Blackwell Publishing AsiaMelbourne, AustraliaINMInternational Journal of Mental Health Nursing1445-83302006 Blackwell Publishing Asia Pty Ltd?

2006152111118Feature ArticlePSYCHIATRIC NURSES, SMOKING AND ETHICS

S. LAWN AND J. CONDON

International Journal of Mental Health Nursing (2006) 15, 111–118 doi: 10.1111/j.1447-0349.2006.00410.x

Feature Article
Psychiatric nurses’ ethical stance on cigarette
smoking by patients: Determinants and dilemmas in
their role in supporting cessation
Sharon Lawn1,2,3 and Judith Condon4
1
Division of Mental Health/Flinders Medical Centre (now known as Southern Adelaide Health Service), 2Department
of Psychiatry, School of Medicine, 3Flinders Human Behaviour and Health Research Unit, and 4School of Nursing and
Midwifery, Flinders University of South Australia, Bedford Park, South Australia, Australia

ABSTRACT: It has been argued that psychiatric nurses are ideally placed to provide smoking
cessation interventions to patients with mental illness. This assumes that psychiatric nurses actively
support smoking cessation. The current paper articulates some of the reasons why this has not
occurred, in particular, some of the ethical beliefs held by nurses that may prevent such activity. Such
an assumption also discounts the evidence that confirms psychiatric nurses to have among the highest
smoking rates in nursing and in the health professions in general. The role and impact of the institution
are also considered. In-depth interviews with seven community and inpatient psychiatric nurses were
thematically analysed. Extensive individual and group discussions were also held with inpatient nurses
from open and locked psychiatric settings during participant observation of the settings. The findings
suggest that psychiatric nurses can be more effective in the primary care role of supporting patients’
smoking cessation if they receive adequate institutional support to do so.
KEY WORDS: ethics, psychiatric nursing, smoking cessation.

INTRODUCTION et al. 1998). This is especially important now that the

harms of smoking for mental health populations are
Within psychiatric inpatient settings, nurses provide a
becoming more apparent. One example of evidence for
high proportion of the direct care and contact with
concern is a major survey of approximately 165 500 adults
patients. Therefore, they are in a unique position to act
with mental illness (known as the Busselton Study), in
as role models and to make a significant impact on
which smokers with mental illness were identified as
patients’ smoking behaviour and the associated risk of
being among those with the greatest risk of premature
suffering tobacco-related diseases by directly supporting
death from all major physical health problems as a con-
and participating in pharmacological and psychosocial
sequence of their smoking and other risk behaviours such
interventions. Research has claimed substantial evidence
as alcohol and other substance abuse, obesity, poor diet
exists that psychiatric nurses can be effective in promot-
and lack of exercise (Coghlan et al. 2001).
ing smoking cessation (Cataldo 2001; Sarna 1999; Wewers
Despite the potential for positive input by psychiatric
nurses, the high rate of smoking by patients continues to
Correspondence: Sharon Lawn, Flinders Human Behaviour and be an insidious problem in psychiatric settings (Lawn
Health Research Unit, Flinders University of South Australia, F6 ‘The 2001). Research consistently shows that rates of smoking
Flats’, PO Box 2100, Adelaide, SA 5001, Australia.
Email: sharon.lawn@fmc.sa.gov.au are significantly greater in populations where mental ill-
Sharon Lawn, BA, DipEd, MSW, PhD. ness is also present (Carosella et al. 1999; Herran et al.
Judith Condon, RN, Dip. Nurse Education, BA(Hons), M Ed.
Studies. 2000; McNeill 2001; Poirier et al. 2002). When people
Accepted October 2005. with mental illness attempt to quit smoking, they are

© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
112
highly vulnerable to relapse to smoking, especially in the
presence of unstable mental illness and other stressors.
Many reasons for this have been proposed including those
associated with shared neurobiology of mental illness and
nicotine, self-medication of symptoms, psychosocial cop-
ing responses, environmental factors, psychological fac-
tors and systemic factors (Adler et al. 1993; Lawn 2001;
Lawn et al. 2002; Lucksted et al. 2000; McChargue et al.
2002; Salokangas et al. 2000; Taiminen et al. 1998).
The rate of substance use by nurses, in particular, the
rate of smoking by psychiatric nurses, continues to be
high compared with nursing in other health-related fields.
The reasons for this are unclear, although some have
suggested that this may be largely due to accessibility, the
emphasis on medication use and work-related stress (Col-
lins et al. 1999; Griffith 1999; Plant et al. 1991; Rowe &
Clark 2000; Tagliacozzo et al. 1982; Trinkoff & Storr
1998). When smoking bans have been imposed in general
hospital settings and other work sites, the rate of smoking
by staff has been shown to decline with many staff taking
the opportunity to quit once bans are imposed (Borland
et al. 1990; Chapman et al. 1999). It is unclear whether
such restrictions would influence psychiatric nursing staff
in this way and what influence their smoking may have
on patients’ smoking behaviours. This paper investigates
the ethical thinking of a small sample of nurses with
regard to smoking by mentally ill patients. It is an attempt
to understand and propose some reasons why psychiatric
nurses have not been as influential as expected in smoking
cessation within psychiatric settings.
MATERIALS AND METHODS
The research was performed with inpatient and commu-
nity nursing staff of a public, government-funded mental
health service within a metropolitan area of Australia with
a population of approximately one million people. The
data reported here form part of a much larger data set,
based on in-depth open-ended interviews performed
with 26 multidisciplinary staff from inpatient and com-
munity psychiatric settings. Interviews were audio-taped
then transcribed, coded and thematically analysed using
a constant comparative, grounded theory approach (Gla-
ser & Strauss 1967; Strauss & Corbin 1990). Seven
psychiatric nurses were interviewed: three from a com-
munity mental health team (two ex-smokers and one non-
smoker), two from an acute locked ward (one ex-smoker
and one non-smoker), and one each from an extended
care ward (current smoker) and acute open ward (current
smoker). Sampling relied on approaching each site pur-
posefully and asking for participants who were willing to
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
S. LAWN AND J. CONDON
be interviewed. An interview time was then negotiated
with these staff at their convenience. All participants
were qualified as clinical nurses or higher and all had at
least 10 years of experience of working in psychiatric set-
tings. Ethical clearance was gained from the Royal Ade-
laide Hospital Ethics Committee and the Flinders
Medical Centre Clinical Investigations Ethics Committee
prior to entry to the field. All interviews were performed
in locations that were negotiated fully with participants,
ensuring complete privacy and confidentiality. Each staff
participant responded to the following interview guide
questions and topic areas:
• Length of mental health service experience
• Their own smoking history, why they smoked, and
smoked while at work
• Being a non-smoker while at work – what this is like
• What occurs in their work setting with regard to
smoking?
• Their views on patients’ smoking and staff smoking
while at work
• What informs their decisions about how they act with
regard to smoking in the workplace?
• What do they think would happen if there was a smok-
ing ban?
• Mental illness and smoking – any links perceived and
why/why not
• Views of their own and other professions’ response to
smoking issue
• Level of involvement in supply of cigarettes to patients,
and how they decide
• How do they respond to patients who demand help to
get cigarettes, and what determines their decision?
• Determine their ethical stance on smoking.
Interview findings were provided to participants for
verification of their accuracy. Data from extensive partic-
ipant observations of the settings were also gathered. This
involved 31 visits to each type of ward of the hospital as
well as observations within the grounds of the site total-
ling approximately 100 hours of observations. The indi-
vidual and group discussion with the larger nursing group
that occurred on these occasions became part of a trian-
gulated process of data clarification, contextualization,
verification and analysis. Several feedback seminars to the
participants, and the region’s nursing group as a whole,
were performed to further validate the findings and to
build further insights about the topic. These seminars
were an opportunity to discuss the research findings, to
clarify and debate the issues arising from the findings, and
to demonstrate that the ethical dilemmas articulated by
the interview participants were common to the larger
PSYCHIATRIC NURSES, SMOKING AND ETHICS
nursing group as well. Elaboration of the methodology
can be found elsewhere (Lawn 2001). An auditor who was
a specialist nurse educator with expertise in qualitative
research and mental health was engaged as part of the
research process. The researcher met with the auditor
regularly during the data collection and analysis phase. At
the conclusion of this phase, the auditor determined that
a comprehensive audit trail was established based on the
researcher successfully addressing the following criteria
(see Lawn 2001 for further detail):
• Evidence of increased insight as a result of observa-
tions and interviews
• Appropriateness of consent process
• Maintenance of confidentiality in process and
reporting
• Inclusion of all stakeholders
• Sensitivity in entering and leaving the field.
Nurses’ ethical thinking emerged as a significant
theme, demonstrating how it influenced nurses’ percep-
tions, feelings and actions about smoking within their
workplace.
FINDINGS
Direct quotes from participants are used to demonstrate
the findings with pseudonyms used to maintain partici-
pants’ anonymity. Nurses are not distinguished according
to professional status as this would allow some to be
clearly identified in settings where, for example, there is
only one clinical nurse manager.
All of the nurses interviewed spoke of a rich smoking
reinforcement history within the psychiatric institution.
All had trained within a system that condoned smoking
by staff and patients and accepted the clinical use of
cigarettes to assist patients with their mental illness
management.
(Terry – Inpatient nurse/extended care wards/smoker)
It was actually work that started me smoking . . . I was a
non-smoker when I started psych nursing. Back in those
days the tobacco was supplied by the hospital in bulk
in big brown paper bags, and nurses, especially in the
(locked) ward because of the patients inability to roll their
own cigarettes, we used to spend hours just sitting there
rolling up cigarettes in bulk, and because the patients
were incapable of lighting their own or handling matches
safely, quite often it was expected that nurses would light
the cigarettes for them and then hand them the lit ciga-
rette. That’s how I started smoking.
Some staff had experienced and reflected on the
former era of care when each inpatient was given a
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
113
tobacco ration for personal use or barter, regardless of
whether they were a smoker. Nursing staff commented
on how cigarettes had been an accepted part of their
interaction with patients.
(Grace – Community nurse/ex-smoker, speaking of her
time working in the hospital in the early 1970s)
And cigarettes were a currency. If you wanted the
patients to do something, you could give them a cigarette
and they’d probably do it. In fact, I can remember my
first ward, the charge sister saying, ‘Go and run this
errand and I’ll give you a cigarette. Go and make your
bed and I’ll give you a cigarette . . . .’ It was how you got
things done.
Participants articulated the ethical component of their
decision-making on smoking by patients and had a range
of ethical justifications for their actions and inactions.
They made decisions on the issue of smoking and smoking
by patients, according to two of the ethical principles
important in nursing ethical decision-making: autonomy,
and beneficence and non-maleficence (see Fry &
Johnstone 2002 for a discussion of the range of princi-
ples). Different nurses had different justifications within
these two principles.
1. Autonomy: justifications arising from this ethical prin-
ciple claim that right action is based on facilitating
individuals’ ability to determine their behaviour acc-
ording to self-chosen plans (Fry & Johnstone 2001):
(i) The right to smoke/self-determination
(ii) Free and informed choice to smoke.
2. Beneficence/non-maleficence: justifications arising
from this ethical principle claim that right action is
based on ‘the obligation to do good’ and ‘the obligation
to avoid doing harm’ (Fry & Johnstone 2001; p. 22).
As will be shown in the participants’ discussion of their
decision-making based on this principle, conflicts and
dilemmas arose between these values and obligations
and which values and principles should take precedence
in particular situations because the process of deciding
which course of action to take was unclear to staff:
(i) A difficult hierarchy and priority of concerns and
harms
(ii) The problem of accountability – not while they’re
unwell, not my role and not my responsibility.
(1.i) The right to smoke/self-determination
When asked what they thought about patients’ smoking,
most participants spoke of their belief in patients’ right to
smoke. Staff were mindful of imposing their own value
judgements on patients, and mindful of the power
114
imbalance in their relationship with patients. Staff iden-
tified strongly with the role of smoking as giving the
patient greater opportunity for autonomous activity. Staff
spoke of the need to compensate patients given a per-
ceived lack of choices within the system of care.
(Jill – Community nurse/ex-smoker)
I try to give them as much freedom to do as they wish,
as they can, which usually involves buying as much ciga-
rettes as they can. I generally like to give people as many
choices as I can in every aspect of their life. I don’t tend
to make social choices for them. I think that’s their
business . . . I believe that people have choices, but that
mental health clients often have choices taken away from
them, and I think every opportunity that we have to give
choices back to them, I try and do that.
Other staff appeared genuinely to struggle to work out
their own ethical stance. They recognized the complex
web of competing forces at work with regard to the treat-
ment of mental illness and the perceived roles of smoking
for clients in alleviating symptoms, relieving boredom,
filling an existential vacuum and helping build rapport
with others. Some staff explained their ethical stance in
the context of it being the person’s right to smoke, seeing
the presence of mental illness or the system of care as
being of minimal influence.
(Janet – Inpatient nurse/locked ward/non-smoker)
I just think everyone has got the right to choose to do
what they want to do . . . They were smoking before they
were detained so what rights have we to stop them from
smoking once they’re detained.
(1.ii) Free informed choice to smoke
Staff also spoke of patients’ smoking as an informed
choice made freely without restriction and based on
patients’ full knowledge of the harms and costs of smok-
ing. Some staff used this reasoning, even when they also
acknowledged that choice was not fully informed. Staff
did not see a duty of care to intervene with these patients
regarding their ‘choice’ to smoke despite the harms. How-
ever, staff used the duty of care argument when seeking
guardianship orders for treatment and financial manage-
ment with regard to other ‘choices’ made by patients that
were deemed to be harmful to their health, and when
their spending on cigarettes occurred at the expense of
meeting core commitments like accommodation costs.
Only two staff clearly argued that smoking was not an
informed choice by patients; one person spoke of the
interaction of mental illness and smoking and the other
person spoke of the role of addiction adversely influenc-
ing the smoker’s decision-making capacity.
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
S. LAWN AND J. CONDON
(Terry – Inpatient nurse/extended care open ward/
smoker)
This ward helps them limit because it recognizes that it
is not informed consent to smoke. That’s right. Other
workers are like fence sitters who just say it’s their right
to smoke rather than buying into the debate. It’s very
much individualized here according to the person’s
capacity, or also their financial capacity to buy smokes.
These two staff questioned those who claimed to be
making value-free judgements as misguided in their eth-
ical thinking, arguing that our actions are never value-
free. Grace attempted to increase the ability of patients
to make a free and informed choice to smoke by providing
them with information.
(Grace – Community nurse/ex-smoker)
If we had safe cigarettes tomorrow, I suppose my argu-
ment would end, but they’re not safe and they never have
been and the politics of smoking is just disgusting. I’m
sure the human rights arguments came from the tobacco
companies . . . Often people, in the pursuit of what they
perceive as their human rights, present spurious argu-
ments. You can’t argue with, ‘Well, I like it and I’m going
to do it’. You can’t argue with that if the person knows
the risks and they choose, but misinformation, you can
argue with, and I tend to give people articles and
cartoons.
(2.i) A difficult hierarchy and priority of concerns
and harms
a. The avoidance of suffering and increased
short-term risk to the patient
b. The avoidance of risk of assault to the staff
Beneficence/non-maleficence was the second form of
reasoning used by participants in deciding their ethical
stance on patients’ smoking. They described having a
hierarchy of ethical concerns that guided them in priori-
tizing harms and duty of care towards patients. Many staff
perceived smoking as ethically causing less damage than
the more immediate problems faced by patients.
(Terry – Inpatient nurse/extended care open ward/
smoker)
I accept that it affects their health in a derogatory way;
however, I think the greater priority is the immediate
client and staff safety. And if withholding cigarettes is
going to increase client irritability and the potential for
aggression or violence, I think the long-term decline in
their health is the lesser of evils, because of the potential
that the immediate violence can cause. And I’ve seen the
results of that, and that has an immediate and devastating
effect on people’s lives.
PSYCHIATRIC NURSES, SMOKING AND ETHICS
Inpatient nurses said they often saw patients at a
greater level of distress than nurses in the community.
The pressure felt by inpatient nurses to meet patients’
immediate needs, as opposed to concern for the long-
term consequences of meeting those needs, was a sig-
nificant difference identified by nurses about the two
settings. For inpatient nurses, the longer-term physical
effects and risks of smoking were seen as the lesser of
evils when compared with the immediate effects of men-
tal illness symptoms, level of distress and the conse-
quences of relapse for the person.
(Marg – Inpatient nurse/open ward/smoker)
Once they go to the locked ward, you have taken away
everything . . . They can’t even choose when they have a
cigarette or if they’re going to have one. They have no
choice left at all. It’s completely taken away, and I can’t
condone that just over a couple of cigarettes . . . Once
they’re here, my aim is to keep them on an open ward
and to get them as well as soon as I can, to get them back
to the community where they belong, and then the choice
is theirs. While they’re acutely unwell, and probably agi-
tated, what right do I have to agitate them further by
telling them they can’t have a cigarette. And to me, I
would consider that to be abusive . . . We’ve had people
agitated and escalating and we have desperately found
cigarettes. All of the nursing staff have given cigarettes to
give this person . . . If it’s going to reduce the negative
impacts of their illness, then surely it’s helpful.
(Janet –Inpatient nurse/locked ward/non-smoker)
I think that because in the inpatient setting you’ve got so
many patients in close proximity to one another, that if
one gets agitated because they haven’t got their ciga-
rettes, then it could just upset all the other people around
them, or they could just go around pestering or being a
nuisance to other patients, saying, ‘Can I have a ciga-
rette?’ So, in the inpatient setting, we try to ensure that
they have cigarettes to keep them settled. And I think the
consequences of not giving them a cigarette can be a lot
worse than giving them. Like, I’ve seen patients hit
because they’ve been pestering other patients for a ciga-
rette because they haven’t got any.
(Janet –Inpatient nurse/locked ward/non-smoker)
(If there was a smoking ban) I think there would be more
medication given; I definitely think a greater amount of
PRN would be given, especially for agitation, and things
like that. And there’d be a lot more incidents and violence
as well . . . Smoking is an easy solution and sometimes it’s
the only one there readily available when someone is
about to snot you one . . . Letting them smoke is the easy
option.
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
115
(Terry – Inpatient nurse/extended care open ward/
smoker)
Both from a nurses’ and client management perspective,
if you can keep the ward running smoothly and minimiz-
ing the amount of aggression by allowing them to smoke,
then allowing them to smoke facilitates that. By all means,
I’d rather have a smooth running ward than go home with
a broken arm.
The nature of the hospital setting posed unique con-
cerns and arguments by staff to justify smoking by
patients. The ward milieu in which patients lived and
interacted in close proximity to each other, often while in
a disturbed or unsettled state, was noted. Patients’ abili-
ties to resolve conflict and to manage their emotions were
seen to be challenged under these circumstances. This
was particularly so for patients who were detained against
their will because they were deemed to be a danger to
themselves or others under the Mental Health Act.
Under these circumstances, smoking was given lesser pri-
ority than concern for the treatment of the person’s men-
tal illness and concern for the safety of the group.
Nicotine dependence was also treated differently from
other drug dependence.
(Marg – Inpatient nurse/open ward/smoker)
What they do here is going to impact on their ability to
stay in an open ward, and on all the other clients as well.
If they get toey at home and smack the wall because they
haven’t got a cigarette, that’s one thing. If they get toey
here and smack the wall; number one, they’re likely to
end up in the closed ward; number two, there are likely
to be other people around because basically it’s a small
community here at any one point in time and whatever
one person does is likely to impact on others . . . and if
it’s going to actually increase the anxiety for other people
and end up with three of them transferred to the locked
ward, then I have a problem with that.
Staff also worried that restricting patients’ smoking at
the times when they were unwell would only hinder their
recovery, that it would be like enforcing a ‘double dose’
of suffering involving withdrawal and illness symptoms.
This was seen as unfair and unnecessary.
(2.ii) The problem of accountability –
not while they’re unwell, not my role and
not my responsibility
Participants were unanimous in the belief that there exists
a time and place for talking with patients about their
smoking. They agreed that it was not appropriate to raise
the topic of quitting or cutting down when the person was
acutely unwell. Various reasons for this were proposed.
116
Staff believed that there was no value in introducing strat-
egies requiring more thinking and planning when some-
one was psychotic because of their level of cognitive
impairment at the time. Inpatient staff also saw the role
of assisting people to quit as a community role for when
the person was out of hospital, in their own environment
and recovered from the acute phase of illness.
(Grace – Community nurse/ex-smoker)
I wouldn’t be talking to them about stopping smoking
when they were very unwell. Then I wouldn’t be talking
to them about it at all. This is not about torture.
Inpatient nursing staff expressed attitudes that
reflected the belief in smoking as one of the patients’ few
pleasures, whereas community staff comments reflected
a tendency to give the patient more responsibility for their
choices. Staff in the locked settings directly placed the
pleasure of having a cigarette in the context of patients
being deprived of other pleasures and basic freedoms in
those environments.
(Janet – Inpatient nurse/locked ward/non-smoker)
(On the locked ward) When they’re in here, they’ve got
so little anyway, that’s one of the pleasures that they’ve
got.
Some nurses who smoked described themselves as
smoking for much the same reasons as their patients and
openly empathized with them and smoked with them.
Non-smoking nurses could also empathize with both
patients and staff who were smokers and likewise accepted
the patients’ ‘need’ to smoke while they were unwell.
(Marg – Inpatient nurse/open ward/smoker)
(Regarding condoning patients’ smoking) To tell you hon-
estly, it’s probably my own nicotine addiction . . . When
I’m stressed about something, I usually have a cigarette
and pace.
Staff proposed various reasons for their actions that
appeared to be based on their beliefs and attitudes
towards mental illness, mental health patients, and the
system of care. This, in turn, informed how they acted or
did not act to assist patients with their smoking and quit-
ting. All nurses stated that the interview process had been
their first opportunity to openly think about the ethics of
their actions and attitudes, and to articulate the complex-
ity of the debate.
Four participants said that smoking by patients posed
dilemmas for them in their role as health-care service
providers within a system in which they actively incorpo-
rate cigarette smoking into treatment and management.
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
S. LAWN AND J. CONDON
(Grace – Community nurse/ex-smoker)
I think, ‘What kind of nurse would I be if I encouraged
people to do things that were not good for their health?’
One participant said they had no ethical dilemma here.
Two staff chose to distance themselves from the debate
altogether.
(Janet – Inpatient nurse/locked ward/non-smoker)
If they want to smoke, that’s fine by me. I haven’t really
thought about it that much. I just never think about it.
(Jill – Community nurse/ex-smoker)
It’s just too complex to think about really. I just treat it as
a day-to-day thing. It’s just in the too hard basket.
Participants described the extensive use of cigarettes
throughout the hospital wards, to aid interpersonal con-
tact with patients, to help establish rapport with patients
and to facilitate assessment. In this sense, staff smoking
was reinforced by the entrenched routines involving
smoking. Nurses who had quit smoking commented on
how they now floundered in these tasks once they could
not use smoking to assist them. Much comment was made
about the use of canteen funds to purchase ward ciga-
rettes, specifically for patients in the locked settings who
had no cigarettes of their own, and also the routine of
handing out cigarettes to patients at set intervals at the
nurses’ station door.
(Paul – Inpatient nurse/locked ward/ex-smoker)
And they know the routine. It’s just, ‘Oh we’re in the
locked ward’. (Knock, knock, knock on the nurses’ station
glass door) It’s just an instant thing. They turn off to it
and so do the staff.
(Paul – Inpatient nurse/locked ward/ex-smoker)
If they didn’t smoke, they wouldn’t come back to the door
every half an hour either. There’s something about having
a closed door between us that makes the difference. It’s
a real power thing. It’s a typical us and them situation.
The staff retreat to be behind the closed door . . . It
seems to be institutionalized. I mean, even if you didn’t
follow that procedure, just merely by being here and
being exposed to the way the ward operates, the policy,
and the staff; staff tend to adopt a certain mentality of
control, just because of the environment. It’s easy to give
people cigarettes. It’s easier than not giving them.
DISCUSSION
This research has highlighted the complicated role played
by nurses within mental health settings where many clients
PSYCHIATRIC NURSES, SMOKING AND ETHICS
are involuntary participants. They acted as custodian,
carer, cigarette source, counsellor, educator, behaviour
modifier and gaoler (see Sykes 1958 for parallels within
the prison system). Smoking appeared to provide the
means by which these role conflicts were eased for nursing
staff. The latent consequence of this was that smoking was
condoned, so much so that it was increasingly relied on
to facilitate interaction. Nursing staff who did not smoke
commented on their perceived loss of this care option
once they stopped smoking. The promotion of clinical
alternatives for staff, to support their practice and care of
patients, is indicated so that they do not rely on smoking
to clinically manage clients. In support, Rydon (2005)
speaks of the general dilemma facing psychiatric nurses
within existing mental health service systems. She states
that, ‘The question remains about how nurses can maintain
positive attitudes and therapeutic practice with users of
mental health services, when the context of mental health
nursing may not support this’ (p. 85).
In the inpatient and community settings, many exam-
ples of smoking reinforcement and conditioned smoking
were apparent for patients and staff. This appeared to be
a group-based phenomenon within the cultural milieu. It
was not limited to individual experiences. The majority of
nursing staff appeared to accept patients’ smoking, seeing
it as a central part of the dominant culture of the settings.
Staff generally relied heavily on medications to treat
patients. One consequence of this was that, when medi-
cations were not adequate, staff were left with few other
effective alternatives to assist patients with their symp-
toms and distress other than to let them smoke or to
smoke with them to give them a sense of comfort and
support. In the same way that many patients had learned
to rely on smoking to self-medicate their illness, it appears
that staff had acquired the belief in these benefits of
smoking for patients. By using cigarettes to overcome
patients’ agitation, patients’ nicotine withdrawal was not
addressed by staff and patients continued to smoke
despite adverse effects (Lawn & Pols 2003). This has
significant implications for successful recovery from men-
tal illness, and for challenging the social inequities cre-
ated by smoking. The findings suggest that these systemic
patterns of learning and reinforcement need to be chal-
lenged and replaced within treatment environments. In a
climate of increasing litigation treatment environments
where smoking continues to be overtly and covertly rein-
forced also leave themselves open to claims of negligence
brought by both patients and staff (see Lawn (2005) for
a further discussion of the legal and occupational health
and safety issues pertaining to smoking in psychiatric
settings).
© 2006 Australian and New Zealand College of Mental Health Nurses Inc.
117
CONCLUSION
Most participants in this study were able to articulate the
ethical principles on which they based their values and
decisions about patients’ smoking. Most were thoughtful,
concerned and very aware of the conflicts inherent in
their ethical decisions and subsequent actions and inac-
tions and they appreciated the opportunity to discuss
these issues. As part of cultural change in psychiatric
services, regarding the issue of patient smoking, it is rec-
ommended that nurses are supported in clarifying their
values and the ethical principles on which they make
decisions and act. Promoting a learning environment
where there is active dialogue among nurses so that they
can navigate through the dilemmas posed by their role
would seem important. The nursing profession involves
inherent conundrums of care, where paradoxes in the
interpersonal therapeutic relationship with patients must
be discussed, understood and resolved (Horsfall et al.
2000). However, considering ethical decision-making in
isolation will not bring about change, but needs to be one
of a number of strategies to address smoking by patients
and staff within psychiatric settings. Psychiatric nurses are
ideally placed to challenge the entrenched culture of
smoking within psychiatric settings if they have the will,
leadership and support to do so.
ACKNOWLEDGEMENTS
The main author would like to thank Dr Rene Pols
(Senior Lecturer, Department of Psychiatry, School of
Medicine, Flinders University and Senior Consultant Psy-
chiatrist, Division of Mental Health/Flinders Medical
Centre (now known as Southern Adelaide Health Ser-
vice) Mental Health Directorate) and Professor Jim Bar-
ber (Head of School of Social Administration and Social
Worker, Flinders University) for their supervision of the
original PhD research from which this paper is drawn, the
auditor and the nurses who contributed their valuable
time and ideas to this issue.
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