The Department of Health has written to all mental health trusts and other providers to remind them that they must be smoke free by 1 July under the smoking ban legislation.

Do people think this is realistic?

I rthink that there will be a lot of resentment from service-users and workers over this. I also think that many people will complain about unworkable policies and the risk of violence as a result.

You ask whether or not it's workable - not whether or not we think it's a good idea.

I think that mental health services will adapt just like every other service has. Just like pubs and clubs etc. Systems evolve to meet requirements.

 The trust I work in introduced the ban on smoking on the inpatient wards in August last year. It was phased in over a few months. As Stuart said, people adapt because they have to and although it wasn't easy, it happened and theTrust is smoke free.

(I can't remember what their reason was for bringing in the ban early - I'm sure there was one.. )

I would agree with Stuart, as the total block on no-smoking in mental health units secure facilities could lead to situations that are unmanageable. As I none smoker it does please me that I am able to go to restaurants etc without having to cope with smoke, but on the other hand, people with a mental illness rely on smoking as a way of coping, take this away and we could have a potential lit fuse situation.

It's bad enough not allowing someone to smoke who are in seclusion for 3-5 days, sometimes longer, this can be controlled but to attempt to control a whole ward of between 8-12 patients would lead to patients defying the legislation.

I do hope that the Gov and/or LA come up with an acceptable policy alowing for patients who are restricted from going outside because of legislation.

Rev Jack.  

 Just another point. I was discussing this issue with my partner who tells me that the ward that she works on, she finds thast the patients appear more cooperatve because of the insentive of being able have leave to go into the courtyard and have a smoke, so, maybe this is one of the options used by the nurses to help with the patients behaviour. As a social worker,it could be a lot easier as I have often taken the patient out onto the hospital grounds for a walk, being able to assess and gain insight into the patients behavioural issues. Just a thought.

Rev Jack. 

Hi Jack,

I'm sorry but I never said that smoke-free units are unmanageable. I said that people will argue that point but that they'll adapt. People tend to do manage in mental health services just as they do in other settings. Not every inpatient unit has a courtyard and grounds access isn't always feasible either depending upon the nature and condition of patients who may well be detained.

Really though I'm amazed at two other comments you make. The first is the idea of a ward of 8 people. The last acute ward I worked on had 27 beds - this is pretty normal in general psychiatry. I think that there must be some very significant differences between psychiatry here and in the antipodes.

The one I really must take issue with though is the notion of people being secluded for 3-5 days at a time. The majority of seclusions I've ever been involved with lasted minutes. In some cases hours but I really can't bring to mind a period of seclusion on acute that lasted days. In my opinion to seclude someone for such protracted periods in general psychiatry represents a significant failure on the part of the nursing staff. Actually to seclude someone at all is a last resort which is why, in my experience, it's very ununsual.

Sorry to disagree so vehemently but I really don't want people to think that such use of seclusion reflected my nursing practice because it most certainly does not.

 Cheers,

Stuart

Sorry Jack - I must seem like a dog with a bone but there's another point here.

To use smoking as an incentive to behave in particular ways in order to get a smoke is another way of saying we'll deprive you of access to the courtyard unless you conform to our rules. This sounds like coersion and abuse of power to me. Using the denial of access to the smoking area as punishment for 'bad' behaviour.

The European Convention on Human Rights is very clear on this sort of issue. The basic notion can be summed up as "No punishment without law".This principle is mirrorred by our own Human Rights Act and latterly by the Mental Capacity Act 2005.

There is a myth that people detained under the Mental Health Act are not covered by the Mental Capacity Act. This isn't so. Decisions made under part IV of the Mental Health Act are largely unaffected by the Mental Capacity Act but decisions about smoking are unlikely to fit into this category. So people have their basic civil rights to access smoking areas where they exist. That right can only be restricted legally if they lack the capacity to make a decision about smoking and then the restriction must be in the individuals best interests. Coersive practice that uses restriction to enforce behaviour desired by the staff is unlikely to be in the idividual's best interests and therefore is almost certainly unlawful in my opinion.

I guess things are different in the antipodes.

 Dear Stuart, I stand corrected, however the other comment about the size of the unit, the Hospital I worked in had a bed capacity of 8 in one and 10 in another. These were med secure. I understand that they have human rights, and I do respect these rights. AS for seclusion, I often had to see my patient in seclusion, and some where there for many days. In fact the longest I came across was 10 days.

I am not sure what area you were talking about, but can assure you that it was not taken lightly to hold someone in seclusion for such a long time. The decision was taken as a joint decision with the Psychiatrist so I think it was unfair to put the blame on the nurses. In fact, I took over some of the nursing roles just to give them a rest because of the demand put on them. (quite legal and agreed by the matron in charge).

I was present most of the times, so I was also one of the team that made the decision to either put an end to the seclusion or to continue seclusion within the terms of he hospitals legislation, and MHA. 

 These patients were not general psychiatry but were Forensic Psychiatry, a specialised area that required more input and a lesser bed capacity because of the diagnoses. 

All units on the Hospital area had approx 10 beds on each ward. There were many complications which meant that some units had to be used for specific ilnesses.

The patient was too much of a risk to allow back on the ward. I won't go intot he diagnosis, but I can assure you that it was necessary. The psychiatrist, the nurse in charge and myself agreed that for reason I cannot publish, had to stay in seclusion. Yes, I have come across it where they have been in seclusion for a few minutes to a few hours, but with complication like we had it was necessary.

 This also meant no smoking, as again, by allowing the person to smoke in seclusion posed a high risk to staff who had to enter.

I would access the patient three times a day for assessments, and we did keep a close watch, but that is what occured.

As for the failure of the nursing staff, I have to disagree with you in this situation. The nursing staff had lost two nurses who had been admitted to A&E for serious assault towards them. 

 In Australia I worked in all three areas where we had large numbers of patients in Acute, Sub-acute and rehab.

The nurses I worked with were very hard working professionals, to have more than 10 patients would have been considered a risk to the staff, as some nurses suffered very traumatic incidences requiring long term recovery. That also put stress on other staff members because of the shortage of nurses.

The problem I see is that the patient is only allowed outside when escorted (depends on the level of security). If they do ban smoking within the hospital grounds, then that means that the patients would not be able to smoke, as patients are not allowed outside the grounds 

Behavioural capacity is of great concern, and if their behaviour was such that it posed a risk, then the patient could go outside unless escorted by 2 staff members. Taking into account that many were under staffed, this posed a problem and a real risk to staff. I think that the setup that you were talking about is certainly not the same type of conditions that I am referring to.

 Their behaviour was rewarded with certain concessions, taking into account the risk factor that they posed. would you allow a patient to go unattended outside for a cigarette, if they posed a significant risk to other patients and staff members? So, it was used as a behavioural role, anger management, whatever you want to call it.

Many of these patients were convicted ina criminal court for serious crimes, they did not just have dementia (no prejudice meant). you would have to use your imigination on what they had committed, as I would not like to say anyhting that would identify them.

However, I treated all patients as human beings no matter what they may have done, but when you have restrictions, and policy predicts behavioural attitudes, seclusion, restrictions, etc,, you have to abide by these policies, legislation etc, whether we may agree or not.

I respect your comments Stuart, but it's clear that we are talking about a different type of patient, illness, and conditions. 

Hi Jack,

OK - it is clear that we have limited understanding of each other's contexts so fair enough. I appreciate that some people are more dangerous than others. However acute wards in UK deal with much more than the dementias although people with dementias do present their own particular difficulties - especially if we hope to help maintain the dignity of our patients on the wards.

But I don't think we are talking about different types of patient, illness and conditions. I worked acute for several years before specialising in severe and enduring mental disorders in hospitals, community settings and voluntary sector residential units too. In my last job before becoming  trainer many of my service-users came straight from prison for various offences - the only common denominator being substance misuse. There aren't that many diagnoses in ICD-10 that I haven't come across.

I still maintain that if there is a mechanism for taking people outside for cigarettes then this should not be dependant upon the nursing staff's opinion of a person's behaviour. It's either a right or it isn't. If it is legal and reasonably practicable for people to smoke then it is legal and reasonably practicable regardless of other considerations.

I train people in behavioural techniques to deal with challenging behaviour on a regular basis. What you are describing is a reinforcement regime (at least I think it is) not unlike the old 'token economy' regimes in principle. However reinforcement involves providing benefits over and above basic civil rights and basic care. This is acceptable practice. To arbitrarily strip people of their existing civil rights and then return those rights as 'priveliges' when the individual pleases the staff is not acceptable practice in my opinion.

You said something about the need to restrict people's liberties because of diagnosis. I wasn't aware that diagnostic categories carried civil rights implications. I thought that civil rights could only be removed through established legal process and apart from the right to liberty, to refuse treatment and in some cases to make financial decisons the mental health act doesn't allow for such interference in rights. Indeed one of the reasons for the extremely long delay in the avent of our new mental health act was because of the very real need to prevent such arbitrary restrictions. In any event I've certainly never heard of the mental health act allowing us to restrict a person's right to smoke unless they conform to our percieved norms.

I still maintain that the practice you described earlier is an abuse of the mental health act, an infringement of civil rights and extremely coersive practice.

Incidentally I'm not saying that people necessarily should be allowed to smoke - that's not for me to decide. I'm simply saying that if the mechanism exists for them to smoke then this should not be dependent upon the arbitrary judgements of nurses or psychiatrists who are not traditionally trained in (or often even particularly aware of) civil rights issues outside of part IV of the mental health act. Quite frankly - that way lies institutionalisation. Indeed if it's a policy to make people's legal entitlements dependant upon the discretion of the staff (who have no legal right to restrict those rights) then I think there may well be a case to investigate for institutional abuse.

Having seen first hand the problems that arise from overly controlling regimes I feel really strongly about that.

Cheers,

Stuart

 Dear Stuart,

Cheers. Sometimes what we need, what we want, and what should be, isn't always in this weird world of ours. :) 

 Rev JackM

 There's just been a court decision on the whole issue of smoking in locked wards, which I have blogged about. The court decided there is no overriding human right to smoke and any such right that there might be can be limited by the legislative imperative to allow people smoke-free air. 

Thanks for that Simeon. It's always helpful to know what the courts have to say as so often parliament makes the rules and the courts decide how they are to be applied.

However I don't think that changes the point that...

Stuart Sorensen:

Incidentally I'm not saying that people necessarily should be allowed to smoke - that's not for me to decide. I'm simply saying that if the mechanism exists for them to smoke then this should not be dependent upon the arbitrary judgements of nurses or psychiatrists who are not traditionally trained in (or often even particularly aware of) civil rights issues outside of part IV of the mental health act. Quite frankly - that way lies institutionalisation.

I also wonder if there might be a difference between having a 'right to smoke' and having the right to prevent someone from smoking when other people are able to do it in the same circumstances, simply because the nurse thinks that's appropriate. Really my point is that health workers should not be making essentially civil decisions in this way. It's too arbitrary, coersive and ultimately damaging. And let's face it - allowing someone to go outside for a *** based on our approval of their behaviour isn't about another person's right to breathe clean air or the ruling would be made irrespective of the person's behaviour - it's about coersion isn't it?

I think that is obvious regardless of the legal position on the right to smoke. If some people can and some people can't then what's the distinction based upon? That's the issue as I see it.

Cheers,

Stuart

Just reread my last post. The 'starred' word is a slang word for cigarette. An alternative might be 'tab' but the one I used has other connotations. Sorry if anyone was confused by that - it seems to have been censored automatically by computer.