Hospital recruitment and participation
Six of the eight selected hospitals (75%; 43% of the 14 eligible hospitals) agreed to participate. Of the two hospitals that declined, one was too busy and the other was unable to obtain hospital ethics approval in sufficient time to be included in the study. Time and budget limited the number of hospitals selected and the ability to replace hospitals that refused participation.
One DM and one SCC were interviewed at each participating hospital with two exceptions; we were unable to interview the DM at one hospital, and at another we interviewed two DMs at their request. Interviews lasted between 16 and 59 minutes (DM mean interview was 39 minutes; SCC mean interview was 47 minutes). Interviews were conducted between October 2009 and December 2009.
DMs held senior hospital administrative roles (e.g., director, clinical manager, chief nursing officer), and all were influential in bringing the OMSC to their hospital. The SCCs were unit nurses (n = 4), program manager (n = 1) and dedicated SCC (n = 1). One SCC had been involved in the initial implementation. Four SCCs had some dedicated time to educate staff and communicate program results, one was responsible for the IVR component only, and one did not have any unique responsibilities pertaining to the OMSC.
Sustainability
Implementation and program design factors
Hospitals differed in how they implemented the OMSC (Additional File 2). Interestingly, we did not see clear differences in these factors between hospitals with sustainable and unsustainable OMSC programs as discussed below.
Three hospitals implemented the OMSC in general inpatient care units, and three selected special care units. Participating hospital units were selected based on staff interest, ability to redeploy resources and patient smoking rates. OMSC counselling was provided by nurses during routine care, by dedicated smoking cessation counsellors, or by specially trained nurses.
UOHI nurse specialists provide the IVR follow-up support to three hospitals. The other three hospitals are responsible for managing their own IVR, and have received funding for up to 1,000 patients. These hospitals provided differing perspectives on continuing patient follow-up with this system. Hospital E plans to continue IVR and is seeking funding. Hospital F does not plan to continue IVR follow-up due to funding concerns and frustrations with the software, and did not discuss alternative approaches to patient follow-up. Hospital C is unsure about the future of the IVR follow-up due to costs and questions the hospital's role in providing the IVR service, as opposed to connecting patients with a service in the community or a smoker's quit line.
All hospitals with a higher level of OMSC activity allocated a percentage of the SCC's time (range from 10% to 100%) to support the program (e.g., educate staff, ensure that patients are counselled, communicate program results). The two hospitals with lower than baseline OMSC activity either had not appointed a SCC or assigned the SCC to manage IVR follow-up only.
Interactional themes
Themes that emerged from the interviews and qualitative analysis are presented below, along with the application to the OMSC. We found that applying the Gruen et al. model [21] and examining the interactions between the health problem (defined by UOHI as 'smoking by patients admitted to hospital'), the program (i.e., the OMSC activities), and program drivers (e.g., key stakeholders such as funders, managers, hospital administrators, policy makers, and community leaders), provided greater insight into the sustainability of the OMSC. These interactions and the likelihood of sustainability were influenced by the social, cultural, political, and economic context within each hospital setting (Figure 1). Application of Figure 1 to the OMSC is outlined below.
Problem definition - how health concerns are identified and defined to meet the needs of people with influence
Key informants (i.e., SCCs and DMs) viewed smoking cessation as an important health issue that fit with the hospitals' corporate objectives of restoring health, or with the hospital's smoke-free property initiative:
'This is the number one type of prevention we can actually do for the top admitting diagnosis, so this is certainly going to affect our length of stays, better outcomes for patients.' (DM 3)
'I think it all comes down to patient health. How can a hospital not be tackling the number one killer?' (SCC 5)
'For years and years, healthcare workers, we made it okay for the public to smoke because we aren't saying that it's not okay. We weren't providing opportunities for them to see alternatives or how to help them, because it is an addiction, it is a disease. I think healthcare needs to lead the way.' (SCC 6)
Study respondents also expressed that addressing smoking cessation within the hospital faced some resistance. One DM relayed the attitude of the medical leadership, 'Is this something that really should fit into the hands of an acute care facility?' Another DM described how the hospital nurses felt the OMSC was an extra-burden on already busy staff. However, the DM believed patient tobacco use is an 'occupier of time':
'And it makes it easier for staff to just have their patients go out and smoke because for that period of time they don't have to deal with them. Rather than taking that time to say to the patient that we need to address your tobacco use as it matches your ability to recover from your medical condition, from your surgical condition, from your other conditions. We still don't have that. I don't think that we have it across a lot of healthcare. I don't think we are unique in that at [DM hospital].' (DM 5)
Staff behaviour began to change when nicotine replacement therapy (NRT) was made available as unit stock and the DM framed delaying the application of NRT as a medication error and patients smoking as a 'failure to treat their nicotine withdrawal.' (DM 5)
Several key informants suggested that framing hospital smoking cessation programs in terms of costs and benefits would influence decisions of the provincial Ministry of Health and Long Term Care to fund hospital cessation programs:
'If we take a very aggressive approach to addressing the use of tobacco in patients then we will have cost savings in our hospitals...we will have reduced days of stay, less infections. So I think that the approach, honestly, needs to talk about, obviously it's a wellness thing, and it's important, but hospital administrators are interested in the bottom line. They need to see this as an investment, not an expense. Because if you save two days of stay on the average length of stay, or even one day of stay for every patient who comes in who is a smoker, compared to patients who don't, who have the same procedure, I think that is very powerful data.' (DM 5)
Political economy - how the program engages stakeholders
Although the four hospitals that implemented the OMSC using unit nurses did so for budgetary reasons, respondents at those hospitals felt that this approach helped embed the program into patient care and fostered sustainability by engaging frontline healthcare workers in the program:
'Nurses are used to healthcare teaching, so they see assessing patients' readiness [to quit smoking] as a good fit. It's amazing once they get committed at that point, how I think that's the sustainability component, because they are living and breathing it every day.' (DM 2)
A SCC with some dedicated time to counsel patients noted that other nurses had difficulty finding time to counsel patients:
'If [the other nurses] know I am coming in, perhaps they won't [deliver the program]; they will leave it for me. Because they don't have the hours dedicated to it, they have to try and fit it into their day and an assessment, the first counselling sessions take about a good 40 minutes or so by the time you are done the paperwork and that is a lot into their already busy day.' (SCC 2)
At another hospital, in order to engage nurses in the counselling process, the sessions were modified to take place when nurses are providing other care.
Two SCCs mentioned that their expectations about the program changed after seeing the effect it had on patients:
'But then when you find that the patient is less irritated, the patient is less restless, if you can provide them with some nicotine replacement and then you get one less problem to deal with, there's a benefit to it.' (SCC 6)
'I would say now, my emphasis is more to make them comfortable while they are in the hospital and hopefully they will [quit]. It is still in the long run to make them quit. However, when they are comfortable in the hospital and they see that they can go craving-free for a few days then that sort of gives them the courage to think about quitting or it teaches them that quitting can be an option.' (SCC 2)
Strategies to engage stakeholders
Engaging champions
Two of the four hospitals with higher levels of OMSC activity mentioned that they used champions (i.e., individuals who promote the OMSC to hospital staff) to overcome staff resistance and gain acceptance of the model, thus promoting stakeholder engagement in the program. Hospitals strategically chose individuals with high credibility, enthusiasm about the program, and their passion for smoking cessation. One hospital, experiencing resistance from the medical leadership, enlisted a physician champion who 'made presentations and started to order medications for patients, to convince colleagues that it's a safe thing to do' (DM 1).
Some respondents also felt that program champions were necessary to keep the issue of smoking cessation on the hospital's 'front burner' amid competing priorities, to be able to add to the program, and to ensure that people comply with the program.
Supporting drivers
The program also engages drivers by providing them with support during the implementation phase. Respondents felt that the UOHI facilitator played a major role, 'She knew how everything should run and it was very, very new to us. She had all of the answers' (SCC 2). A hospital with a lower level of OMSC activity found that UOHI's feedback was helpful in providing input into problems they were experiencing:
'They would meet with us and look at how our audits were reporting, and looking at what some of our problems were, we were identifying how to improve and it was something that I thought was quite acceptable for new programs. You would troubleshoot as you went along.' (SCC 6)
Despite help with specific problems, the two hospitals with lower OMSC activity levels indicated that they did not always feel supported:
'Sometimes I don't feel supported. Sometimes I feel badgered. ...I think at this point we're feeling a little overwhelmed by what's before us.' (DM 5)
'Whenever there was a decrease in numbers, I'm not sure what supports were there from the Heart Institute, because if there is no sustainability, you are just basically saying, Okay, add this to your workload and although you mentioned great that smoking cessation is important, it is an extra item that we are expecting nurses to remember to do, one, and that they will complete, have the discussion about the IVR afterwards, and follow-up in the community.' (DM 6)
When asked if they could envision a time without support from UOHI, many respondents described the role that they felt UOHI could take in sustaining the program. '[UOHI is an] excellent link for us...gives me new research' (SCC 1). 'It is easier to keep a program going if a central institution is involved; it keeps the program on the front burner' (DM 2). Other roles a centralized institution might consider included: offering a mini-refresher course to ensure that everyone knows the newest information available; coordinating various hospital sites to ensure that information is consistent across hospitals; organizing a community of practice teleconference every two to three months between sites so that they could learn from each other; and assisting hospitals with training and resources to manage and process program statistics.
Quality cycle - how the OMSC program demonstrates a positive impact on the health of the target population
Respondents cited the reputation and experience of the OMSC in addressing hospital smoking cessation as a major reason why they decided to implement the OMSC. The ability to demonstrate quit rates appealed to hospitals:
'It was already a success in other hospitals. They had really good evidence to support what they were doing, really good numbers [quit rates] showing how successful they had been, so in many ways it seemed like a really good model.' (SCC 2)
The best practice statement in the model was also appealing:
'It makes it easier for us to try and move the notion forward that not only were we smoke-free property-wide but that we were actually going to try and support patients while in the hospital to achieve that status of not smoking while they were a patient in the hospital.' (DM 5)
The baseline survey and other tracking measures were beneficial because they enabled hospitals to see improvement and track their progress, and increased accountability: 'People realize that the program is important because measures are reported to leadership; if they have to report it then they are held accountable' (DM 1). 'Providing feedback to staff makes them more aware of what is going on; to keep them in the loop and remind them of the processes' (SCC 1). Program results could be used to argue for funding as 'once [you] have outcomes then it becomes more sellable' (DM 2).
Hospitals used this performance feedback to make changes to their processes. When two hospitals noticed a decrease in the number of smokers being identified, one began the process to integrate a late-career nurse to provide support to the program, and the other obtained support from UOHI to develop communication tools and conduct additional training sessions. Another hospital, wanting to increase the IVR follow-up enrolment rate, now asks patients about IVR on admission and at discharge because:
'Some patients are not ready at the beginning of their stay in the hospital, but once they see how they do within the hospital then sometimes they're more open to trying to stay, to remain smoke-free. So, we would suggest the IVR again, we would ask again at the second time.' (SCC 1)
Despite the positive feedback on the measures collected by the OMSC, DMs felt that it is difficult to sustain programs that require data management without dedicated resources. One DM felt that the culture of collecting data for these types of programs has implications for their sustainability because hospitals do not have the infrastructure to collect all of this information, 'It was the reporting that was required, I'm not sure if people knew that up-front, how much reporting was expected or that they would be requested to provide' (DM 6).
Organizational context
The OMSC program was operating within a social, political, and economic context defined by the organizational setting, community environment, and available resources. Some hospitals were challenged during implementation because collecting data and setting up the IVR component of the program involved the cooperation of different hospital departments (e.g., technical and privacy).
While DMs felt that the OMSC was an important initiative and had advocated for the program's implementation and continuation, they were also cognizant that smoking cessation is only one of many hospital initiatives. To avoid the program becoming forgotten amongst other new and competing initiatives, one SCC remarked that they are trying to incorporate the program into other things that the hospital is doing (e.g., posters for skills days), 'When you keep doing the same thing for a long time, you need to spruce it up a bit and talk about it a bit more' (SCC 1).
SCCs also noted that because nurses are busy and have competing priorities, and patients are in the hospital for shorter stays, completing a smoking assessment may not be a top priority and patients may be discharged before being offered the OMSC.
Although all DMs interviewed felt that the continuation of the OMSC depended on resources, only one hospital prepared a plan and budget for continued funding. One DM remarked that the OMSC was funded through the hospital's operating budget, but, 'It is something that I sort of have to vie for and continue to justify with my directors in terms of the hours and how that's needed' (DM 2). At another hospital, the DM reallocated funding in a specialized nursing unit which was not part of the hospital's operating budget to enable the program to continue, but only in that unit.
Study respondents identified that resources are necessary for staff education, data management, and to fund a full-time person dedicated to the OMSC. However, opinions differed as to whether assigning an overall champion or employing full-time smoking cessation counsellors would ensure that all patients receive counselling and are informed about the IVR.
Key informants remarked that the success of the program would depend on how successful hospitals are including smoking cessation as part of best practices for nurses and other health professionals. One DM suggested that for programs that aim to change behaviours, it is necessary to include these concepts in the educational curriculum of the healthcare providers to increase acceptance of the program by professionals, overcome attitudes of resistance, and to have it looked upon as an acute care health issue. Another respondent suggested that physicians become more involved in smoking cessation by talking to patients about their tobacco use prior to hospital admission.