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Practice question

Mrs Smith is dishevelled and dirty. She has declined a bath when offered one. Do I respect her wishes or try to persuade her?


Mrs Smith is entitled to receive compassionate care from nurses. This care should promote health wellbeing and dignity (NMC, 2009). 

  • Care should promote health wellbeing and dignity
  • Nurses must address patient’s fears and work how to maintain their health and dignity
  • If staff mistakenly believe a person who lacks capacity is choosing to decline care and do not provide it they could be considered negligent 
  • If staff mistakenly think a person who lacks capacity is declining care, they can be considered negligent for not providing it

Nurses should treat patients as individuals. In Mrs Smith’s case the nurse should find out why she has declined a bath. Mrs Smith may have her reasons. One woman I looked after slipped in the bath, fractured her wrist and was trapped there for many hours. She decided never to bathe again as the thought of it brought back memories of a traumatic time. Mrs Smith may be in pain and may fear that a bath will make her even more uncomfortable. She may be embarrassed that she is in such a state, or perhaps she did not like the way she was approached. 

The sensitive nurse will find out why Mrs Smith has declined and work in partnership with her to address her fears and work out ways to clean her and to maintain skin health and dignity.  Mrs Smith might have more pressing needs. She might be in pain, hungry or thirsty.  When these have been addressed, the nurse may offer Mrs Smith a shower, or a wash now and shower or bath later. 

Adults who have capacity have the right to make decisions that we may consider imprudent.  The person who has poorly controlled diabetes has the right to eat sweets and a poor diet. The person with lung disease has the right to smoke.  However, not all adults have the capacity to make decisions and they may lack capacity to make a particular decision.  The Mental Capacity Act in England is clear that a person may have capacity to make certain decisions but not others. For example, Mrs Smith might no longer be able to manage her finances, but may retain the ability to make choices about day-to-day matters such as what to eat, what to wear and what leisure activities she wishes to take part in. If Mrs Smith lacks the capacity to understand the decision she is being asked to make and the consequences of her choice then nursing staff have a duty of care. This means that staff have a duty to provide care.  If staff mistakenly think that a person who lacks capacity is choosing to decline care and do not provide it they could be considered negligent. 

If Mrs Smith is confused she may be unaware that she is dirty, dishevelled and smelly. She may have lost track of time and think that she is only just washed.  Confused and cognitively impaired people often respond well to gentle directives such as “I’ve come to give you a wash”, rather than offers to provide care and assistance.  If the person is very confused it can help to use simple language and break a task down into stages. If the person co-operates with the nurse then consent is implied.  If the person refuses care or does not co-operate the nurse can try to persuade the person, try a little later or consult another more experienced member of staff or involve a nurse with specialist expertise in caring for older people

Linda Nazarko is senior lecturer at South Bank University and King’s College (visiting) and nurse consultant for older people at Richmond and Twickenham PCT



Readers' comments (3)

  • You make it sound so simple!! but in reality its not so easy.

    If a patient is able to make their own decisions you have to respect them. No matter how much you want to intervene. Could be considered an assult on the patient.

    If the patient lacks capacity to look after themselves then of course you would do your best to try and talk to them and find out why they don't wqnt to wash etc.
    Family involved or social services to get carers in. Is the patient safe to be at home on her own etc.

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  • This is what we do anyway as trained and registered nurses and trained or experienced HCAs. It is part of our job. Although the article is quite correct it would seem it is written more for the benefit of lay people who are unfamiliar with such a situation and unsure how to handle it.

    It is unclear whether the situation described takes place in a patients' home or in hospital. Presumably, even though the NHS hospitals are rather behind the times they do have safe sit down showers or hoists which may help to make the patient feel more safe and secure if the fear of falls is the issue.

    It must be remembered too that even delightful old ladies can become quite aggressive and cause injury if they are confused, frightened or fear that their autonomy is being removed from them and this issue also needs to be handled safely for all concerned.

    It is a well written and concise article but it is unclear what type of audience it is aimed at.

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  • I think the article is aimed at students or people without much practical experience. It

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