II The Project and Methods
Submitted by Laura McCammon Tripp and Irene Lambraki, Propel Centre for Population Health Impact, University of Waterloo, and Steven Savvaidis, The Program Training and Consultation Centre
Hospitals are important players in the development of a comprehensive tobacco-control strategy in Ontario. They are leaders in the community and have a broad reach, interacting with individuals at a time when they are more open to behaviour changes such as quitting smoking (Rigotti et al., 2012). As such, they should be encouraged to develop comprehensive hospital policies which create 100% smoke-free grounds and provide cessation supports for patients and employees.
Public health practitioners are ideal partners for hospitals looking to implement smoke-free policies. They are experts in tobacco control, and have a mandate to support hospitals with the development of smoke-free hospital policies under the Ontario Public Health Standards.
Many Ontario hospitals have implemented smoke-free policies and have drawn on the expertise of public health to help them. Understanding the processes involved in developing and implementing these policies can provide useful information to hospital and public health professionals about how they can take similar actions in their own jurisdictions. To facilitate this understanding, The Program Training and Consultation Centre (PTCC), in partnership with the Propel Centre for Population Health Impact, University of Waterloo, undertook a study as part of the PTCC’s Documentation of Practice Project (DoP). The study examined the development of smoke-free policies in selected Ontario hospitals, and the role of public health in these processes. This article highlights key study findings.
II The Project and Methods
The PTCC’s DoP studies generate practice-based evidence by documenting local level tobacco control initiatives and illuminate deeper understanding of what it was about the initiatives that worked, for whom, and under what conditions. The current DoP study took a realist approach (Pawson & Tilley, 1997) and used a multiple-case design (Yin, 2009) to understand ‘how’, ‘when’, and ‘why’ smoke-free hospital polices might be successfully implemented and adapted into daily practice. Three hospitals were included in the study – each had 100% smoke-free grounds, cessation supports in place for patients and employees, and worked with public health on the development and implementation of the policies.
Nine key informants participated in the study including public health practitioners, health professionals and hospital administrative staff. Key informants participated in a semi-structured interview and provided documents related to the development and implementation of the policies. Data were analyzed using NVivo at the hospital-level and across hospitals. Results across the hospitals are presented.
The timing of policy implementation can be key to its success. Each participating hospital was able to take advantage of an existing environment of change to initiate the development of its smoke-free policies. These opportunities included hospital mergers, relocation to new sites, and a renewed focus on employee health and wellbeing. Policy development and implementation was led by multi-disciplinary working groups with members representing clinical, administrative and support staff, management, and public health practitioners. Members were passionate about the issue and this motivated them to push the policy development process forward. Within each group, champions emerged who took on additional roles and responsibilities. These champions and working groups were instrumental in each of the mechanisms highlighted below which contributed to the development and implementation of comprehensive policies. Details of each hospital’s policies are included in the full report, available at http://www.ptcc-cfc.on.ca/learn/dops.
Developing smoke-free hospital policies
Three mechanisms led to the development of the smoke-free policies across the three cases. These mechanisms contributed to building awareness for the policies and creating buy-in as described below.
Learning from other hospitals’ successes and lessons learned increased confidence in moving forward. Since many Ontario hospitals have implemented smoke-free policies, working groups conducted environmental scans to obtain information about other hospitals’ policies and experiences. Findings from the scans revealed that comprehensive smoke-free policies were feasible to implement. When shared with hospital management and others, this information reassured the groups that similar policies could work in their own contexts, increasing their confidence and support for policy development.
Understanding staff perspectives. Working groups understood that implementing smoke-free policies would directly impact hospital staff. Consultations were organized by working group members to share information about the proposed policies and to hear staff’s thoughts and concerns. Strategies used included surveys, meetings and informal conversations. This process increased buy-in and provided insights into the resources and tools staff would need to support implementation.
Using diverse communication strategies to increase awareness of smoke-free hospital policies. It was also understood that smoke-free hospital policies would affect volunteers, patients and the broader community. Increasing these stakeholders’ awareness of the policies was important for gaining their support and compliance. Various communication strategies were used to reach each stakeholder group including posters, the hospital website, newsletters, media and signage.
Implementing smoke-free policies
Once hospital policies were developed, efforts turned to ensuring smooth implementation. Four mechanisms were important to this policy phase as described below.
Identifying staff members who are best suited to implement policy activities. For policies to be implemented, a series of tasks needed to be completed. However, hospital staff was busy and had limited capacity to take on additional work. Implementation was most successful in the hospitals that matched tasks to staff’s existing work roles to ensure optimal fit and integrated these tasks into their daily work responsibilities.
Providing training and education to increase knowledge and skills. Once staff members were assigned to their roles, training was provided to support policy implementation. Various strategies were used to ensure training was tailored to individual’s roles in the policy and the context in which they worked. For example, to reach front-line nursing staff, an “on-the-road” approach was used where training was brought directly to the nurses’ station to ensure it was easily accessible. Training content was also tailored to the individuals’ work environment, and the populations they worked with. This approach aimed to address any specific challenges or concerns individuals had related to implementing the policy in their context.
Empowering staff by integrating policy tasks into existing procedures. Policy tasks were also integrated into existing workplace procedures and tools with clear instructions about how to execute tasks. For example, procedures were developed to make clear who was taking the lead on enforcing the smoke-free grounds policy and their roles and responsibilities. These procedures often emphasized that while enforcement fell under the domain of hospital security all hospital staff had the authority to take action if they witnessed an individual breaking smoke-free policies with guidelines on how to address the offence. These activities empowered staff to take action to implement the policy, which enabled the policy tasks to become part of regular, daily practice.
Evaluating policy implementation. Evaluating the policy implementation process was also important because it provided insights into what was working, barriers that were faced and areas where improvements were needed. Hospitals used formal and informal strategies to promote participation of all individuals in the evaluation. Strategies included chart audits, surveys, referral metrics, and informal conversations with staff, patients and community members. Engaging stakeholders in evaluation gave them a voice and contributed to their commitment to the policy and their willingness to make policy improvements. For instance, one hospital’s evaluation revealed a substantial delay between a patient’s initial smoking cessation consultation and when the first dose of nicotine replacement therapy (NRT) was offered. Stakeholders identified this as a barrier to the success of the policy and wanted to address the issue. In response, a medical directive was developed providing specific hospital staff with the authority to order NRT and administer the first dose, drastically reducing the time from admission to the delivery of NRT.
Role of public health
Public health practitioners played a key role in the development of the smoke-free hospital policies. They served as members of the working groups, and as such played a role in each of the mechanisms highlighted throughout the policy development and implementation phases. Their main contributions included:
- Building capacity, including providing and interpreting evidence, identifying key components of comprehensive smoke-free hospital policies, and contributing to staff trainings to build their skills in executing policy tasks.
- Facilitating connections between the hospital and other tobacco control related opportunities (grants, training) and others in the community working in tobacco control (Communities of Practice, informal networks).
- Developing resources and communication tools to increase awareness among key stakeholders within and beyond the hospital settings.
- Providing training and support for the enforcement of smoke-free grounds.
Hospitals can be invaluable partners in tobacco control efforts and as such should be encouraged to develop policies that support tobacco-free living, including smoke-free grounds policies and cessation support policies. Champions from hospitals and public health can work together to ensure policies are developed and effectively implemented. The use of evidence, consultations and communication strategies can engage key stakeholders and build policy buy-in. Assigning policy tasks to appropriate staff, providing training on how to carry out these tasks, giving hospital staff decision-making authority and integrating tasks into their work responsibilities and existing work procedures enabled policy implementation. The mechanisms highlighted in this study can assist others with similar policy initiatives.
Pawson, R., & Tilley, N. (1997). Realistic evaluation. London, United Kingdom: Sage.
Rigotti, N.A., Clair, C., Munafò, M.R., & Stead, L.F. (2012). Interventions for smoking cessation in hospitalized patients (Review). Cochrane Database of Systematic Reviews, Issue 5. DOI: 10.1002/14651858.CD001837.pub3.
Yin, R. (2009). Case study research design and methods, 4th edition. Thousand Oaks, California: Sage Inc.
Program Training and Consultation Centre is a resource centre of the Smoke Free Ontario Strategy. The Documentation of Practices Repository on the site includes resource materials on tobacco control initiatives including the details of each hospital’s policies at http://www.ptcc-cfc.on.ca/learn/dops.
Propel Centre for Population Health Impact at the University of Waterloo is a collaborative enterprise that conducts research, evaluation and knowledge exchange to accelerate improvements in the health of populations: https://uwaterloo.ca/propel/.
Ontario Public Health Standards provide a mandate to public health practitioners to support hospitals with the development of smoke-free hospital policies: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/.