Healthcare Professionals Implementing Smoke-Free Policies at Inpatient Psychiatric Units: An Ethnographic Study

549026 research-article2014 QHRXXX10.1177/1049732314549026Qualitative Health ResearchGrant et al. Article Health Care Professionals Implementing a Smoke-Free Policy at Inpatient Psychiatric Units Qualitative Health Research 2014, Vol. 24(12) 1732­–1744 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732314549026 qhr.sagepub.com Lyle G. Grant1, John L. Oliffe2, Joy L. Johnson2, and Joan L. Bottorff3 Abstract Smoke-free grounds policies (SFGPs) were introduced to inpatient psychiatric hospital settings to improve health among patients, staff, and visitors. We conducted an ethnographic study in Northern British Columbia, Canada, to describe how the implementation of SFGPs is affected by institutional cultures. Data reported here included participant observation, document review, informal discussions (n = 11), and interviews with health care professionals (HCPs; n = 19) and staff (n = 2) at two hospitals. We used iterative and inductive processes to derive thematic findings. Findings related to HCPs illustrate how local contexts and cultural factors affect SFGP implementation. These factors included individual beliefs and attitudes, the influence of group norms, leadership and consensus building, and localespecific norms. Strong, consultative leadership, in which leaders solicited input from and long-term support of people most directly responsible for policy implementation, was key to success. Keywords addiction / substance use; ethnography; health care, remote / rural; health policy / policy analysis; mental health and illness; mental health nursing; research, qualitative; smoking cessation; tobacco and health The reasons for the persistently high prevalence rate of smoking among people living with severe and persistent mental illness (SPMI) are complex and multifaceted, and tobacco control policies can be integral to influencing tobacco use among this population. In addition, secondhand smoke is responsible for serious illness, including heart disease and lung cancer, in otherwise healthy nonsmokers, and tobacco control policies are key to reducing these exposures (Ontario Tobacco Research Unit, 2001; U.S. Department of Health and Human Services, 2006). Smoke-free buildings can eliminate harmful exposure to secondhand smoke (U.S. Department of Health and Human Services, 2006). Health authorities in Canada extended smoke-free building policies to include surrounding grounds and introduced stringent tobacco-free grounds policies to further reduce these exposures (Kunyk, Els, Predy, & Haase, 2007; Parle, Parker, & Steeves, 2005). Implementing these policies can be particularly challenging in contexts in which health care is provided to people living with SPMI because of the complex social environment. The aim of this study was to describe how the implementation of a smoke-free grounds policy (SFGP) was affected by institutional cultures. Institutional cultures pertain “to the multiple aspects of what is shared among people within the same organization: for example, beliefs, values, norms of behavior, routines, traditions, sensemaking” (Parmelli et al., 2011, p. 2). In this article, we present the perspectives of health care professionals (HCPs), describing their underlying beliefs, norms, and the contexts that influence policy implementation. We also suggest some recommendations for applying the study findings to future policy implementation. Smoking and SPMI To understand better the study and our aims, some background on the relationships between smoking and SPMI is necessary. Smoking has been described as a cultural norm in psychiatric settings, and some authorities attribute the high rates of smoking among people with SPMI as influenced primarily by cultural factors (Crockford, 1 Saskatchewan Institute of Applied Science and Technology, Saskatoon, Saskatchewan, Canada 2 University of British Columbia, Vancouver, British Columbia, Canada 3 University of British Columbia, Okanagan Campus, Kelowna, British Columbia, Canada Corresponding Author: Lyle G. Grant, Saskatchewan Institute of Applied Science and Technology, P.O. Box 1520, Saskatoon, Saskatchewan S7K 3R5, Canada. Email: lggrant@ualberta.net Grant et al. Kerfoot, & Currie, 2009; Voci et al., 2010). In these cultures, tobacco is considered a commodity, currency, therapy, and an instrument to change or govern behavior (Grant, 2007; Lawn & Condon, 2006). Many clinicians believe smoking to be inextricably linked to mental illness through physiological and psychosocial mechanisms (Prochaska, 2011). Moreover, smoking has been shown to modify the effects of medications commonly taken by psychiatric patients (Aubin, Rollema, Svensson, & Winterer, 2012; Dome, Lazary, Kalapos, & Rihmer, 2010; Kroon, 2007; Williams, Gandhi, & Benowitz, 2010); conversely, some medications commonly administered for psychiatric illnesses affect smoking behaviors (Keltner & Folks, 2005; Matthews, Wilson, & Mitchell, 2011; Williams et al., 2010). Smoking can also become addictive, and ethical responses to tobacco control include adequately managing the discomfort that hospital patients may experience in association with involuntary abstinence and nicotine withdrawal (Kunyk et al., 2007). Differential approaches to tobacco policy implementation within psychiatric settings have been influenced by human rights arguments (Ratschen, McNeill, Doody, & Britton, 2008) and ethical concerns (Campion, McNeill, & Checinski, 2006; Kunyk et al., 2007; Lawn & Condon, 2006), amid suggestions that such policies have the potential to harm patients (Lawn & Pols, 2005), and compromise staff provision of humane care when smoking cessation is not the choice of the patient (Wolfenden, Campbell, Wiggers, Walsh, & Bailey, 2008). Differential application of smoke-free policies has also been attributable to the unique cultures that typically embrace and affirm tobacco use within psychiatric settings (Reilly, Murphy, & Alderton, 2006). Rationales for differentiated policy approaches in psychiatric inpatient settings in which patients with SPMI reside or seek treatment have not been fully articulated or necessarily supported by empirical evidence. Smoking bans began to be implemented in various Canadian psychiatric settings after 2005 (Kunyk et al., 2007; Schultz, Bartmanovich, et al., 2010; Schultz, Finegan, Nykiforuk, & Kvern, 2011; Schultz, Ramsden, Green, & Snowball, 2010; Voci et al., 2010). Results of studies have indicated that staff members in inpatient psychiatric settings are likely to oppose smoking bans. This resistance may arise from staff beliefs that psychiatric settings face particular challenges arising from high smoking prevalence, related safety risks, adverse effects on patient–HCP relationships, and potential interactions with antipsychotic medication (Ratschen, Britton, & McNeill, 2009). Further sources of staff member resistance have included concerns over violations of patient rights, anticipated violence, assault, relapse, exacerbation of symptoms, suicide, involuntary discharge, death, and other catastrophic events (Jochelson 1733 & Majrowski, 2006; Rich & Knowlden, 2002; Voci et al., 2010). Nurses in the United Kingdom described impending smoking bans on inpatient psychiatric units as especially challenging, anticipating staff overload, logistic and safety issues, and inadequate treatment of tobacco withdrawal (Snow, 2006). Prochaska (2011) suggested five myths that HCPs may believe that contribute to this resistance and wide acceptance of tobacco use by patients with mental illness: (a) Tobacco is necessary for self-medication, (b) people with mental illness are uninterested in quitting smoking, (c) people with mental illness cannot quit smoking, (d) recovery from mental illness is confounded by removing smoking as an important coping mechanism, and (e) smoking is not a priority issue for people with SPMI. Results of a Swiss study indicated that 87% of the staff rejected the idea of a smoking ban (Etter & Etter, 2007), and in a Canadian study, close to 40% opposed a smoking ban (Voci et al., 2010). Inpatient psychiatric staff often supported smoking in designated areas on the basis of the belief that it enhanced therapeutic relationships (Stubbs, Haw, & Garner, 2004). However, more recent studies have demonstrated a shift to increasing staff support for smoking bans (Praveen, Kudlur, Hanabe, & Egbewunmi, 2009; Wye et al., 2010), and that support may increase after the implementation of a smoking ban (Lawn & Pols, 2005; Voci et al., 2010). Demographic characteristics of staff may aid in understanding why someone supports or resists smoking bans in psychiatric settings. Support for smoking bans in psychiatric settings may be stronger among HCPs who are nonsmokers than in those who are smokers (Dougherty et al., 2002; Voci et al., 2010), and HCPs who currently smoke or formerly smoked may be reluctant to provide tobacco dependence treatments to patients (Sarna, Bialous, Wells, & Kotlerman, 2009). Studies in the United Kingdom showed that a majority of staff in psychiatric hospitals opposed total smoking bans, and staff who smoked were more permissive in their attitude toward smoking on inpatient units than were nonsmokers (McNally et al., 2006; Stubbs et al., 2004). HCPs with lower education levels were also less likely to offer tobacco dependence treatments (Ratschen, Britton, Doody, Leonardi-Bee, & McNeill, 2009; Sarna et al., 2009), and nurses were more accommodating of smoking than were physicians (Stubbs et al., 2004). Even though there are some perceived negative consequences of smoking bans in psychiatric facilities, evidence indicates that such bans do not typically increase levels or incidents of aggression, discharge against medical advice, or use of as-needed medication, and they may serve to reduce adverse events (de Nesnera, Folks, & Rauter, 2012; Hollen et al., 2010; Lawn & Pols, 2005; Shetty, Alex, & Bloye, 2010). In general, more problems 1734 with policies that ban smoking were anticipated than actually materialized (Lawn & Pols, 2005; Voci et al., 2010). In a review article, Lawn and Pols (2005) detailed various unintended negative results of smoking bans and illustrated the mixed-results of various studies. In general, however, the literature suggests that smoking bans produce beneficial outcomes (Moss et al., 2010). Key recommendations for successful policy implementation and avoidance of unforeseen problems have included consistent, coordinated, full administrative support for the application of smoking bans, strong leadership to champion the cause, and supporting and continuing education that assists HCPs in enforcement and treatment measures (de Nesnera et al., 2012; Lawn & Pols, 2005; Moss et al., 2010; Voci et al., 2010). Some authorities have argued that the most important elements influencing the implementation of tobacco bans are attitude and culture (de Nesnera et al., 2012; Rich & Knowlden, 2002). Locked psychiatric units have been recognized as particularly complex social environments with unique dynamics and interplay between social actors (Campion et al., 2008). Smoking bans in these settings can affect patients, staff, and visitors in unique ways. In particular, Campion and colleagues (2008) highlighted a lack of research within psychiatric settings in which investigators adequately reviewed the cultural, structural, political, and environmental contexts in which smoking bans are implemented or studied whether variation in implementation strategies is required in response to localized circumstances and contexts. They suggested adequate interrogation and understanding of the nuances of the social context in which policy is applied as critical to the successful implementation of a smoke-free policy. We address this knowledge gap by examining the implementation of a SFGP through the lens of culture within psychiatric settings in Northern British Columbia (BC). These are vital insights for making predictions about the overall effectiveness of the policies and toward suggesting effective future steps for desired implementation. Method Anecdotal reports of tobacco-free policy implementation have revealed diversity among and across health authorities in Canada, despite the similarity of policies. We used ethnographic approaches to focus on context and human interactions occurring within social structures (Emerson, Fretz, & Shaw, 1995). This focus offered perspectives useful for understanding and informing policy implementation within inpatient psychiatric unit settings. Before collecting data, we obtained approval from relevant ethics review boards associated with two universities and the hospital authority where the study was conducted. Qualitative Health Research 24(12) Study Sites Two hospital-based adult, inpatient psychiatric units were intentionally selected within the same health organization (Sites A and B) in Northern BC, Canada, because anecdotal accounts suggested contrasting experiences with implementing the same policy. Geographically, Northern BC is predominantly rural and occupies approximately two thirds (372,800 square miles [600,000 km2]) of the most northerly portion of the province (Northern Health, 2009) and is home to almost 300,000 people, about 6% of the population of the province (BC Stats, 2009). Most of Northern BC is sparsely populated; one third of the population lives in communities of fewer than 3,000 people (BC Stats, 2009). Site A is located in the largest urban center, with about 71,000 inhabitants (11.4% of whom are Aboriginal peoples; Statistics Canada, 2006). Site B, approximately 357 miles (575 km) west of Site A, was in a city with approximately 11,300 inhabitants (21% Aboriginal peoples; Statistics Canada, 2006). The city in which Site B is located was the more rural of the two in terms of nearness to areas with a population of more than 50,000, access to services, inhabitants’ perceptions of rurality, and remoteness (MacLeod et al., 2008; Pitblado, 2005). A vast geographical area and sparse population distribution means that most specialized health services were located in the city of Site A; travel to this city from other Northern BC locations was lengthy at any time and especially difficult and dangerous in the winter. The Site A psychiatric unit was contained within an aging but well maintained, busy, 220-bed hospital originally built in the 1950s. The Site B unit was contained in a quiet, 40-bed, regional hospital built in 1959. At Site B, specialist services were limited, and a psychiatrist traveled from larger urban settings once a week to consult with local primary care physicians. Many people with SPMI migrated to northern cities for access to the regional hospital and specialized mental health care services. The availability of mental health specialist services was limited, and access was often an issue for more than two thirds of clients who lived in Northern BC (BC Stats, 2009; Hunter, 2006). Psychiatric units in both Sites A and B responded to local and regional community needs to accommodate individuals requiring admission to hospital for psychiatric treatment, and a mixture of voluntary and involuntary inpatients were treated. Site A could accommodate 20 patients within the main hospital, whereas Site B had a 10-patient capacity in a building adjoined to the main hospital. The sites, although different in many respects, implemented the same SFGP. Data Collection Procedures Data collection commenced about 1 year after SFGP implementation and was conducted between 2009 and 1735 Grant et al. 2010. Four data collection methods were used: fieldwork, participant observation, document review, and interviews. Fieldwork included mapping the psychiatric units, hospital grounds, and adjacent public lands and examining the hospital grounds for evidence of where smoking activities occurred and for signage and materials related to the SFGP. Participant observations focused on tobacco-related interactions within and between HCPs and patients for which we obtained participant consent. Restricting observations in this way was viewed as least intrusive, fostering acceptance of the researchers (us) at the sites, and reducing potential harm to patients who might have altered perceptions related to their mental illness. We were reflexive about our influence on the participants and analyses, recording such reflections in field notes and journals. We observed participants for a total of 69.5 hours at various times of the day and included all days of the week. With HCPs’ consent, our informal conversations with HCPs were included in the data set. Document review included analysis of template documents about patient care, written policies concerning tobacco use in the unit that were directed to staff, tobacco-related signage, other written tobacco polices related to the unit, and tobacco-related resource materials. HCP interviews focused on personal and professional experiences, observations, perspectives, and impressions of the SFGP. To thickly describe the sites, HCPs were encouraged to talk about their own significant experiences and priorities with regard to the SFGP, and interviews commenced by our prompting participants to “Think about what a typical day on the unit looks like in relation to tobacco use and smoking, and then tell me about that day.” Open-ended questions were used with additional probe questions to increase richness and depth of data (Milne & Oberle, 2005). Individual interviews were conducted with 19 HCPs, including team leaders from each site and a manager from Site B. HCP interviews lasted between 45 and 60 minutes and, with one exception, occurred at the workplace. Sample sizes were based on decisions to ensure that participants reflected diversity and that the data collected had depth and breadth. Data were analyzed contemporaneously with their collection, and sampling continued until data were repeating and representative coverage of emergent themes were saturated (Sandelowski, 1995). Eight individual interviews and eight informal conversations were recorded at Site A; of the interviewed participants, 2 were current smokers, 2 former smokers, 4 nonsmokers, and 12 of the 16 participants were female. At Site B, 11 individual interviews and 3 informal discussions were recorded; of the 11 participants interviewed (9 of whom were female), 1 identified as a current smoker, 4 as former smokers, and 6 as nonsmokers. Ages of participants ranged from 32 to 65 years, with mean ages of 47.6 at Site A and 49.3 at Site B. Participants recorded a mean of 14.3 years of experience in psychiatry; 14 had been in their current positions for more than 4 years. Of the 14 participants who were nurses, 5 reported their highest education as a nursing diploma, 7 as a diploma in psychiatric nursing, and 2 as baccalaureate degrees. Of the 4 non-nurse participants, 2 reported masters’ degrees or equivalent and 2 reported postsecondary diploma or certificate. Sixteen participants self-identified as White, 1 as White/“East Indian,” 1 as Black, and 1 as other, nonspecified race. Data Analysis Interviews were audio recorded digitally and transcribed. Field notes and observation data were jotted in notebooks and subsequently transcribed into electronic documents. Data analysis formally started with analytic notes and memoranda. Electronic files, notes, recordings, and draft manuscripts formed parts of a complete audit trail. Cultural inferences reported in the findings were based on analyses of what people were saying and doing (how they were acting) and the artifacts they were using (Spradley, 1979) as revealed through and triangulated by observations, the documents reviewed, the informal discussions, and formal interviews with HCPs. Interview data often proved the most informative, and quotations are included in this report as illustrative of the findings reported. We were cognizant of our roles as interpreters of the data, recognizing that the data are value laden (Hammersley, 1992), and that the data collection and analysis was shaped by our own sociohistorical locations (Creswell, 2007; Hammersley & Atkinson, 1995). Reflexive journaling and questioning aided processes of discovering and reflecting upon our influences and analyses (Thorne, Kirkham, & MacDonald-Emes, 1997). We conducted a thematic analysis and derived consensus about the findings inductively through discussions among ourselves that continued during the writing of this article. Findings Sites A and B implemented the same SFGP that prohibited tobacco use in all of the hospital authority’s facilities and grounds; with a few exceptions, formal site leaders had agreed to adopt similar but site-specific implementation strategies. As part of the implementation strategies, tobacco and tobacco-related items would be handed in or confiscated from patients on admission to the psychiatric unit and held as contraband until the patient was discharged, at which time the items would be returned. In contrast to previous practices, tobacco and tobacco 1736 paraphernalia were no longer handled by HCPs for patient use or consumption. Under the new policy, previously known “smoke breaks” were renamed “fresh air breaks” (FABs), and patients were prohibited from talking about smoking activities during their inpatient stay, to reduce addiction triggers as part of an ethical response to patients’ withdrawal symptoms. For HCPs, the SFGP could easily emerge as a source of tension and conflict. In referring to the impact of the new SFGP during an informal conversation, one HCP stated, “As we speak today, it is a constant fight.” Other HCPs characterized implementation of the SFGP as an ongoing battle or effort, and our understanding of the policy at each site was contingent on uncovering cultural norms and the structures, beliefs, and attitudes that guided HCP practices. Site A findings are described as reflecting the theme maintaining the status quo, and the results pertaining to Site B reflect the theme new practice challenges. Subthemes are described within each section to support and illustrate the overarching major themes. We present the findings in Site A first, followed by those in Site B, and then we discuss some comparative details about the two sites. Site A: Maintaining the Status Quo When asked to consider what changed with the new policy, a HCP explained that she did not view the SFGP as having created a smoke-free environment but believed that it only caused the smokers to move to the sidewalk. This signaled that most pre-SFGP practices and routines were maintained and thus the status quo was upheld. The inductively derived theme of maintaining the status quo comprised four subthemes: (a) policy as the focus of resistance, (b) patient advocacy through “knowing best,” (c) a culture of ignoring, and (d) tobacco as essential for patient relations. Policy as the focus of resistance. Data suggested that implementation of the SFGP was met with resistance and defensiveness as HCPs fought to maintain the status quo by keeping unit routines and practices around tobacco use the same as before the policy implementation. Recent staff cuts, demotions, and organizational and management restructurings created vulnerabilities that may have prompted HCPs to react in this way. Interview and observational data revealed how HCPs were strongly bound by group norms and processes in adopting a unified stance to regain some control over their workplace. Within an environment in which divisive employee–manager (i.e., “us and them”) elements had already emerged, the SFGP provoked and exacerbated many HCPs’ concerns. In building group unity, HCPs exerted peer pressure as a means of ensuring solidarity in resisting the SFGP-induced Qualitative Health Research 24(12) changes and potential conflict with patients that they believed would result from its implementation. The policy appeared to challenge many HCPs’ personal beliefs about the role of tobacco in patients’ lives, and the HCPs contested the legitimacy of strict policy enforcement. During interviews and informal conversations, many HCPs framed the SFGP as being the idea of someone else, handed down by managers who had little insight to the clinical practice challenges of implementing the policy. Observational and interview data showed how HCPs devised ways to circumvent management: by surreptitiously creating some ambiguity about how the policy was to be implemented and by interpreting individual patient circumstances as trumping the policy parameters. Few HCPs recognized the policy as health promoting and instead focused on reducing the visibility of cigarettes by abandoning the “smoke break” terminology. Questioning the credibility and contesting the power of policymakers was central to HCPs’ resistance. One HCP who was a former smoker illustrated the perceived detachment of policymakers from frontline workers: Well, the policy, I tell you what the problem is . . . for something to work, we all [need to] work as a unit. You cannot rely on the lowest people with the lowest area of power to do the difficult job while the top ones who are the ones with the power and authority ignore it [the policy] completely. This statement underscores the importance of group norms and behaviors and reveals participant actions of resistance to policymakers’ power and the marginalization that it threatened to invoke. This HCP perceived policymakers as uninterested in SFGP implementation and was resistant to implementing a policy to which she or her work group had not agreed in the first place. Policymakers and other leaders were expected to lead and support difficult frontline work. When leaders assumed HCP compliance or did not fully assess the policy implementation, they created opportunities for workers to resist the new policy and draw solace from the inertia of their prepolicy practices. Patient advocacy through “knowing best.” Most HCPs adopted a patient advocacy position through knowing what was “best” for patients. This position may have reflected HCPs’ retaining established practices, beliefs, and norms. Grounded in assertions that the SFGP was about smoking cessation, HCPs’ practice experiences suggested that patients were uninterested in quitting or unable to quit. Long-standing viewpoints that tobacco use was linked to control of symptoms of mental illness and to coping mechanisms were understood as valid and legitimate. HCPs Grant et al. recounted patient behaviors that supported beliefs that patients do not want to quit smoking and that patient hospitalization was the wrong time to address smoking reduction as a priority. Such patient care and treatment priorities imbued with patient advocacy fueled HCPs’ resistance to reductions in tobacco consumption. HCPs’ propensity to hold and withhold cigarettes for patients whom they viewed as vulnerable suggests a paternalistic approach to “knowing best.” Patients assessed as vulnerable were those who were viewed as unable to manage their own tobacco use, those who lacked judgment or cognitive ability to regulate their own tobacco use, or those who risked having their tobacco stolen by other patients. HCPs were concerned for patient welfare and suggested that the new policy sanction prohibiting HCPs from holding and dispensing tobacco to patients abolished means, options, and support for the most vulnerable patients. Paternalism was the norm for expressing caring and was illustrated by one HCP who was a nonsmoker: There’s still the odd patient who has to keep their cigarettes up at the front because maybe they’re too sick to be running around with a whole pack or, you know, they’re not careful enough to look after the whole pack and they can get stolen out of their room and that sort of thing. Holding cigarettes for vulnerable patients was also part of avoiding the conflict and upset that resulted from unexpectedly running out of cigarettes. HCPs argued that they could help regulate consumption of tobacco for the most vulnerable patients through maintaining a practice of holding and dispensing cigarettes (i.e., continuing a pre-SFGP practice). A culture of ignoring. A culture of ignoring helped support resistance to the SFGP and sustain the status quo. “Turning a blind eye,” “What I don’t see, I don’t know,” and “Don’t ask, don’t tell” were HCP responses when asked about the SFGP and current tobacco use by patients. It is arguable that ignoring patients at times had therapeutic purpose in helping patients regulate their behaviors, impulses, and social skills. Such approaches to tobacco regulation reduced patient–HCP conflicts concerning SFGP compliance and also helped HCPs reconcile individual actions with values and beliefs concerning tobacco use by psychiatric patients. For example, a Site A–specific rule under the SFGP was to confiscate tobacco and tobacco-related items on patient admission and when otherwise visible on the unit; however, postadmission confiscation was not routine. Ignoring became a practice of avoiding this aspect of policy implementation, as one HCP explained, I don’t know who smokes now that we have “fresh air breaks.” I do not know if they smoke, and I do not want to 1737 know . . . what they do on their break is not my business . . . . If I see them with cigarettes, I have to take them away because it is the new policy. I have a conflict of interest if I ask them if they smoke, so I don’t want to know. HCPs seemed resistant to completing the tobacco assessment admission information for new patients, a strategy that confirmed their lack of knowledge about who smoked. A culture of ignoring also extended to HCPs’ perceived segregation from the larger hospital community. HCPs regularly responded that they did not know what went on in the rest of the hospital, did not see what was happening on the hospital grounds, and could not speculate about how other staff in the hospital approached the SFGP. Some of these reports were incredulous or willful in isolating the unit from the rest of the wards and hospital. This position may have been derived from transference of stigma associated with mental illness. Through ignoring, HCPs resisted changes that came with the SFGP to support the status quo, and in ignoring, HCPs also strengthened group bonds and SFGP resistance through collective action. Tobacco as essential for patient relations. HCPs viewed tobacco as important in establishing and maintaining therapeutic rapport with patients and in managing patient behaviors, especially unruly ones. The power of tobacco addiction was instrumentally used by HCPs to influence behaviors in patients through a reward system that included discretionary granting of FABs. If a patient was a smoker, HCPs, by granting or withholding hourly FABs, could influence behaviors. Confirmed through observation of and conversations with HCPs, the use of FABs emerged as a bargaining tool in this regard. Many HCPs suggested that controlling tobacco use also forced them to adopt surveillance roles with patients. One HCP, a former smoker, when asked to reflect on a typical day with regard to tobacco use and management, lamented policing and parenting roles, which, she asserted, accompanied the new policy: It can be frustrating. We feel like policemen. We have to have them lined up, and they sign on the board, and they go off every hour, and then “No, you’re not due for another 15 minutes.” And then they’re hounding us. You basically give them a privilege for—It’s almost like for good behavior or like treating children for, like, you know, good behavior, really. You get this privilege if you perform this way. Which I suppose is wrong, but that’s the way it goes here. Frustrated, this HCP weighed personal and professional beliefs in ultimately accepting the existing group norms. The influence of these norms was especially evident in her continued reference to “we” and complicity in 1738 giving way to the “will of the dominant group.” Although critical of the policy, some HCPs implied that dominant clinical practices regarding patients’ tobacco use compromised their ideal nursing care. After all, tobacco-related health concerns about the patient, while giving way to controlling patient behaviors, raised questions about who benefited most from patients’ continuing to smoke: the HCP or the patient. The SFGP brought to the forefront long-standing tobacco-related practices and the use of tobacco to maintain patient relations and, in doing so, revealed some tensions in maintaining the status quo. Overall, these tensions did not give rise to the wholesale changes that would accompany full implementation of the SFGP. We found similarities and contrasts to this finding in Site B. Site B: New Practice Challenges HCPs at Site B consistently referred to practice challenges when asked about their experiences with implementing the SFGP, and this often led to making practice choices about how and what to enforce through the policy. Numerous policy-induced tensions were reported and observed between the patients and HCPs, within the HCP team, and between the unit and staff members in other areas of the hospital. There were high expectations of compliance with the SFGP, and this led HCPs to regulate their practice to ensure that they supported and, as necessary, implemented the specificities of the policy. Amid competing work demands and fatigue, it was evident that HCPs were focused on avoiding conflict by thoughtfully choosing their actions. Under the overarching theme of new practice challenges, which refers to HCPs’ desire to resolve practice challenges amid implementing the SFGP, we derived four subthemes: (a) strong, consultative leadership; (b) HCPs’ discretion in practice; (c) the challenges of broad compliance; and (d) scarcity of resources. Strong, consultative leadership. Strong, consultative leadership from people in management positions at or near the unit level was a distinguishing feature of Site B; here, formal leadership governed and ultimately subtly overrode HCP resistance. Although some resistance was evident, related debate between HCPs was open, a practice encouraged and facilitated by the managers. Managers stated that they encouraged discussion as opportunities to model responses to those who voiced resistance to the policy. Accordingly, formal leaders led frontline HCPs toward countering resistance in their own and others’ practices. Managers communicated their vision for ensuring policy implementation, and because one wellrespected manager was instrumental in developing the SFGP for the governing health authority, the policy was regarded by HCPs as having been developed with the Qualitative Health Research 24(12) input of the unit. Ensuring implementation was a reflection of HCPs’ respect for the manager. In this regard, there was no question about whether the policy would be implemented; rather, the HCPs’ efforts tended to center on how that might best be achieved. Furthermore, to gain HCP support, the site’s team leaders presented the SFGP as a professional practice imperative to respect patients by promoting holistic care equal to that provided to other patients and inclusive of smoking cessation supports. A manager from Site B, a former smoker, explained the importance of leadership in guiding the cultural norms necessary for effective SFGP implementation: The subtle nuances [were] probably the hardest thing, because a lot of “psych” staff can work that way, but if somebody really needs a policy to follow, then it gets harder . . . [guidance] has to come from the team leader. The strength and willingness of HCPs to consult with the formal leadership team potentiated the possibility that the SFGP would be implemented successfully. Nevertheless, there were implementation challenges. In speaking of other HCPs at the hospital, one HCP who smoked explained, It’s us and them [other hospital HCPs]. They’re the good guys because they are letting patients go smoke and we’re these rotten horrible people that are stopping these [patients] from doing this . . . down here [people get frustrated and start questioning the policy] . . . and then emails go around . . . about “Haven’t you done this?” and it’s almost like everyone’s pointing fingers. A lack of unity in supporting the SFGP policy within the hospital began to infiltrate, challenging the unity they had initially enjoyed on the unit. Lack of management consensus shifted the responsibility for decision making about patient smoking to HCPs. HCPs’ discretion in practice. HCPs acknowledged and demonstrated flexibility in interpreting the policy rules, and the subtleties of meaning afforded personal discretion and interpretations that underlay the implementation of the SFGP. The policy was enacted within an array of cultural ideals and practices that shaped the inpatient psychiatric unit. Central to this were HCPs’ practice and triage. HCPs determined their own tolerance for diverse practices. Some staff divisions concerning acceptable levels of policy implementation were evident with regard to occupational health and safety concerns. One HCP who was a former smoker explained, I’ll police it to a point, but I won’t jeopardize my relationship. I won’t jeopardize any of the situations or my safety within Grant et al. it, too. I will turn a blind eye to stuff if it’s going to mean that I’m not being abused, verbally or so on. I protect myself as well, if it’s going to protect other people. Ensuring personal safety was a cultural norm among the HCPs, and although policymakers had anticipated violence as a result of enforcing the SFGP, respect and politeness could also inform lapses in implementing the policy. As a cultural norm, politeness was an organizational value that prevailed in Northern BC. Health authority documents mandated “good citizenship,” and politeness signaled valuing community membership as particularly important in Northern BC. Well-mannered approaches were believed to help avoid violence and conflict when one individual sought to confront another about the policy. Various corporate documents were seen to reflect policymakers’ commitment to providing employees with a safe workplace. Health authorities were also expected to function from a caring perspective as part of their professional practice codes. HCPs indicated that difficulty arose with patients who had acquired brain injury because of the cognitive impairments that limited their ability to comprehend and abide by some of the policy ambiguities. These patients were also thought to be the most likely to react violently to strong enforcement measures because of their misunderstandings of the policy. Determining when and how to exercise HCP discretion with regard to the SFGP required insider knowledge unique to the unit. The challenges of broad compliance. Site B HCPs noticed inconsistencies in policy uptake. The hospital had a strong culture around accepting tobacco, whereby smoking among staff and patients was a long-standing norm. After nearly 18 months of strict compliance, the morale of HCPs working at Site B was wavering, at least in part because of their understandings that employees in other areas of the hospital were not enforcing the SFGP. The tensions that emerged from this discordance grew over time; continuing challenges with SFGP implementation were internalized by some HCPs and gave rise to selfdoubt about the appropriateness of the policy and implementation efforts. HCPs complained that smoking went virtually unchecked around the hospital but that hospital staff were willing to report psychiatric patients’ SFGP violations while ignoring other groups of smokers. Lack of security personnel was a factor that left smoking on the hospital grounds unchecked; however, reporting violations on the part of psychiatric inpatients reflected norms around managing that patient subgroup. Inconsistencies in the application of the SFGP were reported by HCPs as increasing conflict between staff working on Site B and those working on other hospital units. 1739 The language used by the policymakers in official documents related to the SFGP emphasized institutional values and indicated that joint responsibility and solidarity would yield benefits for all. Often emphasizing “responsibility,” these documents suggested that HCPs were expected to enforce the policy actively. When describing how she saw the rest of hospital enforcing the SFGP, one HCP who was a nonsmoker laughed, suggesting, All one has to do is really walk around the hospital to see . . . in Emergency especially . . . I know at one time, it was flatout conflict . . . We’d say, “You need to have [patients] sign the non-smoking policy [the SFGP acknowledgment] before they come down [to our unit]” and . . . be told by the Emergency nurse, “Well, it’s not our policy, it’s yours.” I think that speaks to it. The policy implementation had inadvertently sanctioned boundaries within the hospital, which in turn threatened to alienate the HCPs working on the psychiatric ward, as well as that patient subgroup. Scarcity of resources. A scarcity of HCPs and community and organizational resources also affected implementation of the SFGP. When unit workload was particularly demanding and HCPs’ energy flagged, implementation of the SFGP lapsed. Self-protection efforts included prioritizing practice choices to conserve energy. In discussing how implementation of the SFGP connected to seasonal workload changes, one HCP who was a former smoker stated, Like anything, you start out maybe strong in something and then it just kind of relaxes a little bit . . . We were shortstaffed and we were getting a lot of agency nurses for a while, too, so and it could’ve been that. In the wintertime we definitely had that, so people aren’t as on board with it, too, as people who are flying in for 2 weeks or 4 weeks or something. The use of agency nurses to address workload afforded few opportunities to orient new and temporary workers to the SFGP and its nuances. Although agency staff might have been willing to follow direction, fewer HCPs were championing the policy. Site B had no resident psychiatrist, and so the presence of a consultant psychiatrist was sporadic; this also contributed to practice norms whereby HCPs assumed increased independence in their practices. This also translated into independent practices concerning tobacco assessment and nicotine replacement treatment supports, and promoting smoking reduction or cessation was typically not a priority. Human resource shortages and the shift work structures reportedly curtailed initiatives to support patients’ attempts to quit. 1740 Because human resource shortages were perceived as organizationally bound and outside the control of HCPs, they in turn perceived an inability to provide consistent care to achieve tobacco reduction. That said, HCPs found some creative ways to support smoking reduction/cessation in the presence of HCP shortages. Recreational therapists also developed expertise in tobacco intervention, so that they could counsel patients who smoked. This HCP subgroup attended the psychiatric unit regularly to provide recreational therapy and tobacco reduction support to patients. They could also monitor patients in the community after discharge, and in this regard, nursing staff could defer, at least in part, to other HCPs to assist patients with smoking cessation efforts. Education predominated as the key to changing attitudes and beliefs about tobacco use, in building strengths and uniformity for supporting the SFGP, and as a means of bolstering local resources. Finally, the lack of security personnel at Site B was an important resource scarcity that increased the potential for violence related to the SFGP. If a violent incident were to occur on the unit, wait times for the local police to arrive could be significant. Strategies to avoid violence were therefore especially important. One HCP stated that a reason that the SFGP worked was that HCPs were “skilled at deescalating situations.” Comparing Sites Comparison and contrast of the two sites revealed that specific cultural knowledge and contexts affected SFGPrelated experiences of HCPs. In terms of similarities, HCP experiences at both sites were laden with challenges and struggles. Site A provided an example of resistance to the SFGP to a point at which the policy seemed to have little impact. Site B provided an example of concerted efforts to implement the policy, in which external resistance was managed and addressed, at least in part, with management guidance and the policy presence, and varying degrees of impact and change were visible. Strategic leadership and management at Site B contrasted with frontline HCP leader groups at Site A. Site B had a policy champion who encouraged a sense of HCP ownership of the policy, and Site A did not. Managers at Site B put in place support for changes to HCP practices because of the SFGP; less energy was directed toward this support at Site A. Across both sites, the introduction of the SFGP caused HCPs to question their own practices, knowledge, and attitudes toward tobacco use in this patient population. HCP experiences indicated that SFGP implementation and HCP practices within these contexts required nuanced approaches or subtleties of understanding and tacit cultural knowledge about implementation that must be developed over time. Qualitative Health Research 24(12) Overall, HCPs revealed the importance of various factors, including leadership, staff morale, education, sense of team cohesiveness, cultural norms, passage of time, personal beliefs, resource availability, organizational structures, and locale-related contexts. In terms of locale, Northern BC created unique work environments that included additional considerations of community connections and resource availability. Concepts of caring, safety, autonomy, and fairness undergird many HCP practice choices. For HCPs, patients dominated their concerns in making practice choices related to SFGP implementation, and tobacco-related activities heavily influenced daily routines. Site similarities and differences reminded us that different contexts create unique experiences of SFGP implementation, despite policymakers’ desire to produce uniform implementation. Discussion The study findings revealed prevailing attitudes and beliefs about tobacco acceptance and tobacco control. These attitudes and beliefs were thematically grouped in ways that helped characterize and contrast two sites within the same health organization. Findings mirrored some previous results, including tobacco use as a tool for HCP–patient relations and as assisting with illness management, continuing resistance to tobacco control, and control as a continuing ethical dilemma (Lawn, 2004; Voci et al., 2010). Our study findings also add to existing results of other research focused on SFGP implementation, including the continued presence of smoking at hospitals, staff handling of tobacco, methods of resistance, and concern for patient welfare (Ratschen, Britton, & McNeill, 2008; Schultz, Bartmanovich, et al., 2010; Schultz et al., 2011; Schultz, Ramsden, et al., 2010; Shetty et al., 2010). Also evident was the fact that challenges faced by HCPs were not necessarily anticipated by policymakers, which led to an array of strategies and justifications by which participants subscribed to and yet circumvented and subverted policy implementation. Using ethnographic methods to examine cultural aspects of a patients’ smoking room in a Norwegian psychiatric hospital, Skorpen, Anderssen, Oeye, and Bjelland (2008) found that architecture, ward routines, and other structural factors were important to cultures of resistance. Although their study has some parallels to our study, the Norwegian research centered on a physical space where smoking was permitted within an institutional setting described as a stand-alone, long-term psychiatric treatment hospital. Psychiatric units within stand-alone, longterm psychiatric facilities and psychiatric units within general hospitals probably have different characteristics and cultures that limit direct comparison. We considered factors affecting staff attitudes, including structural Grant et al. elements, in our study and used them to triangulate our findings, but they did not figure as prominently as in Skorpen et al.’s (2008) study. Aligned with the ethnographic methods used, conceptually, the SFGP was implemented through the actions and interactions of individuals within complex social contexts. We confirmed existing research and policy viewpoints (McKenzie & Wharf, 2010; Voci et al., 2010; Wu, Ramesh, Howlett, & Firtzen, 2010), asserting that understanding how culture influences the actions, beliefs, and behaviors of individuals is key to effective policy implementation. Context also helps explain how HCPs’ attitudes, beliefs, and group norms support or challenge the status quo in response to implementation challenges. By conceptualizing and understanding individuals’ behaviors and perspectives within broad contexts, we can illuminate a myriad of factors affecting SFGP implementation that help inform implementation practices and potential avenues to influence change. Individuals’ relationships with management, team leadership, and local communities featured as structural and contextual influences shaping policy implementation. Four of these contexts were informed by and informed the application of the study findings: (a) individual beliefs and attitudes, (b) the influence of group norms, (c) leadership and consensus building, and (d) locale-specific norms. The long-standing prominence of tobacco use in inpatient psychiatric units was sustained through a range of factors, including the enduring individual beliefs and attitudes that predated our policy implementation. HCPs’ beliefs appeared to be driven by better compliance from patients, observations of more amenable patient states, and less visible anxiety and agitation, all justified as preserving therapeutic relationships. HCPs held mixed beliefs about whether the SFGP was about quitting smoking, improving health, or reducing harm. As a result, they interpreted and acted on the SFGP differently. A key feature of policy implementation is ensuring that the goals align with the issues and problems to be addressed. Our findings suggest that the goal of the policy was neither explicitly stated nor uniformly understood. In this regard, HCPs often adopted behaviors based on experiential or personal knowledge while discounting evidence-based knowledge, although with some self-reflection and perhaps interrogation about their current professional practices. Reflective practice might be a first step to changing HCPs’ beliefs and attitudes toward tobacco use among people with SPMI (Miller & Rollnick, 2002). Ever present was the influence of group norms, which prevailed as key to understanding participants’ experiences with the SFGP implementation and their tendencies toward resisting or subverting the policy. Prior and Barnes 1741 (2011), in social policy analysis, conceptualized three types of subversion that were evident to varying degrees in our study: (a) a reinterpretation of policy within specific contexts to subvert the intent of the policy with “official” compliance, but with an unintended outcome; (b) the use of alternative strategies and practices developed through individual or group processes, whereby such practices were initially intended to be outside of the policy intent; and (c) a passive type of resistance that is tantamount to outright refusal to engage in actions consistent with the policy. For example, in the context of our study and the SFGP, HCPs drew limits on implementation of the policy when they assessed it as detrimental to the management of or rapport with the patients and when violent reactions might emerge. Resistance was evident in actions and cultures of ignoring. Common to all these subversive actions was insider knowledge. Prior and Barnes (2011) termed these types of resistive actions as “counter-agency” or “agencies of resistance,” which suggested that they can occur if individuals who implement the policy have the opportunity to choose an alternative course of action that has not been fully prescribed by the policy. The “freedom to choose” permeated the findings in our study. We interpreted strong, consultative leadership as a resource that assisted HCPs in making professional practice decisions to balance patient care with patient management and as a means of addressing an inability to prescribe actions for all circumstances arising under the SFGP. Leadership and consensus building also influenced SFGP implementation. Viewing the SFGP as an organizational change confirms Lawn and Campion’s (2010) results. Specifically, in accordance with Lawn and Campion’s (2010) findings, team leaders in our study who successfully fostered team cohesiveness and consistency in application of the policy—and who facilitated staff education that supported HCPs in negotiating many of the interpersonal challenges associated with the SFGP implementation—were most likely to garner support for desired policy implementation. Strong, consultative leadership, including input and participation by frontline employees most directly responsible for policy implementation, offered the strongest indication that policymaker intent could be implemented; this presence can be viewed as part of the structural elements required to initiate change. HCPs also perceived discordance between official policy documents and postimplementation management actions as inhibiting implementation of the SFGP, a finding supported by previous studies (Schultz, Ramsden, et al., 2010; Shetty et al., 2010). Our study findings and the contrast between the two sites demonstrate the importance of locale-specific norms and signal potential limitations for examining SFGP implementation in cases in which a single organizational 1742 culture prevails (Brooks, Pilgrim, & Rogers, 2011). Our results confirm that SFGP implementation does not necessarily transcend inpatient psychiatric care cultures. Policy implementation that espouses or attempts to drive or trade on homogeneous cultures may be naive. Instead, policymakers and executive hospital managers might best anticipate and thoughtfully attend to heterogeneous cultures when implementing SFGPs. Although our study afforded a rich cross-sectional ethnographic account, it is limited to the observations, interviews, and documents drawn from two sites. In this regard, the locale specificities limit what can be claimed as relevant to other geographic locales and organizations. That said, our findings offer important insights about the complexities involved in catalyzing efforts toward policy development and implementation in health care contexts. Espousing a single recipe for SFGP implementation is somewhat naive in this regard, but the value of repeating our study elsewhere and conducting longitudinal analyses to describe fully changes across time is resoundingly evident. In conclusion, we recommend that HCPs working in inpatient psychiatric settings require long-term commitment of resources and supports to meet the additional demands of professional practices that come with SFGP implementation. These resources may include paid study leave for tobacco-related practice education, time and space in which groups of HCPs can meet to model roles and discuss related practice issues, active HCP engagement in the development and proposal of policy implementation plans, staffing to match resultant workloads, thoughtful attention to and integration of locale-specific factors, and leadership and management courses to support both reflective and changing professional practices. Our findings confirm that policy fidelity to SFGPs in inpatient psychiatric units is encouraged when environments foster strong, consultative leadership and evidenceinformed practices and when long-term supports foster supportive cultures for professional practice development with regard to tobacco use. Acknowledgments We thank Annette Schultz, Sandra Regan, and Heather MacMillan for their contributions and support. Authors’ Note The portions of this article were presented at the International Institute for Qualitative Methods Conference, October 27–29, 2013, Halifax, Nova Scotia, Canada. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Qualitative Health Research 24(12) Funding The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by University of Northern British Columbia; Northern Health; Interdisciplinary Capacity Enhancement Grant, University of Waterloo; University of British Columbia; and The Province of British Columbia. References Aubin, H. J., Rollema, H., Svensson, T. H., & Winterer, G. (2012). Smoking, quitting, and psychiatric disease: A review. Neuroscience & Biobehavioral Reviews, 36, 271–284. doi:10.1016/j.neubiorev.2011.06.007 BC Stats. (2009). 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Preventive Medicine, 46, 346–357. doi:10.1016/j. ypmed.2007.12.003 Wu, X., Ramesh, M., Howlett, M., & Firtzen, S. (2010). The public policy primer: Managing the policy process. London: Routledge. Wye, P., Bowman, J., Wiggers, J., Baker, A., Knight, J., Carr, V., . . . Clancy, R. (2010). Total smoking bans in psychiatric inpatient services: A survey of perceived benefits, barriers and support among staff. BMC Public Health, 10, Article 372. doi:10.1186/1471-2458-10-372 Author Biographies Lyle G. Grant, JD, PhD, RN, is the coordinator of the Institute for Nursing Scholarship at Saskatchewan Institute of Applied Science and Technology, Saskatoon, Saskatchewan, Canada. John L. Oliffe, PhD, RN, is a professor of nursing at University of British Columbia, Vancouver, British Columbia, Canada. Joy L. Johnson, PhD, RN, FCAHS, is a professor of nursing at University of British Columbia, Vancouver, British Columbia, Canada. Joan L. Bottorff, PhD, RN, FCAHS, FAAN, is a professor of nursing and director of the Institute for Healthy Living and Chronic Disease Prevention, University of British Columbia, Okanagan Campus, Kelowna, British Columbia, Canada.