Are You Thinking Clearly? Rooting Out Biases in Clinical Evaluations

Jigsaw puzzleI was raised on Agatha Christie and Arthur Conan Doyle novels and still find shows like Elementary and Sherlock captivating. In fact, it is the detective work inherent in nursing assessment and diagnosis that drew me to the nursing profession and still keeps me interested some 3 decades later. Oh, for the clarity of mind of Hercules Poirot and Sherlock Holmes when tracking down the cause of a patient’s erratic behavior or unexplainable loss of function!

Unlike these fictional characters, though, we mere humans can be burdened by unconscious biases of thought that cloud our judgement and send us toward wrong conclusions. Improving clinical judgement, then, involves intentionally looking for and rooting out these mental biases in our evaluative practices.

Here is a chart of common cognitive biases I developed for my book The Correctional Health Care Patient Safety Handbook.  Let’s take a look at a few of them as they may emerge in a typical nursing sick call encounter.

Bias Definition Corrective Strategy
Availability Determination based on ease of recalling past cases Verify with legitimate statistics
Premature Closure Relying  too heavily on initial impressions Reconsider determination in light of new data or a second opinion, consider extremes
Framing Effects Being swayed by the description of the  problem Examine the case from alternative perspectives
Blind Obedience Showing undue deference to authority or technology Reconsider when authority is more remote; assess test accuracy
Confirmation Seeking data to confirm, rather than refute, a favored hypothesis Consciously seek both confirming and refuting data
Representativeness Guided by typical features of a disease and missing atypical variants Take into account typical and atypical findings before settling on a diagnosis
Sunk Costs Difficulty considering alternative diagnoses once significant time, effort, and resources have been invested in a particular diagnosis Consider involving a second practitioner free of attachment to the favored diagnosis

 

Remember the patient encounter discussed in the Diabetes Primer post? Here it is again.

A 42 year old female inmate submits a sick call request about her ankle. She thinks she sprained it when she stumbled while walking to the exercise yard one morning a couple days ago. A chart review indicates she is a Type II diabetic and is on a combination of metformin and glipizide. She was recently treated for a vaginal yeast infection with fluconazole (Monostat). She has no other acute or chronic conditions of note. Her ankle is only slightly swollen and painful when she bears weight.

The nurse in that situation analyzed all the information and came to an astute conclusion. What might have happened if a few of the common mental biases had been active?

  • Availability: If the pavement is, in fact, uneven on the way to the exercise yard and the nurse has had other patients stumble or fall, it might be easy to conclude that this is a safety issue rather than a medication issue.
  • Premature Closure: Availability bias might then lead to a premature closure of investigation before seeking out all possible causes. Here, the nurse would focus entirely on the ankle and not bring in any additional evaluation data.
  • Framing Effect: If the patient framed the injury in such a way that being dizzy did not enter into the description, the effect might also be to focus only on the safety issue and musculoskeletal injury.
  • Confirmation: Once favoring a focus on the musculoskeletal injury, the nurse might limit the assessment to the ankle and not pursue any medical causes of the stumble.

Clinical evaluation is a highly specialized skill in professional nursing practice that is of particular need in nursing sick call and emergency man-down situations. Intentionally rooting out mental biases in our assessment and nursing diagnosis practices can avoid error and improve patient outcomes.

Have you struggled with any of these common mental biases in your clinical practice? Share your thoughts in the comments section of this post.

Photo Credit: © Tsiumpa

April 2015 News Round Up (Podcast Episode 97)

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cnt-podcast_cover_art-1400x1400Correctional nurse leaders Johnnie Lambert, Margaret Collatt, and Jodie Glewwe join Lorry to discuss the latest correctional health care news items.

CDCR To Limit Punishments for Inmates With Mental Health Issues

Our first story is an update on activities in the California Prison System. They are a happening place – always in the news. This month California Healthline is reporting that CDRC has changes policies about punishing mentally ill inmates. This is a result of a federal lawsuit. Changes include creating segregation units in 16 of their prisons where solitary confinement restrictions can be eased and these inmates can have access to more treatment and therapy. We are hearing a lot about the incarcerated mentally ill in the news.

Challengers to prison solitary gain support from Justice Kennedy

Our next story is a good follow-up to the California update. Here Supreme Court Justice Anthony Kennedy weighed in on the solitary confinement issue while giving testimony to a House committee on the Supreme Court budget. With many civil rights cases about the detrimental effects of solitary confinement, Kennedy is quoted as saying: “Solitary confinement literally drives men mad”. He also said, in regard to our criminal justice system, that “In many respects, I think it’s broken.” There is a ground-swell of support is developing for changes in some of our standard security practices.

Inmates at America’s oldest women’s prison are writing a history of it—and exploding the myth of its benevolent founders.

Inmates in the Indiana Women’s Prison are researching and writing about the institution – which is the oldest women’s prison in the US. The prison was started as the Indiana Reformatory Institute for Women and Girls by Quaker reformers in 1873. That is over 140 years ago! This historical research is uncovering some interesting bits about the institution, the founders, and what incarceration was like for women in the 19th century. Take aways from the news item:

  • The project develops research skills for some of the current inmates
  • Things are never as they seem at first light
  • Context is everything. Culture was very different in the mid 19th

‘RN on wheels’ to treat N.C. inmates

Our final story is about a paraplegic nurse who is setting new standards for disabled workers. Latisha Anderson lost the use of her lower limbs after her cousin fired a gun while arguing with her boyfriend. The bullet hit Latisha, leaving her a paraplegic at age 17. Undeterred, though, she pursued first her G.E.D. and then a nursing degree. She applied for and was accepted into a position at the Central Prison in Raleigh, North Carolina. Will this be an ADA celebration or a security nightmare?

What are your thoughts on this month’s news items? Joint the conversation using the comments section below.

Time Crunch: What to Do When Med Pass is Cancelled

Time of medicineConsider this scenario: Just as you are preparing for morning med pass at a large city jail a man-down alarm is sounded. Your partner is assigned to emergencies today and she grabs the emergency bag and heads to the announced floor. You continue your preparations, making note that you may be handling both passes this morning if your partner is tied up for very long. A few minutes later, as you are rolling the cart out of the medication room, a call comes in. The man-down is an officer assault, the entire facility is in lockdown, and morning medication rounds are cancelled. Now what?

In traditional health care settings, emergencies may delay some services but accommodations are made to overcome resource limitations to keep care delivery on schedule. Delivering health care is the prime mission of these organizations so plans for emergency need are ever present. In a correctional setting, health care is a support service and not the primary organizational mission. Safety trumps health care needs at all times. Yet, nurses working in secure settings have an obligation to make sure needed medical care, including medication, is provided in a timely manner. It definitely takes determination and creativity to pull this off.

To be effective, many medications must be delivered during specific times related to meals or blood levels of prior doses. Yet, medication timing may be affected by any number of security needs in a correctional setting. Security administration does not often consider the implications of delays or cancellation of medication administration processes when making security decisions. It is often left to health care staff to determine ways to provide the required medication in a timely manner to remain effective in treating the patient condition.

Making Choices

Therefore, it is important to establish a working relationship with security administration and develop a mutual understanding of the therapeutic nature of medication administration and the implication of timing in that therapy. Often a mutually agreeable solution can be reached when medication administration must be delayed or cancelled for a security reason. Here are steps to take when normal medication administration processes are halted.

  • Review medications for the particular timing delay/cancellation to determine if any are time-critical (see table below).
  • Shifting non-time critical medications to the next administration time frame. For example, daily or weekly medication can be moved to a later medication administration time.
  • Consult with prescribers for any gray areas. For example, a stable patient on an anticoagulant may be able to have their medication moved to the evening administration time while a patient with fluctuating INR levels may not be able to delay a dose.
  • Negotiating a method for delivering time-critical medications. Methods can include
    • Cell-side administration: A nurse takes the medication directly to the inmate in the housing unit.
    • Officer escort to the medical unit: Specific patients needing time-critical medications are brought to health care for their doses.

Some settings also allow officer-delivered medication. This requires a clear policy and procedure in addition to a review of the state nurse practice act regarding medication delivery and medication administration. There are many safety concerns with this approach and it is not the best option, if it can be avoided.

In all cases, the process for response to medication administration delay should be written into a policy and procedure that is approved by both security and health care leadership. That way there will be no surprises when an emergency situation like the scenario above arises.

Time Critical and Non-Time Critical Medications

The following listing provided by the Institute of Safe Medication Practice is a helpful guide for making determinations when normal medication administration processes are interrupted.

Time Critical Medications

  • Antibiotics
  • Anticoagulants
  • Insulin
  • Anticonvulsants
  • Immunosuppressive agents
  • Pain medication
  • Medications prescribed to be administered within a specific time period
  • Medications that must be administered apart from other medications for optimal therapeutic effect
  • Medications prescribed more frequently than every 4 hours
  • Medications that require administration related to before, after, or with meals

Non Time Critical Medications

  • Daily, weekly, or monthly medications
  • Medications prescribed more frequently than daily but less than every 4 hours (bid, tid) if not in the time critical listing

How do you handle cancelled medication passes? Share your procedures in the comments section of this post.

Photo Credit: © peerayot – Fotolia.com

The Social Order of the Underworld with Author David Skarbek (Podcast Episode 96)

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Social OrderDavid Skarbek, Lecturer in the Department of Political Economy at King’s College in London, England and author of the book The Social Order of the Underworld: How Prison Gangs Govern the American Penal System joins Lorry to talk about prison gangs. He became interested in this topic while a California native. As an economist, Skarbek studies how individuals respond to changes in costs, benefits, and incentives. He contends that economics can provide an organizing framework for understanding prison life and its effect on society as a whole. Indeed, with the total population of US jails and prisons at 2.2 million, this is a large sector of the general population; larger than all but three US cities and greater than the population of 15 states.

Although gangs might seem like a negative influence in the prison system, they actually can provide order and structure to the prison culture and likely reduce some of the brutality that might otherwise be displayed. Prison life involves rules, both formal and informal, and customs.  An economic framework applied to prison culture looks at incentives and consequences of these rules and customs.

The Convict Code

Gangs have a domination over prison life in California but that was not always so. The first 100 years of prison history were managed by something called the convict code; a loose framework of rules for acceptable behavior  such as never inform, never steal, don’t talk a lot, pay your debts, and do your own time. Inmate leaders would meet out justice for those who violate the code. This worked well while the prison population was small and stable.

Gangs Take Over

The inmate code structure began to unravel in the 60’s as prison growth exploded and the inmate population’s cultural background became diverse. It then became difficult for inmates to know each other and deal with reputation. As the inmate code became less effective, gangs emerged to remedy the ensuing chaos. Each gang creates their own rules of conduct and kept tabs on member reputation. Gangs often form along racial lines.

What Gangs Contribute

The popular belief that gangs are only a negative influence misses their positive impact. Here are some findings on the positive outcomes of prison gangs.

  • Rules of conduct are maintained such as respect for individuals and property.
  • Regulation of the membership by providing punishment for rule infraction.
  • Creation of communication networks and channels inside and outside the facility.
  • Regulation of the black market movement of goods and services within the inmate population.
  • Conflict and violence reduction among individuals; providing protection for gang members.

Skarbeck contends that prison gangs have reduced violence and inmate death since their rise in the 70’s when rioting was more common. It is to the gang’s advantage to reduce violence and the consequences as security’s response to quell the upheaval curtails lucrative activities such as drug sales among the inmate population.

Inside Out

Prison gangs are able to maintain power while behind bars as the underworld community on the outside is aware that they are likely to be back inside at some point in their life. Recognizing this possibility, gang members are willing to take direction from prison gang leaders on the inside. So, prison gangs are able to project their power into the surrounding community. Gang activity inside and outside of prison is more cohesive than may be thought.

What has been your experience with gangs in your facility? Share your thoughts in the comments section of this post.

Are You Imprisoned by a Messy Med Room?

Cupboard with opened drawerThe medication room is one of the most complex areas of a jail or prison health unit. The set up and maintenance of a medication room can make or break the medication administration process and eat up hours of nursing time every shift. Medication administration can take up to 40% of a nurse’s time in traditional settings. Some correctional nurses spend the majority of their time preparing for, administering, and then documenting medication administration.  Organizing the layout and management of a medication room can smooth the process and reduce error.

Patient Need and Delivery Method

When first organizing a medication room, analyze the needs of the patient population – both size and make-up. For example, a mixed gender population such as that in a large jail will require a wider variety of medication classes than a male-only prison. A large facility with an older patient population will have expanded need for medication delivery and, therefore, larger storage space.

The type of facility, jail or prison, may also dictate medication room needs. A busy jail has a high rate of intake and release meaning many medications are coming in with the patients and awaiting disposal or pick up at release. Storage of these medications can take up space and require an organized system for management.

The method of medication delivery is also a consideration in creating a medication room. If pill line is centralized, a distribution window is often located within the room and medications need to be easily accessed from that location.  A dispersed system where nurses take carts out to housing areas requires room in the medication room to lock the carts when not in use.

The numbers of people working in the room at the same time is also a factor in medication room management. Sufficient space is needed to prepare for medication administration such as supplying the medication cart and organizing equipment.

Room Layout

Many facilities must make due with the room that is available. Fortunate, indeed, are nurses working in facilities with spacious medication rooms. Some facilities merely have a few cupboards in the corner of a clinical room for medications. It is ideal for the room to be laid out according to function. If space is available, a medication room can have areas for the following functions.

  • Ordering, receiving, scanning in and putting stock away
  • Area for the medication carts in easy reach of stock and supplies
  • Locked areas for narcotics and locked box/cabinet with expired or discontinued medication awaiting pick up or shipment to the source pharmacy

Storage Conditions

Consideration should be given to the storage of medications for efficiency and to maintain potency.

  • Bubble packs work well in containers allowing them to stand up so patient and drug name are easy to read
  • Creams, lotions, inhalers, and liquids require separate storage; away from oral preparations to avoid wrong route errors
  • A reliable refrigerator is needed to maintain chilled temperatures for some medications
  • If intravenous services are provided in an infirmary, an additional area for storing IV supplies and solutions may be needed
  • Emergency medications are also kept in the locked medication room and need to be quickly accessible to take to a man-down situation
  • Sharps for medication administration, such as needles and lancets, are also often secured in the medication room

Standardized Processes

The following maintenance systems should be in place to ensure that medications are available when needed for chronic care, acute conditions, and emergency situations.

  • Check in and storage of new medications arriving from the pharmacy vendor
  • Filing of paperwork and order manifests
  • Inspection of expiration dates and stock rotation (esp. emergency medications)
  • Inventory par levels for stock medications, over-the-counter, and protocol medications with standard ordering process
  • Medication return process with pharmacy vendor
  • Monitoring narcotic control
  • Monitoring storage temperatures for room and refrigeration
  • Processing of new prescription orders
  • Reordering of keep-on-person/self-administered medications
  • Shift counts of controlled substances and sharps
  • Turning over the MARs for a new month

Stable Staffing

Consistent staffing in the medication room is a safety factor.  The complexity of the standard medication room processes needs an in-depth understanding of pharmacy processes and patient needs. This requires an individual who values safety and efficiency. Some sites have a pharmacy technician while others have a med room nurse. If “Everyone” is responsible for med room organization, The result is most often a messy med room.

Principles for Medication Room Systems

Here is a summary of key medication room system principles to maintain organization and safety.

Category Principles
Security
  • Keep the medication room locked at all times
  • Reduce the number of staff with key access to the medication room
  • Do not allow food in the medication room
Layout
  • Minimize what is stored in the medication room since access is limited
  • Keep only medications, medication preparation equipment, and controlled items like sharps locked in the medication room to avoid key control issues
Staffing
  • Limit the number of staff who receive, organize, store, maintain, and dispose of medications
  • Have consistent, knowledgeable staff managing the medication room
Storage
  • Keep topical medication clearly labeled and stored separate from oral medications
  • A quality refrigerator and thermometer are needed to maintain proper temperature and humidity for some medications and vaccines
Medication Intake Processing
  • Check medication delivered to the medication room against the delivery manifest and ordering records
  • Report any missing medications to the pharmacy
  • Process and organize new medications such as on medication delivery carts, baskets, or shelves
Medication Organization
  • Organize medication by inmate name or number
  • Medication may also be organized by housing unit or medication rounding system
Medication Disposal
  • Regularly review and rotate stock based on expiration dates
  • Follow environmental regulations when disposing of expired or contaminated medications.
  • Do not flush medication into the septic system
Medication Security
  • Do not allow patients  in the medication room
  • Avoid using inmate porters for medication room cleaning
  • Staff must monitor inmate porters at all times when they are in the medication room
Medication Administration Equipment and supplies
  • Have necessary medication storage and administration equipment and supplies available in the room
  • Supplies can include pill slicers and crushers, disposable pill cups, sharps containers, and drug book

How are you managing the medication room at your jail or prison? Share your tips and tricks in the comments section of this post.

Gayle Burrow, long-time correctional nurse administrator in Portland, OR and frequent Correctional Nursing Today news panelist, contributed significantly to this post. Thanks, Gayle!

Photo Credit: © Oliver Sved – Fotolia.com

Disaster Planning for Infectious Disease Outbreaks (Podcast Episode #95)

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Sue Lane, RN, CCHP and Sue Smith, MSN, RN, CCHP-RN join Lorry to talk about “Disaster Planning for Infectious Disease Outbreaks”. They are presenting this topic at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference HERE.

cnt-podcast_cover_art-1400x1400Correctional facilities are prone to the rapid spread of infectious disease. The incarcerated patient population has a greater likelihood of being diagnosed with an infectious disease due, in part, to poor lifestyle choices and poor hygiene habits. The overcrowded nature of many correctional settings and the age of some structures add to the potential for an infectious disease outbreak.  In addition, the stress of incarceration can weaken the immune system.

Some of the most common outbreaks include tuberculosis, norovirus, and chicken pox. Flu season brings in H1N1 and there was concern about Ebola recently. If we are not prepared, it can be a disaster.

Preparation Pointers

The basics of disaster planning for infectious disease outbreaks are just that – basic. The difficult part comes in finding the time and motivating staff and organizational leaders to plan ahead to avert a disaster when infection strikes. Here are a few preparation pointers:

  • Create an understandable policy and procedure for managing the various types of possible outbreaks.
  • Regularly education health care staff about the outbreak plan. This should be at orientation and at least annually.
  • Share infection management information with the officer staff. This can reduce panic and stress if an outbreak occurs.
  • Practice the outbreak plan as one of the possible disasters in the disaster drill schedule.
  • Refresh staff and officer information during regular flu seasons and any time there is a high alert for an infection entering the facility.

Are you ready to avert an infection outbreak disaster in your setting? Share your tips in the comments section of this post.

This podcast is part of a series discussing topics addressed during sessions of the2015 NCCHC Spring Conference on Correctional Health Care. All posts and podcasts in this series can be found HERE.

Clinical Management of Polydipsia (Podcast Episode 94)

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Scott Eliason, MD, CCHP-MH, Regional Psychiatric Director for Idaho through Corizon Correctional Health Care talks about polydipsia, its various manifestations, and management in the correctional setting. He is presenting this topic along with Mark Fleming, PhD, CCHP-MH at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference and register HERE.

cnt-podcast_cover_art-1400x1400Psychogenic polydipsia, excessive fluid-seeking, is a life-threatening condition that is more common than believed and very difficult to manage in the correctional environment. The excess water consumed in this state leads to hyponatremia; a diluted sodium level. The low sodium then results in water intoxication; a condition that causes neurological symptoms as the brain swells with fluid. Patients exhibit behavior changes, confusion, slurred speech, and, if left untreated, progress to seizures and death.

Causes

Excessive thirst can result from the hyperglycemia of untreated diabetes, a significant blood loss, dehydration, or bodily fluid shift such as from kidney failure. This symptom resolves once the condition is managed and fluid balance returns to normal. Psychogenic polydipsia, however, is a condition of psychological rather than physiologic origin. When the intake of water exceeds the body’s ability to manage it, imbalance ensues.

Schizophrenia is one of the most common causes of psychogenic polydipsia with as many as 20% of schizophrenic patients having some periods of polydipsia and up to 5% compulsively drinking enough water to lead to self-induced water intoxication.

Even higher rates of polydipsia are found in individuals who are schizophrenic and are also anorexic, have seizures, or are substance abusers. Then, too, medications such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and fluozetine (Prozac), part of many mental health treatment plans can lower sodium levels. Plus, so many medication have dry mouth as a side effect; increasing the desire to drink.

Management Priorities

When treating psychogenic polydipsia, Dr. Eliason likes to start by reviewing the patient’s list of medications to see if any can be adjusted or replaced. He has seen some success with adding clozaril (Clozapine) to decrease water seeking behavior. Although the mechanism is unknown, adding a beta blocker to the regimen may be helpful, as well.

While medication adjustments help long-term outcomes, water restriction is the best treatment for the acute phase of water intoxication. Sodium levels usually correct naturally in a couple days. Significantly low sodium levels need close monitoring in an acute care setting; sometimes even critical care.

Treatment Challenges

The compulsive nature of psychogenic polydipsia combined with restrictions of the correctional environment make treatment difficult. Releasing chronic water seekers from water restriction is tricky. Dr. Eliason describes an inmate’s situation of being locked in a cell with a sink and a toilet as the equivalent of locking an alcoholic in a bar.

Dr. Eliason has had success with excess drinking behavior management through a daily weight monitoring regimen. A patient’s weight is usually baseline in the morning as the body has re-equilibrated overnight. Then, during the day the patient over-hydrates resulting in water weight gain. A weight gain of 4% typically equates to a 10 meq blood sodium reduction. By using a morning and evening weight as a feedback mechanism, a patient can be moved in and out of water restriction status until able to self-manage the desire to drink. As can be expected, a team effort is needed to make this work. Both officers and health care staff must be observant of the regimen over time.

Have you had a patient who could not control their water drinking? How was it handled in your setting?

Diabetes Primer for the Correctional Nurse

Lori Roscoe, PhD, MSN, CCHP-RN, is a Nurse Practitioner and Correctional Health Consultant in Atlanta, GA. This post is based on her session “Diabetes Primer for the Correctional Nurse” taking place at the Spring 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14, 2015. Learn more about the conference and register HERE.

Stethoscope and device for measuring blood sugar levelIf you have been in correctional nursing for a while, you may have noticed an increase in the number of diabetic patients you are managing. The recently released BJS Special Report on Medical Problems of State and Federal Prisoners and Jail Inmates provides national statistics on the medical conditions of our patent population. It compares this data with that found in 2004 (the last time this information was collected). Diabetes Mellitus (DM) doubled in our patient population in that span of years. That means it is more important than ever to understand this chronic condition and the various treatment modalities available. Consider this nursing sick call situation.

A 42 year old female inmate submits a sick call request about her ankle. She thinks she sprained it when she stumbled while walking to the exercise yard one morning a couple days ago. A chart review indicates she is a Type II diabetic and is on a combination of metformin and glipizide. She was recently treated for a vaginal yeast infection with fluconazole (Monostat). She has no other acute or chronic conditions of note. Her ankle is only slightly swollen and painful when she bears weight.

What Type Is It?

As nurses we learned long ago about Type I and Type II Diabetes. However, we may have an outdated mental shorthand about the differences. For example, you may categorize diabetes by those who need insulin and those who do not. You might also, then, categorize your diabetic patients by those that could be hypoglycemic because of too much insulin and those that couldn’t because they don’t take insulin. But, these categories can be unhelpful. Better is a differentiation based on physiology.

Type I Diabetes – No or Low Insulin Production. In Type I DM the body either stops making insulin or makes too little to effectively manage glucose. Therefore, it is a lack of insulin production.

Type II Diabetes – Inability to Use Insulin. In Type II DM the body loses the ability to use insulin to manage glucose. In this case, insulin is being produced by the body but is not metabolizing the glucose. There also may be inadequate insulin production over time.

Med Madness

Understanding insulin production and use in the body is one part of diabetes management. Another part is understanding the complexity of medication options. Over the past few years, new types of insulin and new medication classes have made the treatment of diabetes complex. Our patients may now be entering the correctional system with unusual insulin regimens and unfamiliar oral medications or medication combinations for maintaining a glucose equilibrium.

Although correctional nurses do not prescribe medications, an understanding of their effect/side effect is necessary to administer these newer preparations. In addition, we may be called upon to interpret a regimen change to a patient; this can be especially true in settings where a limited formulary requires that generic substitution be made to standard treatment while the patient is incarcerated.

Besides effects and side effects, nurses need to be aware of any interactions among medications or with food. Medication timing with or between meals can affect drug absorption and can be difficult to manage in the secure setting where our patients do not have control over when they eat or the type of food available.

Go to the Head of the Class

Categorizing medications by therapeutic class provides an organizing framework for better recall of important information in a clinical situation. A therapeutic class is determined by the drug’s mechanism of action and resulting effects/side effects, and interactions. While Biguanides (like Metformin/Glucophage©) and Sulfonylureas (like Glipizide/Glucotrol©) are common therapeutic classes of antidiabetics, you may be seeing other, newer, classes arrive with patients on intake or being added to the standard formulary. Meglitinides (Repaglinide/Prandin©), D-Phenylalanine Derivatives (Nateglinide/Starlix©),  Thiazolidinediones (Pioglitazone/Actos©), DDP-4 Inhibitors (Sitagliptin/Januvia©), Alpha-Glucosidase Inhibitors (Acarbose/Precose©), and Bile Acid Sequestrants (Colesevelam/Welchol©) are being prescribed more frequently in our setting.

Then, there are the combination antidiabetic medications. These combination pills are often non-formulary for a correctional setting and must be switched to the singular medications once the patient is incarcerated. The patient in the above-mentioned sick call situation was originally taking Metaglip©, which is a combination pill containing both metformin and glipizide. After incarceration, she was switched to the equivalent medications as generic single-medication pills.

Confused? The Joslin Diabetes Center provides a handy table of antidiabetic drug classes and combination pills HERE. You might want to print one out and post on your unit (hint, hint).

How to Get Up to Speed

So, how do you stay up-to-date on diabetes treatment, or, for that matter any of the myriad of new medications and therapies becoming available? Here are a few ideas to incorporate into your professional development plan.

  • Think diabetes (and hypertension) in nursing sick call as both these conditions are on the increase in our patient population according to the BJS report. Our patients may be on new medication regimens or may be suffering from lack of treatment or, even, have undiagnosed conditions.
  • Have a current and easy-to-read drug book handy in the sick call and medication administration areas. No one can keep all that information in active memory.
  • Look up new medications when you first hear of them or begin seeing them on the MAR.
  • Categorize medication knowledge into drug classes and add new classes or new medications to your current mental structure as they become prevalent in your setting.
  • Ask prescribers to provide information about new medications coming into use in your setting. You may want to have an informal education session or have someone from the medical staff speak at a monthly staff meeting.

Chronic Disease and Sick Call Evaluation

Back to that sick call patient with a swollen ankle. The astute nurse, after reviewing the chart and examining the ankle, asked the patient these follow-up questions:

  • Have you been feeling dizzy at all?
  • When does it usually happen?
  • What do you do about it?
  • Have the episodes increased since you started treating the yeast infection?

Once asked, the patient offered that she occasionally feels dizzy but just eats a honeybun from the commissary when that happens. Once she thought about it, she realized that her tumble coincided with just such a dizzy spell and that, yes, she has been getting dizzy more frequently of late. Based on a full assessment of both the acute ankle injury and her diabetes management, this patient had her ankle wrapped and was set up for a provider visit later that day to have her medications adjusted. Glipizide is one Type II oral antidiabetic that can cause hypoglycemia and this side effect is potentiated when taken in combination with fluconazole (Monostat).

How do you keep up with the latest changes in diabetes management? Share your tips in the comments section of this post.

This post is part of a series discussing topics that are addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. All posts in this series can be found HERE.

Photo Credit: © maya – Fotolia.com

Book Review: Nursing in Criminal Justice Services

Nursing In Criminal Justice ServiesI am intrigued by correctional nursing practice in other countries. So, It was with great interest that I obtained a review copy of “Nursing in Criminal Justice Services” edited by UK correctional nurse experts Ann Norman and Elizabeth Walsh. I interviewed Ann on a prior Correctional Nursing Today Podcast and met both Ann and Elizabeth at the last Custody and Caring Conference in Saskatchewan, Canada. Their book lifts the hood (or should I say bonnet?) on the inner workings of UK criminal justice services and the concerns of nurses working in the system. It provides insight into the similarities and differences in practice between US and UK systems and provides food for thought to apply to correctional nursing in the U.S. Here is my take on some of the gems found in the thirteen chapters of this book.

What’s in a Name?

I remember well our discussions about the title of our specialty on the ANA Taskforce while revising the Correctional Nursing Scope and Standards of Practice a couple years back. We settled on the term “Correctional Nursing” while defining the specialty as being in the Criminal Justice System. The evolution of practice in Britain was a bit different; as the terms for locations in the criminal justice system are different. However, it seems that UK correctional nurses are “Nurses in Criminal Justice Services” and that includes subsets like custody nurses (jail equivalent), prison nurses, and immigration centre nurses. There seems to be some continued discussion on the term for this specialty nursing practice, though. The authors of the chapter on “Professional attitudes and behaviors” (Chapter 12) used the term “secure care workers” and the author for the chapter “Custodial caritas: Beyond rhetoric in caring and custody” (Ch8) also used the term ‘custodial’. I assume that comes from having patients ‘in custody’ but I’m not sure I’m happy with being custodial. It has the feel of mopping floors in American parlance.

Moving from Prisoner to Patient

Of note is the obvious evolution of health care in the UK criminal justice system toward a patient focus and away from a prisoner focus. Editors Norman and Walsh describe in their introduction (Chapter 1) that prison health care has moved from management through HM (Her Majesty’s) Prison Service to the National Health Service (NHS). A move that aligns with general population health care management in the UK and, therefore, creates patient focus. We have seen similar movement over the last decade in US correctional nursing practice as nurses in jails and prisons struggle with the tension, as described in Chapter 1, of “prisoner and patient, custody and care, security and therapy” (pg. 2). A dialog across the pond on these common issues might be fruitful for nurses in our respective justice systems.

A Vulnerable Patient Population

It is no surprise that the patient population in the UK criminal justice system is aging along with those in the US system. Nor is it surprising that there is increasing concern for mental illness services as this segment of the incarcerated population is growing, as well. Other vulnerable groups such as women, youth, and children are addressed. Of note is an increasing emphasis on disability. Chapter 9 discusses “Caring for vulnerable people: Intellectual disability in the criminal justice system”. We would do well to be more cognizant of the vulnerable nature of those in the US system who have learning disabilities, head injury, and low literacy.

The Struggle to Care

The struggle to care is given a fresh (or should I say Freshwater?) perspective in the previously mentioned Chapter 8 on custodial caritas by author Dawn Freshwater. I was moved by her keynote at the 2013 Custody and Caring Conference where she shared the main themes of this chapter. Here she emphasizes the need for compassion and competence in our nursing practice and highlights the dynamics of a caring relationship. I must admit, this gem is my favorite chapter in the book and has provided many a moment of reflection on the caring/custody friction we all feel.

Making a Connection

Finally, I enjoyed reading about the connection correctional nurses have with some areas we might think of as peripheral to our practice. Chapter 4 on “Forensic nurse examiners: Caring for victims of sexual assault”, Chapter 7 “On the out: Supporting offenders in the community”, and Chapter 11 “Learning opportunities from inquests” got me thinking about our need to ‘think outside the box (or bars?) about our correctional nursing practice.

Conclusion

While nursing in the UK criminal justice system may have ‘grown up’ under different conditions, our key concerns as professional nurses within the system remains the same. The patient population and unique work environment create both opportunities and barriers for meaningful patient outcomes. The seventeen chapter contributors to the book “Nursing in Criminal Justice Services” have helped to clarify these issues for British nurses and, by doing so, provide an interesting reading opportunity for us all. Do put this book on your reading list!

What are your thoughts on correctional nursing practice in other countries? Share your ideas in the comments section of this post.

Correctional Nurse Scope of Practice and Delegation (Podcast Episode 93)

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Mary Muse, MS, RN, CCHP-RN, CCHP-A, is Nursing Director, Bureau of Health Services, Wisconsin Department of Corrections. This podcast is based on the Preconference Seminar “Nurses’ Scope of Practice and Delegation Authority” taking place at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14, 2015. Learn more about the conference and register HERE.

cnt-podcast_cover_art-1400x1400The National Commission on Correctional Health Care (NCCHC) recently published a resource document on the scope of practice and delegation authority of correctional nurses based on the input of a taskforce of correctional nurse leaders from around the country. Both scope of practice and delegation have emerged as concerns for nurses working in the criminal justice system. This document can help bring clarity to the issue. In this podcast, Mary provides the following guidance.

Scope of Practice

  • The document promotes best practices for maintaining scope of practice and appropriate delegation in nursing services. After all, nurses are the primary health care service provider in the specialty.
  • Infrastructure for nursing services may not be available for supporting appropriate practice standards. Correctional nurses might work in small settings without true nursing leadership.
  • The document provides the context for application of standard professional principles to the correctional health care environment.
  • Often correctional nurses slide into poor practices in trying to help their patient or may be unaware a request is inappropriate for a nurse to do.
  • Sick Call is a key area where scope of practice boundaries are breached. For example, nurses may be
    • Assess patients and making medical diagnoses rather than nursing diagnoses
    • Practicing without collaborating with medical colleagues when they should
  • Facilities also have responsibilities for ensuring that structures are in place to support the boundaries of scope of practice for all health care staff. Responsibilities can include
    • Staffing patterns
    • Job descriptions
    • Policies and procedures
  • Nurses, though, also have a responsibility to understand their scope of practice based on their state licensure. If a nurse is concerned about an assignment, here are some action steps to take.
    • Step back and consider the request. What is being asked?
    • Consider how the request or assignment is beyond the scope of licensure
    • Write down some objective thoughts about how the scope of practice is being breached in the situation
    • Engage in a dialogue with your supervisor about the scope of practice issue
    • Come to the discussion with a positive perspective that something can be worked out to meet everyone’s needs
    • May want to refer to a document like the NCCHC document
    • If additional help or guidance is needed, consider asking for help from the state board of nursing or local nurse leadership

Delegation Authority

  • Although we may perceive that delegation is different in correction, it is not.
  • Nurses should not delegate nursing assessment and treatment determination to officers, even for something simple like providing medication for a headache.
  • In cases where nurses are not onsite to evaluate a patient, it is best to communicate directly with the patient rather than require the officer to relay information from the patient.
  • Here are key components of nurse delegation.
    • Know who you are delegating to – their abilities and licensure
    • Ensure that what you are delegating is appropriate for that person based on ability and licensure
    • The person taking on the delegated function must understand what is being asked of them
    • Determine if the person needs supervision in completing the delegated function
    • Accountability remains with the nurse delegating the function

This post is part of a series discussing topics addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. All posts and podcasts in this series can be found HERE.

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