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'Inconsistent practice can lead to patients becoming frustrated'

Sian Rodger
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A junior nurse approached me on the ward and explained that she was feeling frustrated because one of our patients had asked to be wheeled outside in his bed so he could smoke a cigarette.

The nurse declined his request as the patient is on bedrest due to a pressure injury to his ischial tuberosity (sitting bone). The nurse reported that the patient then became irritated and angry because the previous day his request had been carried out by a different nurse. The junior nurse wanted clarity (rightly so) on what was the right course of action.

My initial thoughts were that nursing staff should not be helping a patient with skin issues to smoke as:

  • Smoking slows down the healing process;
  • Nursing staff could be viewed as condoning smoking;
  • We work at a non-smoking trust;
  • There are health and safety risks associated with moving the patient and with smoking in bed.

These were the thoughts of my nursing head, but my nursing heart felt slightly different as: 

  • This patient has been on bedrest for a number of weeks prior to admission at the referring hospital and was very dependent on staff;
  • The patient was coming to terms with a life-changing traumatic injury;
  • He understandably had a low mood because of bedrest;
  • He was finding the days frustrating and boring, viewing smoking as the only pleasure he has.

I spoke to the patient and explained that due to his skin issues, nurses cannot agree to his request. The patient remained calm while expressing his disappointment, stating that he was fully aware of the risks but as a consenting adult he still wished to smoke.

Even though I knew we could not help in something that was going to delay a patient’s rehabilitation further, I sought the advice of my manager.

The patient had been calm and polite to me and I knew that he was not always as even-tempered with other nurses, especially at the weekend.

”We need to support each other to make difficult decisions” 

This was why his request was agreed by one nurse as she let her compassion and empathy rule her decision alone, whereas the other nurse had let her knowledge and adherence to protocol rule her decision.

Inconsistent practice by nurses can lead to patients becoming frustrated and angry which can then lead to confrontation and breakdown in the nurse-patient relationship.

On discussion with my manager, we decided to draw up some guidelines to ensure difficult decisions are guided by compassion, empathy, knowledge and adherence to protocol.

Our guidelines consisted of following hospital policy, escalation to senior nursing staff, support for patients’ medical and psychological needs, and support for nurses when having to make difficult decisions.

It’s not easy to deny patients what they see as their only pleasure in life, and I imagine there are plenty of other examples of this throughout the NHS. However, we need to support each other to make difficult decisions while upholding the firm foundations of evidence-based practice that our care is determined by.

Sian Rodger is patient education and health coaching lead, London Spinal Cord Injury Centre

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