De-Escalating Critical Incidents (podcast)

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cnt-podcast_cover_art-1400x1400Melissa Caldwell, PhD, a clinical psychologist and Director of Mental Health Services for Advanced Correctional Healthcare in Peoria, IL, shares tips for dealing with escalating patient anger or frustration. Do you practice Mental Health Standard Precautions at work? Dr. Caldwell relates this concept in the podcast as being continually aware that any patient situation could become volatile and prepare accordingly. Good advice! We are working with patients who are confined because they are a risk to the public yet we forget that they continue to be a risk while in the facility. That risk has not been neutralized. It should always be in the back of our mind that any patient could become unexpectedly volatile; initiated in some unanticipated way. Don’t be caught unaware.

Here are some other tips from Dr. Caldwell’s discussion on this podcast:

  • Anger and frustration can come from both our patients and ourselves in a patient encounter. Monitoring our own professional approaches to our patient population can help us manage critical incidents.
  • Think of your therapeutic approach as a tool in the health care tool box. Develop your ability just as you would any other nursing skill.
  • Hold unconditional positive regard for the patient. See your patient as a person deserving appropriate care. Maintain a climate of mutual respect. You can respect someone even if you don’t like them.
  • Verbalizing what you are seeing can help the patient see that you understand. This does not necessarily mean you are saying that how they are responding is appropriate. That is an important difference.
  • Listen without interruption. Allow the patient to fully express themselves before responding.
  • Confrontation has little to do with you; but you can make it worse or better by how you respond. Be aware when a patient is getting under your skin.
  • Express empathy with the patient’s perspective. You can empathize with someone even if you don’t agree with them.
  • Have congruency between what you say and what you do. Words and actions must match. For example, don’t make promises that can’t be kept. If you say something, do it. If you can’t do something explain the reasons.
  • Center yourself before a patient interaction. Assess your own mindset. Be particularly attentive if you are having a bad time in your personal life or are ill.
  • Be mindful of your peers in their responses to patients. Help each other to reduce confrontations.
  • Sometimes just letting the person calm down is all that is needed. If there is space and everyone is safe, let the patient run out of steam before responding.
  • Sometimes the best tool we have is to sit calmly and listen with a calm facial expression and head nodding.
  • You don’t necessarily need to be directive. It is better to help the patient discover the way to solve their own issue. We can give support and guidance rather than give them the solution to their problem.
  • Have an exit plan if the patient continues to be volatile. Be sure you know where the officer is and how to activate their involvement.
  • If you know that you are going to deliver bad news (can’t provide medication or treatment desired) you may need to alert the officer on duty to be available for an escalated situation.

In the News

Sugar, not Salt may be Causing Hypertension

The British Medical Journal published an article suggesting that we have been focusing attention on reducing salt intake to reduce hypertension when it may be the sugar in highly processed foods that is the culprit. The article lays out a defense of this proposition based on epidemiology studies. The author concludes that reducing high sugar over-processed foods can be of benefit in reducing hypertension. Correctional nurses can advocate for healthier menus and commissary options for our patients.

Violence Against Nurses Continues

Violence against nurses in hospitals across the country is chronicled in this article from Medscape. Reported violence against nurses is on the increase – up over 6% – according to the Bureau of Labor Statistics. The specialty cited as experiencing the greatest number of incidents is emergency nursing. I wonder if nurses in correctional settings were even a part of that study. It would be interesting to compare violent incidents toward emergency and correctional nurses. I’m thinking that the greater availability of security officers in our setting might bring our numbers down below those in the emergency setting. What do you think?

Have you ever been in a volatile situation with a patient? How did you handle it? Share your thoughts in the comments section of this post.

I Found Correctional Nursing and I Love it!

Smiling, happy health care professional, nurse making hand heartThis guest post is written by Sarah Medved, a senior nursing student at Grand Canyon University. She shares her story of finding correctional nursing as a specialty.

Nearing graduation, I get a lot of congratulations and questions about where I want to work. I usually get raised eyebrows when I proudly state that I want to be a correctional nurse. I also get plenty of weird looks and discouragements. Some people don’t even know what I am talking about. “What is that?” they say. It gives me an opportunity to talk about the invisible world of nursing behind bars.

I became interested in correctional nursing through an assignment during my first year of nursing school. The assignment was to research an area of interest in nursing. I looked up all the different types of nurses on the internet and noticed correctional health on the list. I thought it sounded different and kind of exciting so I gathered some information, and presented my findings to my classmates. From that point on, all my classmates knew how interested I was in correctional nursing!

Being involved in my school’s Student Nurses Association allowed me the opportunity to attend the Arizona Nurses Association Symposium/Student Nurses Association Convention. This year there was a raffle for the students to win a coffee date with a professional nurse in various fields. I noticed there was a correctional nurse as one of the options, so, of course, I bought a handful of tickets to ensure I would win this great opportunity!

When I met with the correctional nurse, I was beyond excited because I never had the chance to talk to someone who was actually in the field. She provided a massive amount of information and excellent insight into the profession. I always had a light inside fueling my passion, but that day my light turned into a burning fire of desire.

Since then, I have had the opportunity to network with a new graduate in the field of correctional nursing. I always thought it was impossible for a new graduate to get a job in what seems like such a specialty area. The common advice for new graduate nurses is to work at least a year or two on a medical/surgical unit to gain basic skill. But, I had one inspirational instructor who told me to follow my dream of being a correctional nurse; to go into the area I am passionate about. My coffee date confirmed this. It was important for a correctional nurse to suggest going right into the specialty from school. Are the basic skill sets that much different?

As I reflect on my experience as a student nurse discovering the correctional nursing specialty, I am wondering why more nurses don’t know about this hidden opportunity. It seems like a well-kept secret. I also wonder why the responses I get about correctional nursing are not very positive. Are nurses who work with inmates somehow considered insignificant or inferior among others in the nursing profession?

Nurses take care of millions of people coming from all walks of life. To me, the only difference in a correctional nurse is knowing that the person is incarcerated. Nurses in a hospital take care of people who have been in jail, but they just may not know it. In some cases, people are wrongly accused and end up in jail for things they never did. Anyone can be at risk for going to jail no matter how unlikely that may seem. As a nurse, I want to provide equal and just healthcare to everyone regardless of their criminal background. I am not treating a person based on their lifestyle or circumstances. I am treating a person – PERIOD!

Have you experienced raised eyebrows or discouragement when you shared your correctional nursing background or interest? Share your thoughts in the comments section of this post. Are you a correctional nurse with an inspiring story to share on the correctionalnurse.net blog? Contact lorry@correctionalnurse.net. Correctional nurse authors of posted stories receive an autographed copy of one of Lorry’s books.

Photo Credit: © pathdoc

Correctional Nurse Legal Briefs: Common Areas of Nursing Malpractice Claims

Medical LawsuitA study of nursing liability claims by a major nursing malpractice insurance provider grouped common allegations by the amount of paid indemnity (money paid out by the insurance company for the case) as well as frequency of the claim. Although this data cuts across all nursing specialties, the top categories of malpractice claims have application in the correctional nursing specialty. Let’s review these as they relate to the particular perils of correctional nursing practice.

Scope of Practice: Scope of practice claims brought the highest payouts. The insurance provider proposed that this is due to a perception that practicing outside of a nurse’s professional license is considered to be of high concern. Correctional nurses have high risk of practicing outside the scope of licensure. Our specialty practice has few boundaries. Correctional peers may have little understanding of what nurses can and can not be asked to do. There may be pressure to limit the involvement of costly outside resources. Wanting to be helpful in a difficult situation, nurses may slip into poor practice outside licensure limits. All nurses must understand the limits of their licensure, but correctional nurses, in particular, must also be willing to speak up when asked to perform outside the boundaries.

Patient Assessment: Claims in this category are frequent. Patient assessment is a major component of correctional nursing practice as nurses are most likely the first to see the patient and a timely assessment indicates need for monitoring, treatment, or referral to another professional such as a provider, dentist, or mental health specialist. The most frequent successful claims in this category were failure to properly or fully complete a patient assessment and failure to assess the need for medical intervention. Of note is a category of claims related to failure to consider or assess the patient’s expressed complaints or symptoms. Correctional nurses can easily slip into a pattern of considering patient complaints to be malingering, manipulation, or attention-seeking. Yet, all patient complaints and expressed symptoms must be objectively evaluated as a part of professional nursing practice.

Patient Monitoring: Once again, correctional nurses, as the primary health care staff in a correctional setting are required to monitor patient conditions and alert providers if changes warrant treatment alterations. The highest percentage of closed claims in this category were related to monitor and report changes in the patient’s medical or emotional condition to the practitioner.

Treatment/Care: This was a broad category in the nursing malpractice data. It included not completing orders for patient treatment as well as delays in completing orders. Mentioned in the report was the need for effective communication among practitioners as many claims were the result of communication failures. Correctional nurses often work with providers who are only minimally on-site and must be contacted by phone for orders or evaluations. Broken communication systems or delays in communication are frequent in an on-call situation. In addition, staff nurses and providers may be unfamiliar with each other, leading to judgment concerns and unfamiliarity with style and perspective. If a provider or nurse is known to be hostile or uncivil, hesitation and delay in communication can result.

Medication Administration: Drug-related errors figure prominently in this evaluation of nursing malpractice claims. The most frequent cause of medication administration claims was giving the wrong dose of medication followed by using improper technique, and administering the wrong medication. Authors of this report noted, once again, the importance of communication, particularly in clarification of confusing medication orders before administration. Medication administration in the correctional setting has additional challenges that increase risk. Pill lines are often long and nurses can be pressured to complete medication administration quickly due to other security concerns. Cell-side medication delivery in high-risk areas such as administrative segregation can lead to pre-pouring medication; an increased error risk.

Documentation Deficiencies: As expected, poor documentation of nursing care contributed to many of the closed malpractice claims against nurses. Incomplete documentation was a factor in many of the above categories and bears mention as a liability risk. Correctional nurses are often called upon to maintain patient record documentation in less-than-ideal situations. If a physical charting system is in use the single chart may be unavailable at the time and location of care delivery. Even electronic medical records require computer availability (great enough number) and accessibility (located where care is delivered). Nurses delivering care in a disseminated system may not be able to chart until returning to the medical unit many hours later.

There are many legal risks to working in a correctional setting, but nurses can greatly reduce the chance of a malpractice claim by attending to the above areas of vulnerability.

Have you experienced any of these liabilities in your practice setting? Share your thoughts in the comments section of this post.

Photo Credit: @ Matthew Benoit – Fotolia.com

November 2014 News Round-Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts C.J. Young and Sue Lane join Lorry to discuss the latest correctional health care news.

Ohio Prison Inmate Being Treated for Leprosy

The Ohio prison system recently had an inmate diagnosed with leprosy. He was first treated for a bacterial skin infection. When it worsened, he was tested for leprosy. We discuss leprosy, the modern disease is called Hansen’s disease, and any concerns for correctional facilities.

Restraints Cited in Three Deaths at Bridgewater

The Boston Globe reports on three deaths of restrained patients at Bridgewater, a Massachusetts state prison for people with mental illness. Bridgewater is a 325 bed medium security prison that is the only one accepting mentally ill patients that require strict custody, the article described. One patient died of a blood clot after spending 3 days strapped to a bed. Another died of a heart arrhythmia after being immobilized with wrist and ankle restraints for many months, and a third died after being in 5 point restraints for a long period of time, as well. Panelists discuss the physical and ethical concerns of restraints and how correctional nurses might intervene to reduce their use.

 Ethical Issues for Nurses in Force-Feeding Guantánamo Bay Detainees

An article from the latest issue of the American Journal of Nursing discusses the ethical issues for nurses in force-feeding Guantanamo Bay Detainees. Military nurses, like correctional nurses, can have conflicting moral obligations in practice. This article discusses the conflicting moral obligation military nurses have to their patients and to their military mission as determined by their superior officers.

The authors contend that the ANA Code of Ethics establishes the nurse’s primary commitment as to the patient and that the code forbids forcing a treatment on a competent patient. Yet the government contends that force-feeding is an ethical matter of beneficence to, in the best interest of the patient, keep him or her from dying.

A Washington Prison Unit Where ‘No One Picks On You For Being Slow’

The Washington State Prison System has created a unit at the Washington Correctional Center for inmates with autism, intellectual disabilities, or traumatic brain injury. It is protective housing for those who are easy prey for manipulation and abuse in the general population. In many traditional correctional settings, these individuals end up in segregation because they are not compliant with prison rules or direction from officers. Segregation is detrimental to even mentally healthy people, but it can be devastating to the mentally impaired.

Share your thoughts on these news stories and panelist’s perspectives in the comments section of this post.

Correctional Nurse Legal Briefs: Understanding Professional Liability

Medical Lawsuit

This post is part of a continuing series on legal issues important to correctional nurses. Find other topics in the series here.

From my case files:

A nurse hears a man down code called overhead while returning from providing sick call in one of the housing units. When she arrives at the scene she sees that the inmate is sprawled out on the cell floor and appears unconscious. The housing officer tells her the inmate is breathing so she runs back to the medical unit to get oxygen and emergency supplies. When she reaches the medical unit she tells another nurse to activate emergency medical services as the patient will definitely be heading to the hospital. The sick call nurse returns to the housing unit with the emergency supplies, provides standard emergency treatment, and, some minutes later, assists the emergency personnel to prepare the patient for transport. Three months later she is named in a malpractice lawsuit.

As professional health care providers, nurses are held to standards of practice related to our licensure. Malpractice is claimed when a professional acts or fails to act to the level of their professional education and skill. This is also referred to as professional negligence as negligence, itself, is a general term for carelessness or a deviation from actions that would be taken by a reasonable person in the same situation.

Components of a Malpractice Claim

Six elements must be present in a malpractice claim to prevail. All factors must be convincingly presented for the nurse to be deemed liable in a malpractice case.

Duty owed the patient: Nurses owe a duty of care based on licensure and role at the time of the claim. A nurse-patient relationship is established by a nurse accepting an assignment involving the patient and continues until closure of that assignment. That closure can come when the patient is handed over to another qualified individual, as in the case of infirmary care, or when the patient is released to personal self-care as at the conclusion of a sick call episode or release from the facility. That a duty is owed in a particular circumstance is fairly easy to establish. If a nurse is in the midst of a shift and working under a job description when presented with a patient such as in our case above, the nurse owes a duty to the patient to respond as any prudent nurse would in a similar situation.

The nature of the duty is established by the circumstances of the incident. This can be less clear and, in a court case, often requires the testimony of expert witnesses of similar background. These expert witnesses base their testimony on practical experience in a similar setting but also on published standards. Standards for correctional nursing practice are published by the American Nurses Association and are structured around the nursing process. Expert witnesses may also rely on accreditation standards. In correctional settings, that would be the National Commission on Correctional Health Care Standards and the American Correctional Association Standards. Although voluntary, these standards lay out indicators of quality health care processes that may be in question in a legal claim. There are also some states that have specific state statutes and regulations that address minimum standards of care expected in the correctional setting.

Breach of the duty owed: Once duty is established, a breach of that duty then needs to be clearly presented. The groundwork has already been laid by the expert witness(es). A breach of duty relates to action or inaction that does not meet the expected standard of care for the situation. Duty owed can be established through various, often written, sources such as:

  • Standing policy, procedures, protocols
  • Emergency procedures
  • National guidelines and standards

Foreseeability: A successful malpractice case must also establish that the nurse should have reasonably been able to foresee that harm would come. No one has a crystal ball to see into the future and some random harm can come from nurse actions. Foreseeability establishes that the injury could have been considered and steps taken to keep the patient from harm. In our case example, a nurse was called to an emergency man-down in a housing unit and was the only health care staff on the scene. Patient abandonment was alleged as the nurse did not assess the patient or provide immediate care before leaving the scene. A prudent nurse, it was claimed, would have stayed with the patient, rendering care while an unlicensed staff member brought the equipment. The plaintiff’s lawyer argued that the nurse should have foreseen that the patient would be harmed by her departure without any other healthcare provider left there to deliver care.

Causation: The case now moves to cause. Did the nurse’s breach of established duty directly cause the injury? Causation of an injury can be multi-faceted so narrowing down cause to the nurse’s action or inaction in breach of duty may be challenging. In this case, the patient suffered a hypoxic stroke, but would the outcome have been different if the nurse had repositioned the patient and provided rescue breathing? That would be for the plaintiff’s legal counsel to support through the use of medical experts with experience in a similar setting.

Injury: Physical injury must then be established. This, again, must be directly linked to the nurse’s breach of duty. There are some rare exceptions here, but injury must be quantifiably physical rather than merely psychological in nature. In the case above, the nurse’s abandonment must be established as the proximate cause of a physical injury to the patient. This patient was permanently disabled due to brain injury.

Damages: The final element of a malpractice allegation is damages incurred. This infers the level of the injury to the plaintiff caused by the nurse but damages can also be ascribed in a broader manner. There are three main categories of damages sought:

  • Special damages (out-of-pocket): These are the primary damages of a malpractice case and are determined by actual economic loss such as lost wages, medical expenses, medications, or therapy. These damages can only be claimed with proof such as receipts and bills.
  • General damages (noneconomic): These are less quantifiable damages such as pain and suffering or emotional distress. Although receipts or bills would not be available to establish this type of damage, the plaintiff much have some evidence to support the request.
  • Punitive damages: Punitive damages are intended to add a punishment to the defendant. If a clinician lapse is particularly egregious or misconduct or tampering are discovered in the case, punitive damages may be high.

Although not part of the legal case, malpractice determinations are reportable and considered by State Licensing Boards for disciplinary action such as suspension or revocation of licensure.

In this particular case, settlement was reached before trial, as so often is the case. The plaintiff was awarded a large but undisclosed settlement. Was the nurse guilty of malpractice? What do you think?

Photo Credit:© Matthew Benoit – Fotolia.com

Caring Within The Culture of Incarceration (podcast)

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cnt-podcast_cover_art-1400x1400Dr. Stacy Christensen, a nursing professor at the Central Connecticut State University in New Britain, CT, talks about her work with incarcerated women in the Connecticut State Prison System and her article about the application of Leininger’s theory of Culture Care in the correctional setting. Enhancing Nurses’ Ability to Care Within the Culture of Incarceration” was published in the June 2014 issue of the Journal of Transcultural Nursing.

In this episode she explains the key elements of Leininger’s theory of Culture Care and how incarceration can be thought of as a culture. The incarcerated patient population has a common language, customs, and rituals. Leininger defined culture as the learned, shared, and transmitted values, beliefs, norms, and lifeways of a group. Correctional nurses need to be culturally aware to effectively deliver care in this setting.

News Items

Coffee Consumption and Mortality

Findings from a meta-analysis of more than 20 published studies indicate that coffee consumption is inversely associated with all causes of mortality. Best mortality figures were for those drinking 4 cups per day. They also found no association between coffee consumption and cancer mortality. Although past studies indicated a concern for caffeine related to increased blood pressure, insulin resistance, and elevated lipids, habitual coffee consumption results in a tolerance for the acute effects of caffeine. Researchers aren’t sure what components of coffee are beneficial but indicate that coffee is a major source of antioxidants, which could be part of the positive effect. In addition to reduced mortality, coffee consumption was linked to reduced risk of suicide, Parkinson’s disease, and gallstones.

Increases in Heroin Overdose Deaths — 28 States, 2010 to 2012

The CDC has published data on Increases in heroin overdose deaths between 2010 and 2012 in the latest issue of the MMWR – Morbidity and Mortality Weekly Report. There has been an alarming rise of heroin overdose deaths in the last two years – more than double. Deaths have increased across gender, age, ethinic groups, and geographic region – although the increase is more significant in the northeast and south regions. In a related news story, the study’s co-author Dr. Len Paulozzi, a medical epidemiologist at CDC’s National Center for Injury Prevention and Control, said that the over-prescribing of narcotic painkillers (such as Oxycontin and Vicodin), which has been going on for 20 years, is responsible for the increase in heroin use and overdoses. He continues by commenting that solving the problem of deaths from heroin overdose begins with stopping the addiction to narcotic painkillers. Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing, is also quoted in the news item as saying that there is very little difference between heroin and Oxycontin or Vicodin and that the medical community has to prescribe more cautiously.

Do you think a theory of cultural care would work in correctional nursing? What do you think about the positive effects of coffee? Have you seen an increase in heroin addiction in your patient population? Share your thoughts and insights in the comments section of this post.

Eight Ways to Improve Clinical Judgment

医者の表情Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most-often the first healthcare provider to see the patient situation. As a gatekeeper, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved. Therefore, clinical judgment skills are absolutely essential for nurses working behind bars. Recent posts have discussed the vital role of clinical judgment, reasons correctional nurses need clinical judgment, and clinical judgment booby traps to avoid. In this final post of the series, we are turning to ways to improve clinical judgment. Incorporate these methods from traditional clinical settings and educational programs to improve your clinical judgment and that of nurses you work with.

Clinical Practices

 Case Review

Case review is one of the best ways to develop clinical judgment, especially with nurses new to the specialty. Although you can use cases developed purposefully it may be even better to include review of actual cases as a regular part of the process of unit management. For example, reviewing actions, reactions, and interactions of a recent complex or emergent patient situation can allow nursing staff an opportunity to learn from the experience and from each other. Much can be gained by providing an opportunity for staff to dialog about clinical judgment and reflect on their practice and the practice of others. Of course, this dialog must be carefully facilitated so that team members develop abilities to critically review a case without being critical of each other. You want this to be an empowering experience rather than a disempowering one. Careful guidance is needed until staff develop the skills necessary to be encouraging, purposeful, and thoughtful in their dialog.

Peer Review

Guided peer review is another way in which staff can develop clinical judgment skills. Similar to traditional physician peer-review, nursing peer review is a analysis of written documentation of past patient care on an individual practice basis. This process, by the way, is also helpful to encourage more thorough documentation. Learn more about nursing peer review in corrections from this series.

Reflection

Reflective practice is another clinical activity encouraging development of clinical judgment. Reflection on an actual significant clinical experience such as an unexpected death or near-miss experience can yield a wealth of wisdom for the nurses involved. By guiding the discussion toward analysis and synthesis of information, the experience can expand both individual and group learning. New staff members can be asked to keep a journal of their patient experiences that is reviewed periodically with the nurse manager or a senior staff member. The journal activity helps with reflection and the documentation can guide discussion into deeper meanings of assessments or a better understanding of facility processes.

Simulation

Another clinical activity that builds clinical judgment is simulation. Simulation allows a safe practice experience while developing procedural skill and team kills in collaboration and coordination of care. Use the disaster drill and man-down simulations to encourage clinical judgment development. Debrief the simulations as you would an actual experience and guide staff to truly think about why various decisions were made.

Educational Practices

Clinical judgment development can also be infused into standard educational programming. Many in-services involve a lot of information with little application. Instead, a better way is to provide foundational information and then engage staff in a dialog about how to apply this information in practical and realistic situations. An example of how not to do this is an inservice I taught on dealing with chest pain in correctional settings. It had a ton of information about assessment, interventions, and facility policy. We even talked about how to deal with the on-call physician. Participants left with a head full of what and how but not much application or critical thinking about dealing with chest pain. Here are some ways this program could have been improved to help develop clinical judgment.

Dialogue

Adding interaction and dialog to a learning experience engages the learners in thinking and applying the information. Providing real life examples and cases is an excellent way to encourage discussion.

Probing Questions

Probing questions combine with interactive dialogue to fully engage participants. A probing questions looks beyond yes or no and moves the thinker from reaction to reflection. Questions such as “What do you think would happen if……” or “Why do you think that might happen?” encourage learners to analyze a situation and work through possible solutions.

Mind Mapping

Mind mapping, also called concept mapping, is a creative method of displaying information and how it connects together. This process is gaining popularity in undergraduate nursing programs to help students think about the various elements of a clinical situation. Why not use it with practicing nurses? A mind map is a visual organization around a core concept. Here is an example of a mind map developed during a presentation on chest trauma.

mindmap

Algorhythms

An algorhythm is a decision tree that guides through a particular situation. While a mind map is based on relationship of information, an algorhythm is a decision tree and is expressed in a linear fashion, often answering questions of yes or no and then moving on. This example is from an ACLS course on responding to bradycardia. For the chest pain inservice I described earlier, I might have asked participants to develop algorhythms for respond to chest pain.

algorhythm

The key to clinical judgment development in an educational setting is to engage the learner with the thinking processes and to reflect on their own practice and how they might incorporate this new knowledge into their practice.

Do you have ideas for how to apply these eight processes in clinical and educational practices in your setting?

Photo Credit: © ぶぶたん – Fotolia.com

Three Clinical Judgment Booby Traps to Avoid

Risk concept. Sign question on bear trap.Over time, as we develop our practice, we store up clinical reasoning helps that can speed our decision-making for commonly reoccurring scenarios. We begin, for example, to develop rules of thumb and analogies resulting from common pattern recognition that originate from past successes. The formal term for this is heuristics. In fact, clinicians rarely use formal computations to make patient care decisions in day-to-day practice. Rather, we develop an intuitive understanding of probabilities combined with a concoction of rules of thumb, educated guesses, or mental shortcuts.

Without care, other factors can cloud our thinking. In particular, we must be mindful of our biases, cultural background, and assumptions when making clinical judgments.

Biases

Biases are rooted in our human nature and hard to avoid. We can, however, mindfully consider them as we reflect to improve practice. A few biases of importance to avoid when making clinical judgment are described here.

Premature closure is one of the most common errors. In this bias clinicians make a quick diagnosis (often based on pattern recognition), fail to consider other possible diagnoses, and stop collecting data (jump to conclusions). In fact, even the suspected diagnosis is not always confirmed by appropriate testing. A premature closure issue common in correctional nursing might be “I know this patient-he is faking this condition to get attention”.

Confirmation bias occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not. Clinicians who rely heavily on pattern recognition and become overconfident in diagnostic abilities can fall prey to premature closure and confirmation biases. If a patient is acting erratically and an officer shares a high breathalyzer reading, a nurse may settle on an alcohol intoxication diagnosis when there are also signs of a head injury.

Availability bias results in overweighing evidence that comes easily to mind. This could be recent evidence or what we perceive as meaningful events. For example, if you have ever had a legal claim against you for a particular diagnoses or clinical action, you have had heightened awareness of that diagnoses for some time afterward.

Assumptions

Assumptions about what is and isn’t present can also affect our thinking and judgment. A simple example can underscore how assumptions can get us tripped up. Consider this puzzle that you must solve. A donkey is tied to a 6 foot rope. A bale of hay is 8 feet away from the donkey. Without biting through the rope, how can the donkey get to the bale of hay? Answer: He just walks over to it. There is not mention that the rope is anchored to the ground. Most people hearing this story, though, assume that the donkey is tethered. Sometimes we need to see what isn’t there as well as what is there when evaluating a patient, too.

Culture

Our culture can lead to unconscious ‘habits of the mind’ that affect clinical judgment. Repeated personal experiences and cultural socialization are absorbed into our ways of thinking about the world around us. For example, over time, correctional clinicians may absorb a jaded view of inmate intentionality or the surrounding security culture of the facility. Attitudes about patient motivation can cloud our judgment and alter subjective interpretation of symptoms.

Sometimes getting over our biases, assumptions, and culture in clinical judgment is as easy as changing the questions we ask ourselves. Imagine seeing a drawing of 2 triangles a square and a circle. If you ask yourself the question “What is this?” You may answer – 2 triangles, 1 square, and 1 circle. How might that change if you ask yourself “What could this be?” Maybe the answer now is – a jack-o-lantern or a clown face. Sometimes self-questioning can break us out of our biases, assumptions, and cultural norms.

How have you seen biases, assumptions, and culture affect clinical judgment? Share your experiences in the comments section of this post.

Photo Credit: © valentinT – Fotolia.com

October 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts Mari Knight, Johnnie Lambert, Denise Rahaman, and Sue Smith join Lorry to discuss the hot topics in correctional healthcare news in this monthly round-up.

Ohio prisons credit $10M savings to Medicaid changes

Our first story comes from the Ohio prison system where they are reporting saving $10 million dollars in medical expenses this fiscal year through maximum use of the Medicaid system and Affordable Care Act. Frankly, the various ways prison and jail systems cover inmate medical expenses can be confusing. Of note is the enrollment of inmates in Medicaid for better continuity of care and access to medications.

How Gangs Took Over Prisons

Our next news item is an extensive article in the Atlantic about how gangs took over prisons. The information is fascinating. The article mainly focused on gang activity in the California Prisons System – Pelican Bay State Prison, in particular – and relied heavily on a book by David Skarbek called “The Social Order of the Underworld”. It can be helpful for nurses to understand their patient’s culture. Information from this article and the book may be of particular interest for nurses working in facilities with major gang activity.

NLN Recognizes the Role of the LPN/LVN

This next item is a document published by the National League for Nursing on the recognition of the role of Licensed Practical/Vocational Nurses in advancing the nation’s health. This is of particular importance in our practice setting as we have a high percentage of nursing care delivered by LPNs/LVNs. Based on surveying the changing employment characteristics of LPNs, the NLN is recommending curriculum revisions to meet healthcare system needs – such as adding geriatric and culturally relevant care. The paper reports movement of LPN practice into long term care and community settings where they are dealing with predictable chronic conditions. Of note is a section on Scope of Practice variability and what they call “the growing disconnect between scope of practice standards and the reality of practice”.

Nursing Student’s Program Helps Save Lives in State Prison

Our final story discusses a nursing graduate student who is positively affecting patient care in the California Prison System. The student is Kelly Ranson, chief nurse executive, at Kern Valley State Prison, a high security prison in the state system. She gained approval to implement her Health Promotion and Disease Prevention course project in the facility. This involved diabetic self-management among the male inmate population. The article noted collaboration with security administration and a team approach with mental health staff, dieticians, medical staff and peer support. This report provides a model for implementing health care innovations in a correctional setting.

Five Reasons Correctional Nurses Need Clinical Judgment Skill

Green plant mazeIn corrections, nurses are usually the first health care professional to assess a health concern or complaint. Patients present with virtually every type of health problem, and many have co-occurring conditions that can complicate the diagnosis and plan of care. Therefore, correctional nursing practice requires knowledge and experience with a broad array of conditions and presenting problems to make clinical judgments about the nature of the problem, actions to be taken, and urgency of response.

Correctional nurses also coordinate and negotiate for the delivery of care within the restrictions and expectations of the organization, which requires decision-making conviction. Clinical judgment guides direct care delivered by the nurse as well as communication with others to coordinate care and ensure patient safety. Accuracy in judgment improves patient outcomes and quality of care by eliminating unnecessary actions and reducing delay in definitive care and treatment.

Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most-often the first healthcare provider to see the patient situation. As a gatekeeper, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved.

Here are five reasons clinical judgment is especially important for correctional nurses:

  1. Detainees or inmates are entitled to a clinical judgment under the 8th or 14th amendment whenever attention to a health concern is requested. See this post for more information on the right to a clinical judgment.
  2. Nurses most often are the first health care provider to see a detainee or inmate for any health concern. The nurse’s clinical judgment will determine if the person sees any of the other health care providers and if so, how soon.
  3. Ineffective clinical judgment affects the patient adversely now and perhaps in the future, it affects other nursing staff and providers. It can also affect our relationship with custody staff.
  4. Correctional nurses must make judgments in a wide array of situations from minor discomforts to life-threatening emergencies.
  5. And, they must do it while navigating the correctional environment with safety, location, and resource challenges.

What other reasons are there for correctional nurses to be skillful in clinical judgment? Share your ideas in the comments section of this post.

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