Smoke Free WA Health System Policy – partial exemption for involuntary mental health patients

These Guidelines should be used by Mental Health Services to support the implementation of the partial exemption within the OD 0414/13 Smoke Free WA Health System Policy (external site) (the Policy).

1. Criteria

1.1 In order to apply the partial exemption to the Policy within mental health service facilities, the following criteria should be met:

  • patients must be involuntary mental health patients
  • patients must be aged 18 years and over
  • an appropriate outdoor designated smoking area is available (see below)
  • smoking will not interfere with the patient’s treatment regime and/or safe operation of the service
  • appropriate observation, which is in accordance with agreed patient/clinical management plan, is available for when the patient chooses to smoke
  • patient has his/her own supply of tobacco/cigarettes
  • non-smokers including staff, patients, visitors and contractors are protected from exposure to environmental tobacco smoke.

2. Smoking area specifications

2.1 The outdoor smoking area must:

  • not be within an enclosed workplace as per the Occupational Safety and Health regulations 1996 (external site) (regulation 3.44AA)
  • meet the infrastructure requirements of a secure area
  • meet fire precaution requirements
  • be a minimum of 5 metres from doorways and 10 metres from ventilation inlets
  • include the provision of shade, minimising ligature points
  • be clearly signed as being a designated smoking area for those who have been given permission to smoke under the partial exemption of the Policy
  • sufficient space must be available for non-smoking involuntary patients.

2.2 The smoking area should:

  • ideally allow for natural observation without exposure to environmental tobacco smoke of staff
  • offer wall mounted cigarette lighters, wherever possible
  • include appropriate provisions for the safe waste disposal of cigarettes (cigarette receptacle)
  • encourage patients to dispose of their cigarettes in a safe manner after use.

3. Occupational Safety and Health (OSH) issues

3.1 Implementation of the partial exemption to the Policy must adhere to Occupational Health and Safety legislation requirements under the Occupational Safety and Health Act 1984 (external site).

The following issues must be appropriately addressed.

3.1.1 A risk assessment must be conducted before allowing patients to smoke.

The risk assessment must take into account the following:

i) Assess the risk of exposure to environmental tobacco smoke by patients, staff, contractors and visitors:

  • ensure that the smoking area meets site specifications
  • assess the risk of staff moving through or accessing the area in the course of their work.

ii) Assess the risk of fire:

  • identify availability of sources of ignition and the proximity to fuels in the area (e.g. dry leaves, rubbish, furniture and other flammable items)
  • ensure adequate emergency evacuation and emergency warning signs in the area
  • ensure adequate availability of fire extinguishers
  • assess whether there is an increased risk to building occupants in an emergency for example persons at greater risk such as babies or children, elderly, people with disabilities).

iii) Assess the risk from associated violence and aggression:

  • assess patients’ risk of aggression whilst utilising the smoking area, including the potential mix of patients in the area
  • assess the ability of early response teams” or “code black teams” to access the area
  • ensure the ability of the required observation to be provided.

3.2 It is the responsibility of the line manager of each site to ensure that they carry out the following:

  • provide and implement procedures for a safe system of work for staff
  • consult with OSH Reps and staff in conducting risk assessments for areas where involuntary patients may potentially smoke
  • provide staff with appropriate training and information as it relates to management of designated smoking areas.

4. Environmental considerations

4.1 Consideration must be given to the environmental circumstances and the dynamics of the ward e.g. personalities, ages or patient cohorts within a ward.

4.2 It must be ensured that allowing the exemption in the current environment would not:

  • cause extreme disruption to the ward
  • risk the safety of other patients or staff
  • greatly affect the capacity of the service to ensure treatment of the patients as the main priority.

5. Developing site-specific instructions

5.1 Each site will need to develop their own protocols for how the partial exemption will be implemented locally.

5.2 Development of the protocols should include wide consultation with the appropriate people (Staff, OSH reps and if appropriate patients and visitors).

5.3 Site specific implementation should be developed in a way that minimises all risks identified in the OSH Risk Assessment, as far as practicable.

6. Managing frequency of smoking

6.1 The following factors should also be considered in determining the partial exemption:

  • therapeutic activity times
  • availability of staff to supervise the area
  • availability of staff to provide the patient with their smoking supplies (where these are held by staff)
  • use of smoking area by non-smokers, where the smoking area is within a confined area and is the only accessible outdoor area for a group of patients
  • in the evening when visibility and supervision may be compromised.

6.2 Suitable strategies should be developed with the patient to enable them to manage their nicotine cravings during those times when they are unable to access the designated smoking area or where there is no available designated smoking area.

This should be discussed in the patient’s Nicotine Withdrawal Management Plan (see 9.1 below).

6.3 Smoking should not be a social event and site policies should ensure that opportunities for this to occur are minimised.

7. Supervision of smoking patients

7.1 The level of supervision available to monitor the designated area should be at levels required for the patient. There will be no additional resources to monitor outdoor areas.

7.2 Staff members cannot be directed to put themselves in direct contact with environmental tobacco smoke as per s107F(2) of the Tobacco Products Control Act 2006 (external site) and s26(1) of the Occupational Safety and Health Act 1984.

7.3 Natural observation from inside buildings or from a sufficient distance is encouraged where it meets the surveillance requirements of the patient care plan.

8. Management of smoking materials

8.1 The responsibility for the supply of cigarettes, tobacco, and/or associated smoking materials will lie with the patient.

8.2 Consider availability of storage facilities for patients’ smoking materials and whether individual patients can take responsibility for their own material.

8.3 Consider availability of wall mounted lighters in the designated smoking area.

8.4 Patients should be encouraged to look after their own cigarettes, tobacco, and/or associated smoking materials/storage key in a way that promotes personal responsibility.

8.5 Patients should be encouraged to clean up after themselves to maintain the area at a suitable standard for everyone to use.

8.6 The following issues should be considered when implementing the management of materials:

  • impact on staff time
  • identification/separation of individual patients’ property
  • managing fire risk
  • enabling access when required.

9. Assessment and management of smoking

It is recommended that all mental health services refer to:

9.1 The assessed smoking status of patients at the time of admission using the Fagerstrom test, and note in the patient’s medical record. Develop a Nicotine Withdrawal Management Plan for all patients who smoke, as part of their overall care plan. The potential impact of nicotine on other pharmacotherapies should also be noted.

9.2 In addition, it is also encouraged that a cessation plan is created. The Cessation Plan should encourage smokers to quit and assesses their readiness to do so instead of purely managing a patient’s nicotine addiction.

9.3 The Cessation Plan should be created with the patient and should be ongoing and reviewed.  It is suggested that issues such as frequency of smoking be discussed and noted within the Plan.

9.4 The Cessation Plan should also include provisions that allow for ongoing support in the community on discharge.

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