Chris Phillips outlines the steps NHS employers should take to implement a successful smoking ban and explains how to deal with possible dissent from patients, visitors and staff

One of the driving forces behind NHS Lothian's tobacco policy is its duty to protect staff from harmful substances in the workplace and to take all reasonable measures to secure the health, safety and welfare of its employees.

So why, as NHS Lothian moves toward a complete smoking ban on all its land by Spring 2009, are some now arguing the policy puts staff at risk?

Particular concern has been expressed by Unison, which fears that staff may bear the brunt of having to tell patients and stressed or grieving relatives they must be completely clear of NHS grounds before lighting up.

Sound preparation

The action plan for implementing the policy sets out that inpatients should be informed of the rules before admission. The policy also calls for signs to make visitors aware of the rules and for staff to be informed of the policy during the recruitment process, before the employment relationship begins.

These measures have been implemented in NHS Lothian premises and vehicles, as well as around entrances to buildings.

However, in practice, employees could well have to ask members of the public or colleagues to stub out - a likelihood that will increase as areas affected by the ban are widened.

To minimise the risk of staff being subjected to verbal or even physical abuse as a result of their intervention, support and training for employees is vitally important.

They should be fully trained on how to communicate the policy and, crucially, the reasons for it. They should be taught techniques for keeping a situation calm and be able to identify when to withdraw from a situation before it escalates. Security staff - not nurses or doctors - are best placed to deal with abusive behaviour.

Enforcement

Staff should be encouraged to report any incidents of abusive behaviour through clear reporting lines, to ensure managers are kept fully informed. Action should then be taken that is proportionate to the level of abuse reported. Offenders must be dealt with in a way that sends out a firm message that similar occurrences will not be tolerated.

Where physical violence has occurred or been threatened, the police should be involved. Incident forms should be kept under review to assist management in pinpointing any particular areas of concern, leading, if necessary, to a review of practices.

When dealing with employees who break the rules, employers should deliver a stern warning about future conduct. The first stage in dealing with enforcement would often be the offer of smoking cessation support and/or nicotine replacement therapy. Where this fails, or where a breach is more serious, formal disciplinary action must be applied.

Such action could simply be a verbal warning. For example, where a member of staff lights up as they approach the perimeter gate on their way out of the grounds. Alternatively, a written warning or even dismissal may be justified where there have been repeated breaches of policy. This may include incidents where somebody acts contrary to the smoke-free legislation by smoking in an enclosed public place, or where it may directly cause a health and safety hazard, such as smoking close to flammable substances.

Staff also need to be aware of their own personal safety and must be dissuaded from finding a remote or poorly lit location in the grounds to smoke, where they may be at risk of assault or theft.

Clearly communicating the policy to staff, patients and visitors will be a key step in ensuring everyone's safety. These measures, backed up with staff training and support, will help ensure the policy can be rolled out without a backlash from employees or patients.