how to manage patients who smoke

This is one of the biggest challenges nurses now face on their units. Sad but true, nurses must manage patients in the hospital setting who wish to smoke, yet the campus is Smoke-Free. This may sound simple enough, rest assured if comes with many challenges. 

Nurses often wonder....am I now the campus security in addition to my million other responsibilities?

So, how do you manage patients who smoke? What are some techniques you can use if the hospital grounds claim to be 100% smoke free. 

Why are Hospital Campuses choosing to be smoke free?

Agree or disagree, smoking has known health problems and therefor unhealthy habits should be avoided. Sounds simple. Great, just tell that to your patient next time they want a cigarette at 10 pm at night when they can't seem to relax. 

If you look back to around 2006, you will find a new trend the country begins to adopt. This trend is a smoking ban, prohibiting people from smoking at work and in public places. The rationale? Simple, smoking is an option while breathing is not. Smoking causes multiple second hand health conditions while being linked to cancer, emphysema, and heart disease to name a few. this push carried over to medical organizations to ensure healthy habits were promoted. Regulatory agencies began recommending smoke free hospital campuses. The Joint Commission's brochure, Keeping Your Hospital Property Smoke Free, examines hospital success thru strategies before implementing a smoke free campus to supporting the environment and messaging to smokers. 

With the ongoing urge of hospital campuses to become smoke free, where does this leave the nurse?

Answer: DIRECTLY SMACK IN THE MIDDLE

Patient's can not leave the units to go smoke!

Every employee hears this and agrees and vows to make this policy a reality. HOWEVER, typically when you drill down the staff truly responsible for enforcing this policy and dealing with the consequences, are the nursing staff. 

The conundrum of the clinical/bedside nurse:

Patients are assessed and determined if they are a fall risk or not. the patient is independent and does not require a bed or chair alarm, thus they can ambulate around the room independently. The nurse explains to the patient that they can't leave the unit to smoke because it is hospital policy. Many times the patient states they understand as well as "well I am going to anyways" to the nurse. The nurse must tip toe around this issue simply because they need to have a connection with the patient to ensure nursing care and medical treatments are delivered. Detouring the patient right away can lead to refusal of care out of anger and thus, why is the patient even at the hospital then?

The nurse provides hundreds of tasks throughout the shift. Later on the nurse learns the patient left the unit to go smoke. The nurse speaks to the patient and the patient agrees not to leave again. The next nurse arrive and the patient leaves the unit. This nurse has a crazy busy shift and does not address the smoking. The next nurse arrives and attempts to address the smoking to hear from the patient, "the last nurse let me leave, so why are you being difficult?"

This type of scenario can go on and on, leaving each nurse caught in the middle and wonder why they are left to "police" this hospital policy. The nurse simply wants to provide good care to all their patients, however in scenarios like this, the patient does not allow them to.


Here are 10 tips on how to manage patients who smoke!

  1. Accurately identify patients abilities to walk freely around the unit and implement interventions accordingly. If the patient is receiving pain medications, chances are this increases their risk for falling. Set the bed alarm as a safety measure to reduce falls. Now you will know when your patient is out of bed. I know this sounds easier on paper. As both a clinical nurse and manager, I tell staff safety trumps everything. I turn on alarms when patients refuse. i would rather be yelled at then have a fallen or lost patient off the unit.Be consistent 
  2. Get the Doctor or Provider involved! Seriously, call the doctor and let them know the patient left the unit to smoke. Encourage the physician to come see the patient. This can go a couple ways. 1 - the patient will leave against medical advice. Not that we want this, however if the patient is going to continue with risky behavior it relieves the hospital from liability and the nurse from the stress of the situation. 2 - the patient will contract with the physician, especially since the doctor writes the medication orders. 
  3. Encourage family pressure. I have asked family members to encourage the patient not to leave. Again this can go two ways as well. Assess the dynamics first and use judgement if this technique may be beneficial.
  4. Request security presence to help enforce the campus policy. Many organizations provide fines and even involve the police now. 
  5. Demand organizational support from management and administration. Policies can't be stated, yet expected to be managed by the clinical staff. Staff often ask for me to see patients who leave. this allows me to be "the bad guy" and allows the nurse to be the nurse. Approach with care and be sympathetic. A subtle "wel now you know the policy and please notify your nurse if you feel the urge."
  6. With that last line, make sure nicotine replacement is offered and ordered!
  7. Educate the patient to why they are here. Chances are if it is related to smoking they will be receptive to want to quite. Those hospitalized for other reasons are the challenge. Educate the health consequences they may have secondary to smoking and how avoiding care can potentiate their current problem. Nurses make it very real to people, yet stay sympathetic. Often times the stress of the illness makes the demand for the cigarette ten times greater. 
  8. Care plan and navigate ways to get the patient thru the cravings and share this with those caring for the patient. This allows the nurses to be on the same page and avoid opinions and different responses. 
  9. Provide a smoking cessation nurse or resource if available
  10. Sometimes discharge is the only way! I have asked physicians to discharge because well "if they are good enough to be off the unit frequently to smoke, then they are good enough to be home." This can sound insensitive, however think about it. When patients are super sick, nurses rarely have this problem. Patients that are leaving and smoking are not as sick and can be set up with services at home and/or out patient. this saves the hospital the headache! 

Document, document, document!

Chart your interactions, plans of care, educational moments with the patient, and discussions with the provider. This helps protect you and the organization. Patients who are alert, oriented, and competent are accountable for their behaviors. Ensure this is the case before simply allowing them to leave regardless of your efforts. You are not the police. Let the patient go and make a call. 

Certainly if the patient is not alert, oriented, or competent, you must keep them on the unit and prevent them harm. The nurse and organization are held to a higher reliability. 

You want and need the chart to reflect this!


Good luck managing your patient's Nurses and hopefully some of these tips will come in handy!