Nasty residents, smoking, and insubordination

[CapeCodMermaid, RN]

Where to begin? My facility is a non smoking facility. We got a resident with a newly repaired hip who hopped off the stretcher and announced he was going outside to smoke. The nurses told him we were a non smoking facility. I don't care he said so they called the doctor and got an order for him to be able to smoke. THEN they called me (the DNS)...no I said, he cannot smoke. I spoke to the charge nurse who told me that I would have to drive in to tell him because he was 6 feet tall and she wasn't going to speak to him. I couldn't believe what I was hearing. The long and short of it is, he left in a taxi to go home with a doctor's order.

What would you do about this nurse? If I were at home, I might have hopped in the car and have gone to work to calm things down, but she is being paid to be a charge nurse and it makes me angry that she should act this way.

Just as well, if you ask me, that the man left. If he was so nasty about smoking, perhaps he would have been just as nasty and non compliant around the schedule for his pain medications. Sorry for the rant!

[noc4senuf]

We too are non-smoking. We admit to the short-term rehab those that "promise" not to smoke and find them lighting up in their rooms. We take the cigarettes away and the family bring more.

As for the nurse, it is clear insubordination and I would be firing her come Monday but, I know CCM that you have mentioned in the past it is difficult for you to find nurses.... maybe a suspension and final warning.

[caliotter3]

You said she is being paid to be the charge nurse. If she is getting a differential for this, as a minimum, come Monday, that should end. I would give her the warning and give her one more chance unless she has been not up to par before this. If she can not deal with an issue like smoking, then how can you rest easy at home that she can deal with any other issue that a charge nurse is expected to handle? You might be better off just getting rid of her on Monday.

Oh, and good riddance to the smoker. Now you don't have to deal with the problem.

[susanthomas1954]

As per usual, the report you got from your charge nurse was probably not the whole story. There were probably a dozen other problems with the patient, and she chose to focus on that one because it was actually the most easily described.

Surely your facility has an exit, and surely you have staff members that smoke, even if they have to go out to the sidewalk, off property. Good customer service would allow a patient (short-term rehab patient) to go outside with a staff member twice a shift for supervised smoking.

Can you tell I have had a hip replacement, and that I smoke? The hospitals do not let people smoke, at all. Rehab can and should be a different environment. We should be trying to get people to their highest level of function, which includes assessing their ability to smoke safely.

Again, I'm guessing the charge nurse focussed on that issue to prevent dealing with something more sticky.

ST

[caliotter3]

As per usual, the report you got from your charge nurse was probably not the whole story. There were probably a dozen other problems with the patient, and she chose to focus on that one because it was actually the most easily described.

Surely your facility has an exit, and surely you have staff members that smoke, even if they have to go out to the sidewalk, off property. Good customer service would allow a patient (short-term rehab patient) to go outside with a staff member twice a shift for supervised smoking.

Can you tell I have had a hip replacement, and that I smoke? The hospitals do not let people smoke, at all. Rehab can and should be a different environment. We should be trying to get people to their highest level of function, which includes assessing their ability to smoke safely.

Again, I'm guessing the charge nurse focussed on that issue to prevent dealing with something more sticky.

ST

Good point here. You might want to ask her about this before you focus on her failure to deal with the problem.

[CapeCodMermaid, RN]

She couldn't deal with his smoking...sorry NOT allowed..has nothing to do with regaining one's highest level of function and actually impedes wound healing. She couldn't deal with his hopping out of bed and marching around not following hip precautions...couldn't deal at all.

[elkpark]

As per usual, the report you got from your charge nurse was probably not the whole story. There were probably a dozen other problems with the patient, and she chose to focus on that one because it was actually the most easily described.

Surely your facility has an exit, and surely you have staff members that smoke, even if they have to go out to the sidewalk, off property. Good customer service would allow a patient (short-term rehab patient) to go outside with a staff member twice a shift for supervised smoking.

Can you tell I have had a hip replacement, and that I smoke? The hospitals do not let people smoke, at all. Rehab can and should be a different environment. We should be trying to get people to their highest level of function, which includes assessing their ability to smoke safely.

Again, I'm guessing the charge nurse focussed on that issue to prevent dealing with something more sticky.

ST

Why "should" rehab be a different environment that permits smoking, and what on earth does the "ability" to smoke have to do with people functioning at their highest level? I work in a free-standing acute psychiatric inpatient facility in "the tobacco belt" that is smoke-free (and believe me, we get plenty of clients who are smokers -- in fact, we rarely get non-smokers). Staff can only smoke on the property within their cars (windows closed). Clients are informed up front, before they're admitted, that they will not be allowed to smoke (however long they're there), that nicotine patches and/or gum can be provided (if they're not contraindicated for some reason), and, if that's not agreeable to them, they can choose to not be admitted and go somewhere else. What's complicated about that??

[rn/writer, RN]

Was this an attitude problem with a subordinate who is often difficult, or was this a nurse who folded like a house of cards because she really didn't know what to do with a patient she found intimidating. If it's the former, sounds like some discipline might be in order. But if it's the latter, you might get better results by giving her some new tricks to put up her sleeve. Tell her what you would have said and done had you been on site. How would you have drawn lines assertively without trampling on the patient's autonomy? It's hard to come up with an effective strategy when someone puts you on the spot and you haven't already thought things through.

The blend of the two approaches--discipline vs. education--would mean offering her ways to improve her skills AND letting her know that declining to learn is not one of the choices.

Use this opportunity to teach your staff how to set good boundaries and when, where and how to let go when a patient refuses to cooperate. Equip them with assertive language. Tell them when they need to call a doc and what they should say.

We all know that there are folks who are stubborn, difficult and lazy. But, sometimes what looks like a bad attitude is the person saying, "I'm afraid, and I don't know what to do."

[rebelgirl#1]

I love the last response which would be to teacher her to be more effect. Most of us are not taught good communications skills, nor how to manage effectively. After that if she still is not up to par, no more charge for her.

[canoehead, BSN, RN]

There must have been more than his being a 6 foot man that was frightening her. She needs to be able to verbalize what behaviors were bothering her, rather than just refusing to deal. If she felt threatened by a resident I assume you have policies in place that allow her to call for backup staff or police- would it have been appropriate to do that in this situation?

The patient can accept or refuse most anything, including mobility restrictions or smoking policies. If I had been calling you I would have planned on telling him that if he did X the consequences would be Y, and making sure you'd back me up on that. If the policy is no smoking you should be sticking to it, or else it's not really a policy. So if he goes out to smoke, he will be discharged, possibly escorted off the property by police if continues to behave in a threatening manner (she has to be able to list what she finds threatening).

Possibly the patient wasn't threatening, just bizarre, or noncompliant. It would be nice to hear from someone besides that one nurse about how they found his behavior. I don't think it's acceptable for the charge nurse to just give up on her responsibilities midshift. Things need to be worked through, and the policies in place should give her some kind of a framework as far as what to do when a patient behaves unacceptably.

[heron, ASN, RN]

With all due respect, from what you posted, the patient had already been spoken to about this and refused to comply ... the nurses on the scene had gotten a compromise of sorts with the dr. order ... then you wanted the charge to go back and fight it out all over again.

What was she supposed to do ... restrain him?

You set her up by catching her between a rock - the patient - and a hard place - your orders. If the pt was physically threatening her, then you put her at physical risk, as well.

It would be different if she had made no attempt to talk to the pt or deal with the situation ... but your OP says this wasn't the case.

When doctors do this to me ... "ordering" me to make a competent patient do something they already refused to do, I do exactly what your staffer did ... tell the doc to come convince the pt. themselves. I don't see this situation as much different.

[CapeCodMermaid, RN]

It was inappropriate of her to call the doctor to get an order to smoke in a non smoking facility. Perhaps I am fearless. In my last building, a family member was swearing a blue streak and screaming at the staff development coordinator. HE called ME....he was 6'2...I am 5'3. I would never put my staff in harm's way. I think this nurse just didn't want to deal with it so she didn't.