Psychiatric nurses’ ethical stance on cigarette smoking

8/8/2019 Psychiatric nurses ethical stance on cigarette smoking

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International Journal of Mental Health Nursing (2006) 15, 111118 doi: 10.1111/j.1447-0349.2006.00410.x

2006 Australian and New Zealand College of Mental Health Nurses Inc.

Feature Article

Psychiatric nurses ethical stance on cigarettesmoking by patients: Determinants and dilemmas intheir role in supporting cessation

Sharon Lawn1,2,3 and Judith Condon41Division 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 smokingcessation 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 notoccurred, in particular, some of the ethical beliefs held by nurses that may prevent such activity. Suchan 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 institutionare 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 nursesfrom open and locked psychiatric settings during participant observation of the settings. The findingssuggest that psychiatric nurses can be more effective in the primary care role of supporting patientssmoking cessation if they receive adequate institutional support to do so.

KEY WORDS: ethics,psychiatric nursing,smoking cessation.

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

Correspondence: Sharon Lawn, Flinders Human Behaviour andHealth Research Unit, Flinders University of South Australia, F6 TheFlats, PO Box 2100, Adelaide, SA 5001, Australia.Email: [email protected]

Sharon Lawn, BA, DipEd, MSW, PhD.Judith Condon, RN, Dip. Nurse Education, BA(Hons), M Ed.

Studies.Accepted October 2005.

INTRODUCTION

Within psychiatric inpatient settings, nurses provide ahigh proportion of the direct care and contact withpatients. Therefore, they are in a unique position to actas role models and to make a significant impact onpatients smoking behaviour and the associated risk ofsuffering tobacco-related diseases by directly supporting

and participating in pharmacological and psychosocialinterventions. Research has claimed substantial evidenceexists that psychiatric nurses can be effective in promot-ing smoking cessation (Cataldo 2001; Sarna 1999; Wewers

et al. 1998). This is especially important now that theharms of smoking for mental health populations arebecoming more apparent. One example of evidence forconcern is a major survey of approximately 165 500 adults

with mental illness (known as the Busselton Study), in which smokers with mental illness were identified asbeing among those with the greatest risk of prematuredeath from all major physical health problems as a con-

sequence of their smoking and other risk behaviours suchas alcohol and other substance abuse, obesity, poor dietand lack of exercise (Coghlan et al. 2001).

Despite the potential for positive input by psychiatricnurses, the high rate of smoking by patients continues tobe an insidious problem in psychiatric settings (Lawn2001). Research consistently shows that rates of smokingare significantly greater in populations where mental ill-ness is also present (Carosella et al. 1999; Herran et al.2000; McNeill 2001; Poirier et al. 2002). When people

with mental illness attempt to quit smoking, they are


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112 S. LAWN AND J. CONDON


highly vulnerable to relapse to smoking, especially in thepresence of unstable mental illness and other stressors.Many reasons for this have been proposed including thoseassociated 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, therate of smoking by psychiatric nurses, continues to behigh compared with nursing in other health-related fields.The reasons for this are unclear, although some havesuggested that this may be largely due to accessibility, theemphasis 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 & Storr1998). When smoking bans have been imposed in generalhospital settings and other work sites, the rate of smokingby staff has been shown to decline with many staff takingthe opportunity to quit once bans are imposed (Borlandet al. 1990; Chapman et al. 1999). It is unclear whethersuch restrictions would influence psychiatric nursing staffin this way and what influence their smoking may haveon patients smoking behaviours. This paper investigatesthe ethical thinking of a small sample of nurses withregard to smoking by mentally ill patients. It is an attemptto understand and propose some reasons why psychiatric

nurses have not been as influential as expected in smokingcessation within psychiatric settings.

MATERIALS AND METHODS

The research was performed with inpatient and commu-nity nursing staff of a public, government-funded mentalhealth service within a metropolitan area of Australia witha population of approximately one million people. Thedata 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-tapedthen transcribed, coded and thematically analysed usinga constant comparative, grounded theory approach (Gla-ser & Strauss 1967; Strauss & Corbin 1990). Sevenpsychiatric 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-smokerand one non-smoker), and one each from an extendedcare ward (current smoker) and acute open ward (currentsmoker). Sampling relied on approaching each site pur-posefully and asking for participants who were willing to

be interviewed. An interview time was then negotiated with these staff at their convenience. All participantswere qualified as clinical nurses or higher and all had atleast 10 years of experience of working in psychiatric set-

tings. Ethical clearance was gained from the Royal Ade-laide Hospital Ethics Committee and the FlindersMedical Centre Clinical Investigations Ethics Committeeprior to entry to the field. All interviews were performedin locations that were negotiated fully with participants,ensuring complete privacy and confidentiality. Each staffparticipant responded to the following interview guidequestions 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 tosmoking?

Their views on patients smoking and staff smokingwhile at work

What informs their decisions about how they act withregard 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 andwhy/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 toget cigarettes, and what determines their decision?

Determine their ethical stance on smoking.

Interview findings were provided to participants forverification of their accuracy. Data from extensive partic-ipant observations of the settings were also gathered. Thisinvolved 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 groupthat occurred on these occasions became part of a trian-gulated process of data clarification, contextualization,

verification and analysis. Several feedback seminars to theparticipants, and the regions nursing group as a whole,

were performed to further validate the findings and tobuild further insights about the topic. These seminars

were an opportunity to discuss the research findings, toclarify and debate the issues arising from the findings, andto demonstrate that the ethical dilemmas articulated bythe interview participants were common to the larger


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PSYCHIATRIC NURSES, SMOKING AND ETHICS 113


nursing group as well. Elaboration of the methodologycan be found elsewhere (Lawn 2001). An auditor who wasa specialist nurse educator with expertise in qualitativeresearch and mental health was engaged as part of the

research process. The researcher met with the auditorregularly during the data collection and analysis phase. Atthe conclusion of this phase, the auditor determined thata comprehensive audit trail was established based on theresearcher 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 significanttheme, demonstrating how it influenced nurses percep-tions, feelings and actions about smoking within their

workplace.

FINDINGS

Direct quotes from participants are used to demonstratethe findings with pseudonyms used to maintain partici-pants anonymity. Nurses are not distinguished accordingto professional status as this would allow some to beclearly identified in settings where, for example, there isonly one clinical nurse manager.

All of the nurses interviewed spoke of a rich smokingreinforcement history within the psychiatric institution.All had trained within a system that condoned smokingby staff and patients and accepted the clinical use ofcigarettes to assist patients with their mental illnessmanagement.

(Terry Inpatient nurse/extended care wards/smoker)

It was actually work that started me smoking . . . I was anon-smoker when I started psych nursing. Back in thosedays the tobacco was supplied by the hospital in bulkin big brown paper bags, and nurses, especially in the(locked) ward because of the patients inability to roll theirown cigarettes, we used to spend hours just sitting thererolling up cigarettes in bulk, and because the patientswere incapable of lighting their own or handling matchessafely, quite often it was expected that nurses would lightthe cigarettes for them and then hand them the lit ciga-rette. Thats how I started smoking.

Some staff had experienced and reflected on theformer era of care when each inpatient was given a

tobacco ration for personal use or barter, regardless ofwhether they were a smoker. Nursing staff commentedon how cigarettes had been an accepted part of theirinteraction with patients.

(Grace Community nurse/ex-smoker, speaking of hertime working in the hospital in the early 1970s)

And cigarettes were a currency. If you wanted thepatients to do something, you could give them a cigaretteand theyd probably do it. In fact, I can remember myfirst ward, the charge sister saying, Go and run thiserrand and Ill give you a cigarette. Go and make yourbed and Ill give you a cigarette . . . . It was how you gotthings done.

Participants articulated the ethical component of theirdecision-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 smokingby patients, according to two of the ethical principlesimportant 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 withinthese two principles.

1. Autonomy: justifications arising from this ethical prin-ciple claim that right action is based on facilitatingindividuals 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 arisingfrom this ethical principle claim that right action isbased on the obligation to do good and the obligationto avoid doing harm (Fry & Johnstone 2001; p. 22).As will be shown in the participants discussion of theirdecision-making based on this principle, conflicts anddilemmas arose between these values and obligationsand which values and principles should take precedencein 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 theyre

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 tosmoke. Staff were mindful of imposing their own value

judgements on patients, and mindful of the power


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imbalance in their relationship with patients. Staff iden-tified strongly with the role of smoking as giving thepatient greater opportunity for autonomous activity. Staffspoke 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 manychoices as I can in every aspect of their life. I dont tendto make social choices for them. I think thats theirbusiness . . . I believe that people have choices, but thatmental health clients often have choices taken away fromthem, and I think every opportunity that we have to givechoices back to them, I try and do that.

Other staff appeared genuinely to struggle to work outtheir own ethical stance. They recognized the complexweb of competing forces at work with regard to the treat-ment of mental illness and the perceived roles of smokingfor clients in alleviating symptoms, relieving boredom,filling an existential vacuum and helping build rapport

with others. Some staff explained their ethical stance inthe context of it being the persons right to smoke, seeingthe presence of mental illness or the system of care asbeing of minimal influence.

(Janet Inpatient nurse/locked ward/non-smoker)

I just think everyone has got the right to choose to dowhat they want to do . . . They were smoking before theywere detained so what rights have we to stop them fromsmoking once theyre detained.

(1.ii) Free informed choice to smoke

Staff also spoke of patients smoking as an informedchoice made freely without restriction and based onpatients full knowledge of the harms and costs of smok-ing. Some staff used this reasoning, even when they alsoacknowledged that choice was not fully informed. Staffdid not see a duty of care to intervene with these patientsregarding their choice to smoke despite the harms. How-

ever, staff used the duty of care argument when seekingguardianship 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 whentheir spending on cigarettes occurred at the expense ofmeeting core commitments like accommodation costs.

Only two staff clearly argued that smoking was not aninformed choice by patients; one person spoke of theinteraction of mental illness and smoking and the otherperson spoke of the role of addiction adversely influenc-ing the smokers decision-making capacity.

(Terry Inpatient nurse/extended care open ward/smoker)

This ward helps them limit because it recognizes that itis not informed consent to smoke. Thats right. Other

workers are like fence sitters who just say its their rightto smoke rather than buying into the debate. Its verymuch individualized here according to the personscapacity, or also their financial capacity to buy smokes.

These two staff questioned those who claimed to bemaking 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 patientsto make a free and informed choice to smoke by providingthem with information.

(Grace Community nurse/ex-smoker)

If we had safe cigarettes tomorrow, I suppose my argu-ment would end, but theyre not safe and they never havebeen and the politics of smoking is just disgusting. Imsure the human rights arguments came from the tobaccocompanies . . . Often people, in the pursuit of what theyperceive as their human rights, present spurious argu-ments. You cant argue with, Well, I like it and Im goingto do it. You cant argue with that if the person knowsthe risks and they choose, but misinformation, you canargue with, and I tend to give people articles andcartoons.

(2.i) A difficult hierarchy and priority of concernsand harmsa. The avoidance of suffering and increased

short-term risk to the patientb. The avoidance of risk of assault to the staff

Beneficence/non-maleficence was the second form ofreasoning used by participants in deciding their ethicalstance on patients smoking. They described having ahierarchy of ethical concerns that guided them in priori-tizing harms and duty of care towards patients. Many staffperceived smoking as ethically causing less damage thanthe more immediate problems faced by patients.


I accept that it affects their health in a derogatory way;however, I think the greater priority is the immediateclient and staff safety. And if withholding cigarettes isgoing to increase client irritability and the potential foraggression or violence, I think the long-term decline intheir health is the lesser of evils, because of the potentialthat the immediate violence can cause. And Ive seen theresults of that, and that has an immediate and devastatingeffect on peoples lives.


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Inpatient nurses said they often saw patients at agreater level of distress than nurses in the community.The pressure felt by inpatient nurses to meet patientsimmediate needs, as opposed to concern for the long-

term consequences of meeting those needs, was a sig-nificant difference identified by nurses about the twosettings. For inpatient nurses, the longer-term physicaleffects and risks of smoking were seen as the lesser ofevils 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 awayeverything . . . They cant even choose when they have a

cigarette or if theyre going to have one. They have nochoice left at all. Its completely taken away, and I cantcondone that just over a couple of cigarettes . . . Oncetheyre here, my aim is to keep them on an open wardand to get them as well as soon as I can, to get them backto the community where they belong, and then the choiceis theirs. While theyre acutely unwell, and probably agi-tated, what right do I have to agitate them further bytelling them they cant have a cigarette. And to me, Iwould consider that to be abusive . . . Weve had peopleagitated and escalating and we have desperately foundcigarettes. All of the nursing staff have given cigarettes togive this person . . . If its going to reduce the negative

impacts of their illness, then surely its helpful.(Janet Inpatient nurse/locked ward/non-smoker)

I think that because in the inpatient setting youve got somany patients in close proximity to one another, that ifone gets agitated because they havent got their ciga-rettes, then it could just upset all the other people aroundthem, or they could just go around pestering or being anuisance to other patients, saying, Can I have a ciga-rette? So, in the inpatient setting, we try to ensure thatthey have cigarettes to keep them settled. And I think theconsequences of not giving them a cigarette can be a lot worse than giving them. Like, Ive seen patients hit

because theyve been pestering other patients for a ciga-rette because they havent got any.


(If there was a smoking ban) I think there would be moremedication given; I definitely think a greater amount ofPRN would be given, especially for agitation, and thingslike that. And thered be a lot more incidents and violenceas well . . . Smoking is an easy solution and sometimes itsthe only one there readily available when someone isabout to snot you one . . . Letting them smoke is the easyoption.


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,Id rather have a smooth running ward than go home witha broken arm.

The nature of the hospital setting posed unique con-cerns and arguments by staff to justify smoking bypatients. The ward milieu in which patients lived andinteracted in close proximity to each other, often while ina disturbed or unsettled state, was noted. Patients abili-ties to resolve conflict and to manage their emotions wereseen to be challenged under these circumstances. This

was particularly so for patients who were detained againsttheir will because they were deemed to be a danger tothemselves or others under the Mental Health Act.Under these circumstances, smoking was given lesser pri-ority than concern for the treatment of the persons men-tal illness and concern for the safety of the group.Nicotine dependence was also treated differently fromother drug dependence.


What they do here is going to impact on their ability tostay in an open ward, and on all the other clients as well.If they get toey at home and smack the wall because theyhavent got a cigarette, thats one thing. If they get toeyhere and smack the wall; number one, theyre likely toend up in the closed ward; number two, there are likelyto be other people around because basically its a smallcommunity here at any one point in time and whateverone person does is likely to impact on others . . . and ifits going to actually increase the anxiety for other peopleand end up with three of them transferred to the lockedward, then I have a problem with that.

Staff also worried that restricting patients smoking atthe times when they were unwell would only hinder theirrecovery, 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 theyre unwell, not my role andnot my responsibility

Participants were unanimous in the belief that there existsa time and place for talking with patients about theirsmoking. They agreed that it was not appropriate to raisethe topic of quitting or cutting down when the person wasacutely unwell. Various reasons for this were proposed.


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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 cognitiveimpairment at the time. Inpatient staff also saw the role

of assisting people to quit as a community role for whenthe person was out of hospital, in their own environmentand recovered from the acute phase of illness.


I wouldnt be talking to them about stopping smokingwhen they were very unwell. Then I wouldnt be talkingto them about it at all. This is not about torture.

Inpatient nursing staff expressed attitudes thatreflected the belief in smoking as one of the patients fewpleasures, whereas community staff comments reflecteda tendency to give the patient more responsibility for theirchoices. Staff in the locked settings directly placed thepleasure of having a cigarette in the context of patientsbeing deprived of other pleasures and basic freedoms inthose environments.


(On the locked ward) When theyre in here, theyve gotso little anyway, thats one of the pleasures that theyvegot.

Some nurses who smoked described themselves assmoking for much the same reasons as their patients and

openly empathized with them and smoked with them.Non-smoking nurses could also empathize with bothpatients and staff who were smokers and likewise acceptedthe patients need to smoke while they were unwell.


(Regarding condoning patients smoking) To tell you hon-estly, its probably my own nicotine addiction . . . WhenIm stressed about something, I usually have a cigaretteand pace.

Staff proposed various reasons for their actions thatappeared to be based on their beliefs and attitudes

towards mental illness, mental health patients, and thesystem of care. This, in turn, informed how they acted ordid not act to assist patients with their smoking and quit-ting. All nurses stated that the interview process had beentheir first opportunity to openly think about the ethics oftheir actions and attitudes, and to articulate the complex-ity of the debate.

Four participants said that smoking by patients poseddilemmas for them in their role as health-care serviceproviders within a system in which they actively incorpo-rate cigarette smoking into treatment and management.


I think, What kind of nurse would I be if I encouragedpeople 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 debatealtogether.


If they want to smoke, thats fine by me. I havent reallythought about it that much. I just never think about it.

(Jill Community nurse/ex-smoker)

Its just too complex to think about really. I just treat it asa day-to-day thing. Its 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 patientsand to facilitate assessment. In this sense, staff smoking

was reinforced by the entrenched routines involvingsmoking. Nurses who had quit smoking commented onhow they now floundered in these tasks once they couldnot use smoking to assist them. Much comment was madeabout the use of canteen funds to purchase ward ciga-rettes, specifically for patients in the locked settings whohad no cigarettes of their own, and also the routine ofhanding out cigarettes to patients at set intervals at thenurses station door.

(Paul Inpatient nurse/locked ward/ex-smoker)

And they know the routine. Its just, Oh were in thelocked ward. (Knock, knock, knock on the nurses stationglass door) Its just an instant thing. They turn off to itand so do the staff.

(Paul Inpatient nurse/locked ward/ex-smoker)

If they didnt smoke, they wouldnt come back to the doorevery half an hour either. Theres something about havinga closed door between us that makes the difference. Itsa real power thing. Its a typical us and them situation.

The staff retreat to be behind the closed door . . . Itseems to be institutionalized. I mean, even if you didntfollow that procedure, just merely by being here andbeing exposed to the way the ward operates, the policy,and the staff; staff tend to adopt a certain mentality ofcontrol, just because of the environment. Its easy to givepeople cigarettes. Its easier than not giving them.

DISCUSSION

This research has highlighted the complicated role playedby nurses within mental health settings where many clients


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are involuntary participants. They acted as custodian,carer, cigarette source, counsellor, educator, behaviourmodifier and gaoler (see Sykes 1958 for parallels withinthe prison system). Smoking appeared to provide the

means by which these role conflicts were eased for nursingstaff. The latent consequence of this was that smoking wascondoned, so much so that it was increasingly relied onto facilitate interaction. Nursing staff who did not smokecommented on their perceived loss of this care optiononce they stopped smoking. The promotion of clinicalalternatives for staff, to support their practice and care ofpatients, is indicated so that they do not rely on smokingto clinically manage clients. In support, Rydon (2005)speaks of the general dilemma facing psychiatric nurses

within existing mental health service systems. She statesthat, The question remains about how nurses can maintain

positive attitudes and therapeutic practice with users ofmental health services, when the context of mental healthnursing 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 bea group-based phenomenon within the cultural milieu. It

was not limited to individual experiences. The majority ofnursing staff appeared to accept patients smoking, seeingit as a central part of the dominant culture of the settings.Staff generally relied heavily on medications to treatpatients. One consequence of this was that, when medi-

cations were not adequate, staff were left with few othereffective alternatives to assist patients with their symp-toms and distress other than to let them smoke or tosmoke with them to give them a sense of comfort andsupport. In the same way that many patients had learnedto rely on smoking to self-medicate their illness, it appearsthat staff had acquired the belief in these benefits ofsmoking for patients. By using cigarettes to overcomepatients agitation, patients nicotine withdrawal was notaddressed by staff and patients continued to smokedespite adverse effects (Lawn & Pols 2003). This hassignificant implications for successful recovery from men-

tal illness, and for challenging the social inequities cre-ated by smoking. The findings suggest that these systemicpatterns of learning and reinforcement need to be chal-lenged and replaced within treatment environments. In aclimate of increasing litigation treatment environments

where smoking continues to be overtly and covertly rein-forced also leave themselves open to claims of negligencebrought by both patients and staff (see Lawn (2005) fora further discussion of the legal and occupational healthand safety issues pertaining to smoking in psychiatricsettings).

CONCLUSION

Most participants in this study were able to articulate theethical principles on which they based their values anddecisions about patients smoking. Most were thoughtful,concerned and very aware of the conflicts inherent intheir ethical decisions and subsequent actions and inac-tions and they appreciated the opportunity to discussthese issues. As part of cultural change in psychiatricservices, 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 makedecisions and act. Promoting a learning environment

where there is active dialogue among nurses so that theycan navigate through the dilemmas posed by their role

would seem important. The nursing profession involvesinherent conundrums of care, where paradoxes in theinterpersonal therapeutic relationship with patients mustbe discussed, understood and resolved (Horsfall et al.2000). However, considering ethical decision-making inisolation will not bring about change, but needs to be oneof a number of strategies to address smoking by patientsand staff within psychiatric settings. Psychiatric nurses areideally placed to challenge the entrenched culture ofsmoking 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 ofMedicine, Flinders University and Senior Consultant Psy-chiatrist, Division of Mental Health/Flinders MedicalCentre (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 theoriginal PhD research from which this paper is drawn, theauditor and the nurses who contributed their valuabletime and ideas to this issue.

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Psychiatric nurses’ ethical stance on cigarette smoking