Exploring mental health professionals’ practice in relation to smoke-free policy within a mental health trust: a qualitative study using the COM-B model of behaviour

Abstract

BackgroundSmoking has played a significant role in the historical culture of mental healthcare settings. Mental health professionals (MHPs) often hold dismissive attitudes regarding the importance of smoking cessation in the context of mental healthcare. In 2007, English mental health inpatient buildings were required by law to become smoke-free, and healthcare trusts have more recently begun to implement comprehensive policies (i.e. smoke-free grounds and buildings) and staff training in response to national guidance. It is therefore important to explore MHPs practice around smoking, smoking cessation, and smoke-free policy adherence. This study aimed to explore these issues by using the COM-B (capability, opportunity, motivation, behaviour) model to systematically identify barriers to, and facilitators for, MHPs addressing smoking with their patients.MethodsFive focus groups with a total of 36 MHPs were conducted between March and August 2017. MHPs were recruited from one of the largest mental health trusts in Europe. Discussions were guided by a semi-structured guide. Responses were audio recorded, transcribed and coded using thematic analysis and the COM-B framework.ResultsAddressing smoking with patients was undermined by MHPs’ 1) psychological capability to recall training content, misunderstand the potential benefits of addressing patient smoking and harm reduction approaches; 2) physical opportunity in terms of time constraints, and easy accessibility of tobacco in the community; 3) social opportunity in terms of increased cultural value of tobacco following inpatient smoke-free policy implementation, and lack of support from colleagues to enforce the smoke-free policy; 4) automatic motivation, including intrinsic biases regarding patients abilities and motivations to quit, and 5) reflective motivation, including perceived job role and decision making processes related to addressing behaviours deemed more important than smoking. The main facilitating factors identified were MHPs’ having opportunity in the form of patients asking directly for support, and MHPs having access to resources such as stop smoking services and spirometers.ConclusionMultiple barriers were identified across all key domains of the COM-B framework that undermine MHPs’ practice regarding smoking cessation. Few facilitators were identified which may have implications for future smoke-free policy and clinical practice.

Mental health professionals' perceptions, judgements and decision-making practices regarding the use of electronic cigarettes as a tobacco harm reduction intervention in mental healthcare: A qualitative focus group study

“…We report elsewhere that MHPs in the current study experience constraints in their capability, opportunity and motivation to address smoking with their patients, including having the belief that smoking is not a priority behaviour to address with mental health patients ( Smith et al, 2019 ). This is a persistent issue which has not only been found in mental healthcare, but also among healthcare professionals who work with other socially disadvantaged groups experiencing high smoking prevalence, including those in addiction services and the homeless ( Cookson et al, 2014 ; Garner & Ratschen, 2013 ).…”

“…Therefore, it is crucial for research to explore the cause of these concerns, in order to develop interventions to minimise them. One explanation may be that MHPs heavily rely on mental shortcuts when making decisions regarding ECs, especially in light of resource constraints ( Smith et al, 2019 ). For instance, judging ECs based on perceived analogies with conventional cigarettes may be explained by the cognitive bias known as representative heuristics, and the tendency to recall information frequently presented by the media over less frequent training content and scientific publications may be the consequence of information and availability bias ( Tversky & Kahneman, 1974 ) ( Table 2 presents finding from theme 1 using a cognitive psychology framework).…”

“…For instance, judging ECs based on perceived analogies with conventional cigarettes may be explained by the cognitive bias known as representative heuristics, and the tendency to recall information frequently presented by the media over less frequent training content and scientific publications may be the consequence of information and availability bias ( Tversky & Kahneman, 1974 ) ( Table 2 presents finding from theme 1 using a cognitive psychology framework). Indeed, it is widely known that negative press regarding ECs tends to be more prevalent in the media compared with positive messages ( McNeill et al, 2018 ), and so it may not necessarily be of surprise that such sources are being utilised, particularly among MHPs who feel they lack resources to address smoking with patients ( Smith et al, 2019 ).…”

“…For the purpose of the aims of this research paper, the data obtained from questions three and four (regarding THR and ECs) were included in the analysis of this paper. Data regarding MHPs' experiences of providing smoking cessation interventions and attitudes/compliance toward the smoke-free policy are reported in another qualitative paper by the same authors ( Smith, McNeill, Kock, & Shahab, 2019 ).…”

Improving case detection of tuberculosis in hospitalised Kenyan children– employing the Behaviour Change Wheel to aid intervention design and implementation

“…Behaviour Change Techniques are the active, observable and replicable components that make up an intervention. COM-B/BCW have been used successfully for behavioural analysis and to design interventions in both health and non-health-related elds [26,[36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54][55], but to our knowledge, has been used in only one study of TB on contact tracing in a low-resource setting, to identify barriers and facilitators and to tailor interventions to improve contact investigation in Kampala [26]. In the qualitative arm, to understand the challenges in recognising and testing for TB in admitted children we analysed data from: i) semi-structured interviews, small-group discussions and key informant interviews with front line health workers and mid-level managers; ii) observations of TB trainings, sensitisation meetings, policy meetings, and hospital practices, and iii) desk review of guidelines, job aides and policy documents, which have been reported elsewhere [31].…”