Advocating for patients, in my opinion, is one of our most privileged roles and one we should take very seriously. I have often found, our position as Student Nurses affords us a certain advantage when it comes to patient’s openness right from day 1. Because we are often very hands-on, we know our patients very intimately and they feel more able to open-up to us about smaller concerns they may not feel were important enough to raise with their doctor or consultant for example. This carries a responsibility for us to make sure we take all patient’s concerns seriously and act on/escalate anything that, using our theoretical knowledge, may be of importance to their care. This also takes a pinch of courage to have confidence in your instincts and “back yourself” as we say on the Rugby pitch.
Last week while assisting a patient with his wash (which is often a time when I learn the most about a patient) he told me he hadn’t slept well that evening as he had visited the bathroom over 10 times in the night. This patient was due for discharge in the coming days so this was concerning for me. As an elderly gentleman with hypertension, heart disease and other comorbidities, he was at risk of Falls and if he is going up and down to the bathroom so regularly, especially in the night, he may sustain a serious injury such as a fractured neck of femur. I looked through his drug kardex and found he was on very high doses of furosemide, a loop diuretic that is often prescribed to patients with Heart failure to prevent oedema.
I asked the patient if he was happy for me to discuss this with his doctors and a specialist continence nurse to see if something could be done to help either reduce this frequency or make provisions for his discharge so he isn’t at an increased falls risk, he agreed and I approached his doctor.
This encounter wasn’t entirely successful. When I proposed reducing his diuretics to the doctor, initially his response was “Do you want him to die of heart failure?” – in front of the patient…
Not exactly the response I was hoping for, but I explained my concerns from a Nursing point of view and emphasised I am aware that his furosemide was prescribed for a reason and it is entirely his decision, I just wanted to advocate my patient’s best interests.
This exchange I felt didn’t end on a particularly positive note, so later in the day I apologised to the doctor saying “I didn’t mean to question his treatment I just wouldn’t feel comfortable if I didn’t make you aware of his concerns to see if we could work together towards a solution”. The doctor was much more amicable and smiled and said he understood and would consider what could be done.
Not long after this, the same doctor stopped me and said he had written a letter to the patient’s GP to recommend reducing his diuretics in the community and observe his response. He felt changing his medications the day before discharge might impact on his fitness for discharge. He also suggested trialling Oxybutynin. When I recognised Oxybutynin as an anti-muscarinic (which would improve his feelings of urgency), his face lit up. I have a feeling, he may not have expected me to possess such knowledge.
Only upon writing this have I realised just how many units of study went into this encounter; Communications, Anatomy and Physiology, Pharmacology, Applied Pharmacology, Nursing Therapeutics, Recovery focused care and Medicines Management all informed my actions in this case. Reflecting on this scenario I am really pleased with the outcomes we achieved. Not only was the gentleman’s GP made aware of our concerns and recommendations but I managed to speak to the Trust’s continence specialist nurse and get her recommendations for interim provisions to help the patient transition into community. I fed all this back to the patient who was visibly relieved and so grateful we had pursued his concerns and formulated an action plan he understood and would work for him.
Advocating for patients is a vital part of the Nursing role and we can see advocacy in the NMC code in various different guises (see 3.4, 4.1, 8.6, 8.7 & 9.3).