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Clinical Audit and Consumer Survey of Attitudes towards a Smoke Free Campus Policy 2014

Authors: Pauline Kent, Catherine O’ Leary, Eimear Flatley Sligo Regional Hospital 1

Introduction: Sligo Regional Hospital (SRH) is a health-promoting hospital and has achieved a number of awards to acknowledge its progress in tobacco control policies. It is committed to its responsibility as a health care provider, not only to its patients, but also to its staff and visitors. SRH is committed to and has an obligation to optimising and sustaining the quality of the hospital environment for everyone, this applies in particular to smoking and the use of tobacco products. This obligation includes not only a smoke free environment but also the provision of an active Smoking Cessation Services (SCS) for individuals who smoke. SRH smoke free campus (SFC) initiative commenced on 31st of May 2013 and the SFC committee embarked on an audit one year post implementation. The committee conduct monthly site audits to ensure sustainability of the project however the audit would determine current awareness and attitudes towards the policy including challenges in the policy’s implementation. As a Health Promoting Hospital, SRH has developed and implemented an extensive SFC Policy which supports the European Network of Smoke Free Hospitals (ENSH) initiative and the Tobacco Control framework plan 2010- 2015.


The SFC policy has been developed to:

1. Protect and improve the health, safety and welfare of staff, patients, visitors and all who access the site by reducing if not eliminating exposure to environmental tobacco smoke 2. Provide a better health outcome for patients/service users by treating tobacco addiction as a health care issue for the duration of their hospital stay 3. Create a supportive environment for patients/service users and staff to support them in quitting smoking should they wish to do so 4. Provide an environment that is cleaner, safer and healthier for all 5. Help change social norms around tobacco use 6. Support management and staff in the implementation of the SFC policy 7. Provide clarity to staff on their role in the implementation of the SFC policy , and in promoting and supporting healthier lifestyle choices 8. Educate staff and service users re electronic cigarettes which are prohibited on campus

The HSE adopted the Tobacco Control Framework in 2010. The TCF is based on MPOWER model presented in the WHO report on the global epidemic 2008. The MPOWER package includes the six most important, effective and evidence based tobacco control policies. A national implementation group was established to deliver the 61 actions identified under the framework.

Key actions progressed to date include: 1. Implementation of a TFC in 20 acute healthcare settings, a number of Primary care sites and all newly opened primary care centres. 2. Social marketing QUIT campaign 3. Accredited national brief intervention training programme for smoking cessation 4. National standards for Smoking cessation services 5. Tobacco control stakeholder network established with representation from 16 key nongovernmental and professional bodies


6. Audit of smoking behaviour among HSE staff 7. Development of policy protecting HSE staff from exposure to second-hand smoke in domestic settings.

Evidence: 1. Tobacco use is the leading cause of preventable death in Ireland (tobacco free Ireland, 2013) 2. Each year at least 5200 people die from diseases caused by tobacco use. (Healthy Ireland, 2013) 3. This represents approximately 19% of all deaths. (Healthy Ireland, 2013) 4. The Irish heart foundation has reported that smoking is the cause of up to 2500 strokes, 500 stroke related deaths per year. (Tobacco free Ireland, 2013) 5. In Ireland the average cost per admission of treating a smoker in an inpatient setting for tobacco related illness is â‚Ź7700. (Tobacco free Ireland, 2013) 6. The World Bank estimates that if the number of adult smokers halved by 2020 there would be 200,000,000 less tobacco related deaths worldwide by 2050. 7. One in every two smokers will die of a tobacco related disease, these diseases include a wide range of cancers as well as respiratory and cardiovascular diseases(Healthy Ireland, 2013)


Baseline information: 

Number of staff in SRH: 1569


Number of beds in SRH: 265

Aims and objectives: Aim: To identify the impact of a smoke free campus initiative in an Acute hospital setting.

Objectives: 1. The investigation seeks to evaluate current compliance of staff, patients and visitors to Sligo Regional Hospital SFC Policy 2. Evaluate awareness of staff to their role in implementation of the policy and to their role in supporting service users who smoke. 3. Evaluate satisfaction levels of the SFC policy by staff, service users and visitors.

Methodology: The audit was conducted by two independent health promotion researchers, external from Sligo Regional hospital, which negated the possibility of research bias 1. The audit was conducted over a 4 week period commencing 30th April 2014 concluding 21st May 2014. 2. It employed a multi-method approach based on quantitative questionnaires and observation assessments throughout the hospital campus and its associated buildings. 3. Questionnaires were designed specific to each population group


Patients: Each department head was informed electronically in advance of pending audit in addition permission was obtained at department level to identify the suitability and ability of patients to partake.

1. Patient questionnaires were administered on a one to one approach 2. Small select number of patients were auditioned as a pilot prior to commencing official audit 3. The two researchers obtained a daily report from the hospital in-patients management systems which identified the % and location of patients who smoke each day 4. Patients were selected based on suitability for the study. 5. Permission was gained from each ward manager and suitable patients were selected in terms of their ability to participate. 6. Data was analysed using Microsoft excel.

Visitors: 1. Visitor questionnaires were administered incorporating a one to one approach. 2. The visitor population samples were chosen systematically to ensure no researcher bias. 3. Permission for observation was obtained from relevant personnel. 4. Researchers approached visitors in various waiting areas throughout hospital. 5. Data was analysed using Microsoft excel.

Staff: 1. Researchers targeted staff in various settings for pilot questionnaire such as canteen, wards and waiting areas. 2. Staff and wards were chosen systematically to ensure no bias. 3. For official questionnaire an email was sent out to all departments outlining the purpose of the study 4. Permission was obtained by the relevant personnel of each ward and surveys were left there for completion by staff and collected the following week. 5. Surveys were left in envelopes at the reception/ most visual area in various staff settings such as offices, canteen and wards. 6

6. Data was analysed using Microsoft excel.

Criteria and Standards: Clinical audit as a standard based approach is considered to be the most effective tool in achieving aims and objectives. Clinical audit can be defined as “A cycle which involves defining standards, collecting data to measure current practice against those standards and implementing any changes deemed necessary” (Jones, 2002) The audit process composed of 4 distinct audit sections and the process was carried out during a specified period, the 4 sections identified were;

1. Survey with a sample of staff 2. Survey with a sample of patients 3. Survey with a sample of visitors 4. Observation of compliance with smoke free campus at various points throughout hospital campus.

In order to effectively evaluate performance it is essential to firstly establish the baseline set of standards. “An audit standard is a minimum level of acceptable performance for that criterion” (Harris, 2004) SRH has based the hospitals standards in relation to tobacco control on the evidence of best practice guidelines of the British Thoracic Society and the standards for HPH while keeping these standards in line with the principle of the Ottawa charter (1986). SRH also uses the minimum standards set out in Irish hospitals by the Irish National HPH network, National Tobacco Legislation and the Department of Public Medicine and Epidemiology.


Standard 1-Commitment: The healthcare organisation engages decision makers, appoints a tobacco free policy working group and is committed to rejecting all tobacco industry sponsorship and designates.

Standard 2-Communication: The working group/committee is responsible for clearly defining systems of communication using a variety of specifically designed media to inform all staff, patients, residents and the community of the organisations tobacco free policy and cessation support system.

Standard 3- Education training: The healthcare organisation sets up a training plan to instruct all staff on how to best approach tobacco users and support tobacco cessation.

Standard 4- Identification and cessation support: The healthcare organisation identifies tobacco users and provides cessation support facilities and ensures continuity of support for patients/residents after discharge.

Standard 5- Tobacco control: The healthcare organisation has developed and is maintaining tobacco free campus grounds.

Standard 6- environment: The healthcare organisation displays clear tobacco free signage(where relevant) and bans all incentives for tobacco use(i.e. no advertising, no ashtrays, and no tobacco sales)

Standard 7- Healthy workplace: The healthcare organisation has human resource management policies and support systems in place to protect and promote the health of all that work in the organisation.

Standard 8- Health promotion: The healthcare organisation contributes to and promotes tobacco control activities in the community setting.

Standard 9-Compliance monitoring: The healthcare organisation renews and broadens information regularly to maintain commitment to the tobacco free policy, cessation follow up and quality assurance.

Standard 10- Policy implementation.


Results: Participant Rates

Patients 14% Patients Staff

Visitors 53%

Staff 33%


53% (72/136) of participants were visitors 33% (45/136) of participants were staff 14% (19/136) of participants were patients

Overall Agreement with Smoke Free Campus Poliicy

9% 7% Yes No Unsure


84% of participants surveyed agreed with the Smoke Free Campus Policy 9% of participants surveyed were unsure about the Smoke Free Campus Policy 7% of participants surveyed disagreed with the Smoke Free Campus Policy.



Visitor's Smoking Status


Smoker Non Smoker


Of the 72 visitors surveyed 89% (64/72) were non smokers 11% (8/72) were smokers

Visitor's awareness of The Smoke Free Campus Policy


Yes No


When asked if the visitors were aware that the hospital was a Smoke Free Campus 94% (68/72) were aware it was a Smoke Free Campus 6% (4/72) were not aware it was a Smoke Free Campus


Agreement with the introduction of the Smoke Free Campus Policy 67

No. of Respondents

70 60 50 40 30 20



10 0 Yes



When asked did they agree with the introduction of the Smoke Free Campus Policy 67 out of 72 responded positively and 5 out of 72 stated they were unsure whether they agreed with it or not.

Exposure to Enviromental Tobacco Smoke during visitor's stay


Yes No


When asked if the visitors had been exposed to any environmental tobacco smoke while visiting the hospital: 75% (54/72) had not been exposed to any environmental tobacco smoke 25% (18/72) had said they had been exposed to environmental tobacco smoke

When asked where they had been exposed to environmental tobacco smoke the most cited place was the main entrance


Precieved Benefits of a Smoke Free Campus

No. of Respondents

59 60



50 40


30 20 10 0 Less Second Hand smoke

Cleaner Enviroment

No Smell of Cigarettes

Smoking Less visible which may influence Young People

When asked what were the potential benefits of a Smoke Free Campus Policy. The participants were allowed tick as many boxes as they felt necessary. 51 agreed with less second hand 59 agreed with a cleaner environment 50 agreed with no smell of cigarettes 31 agreed with smoking less visible which may influence young people taking up the habit.

Precieved problems with The Smoke Free Campus





People will still smoke regardless Compliance Enforcement Unfair to Patients




Unfair to elderly patients

When asked what the visitors viewed as problems with the Smoke Free Campus 45% felt there was no problem with the Smoke Free Campus 33% felt it was unfair to patients who smoke 8% felt that people will smoke regardless


6% felt it was unfair to the elderly people 4% felt that enforcement was a problem with the Smoke Free Campus 4% felt that compliance with the policy was the problem


Staff Smoking Status


Yes No


82% (37/45) of staff surveyed didn’t smoke 18% (8/45) of staff surveyed smoked

Staff Agreement with Smoke Free Campus Policy

13% 18%

Yes No Unsure 69%

69% (31/45) of staff surveyed agreed with the Smoke Free Campus Policy


18% (8/45) of staff surveyed didn’t agree with the Smoke Free Campus policy 13% (6/45) of staff surveyed were unsure about the Smoke Free Campus Policy

Staff views on compliance to Smoke Free Campus as their responsibility


Yes No


When asked if the staff though compliance with the Smoke Free Campus Policy was part of their responsibility. 82% (37/45) felt it was part of their responsibility 18% (8/450 felt it was not their responsibility

No. of Respondents

Complicance Rating of Smoke Free Campus Policy 18 16 14



12 10 8



6 4 2 0

1 Poor






When staff was asked how they rated the compliance with the Smoke Free Campus (17/45) rated it fair with only (1/45) rating it excellent

level of awarenss of The Smoking Cessation Services among Staff 39

No. of Respondents

40 30 20 6 10 0 Yes


When asked if the staff were aware of the Smoking Cessation services 39 responded positively and 6 responded negatively

Possibility of uptake of Smoking Cessation Services by Staff


No. of Respondents

25 20


15 8 10 5 0 Yes



When asked if the staff would use the smoking cessation services to quit smoking 23 responded yes 8 responded no 14 responded not applicable


Awareness of referral systems pathway to the Smoking Cessation Services for Patients


Yes No


The staff awareness level of the referral systems pathway to the smoking cessation services for patients 82% (37/45) were aware of the referral system pathway 18% (8/45) were unaware of the referral system pathway

Patients Patients Smoking Status

37% Smoker Non smoker 63%

63% (12/19) were non smokers 37% (7/19) were smokers


Smoking Status Assessed Upon Arrival 13

No. of Respondents

14 12 10 8


6 4


2 0 Yes



13 out of 19 said they had been asked about their smoking status upon arrival 5 out of 19 said no they were not asked about their smoking status upon arrival 1 out of 19 was unsure whether they were asked about their smoking status due to be confused

What Member of Staff Assessed Smoking Status 10

No. of Respondents

10 8


6 3

4 2 0 Nurse



10 out of 19 had said it was a nurse that had asked about their smoking status 3 out of 19 had said it was a doctor that had asked about their smoking status 6 out of 19 has said they were unsure also due to confusion


Patients awareness of Non Smoking Campus Policy


Yes No


95% (18/19) were aware of the Smoke Free Campus Policy 5% (1/19) were not aware of the Smoke Free Campus Policy

Exposure to Enviromental Tobacco Smoke During Stay in Hospital


Yes No


89% (17/19) had said no they were not exposed to any environmental tobacco smoke during their stay in hospital 11% (2/19) had said they were exposed to environmental tobacco smoke during their stay in the hospital The most cited area for exposure to environmental tobacco smoke was again the main entrance.


Support Recieved for Smoking Cessation 5

No. of Respondents





3 2 1 0 Informed of Smoke Free Campus Policy

Offered Nicotine Replacement Therapy

Referral to Smoking Cessation Service

5 out of 19 said they were informed of the Smoke Free Campus Policy 3 out of 19 said they were offered nicotine replacement therapy 4 out of 19 said they were offered referral to Smoking Cessation Services

Evaluation of Excemption Site



Medical South


Coronary Care Unit Oncology 53%


Medical North Medical 7


Emergeny Department

15 people accessed the exemption site over a one year period.


Observational Audit Location: Main Entrance There was evidence of compliance with clear and adequate signage and the voice over projecting loudly. However there was some evidence of cigarette butts littered in the area in particular along the railings. Underneath a non smoking stand along the pathway to the main entrance there was a small amount of littering of cigarette butts.

Location: Coffee Dock under canopy There was clear no smoking signage, there was also some light littering of cigarette butts

Location: Level 2 Recycling area There was no evidence of cigarette butts along this area

Location: Level 2 Cat Lab There was no evidence of cigarette butts along this area


Location: Emergency Department There was clear evidence of Smoke Free Campus signage There was a pregnant lady sitting on the curb smoking There were cigarette butts clustered in a corner

Location: Doctor’s Residence There is clear evidence that this is an area that needs attention there is cigarette butts and used cigarette boxes littering behind the doctor’s residence.


Location: Behind Mosk Evidence of cigarette butt littering at the back again, however not so much at the front of the buildings

Location: Orthopaedics There was light littering of cigarette butts however nothing major

Location: Off Site Area (outside blue line) Evidence of cigarette butts and other general rubbish Has a very dirty appearance Needs some attention


Recommendations: After thorough analysis of data the following recommendations are hereby made; 1. Monitoring of areas where breaches identified and continue to seek to address this anomaly. 2. Education and awareness around smoking and its harmful consequences to health. 3. Maintenance of hospital grounds and surrounding areas

Conclusion: Through using both quantitative and qualitative methods of data collection over a 4 week period the smoke free campus in Sligo Regional Hospital was evaluated and was found to have an overall positive response from staff, patients and visitors. The majority of staff, patients and visitors were aware and in agreement with the SFC policy. Most staff members were aware of the referral pathway for patients and that they had a role in implementing the policy. Substantial progress has been made in ensuring that service users who access the site experience no exposure to environmental tobacco smoke however further improvements can be made to achieve a gold standard through routine monitoring, pro active smoke free campus committee ,education and awareness around smoking cessation within and outside the hospital environment. While there is an exemption policy for a small cohort of patients, on evaluation this site was accessed by < 1% of the population. The majority of visitors had not been exposed to environmental tobacco smoke however those that were found the most common area of exposure was the main entrance. With regards to the observational audit, it is clear that the policy is being adhered to with the main breaches being evidence of butts at the main entrance, emergency department entrance and Doctors on- call residence. To conclude this current audit demonstrates that the overall compliance with the smoke free campus policy can be rated as good however on going monitoring and evaluation is crucial to ensuring its sustainability long-term.


References: 1. Brugha R, Tully N, Dicker P, Shelley E, Ward M, McGee H. SLĂ N 2007: Survey of Lifestyle, Attitudes and Nutrition in Ireland. Smoking Patterns in Ireland: Implication for policy and services. Dublin: Department of Health and Children, 2009. 2. Buckley, M ., Kent, P., Martin, L. (2004) Smoke-Free workplace policy. Sligo General Hospital Sligo. 3. Healthy Ireland, a framework for improved health and well being, healthy Ireland (2013) Dublin. Available [Accessed 5 /6/14] 4. Jones, T.(2002) What is a clinical audit? Available from: [accessed1/06/14] 5. Ottawa charter for health promotion(1986) [online]. Available from: Ottawa, world health organization [Accessed 26/4/5] 6. Tobacco Free Ireland (2013) Policy framework (online). Available from : Department of health, [Accessed 26/5/14]


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