| Summary: | Smoke-free grounds policies (SFGPs) were introduced in acute psychiatric hospital settings to help improve health among patients, staff, and visitors. However, enacting these policies has been challenging. Recognizing that cultural norms around tobacco use may influence policy enactment, a qualitative ethnographic study was undertaken in Northern British Columbia, Canada to improve understandings about how SFGPs are affected by institutional cultures. Data included participant observation, document analysis, informal fieldwork discussions (n=11), and interviews with patients (n=20), healthcare professionals (n=19), and key informants (n=2) at two hospitals. Data were analyzed using iterative processes to inductively derive thematic findings and develop cultural understandings. Cultural factors supported some healthcare professionals in subverting and resisting the SFGP while advocating and caring for patients. Strong consultative leadership, including input and participation by those most directly responsible for policy implementation, offered the strongest indication that policy-maker intent could be implemented. This study highlights the actions taken and challenges faced by those implementing SFGPs in inpatient psychiatric settings. Consistency in implementing the SFGP across the organization was a significant challenge, influenced by local context, the nature of the policy, resource availability, and healthcare professional discretion under the policy. Patients responded to the SFGP in a variety of ways, but ultimately remained resigned to smoking and believed hospitals had a duty to accommodate them and their smoking. The centrality of smoking was rooted in personal beliefs sustained by both healthcare professionals and patients, and enforced through group norms. The study offers new evidence about the importance of local and cultural contexts to SFGP implementation and reports for the first time how rurality may influence SFGP implementation in psychiatric settings in Canada. Local contexts and cultural factors can be conceptualized in a socio-ecological model of intra-personal, inter-personal, institutional factors, and community/environment spheres of influence, to structure inquiry and analysis of SFGP implementation. It is suggested that policy-makers avoid oversimplified macro-level approaches to SFGP development and implementation in favour of more localized, simultaneous, top-down, bottom-up approaches, with accompanying support for those most directly involved in implementation efforts to improve policy fidelity and any needed shift of cultural norms.
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