness and ability of psychiatric nurses to engage in collaborative safety management with patients who have specific conditions, such as suicidal ideation and emotional harm.     

Adaptation of a sustained care cessation intervention for smokers hospitalized for psychiatric disorders: Study protocol for a randomized controlled trial

BackgroundIndividuals with serious mental illness (SMI) smoke at disproportionately higher rates than those without SMI, have lifespans 25–32 years shorter, and thus bear an especially large burden of tobacco-related morbidity and mortality. Several recent studies demonstrate that smokers with SMI can successfully quit smoking with adequate support. Further evidence shows that using technology to deliver sustained care interventions to hospitalized smokers can lead to smoking cessation up to 6 months after discharge. The current comparative effectiveness trial adapts a technology-assisted sustained care intervention designed for smokers admitted to a general hospital and tests whether this approach can produce higher cessation rates compared to usual care for smokers admitted to a psychiatric inpatient unit.MethodsA total of 353 eligible patients hospitalized for psychiatric illness are randomized by cohort into one of two conditions, Sustained Care (SusC) or Usual Care (UC), and are followed for six months after discharge. Participants assigned to UC receive brief tobacco education delivered by a hospital nurse during or soon after admission. Those assigned to SusC receive a 40-min, in-hospital motivational counseling intervention. Upon discharge, they also receive up to 8 weeks of free nicotine patches, automated interactive voice response (IVR) telephone and text messaging, and access to cessation counseling resources lasting 3 months post discharge. Smoking cessation outcomes are measured at 1-, 3- and 6-months post hospital discharge.ConclusionResults from this comparative effectiveness trial will add to our understanding of acceptable and effective smoking cessation approaches for patients hospitalized with SMI.     

Predictors for clinical deterioration of mental state in patients assessed by telephone‐based mental health triage

Patient safety research focussing on recognizing and responding to clinical deterioration is gaining momentum in generalist health, but has received little attention in mental health settings. The focus on early identification and prompt intervention for clinical deterioration enshrined in patient safety research is equally relevant to mental health, especially in triage and crisis care contexts, yet the knowledge gap in this area is substantial. The present study was a controlled cohort study (n = 817) that aimed to identify patient and service characteristics associated with clinical deterioration of mental state indicated by unplanned admission to an inpatient psychiatric unit following assessment by telephone‐based mental health triage. The main objective of the research was to produce knowledge to improve understandings of mental deterioration that can be used to inform early detection, intervention, and prevention strategies at the point of triage. The results of the study found that the clinical profile of admitted patients was one of complexity and severity. Admitted patients were more likely to have had complex psychiatric histories with multiple psychiatric admissions, severe psychotic symptoms, a history of treatment non‐adherence, and poorer social functioning than non‐admitted patients.