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Miriam Gunning. La experiència a Irlanda


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Jornada de tabac i salut mental (2009). Xarxa Catalana d'Hospitals sense Fum // Departament de Salut.

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Miriam Gunning. La experiència a Irlanda

  1. 1. Guidelines for Tobacco Management in Mental Health Settings Miriam Gunning Co-ordinator Irish Tobacco free Hospital Initiative (TFHI) 19th March 2009 I want to quit
  2. 2. Background to the Irish situation 2004 Tobacco legislation & exempted premises Duty of care to staff V rights of clients Variation in settings – no exemption if part of general hospital facility Little guidance for exempted premises Lack of resources Concerns in relation to litigation
  3. 3. Acute MH units in general Hospital facility Facilities for MH clients only (inc. acute care facilities) Residential Long term Care centres Community residential care units for MH clients (hostels) Day care facilities For MH clients (day hospitals)
  4. 4. Legislation in Ireland Mental Health Services are exempt from the workplace smoking ban because they can be considered a patient’s home Acute Mental Health units attached to a general hospital are not exempt Smoking is permitted for patients only – not for staff Mental health units can choose to implement the indoor smoking ban and are encouraged to do so
  5. 5. Process used in Ireland Jan – Mar 2006 - Research best practice, agree membership of expert group & draft discussion document April 2006 – 1st Expert group meeting & 1st draft of guidelines, email consultation process May 2006 – National Workshop, wide consultation process, updated document & email consultation process Sept 2006 – 2nd Expert group meeting, updated document & email consultation process Nov 2006 – Agree final document content & layout
  6. 6. ENSH Project Aim & objectives To develop “Consensus Management Guidelines” for smoke free psychiatric / mental health services To identify and analyse existing European guidelines for smoke free psychiatric / mental health services To identify management models of good practice in psychiatric / mental health hospitals from within participating European Partners To make recommendations on a common set of management guidelines for European psychiatric / mental health services
  8. 8. Project plan December 2006 - June 2007 Engage psychiatric/mental health services Develop survey tool Survey participating psychiatric / mental health services Review literature to assess the range, gaps and effectiveness of European smoke-free legislation and management guidelines in relation to psychiatric and mental health services Review and return feedback from survey Translate identified materials Participate at expert workshop to discuss findings and agree draft European Recommendations Review feedback on draft recommendations Agree final draft
  9. 9. Smoking rates by mental health disorders (HDA 2004)
  10. 10. Smoking rates Mc Neill 2001 - different psychiatric disorders 40% of people diagnosed with neurotic disorders (e.g. depression, anxiety disorder, phobia, obsessive compulsive disorder) are smokers The more neurotic symptoms a person has the higher the smoking level Smoking prevalence is highest in those with diagnosed psychotic disorders. 88% of Schizophrenia patients smoke with over 50% being heavy smokers (>20 cigarettes/day) Over 70% of patients living in psychiatric hospitals and institutions smoke
  11. 11. Smoking Legislation - UK Long-stay care institutes where patients are resident for more than 6 months are allowed to have designated smoking places The average length of stay on a psychiatric ward is 58 days (Jochelson, 2006) implying most psychiatric units do not qualify for such an exemption Psychiatric units have been given a one-year extension until July 2008 to provide secure outdoor smoking areas (Draft Statutory Instrument 2007 No.)
  12. 12. Smoking Legislation - France Total smoking ban introduced in February 2007 includes psychiatric hospitals and units Patients and staff are only allowed to smoke outside The only exception will be for long stay units where smoking will be permitted in patients’ rooms as these are considered their private space
  13. 13. Literature findings Keizer and Eytan, 2005 Many patients who enter as non-smokers leave as smokers Jochelson and Majrowski (2006) Banning indoor smoking throws up the debate of the right of the individual to smoke versus the right of other patients and staff not to work in a smoky atmosphere
  14. 14. King’s Fund report (2006) The right of staff to work in a safe work environment. The right of patients to choose their lifestyle. The right of patients to smoke against the right of nonsmoking patients
  15. 15. King’s Fund report (2006) Against Lack of indoor smoking in residential units may be perceived as a breach of a patient’s rights Staff have preconceived ideas of impracticality, and expect an increase in abusive behaviour. Severe withdrawl and relapse is more common amidst the mentally ill (Glassman et al, 1990) A new episode of major depression may appear up to six months after cessation in those suffering from depression (Covey et al, 1997; Glasman et al, 2001) During tobacco cessation patients can relapse to other drugs
  16. 16. Findings Health promotion should be considered part of mental health services Total indoor bans compared with partial bans are less likely to result in aggressive behaviour (Jochelson and Majrowski, 2006) Indoor smoking bans do not prevent patients from smoking Patient resistence has not been experienced where nosmoking policies have been implemented Patients conform when policies are clarified It is difficult to motivate patients to quit when smoking is allowed indoors
  17. 17. Findings contd. Staff accept the no-smoking policies when they are enforced Cigarette consumption is reduced when it is more difficult to smoke Patients become calmer and sleep better When staff don’t smoke it creates a ripple effect A smoking ban is an opportunity to ask about tobacco use and give a short counselling session There is no proof that smoking cessation increases the effects of schizophrenia Serious smoking-related diseases and mortality are more common in schizophrenics due to their high smoking prevalence and heavy smoking rates (Brown et al, 2000)
  18. 18. Effectiveness of smoking bans in psychiatric units Willemsen et al, 2004 (Holland) 87% of individuals in psychiatric units exposed to ETS when no ban on smoking Even where a general smoking ban existed, where smoking was meant to be confined to designated areas, non-compliance resulted in a high exposure to ETS Only when a complete ban was implemented was compliance high and employees sufficiently protected from ETS
  19. 19. Jochelson 2006 reported 60% of psychiatric nursing staff disapproving of the ban beliving staff should smoke with patients in order to break down barriers, a view supported by 78% of patients US (el-Guebaly, 2002) & Canadian Research (Willemsen, 2004) supports smoke-free policies in psychiatric units with careful planning and consistency by all staff Patten et al, 1995 Fewer than expected adverse effects anticipated by staff were produced on implementing a smoke-free policy
  20. 20. Role of psychiatric nursing staff in aiding smoking cessation Psychiatric nurses ideal to aid their patients in quitting smoking Nurses, especially those who smoke themselves, appear reluctant to advise their patients to quit (Pelkonen and Kankkunen, 2001) This reluctance stems from nurses’ respect for their patients’ rights to make their own decisions Nurses are often with patients who have been sectioned and smoking aids interaction between them and such patients Lawn and Condon (2006) found that nurses have to be properly trained to be more effective in supporting patients’ quit attempts
  21. 21. Smoking cessation support for psychiatric patients All patients should be advised to quit (Swedish Psychologists Against Tobacco, 2005) West el al 2000 (England) suggested the following evidence based guidelines brief interventions for smoking cessation should be given to all patients identified as smokers More intensive smoking cessation support should also be available during a patient’s period of hospitalisation Support should be provided through specialist trained staff or if not through primary healthcare staff with smoking cessation counselling skills
  22. 22. Pharmacological aids for psychiatric patients The psychiatric illness with which a patient suffers must be taken into consideration prior to describing bupropion as it can be contra indicated Two or more strategies tend to be better than using only one method of intervention, which applies to the population as a whole On being discharged from a psychiatric unit, smoking cessation support should be continued (Jochelson, 2006), and patients whose medication is linked to their smoking/non-smoking need additional monitoring and advice
  23. 23. Training for health professionals Staff need to be trained in intervention methods to maximise the benefits they can offer to smokers A variety of training practices are in operation across Europe, within hospitals and community health services The European Network of Smoke Free Hospitals (ENSH) assessed the current available smoking cessation services within European hospitals in 15 countries (McLoughin,2006a,b) The report considered it necessary to tailor smoking cessation training for specific groups such as mental health
  24. 24. Summary - psychiatric services can work effectively by being smoke-free without adverse patient effect National smoking legislation could be expanded to include psychiatric institutes with special considerations taken into account Psychiatric services should be supported to go smoke-free indoors Need to raise awareness about the problems of smoking in the mental health services and bring about cultural change Psychiatric services need a well-thought out tobacco policy It is difficult to get patients to quit as long as it is permitted indoors
  25. 25. Summary - psychiatric patients Designated secure outdoor smoking facilities should be provided for patients Adequate smoking cessation support needs to be provided for patients when they are resident in psychiatric units and should continued when they leave the unit Smoking cessation support needs to be adapted to the specific clinical needs of a patient Cigarettes should not be used as rewards Patients should be asked about their tobacco use and offered brief smoking cessation intervention NRT should be supplied to patients
  26. 26. Summary - psychiatric staff Staff have a strategic role to play in supporting smoking cessation in patients Staff need to be trained in smoking cessation counselling Psychiatric staff need support to help them quit smoking Staff should have separate smoking facilities to patients Staff should avoid smoking in front of patients and visitors
  27. 27. Conclusion It’s cynical to treat the psychiatric disorder and leave the patient to die from smoking! Thank you for listening!