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Listening to the experts

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VOL: 97, ISSUE: 02, PAGE NO: 34

Anita Rigby, BN, RGON (New Zealand), OND, is a staff nurse, intensive care unit, Harefield Hospital, Middlesex

Anne was a 45-year-old woman who had been admitted to our critical care unit with unstable angina. Once her chest pain had settled, she went to the ward for mobilisation. Transfer to the nearest tertiary hospital for further investigations and possible angioplasty or coronary artery bypass grafting was arranged for the following Tuesday.

Anne was a 45-year-old woman who had been admitted to our critical care unit with unstable angina. Once her chest pain had settled, she went to the ward for mobilisation. Transfer to the nearest tertiary hospital for further investigations and possible angioplasty or coronary artery bypass grafting was arranged for the following Tuesday.

I met Anne on the Saturday while on morning duty. I knew her from previous admissions to the CCU (this was her third admission for unstable angina in six months). She had had a myocardial infarction in the past and an angiogram had shown severe blockages of her right coronary and left anterior descending arteries. It would only be a matter of time before Anne experienced another infarction.

I knew that Anne disliked hospitals and that she had earned a reputation from some of the nurses for being a 'non-compliant' patient who continued to smoke heavily, despite warnings from the health professionals.

When I met Anne that morning, I wasn't surprised to find her anxious, saying that she wanted to go home. I also knew that her frequent trips to the garden were not just to admire the flowers or scenery. She was a 'mess' and clearly something had to be done. If she carried on like this, I could envisage her being transferred back to CCU. So, I sat down with her and listened to what she had to say. She wanted to go home where she felt she would be better off 'stroking her animals'.

I looked at her husband, John, who sat quietly with her and appeared to be agreeing with what his wife was saying. Anne felt that being at home 'among my things' would be less stressful, which would mean less smoking. I couldn't help thinking that she was probably right.

After she had finished speaking, I put forward my concerns. I explained that it was a Saturday and a locum physician from another hospital was on call. I wasn't sure that he would be willing to discharge another doctor's patient or even spend time with her to explain the pros and cons of discharge. From a practical point of view, Anne lived more than 20km away from the hospital and she needed to continue her subcutaneous enoxaparin. Was she prepared to return twice daily to the hospital for her injections?

Anne had anticipated these concerns and had an answer for all of them. Her husband was a St John Ambulance volunteer and drove the local ambulance. He knew how to perform cardio-pulmonary resuscitation and yes, Anne and her husband were fully aware of the consequences should she suffer a cardiac arrest or myocardial infarction while at home and away from the treatment and care immediately available in hospital. She agreed to return for her treatment.

It was clear to me that Anne was serious about her request to be allowed home. Recognising how stress and anxiety can have a detrimental effect on patients with unstable angina, I agreed to talk to the locum physician when he came to the ward.

When the doctor arrived, I explained Anne's situation and he agreed to see her. He again explained the pros and cons of discharge and why she should stay in hospital. Like me, during our conversation, he agreed that going home would help relieve Anne's stress and anxiety. She was so happy to be leaving hospital, she gave me a big hug and thanked me 'for being so understanding'.

Over the next few days Anne returned regularly for her treatment, accompanied by her husband and friends. She seemed relaxed. She told me that she hadn't needed as many cigarettes and she had had no further bouts of chest pain. Her husband was going to drive her to the tertiary hospital himself, which is what she wanted. I was able to ensure all was going well while I administered her enoxaparin and checked her vital signs.

Lessons learnt
What have I learnt from the above situation? Thanks to Anne's insistence on her rights and the positive outcome, in the short-term at least, this experience has made me realise that health professionals don't always make the best decisions for patients. It is important to listen to and involve our patients in making informed decisions about their own care.

I remember, in the past, how medical and nursing staff called all the shots and patients had no option but to go along with what they said. Today we can only advise on what may be the best options and help patients make an informed choice. Like Anne, ultimately, it should be the patient and family who make the decisions which are best for them.

Anne knew what was best for her. Nursing is all about compromise, partnership and sharing power. I didn't just see Anne as a disease, as an 'unstable angina', but as a whole person - an individual with her own cultural identity, values and beliefs. In doing so, I believe I provided holistic care for Anne and her family.

My experience with Anne and her family made me think and reflect upon my practice as a nurse. It made me question my behaviour and attitudes and how I may have reacted to such a situation in the past. It made me realise how much I have changed in my practice and how, I hope, I will continue to develop and improve what I do.

As health professionals, we need to be flexible and to tailor our work to take into account the individuality of our patients. It's all about empowering them and giving them control of their lives. Sometimes, doing this may mean bending 'the rules' a little and going outside the 'accepted' practice. We need to balance 'technology' with human qualities, such as sensitivity, understanding and caring. And, I believe, caring is the essence of nursing.

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