Correctional Nurse Perspective: Inmate or Patient?

“It’s not what you look at that matters, it’s what you see” – Thoreau

Perspective1Recently a correctional nurse manager commented that she was getting grief from correctional officers for referring to inmates as patients in the prison medical record. I have heard this issue before and often see medical record charting using inmate to refer to the person receiving health care. I also remember a long discussion with the workgroup as we determined how to refer to our patient population in various sections of the Correctional Nursing Scope and Standards of Practice.*

It may seem a small issue or even unimportant whether you deliver nursing care to patients or inmate. In fact, your perspective on your patient has everything to do with professional nursing practice in the criminal justice system.

Consider this dichotomy. When you look at your patient in a health care encounter, which do you see?

  • A criminal who happens to need health care
  • A patient who happens to have broken the law

Focus of Nursing Practice

Nursing practice in inherently patient-centered. Our professional values call us to seek the health and well-being of our patients. Our primary commitment, in fact, is to our patients. A patient perspective in correctional nursing practice, then, sets us squarely on a solid foundation clinically, ethically, and legally. The right to health care is universal and transcends all individual differences (Code of Ethics 1.1). In particular, a patient’s social status and lifestyle choices cannot be considered in our delivery of nursing care.

On the other hand, seeing the person receiving nursing care as an inmate is inherently custody-centric. Rather than focusing our intentions on seeking health and well-being, an inmate perspective can leave us in a defensive position or in an exchange relationship that can be both dehumanizing and depersonalizing. An inmate perspective does take into consideration the social status and lifestyle choices of our patients; becoming factors in our care decisions.

The Nurse-Patient Relationship

The basis of every nurse-patient relationship is therapeutic. Our patient’s interests are primary in this relationship. In a correctional setting, a patient’s interests can be abrogated by the security system. Nurses must engage in collaborative dialog to advocate for a patient’s health and well-being when the correctional culture is unnecessarily abridging health interests.

While a patient perspective is likely to lead to necessary patient advocacy, an inmate perspective blurs this focus and can unnaturally align nurses with a punitive or merely disinterested perspective toward an individual patient and the patient population, as a whole. In addition, mutual respect within the nurse-patient relationship is threatened when the patient is viewed as having less societal value, human rights, or inherent dignity.

Response to the Inmate-Patient Dichotomy

Do we care for patients or inmates in the criminal justice system? Our professional ethic calls us to care for patients and to view our patients from a perspective of human dignity and intrinsic value…..even when they may have shown themselves to be untrustworthy, selfish, or even evil.

The correctional nurse manager dealing with pressure to call her patients inmates has an opportunity to inform and educate the officer corps in her facility about professional nursing practice. The correctional setting is a unique environment with a unique patient population but the principles of nursing practice and the values that undergird that practice remain unchanged in the criminal justice system.

So, what do you think? Patient or inmate? Share your thoughts in the comments section of this post.

*We settled on using the term patient when discussing correctional nursing practice while using inmate when discussing the patient population of our care.

B. Jaye Anno: Legendary Correctional Health Care Pioneer (1947 -2015)

BJayeAnnoThose of us working in correctional health care owe a debt of gratitude to early leaders who stepped forward to make a difference in the lives and health of our patients just a few short decades ago. One such leader was B. Jaye Anno. I was sad to learn of her unexpected passing on November 3. Although not a nurse, she had been a great inspiration to me in my efforts to encourage professional nursing practice in the criminal justice system.

Like many of us in correctional nursing, her work in correctional health care began accidentally, even incidentally. As she recounts in a short article on Women in Correctional Medicine, she was working as a parole officer in New Jersey in 1972 when she was connected with the American Medical Association (AMA) through her sister who was working there at the time. The AMA was developing a taskforce on health care delivery in US jails and needed an expert on corrections. As she states in the article, “At the tender age of 25, I became the AMA’s ‘expert’ on corrections.”

Correctional health care is a relatively new clinical specialty. Unlike many traditional specialties that have decades and even centuries of history, correctional practice is but 40 or so years old. Some point to the 1976 Supreme Court decision on Estelle v. Gamble as the start of the specialty. The decision that withholding medical treatment was a violation of the 8th Amendment to the US Constitution, which forbids the cruel and unusual punishment of prisoners, certainly formed the legal basis for healthcare delivery behind bars.

But no great movement starts by spontaneous generation and, actually, the correctional health care specialty was developing in parallel with Estelle v. Gamble moving through the courts. In the early 1970s both the American Bar Association and the American Medical Association became concerned about health care in the criminal justice system. This was also during a period of prison riots, some with specific healthcare concerns.

Anno was recruited for the AMA taskforce ‘by chance’ but she took advantage of that opportunity to do good for a large and growing segment of the American population.  After her taskforce work she held the position of director of the correctional health care department of the AMA from 1979 to 1982 and then cofounded the National Commission on Correctional Health Care (NCCHC) in 1983.

Starting as a parole officer and then becoming involved in correctional health care through her AMA work, she obtained an M.A. in Criminal Justice from John Jay College of Criminal Justice, New York City, in 1974 and a Ph.D. in Criminology from the University of Maryland, College Park in 1981. She combined her experience with education as a foundation for her growing impact in the criminal justice system.

Dr. Anno was a prolific writer and was principal author of the major reference book for the field, Correctional Health Care: Guidelines for the Management of an Adequate Delivery System. Written in 2001, this text is still in use today as a primary resource in the specialty. She was a past editor of the Journal of Correctional Health Care and co-edited The Health Status of Soon-to-be-Released Inmates: A Report to Congress (2002) and Addressing the Needs of Elderly, Chronically Ill, and Terminally Ill Inmates (2004). Her work helped me develop a full understanding of the scope of correctional health care issues when I started my ‘accidental’ journey into correctional nursing in the NJ prison system. Later she was an inspiration for my writing journey.

In 1998 the NCCHC created the Award of Excellence in Correctional Health Care Communication, which was later renamed the B. Jaye Anno Award of Excellence in Communication. I was honored to be the 2013 recipient and first nurse to receive the award. I also found out I was the only woman awardee besides Dr. Anno herself. What a thrill to receive the award directly from this living legend.

The fantastic thing about B. Jaye Anno was how personable and approachable she was. She participated at NCCHC conferences and could be seen in the crowded hallways, just like any ‘ordinary’ participant. I had several chance conversations with her, including just a couple weeks ago at the 2015 National Conference in Dallas. She was a role model for how to make a difference wherever you have opportunity. I gather that she had little understanding of where her journey in the criminal justice system would lead when she took her NJ parole officer position in her 20s. By leveraging the opportunities placed before her, she is leaving a lasting and significant body of work that has changed the face of correctional health care and affected the practice of every one of us in the specialty.

I hope, like me, the life and accomplishments of B. Jaye Anno are an inspiration to your correctional practice wherever you are working. She truly affected the lives and health of millions of our patients. B. Jaye Anno, you will be greatly missed but your legacy lives on!

Correctional Nursing Research Priorities

Research PrioritiesI was excited to see my correctional nurse research published in the October, 2015, issue of Journal of Correctional Health Care (JCHC) for several reasons. Of course, it is always professionally fulfilling to see your writing in print; especially in a peer-reviewed scholarly journal such as JCHC. Performing nursing research, in itself, is a rewarding and difficult enterprise, so just completing the study was satisfying. But, the top reason for my pleasure in seeing this research in print is the promise that it might spur meaningful research in our specialty. This is much needed as we move forward to establish professional correctional nursing practice. I encourage you to read the full article, if you are able. However, here is a summary of the key points of the study.

The Delphi Method

The Delphi research method is a survey of expert in a particular discipline. It has been used to determine research priorities in a number of nursing specialties and was familiar to me as I used it to determine research priorities for the nursing staff development specialty many years ago. In the Delphi approach a group of experts in a field of study are asked to list, from their perspective, top priorities for a particular area of study. It could be research or it could be priorities for competencies or even components of a practice guideline or standard of care.

For my study, I put out an email call for participation to a large group of correctional nursing experts I had met in my various activities in the field. Those who responded included their resume to confirm expertise and background. Eighteen experts were included in the Delphi panel.

A three-round Delphi method was used and included these rounds:

  • The first round asked the question – What are the most significant problems or questions affecting correctional nursing practice that can be solved or answered through nursing research?
  • The second round had panelists rate the list of research questions obtained from the first round.
  • The third round allowed panelists to see the second round mean rating of each question and have an opportunity to rate the research questions using that feedback.

Top Correctional Nursing Research Needs

Here are the key areas of correctional nursing research needs as determined by this expert group.

  • Critical Thinking/Clinical Judgment: How are critical thinking and clinical judgment affected by our unique environment and the particulars of our patient population?
  • Competency/Educational Level: What are the core competencies for correctional nursing practice?
  • Assessment: How can nurses rapidly, yet effectively, assess correctional patients?
  • Nursing Protocols: What are the best formats and methods for nursing protocols that stay within scope of practice?
  • Effect on Patient Outcomes: What are correctional nurse-sensitive patient outcomes?
  • Environment of Care: In what ways does the care environment affect correctional nursing practice?

Now What?

How can this study be used to increase correctional nursing research? Here are some ideas.

  • Determine the theme of a thesis or dissertation when pursuing an advanced degree.
  • Determine areas for best practice development for a site or correctional system.
  • Establish research topics for a grant proposal.
  • Gather a collaborative group across systems to pursue an understanding of one of the themes.
  • Topics for conference presentations.
  • Topics for journal manuscripts.

So what do you think? Are there other ways to apply correctional nursing research priorities? Share your ideas in the comments section of this post.

Does Your Patient Understand You? Health Literacy Behind Bars*

Does Your Patient Understand YouInmate Franken was called to medical and told the result of his recent blood test. He is HIV positive. The infectious disease nurse at the medium security prison is now talking to him about what this means and the treatment plan ahead. He nods each time the nurse asks if he understands what she is saying. After 20 minutes, he leaves the medical unit with a new appointment and 5 pages of information to read before returning.

What is Health Literacy?

Health Literacy is the ability to obtain, process and understand basic health information and services needed to make appropriate health decisions. Inmate Franken is facing an uphill battle to understand his new condition and the lifestyle changes, treatment options, and future implications of this diagnosis. This struggle can be compounded by difficulty understanding and interpreting the health information he is given.

It is easy to assume that our patients have foundational skills to process basic health information, but that may not be true. Here are some common skills Inmate Franken would need in this highly-charged emotional situation.

  • Understand written English
  • Interpret graphs and figures
  • Analyze relative risks and benefits
  • Calculate numeric data
  • Verbal skills to describe symptoms and treatment effects

Low Health Literacy is Common

According to the National Assessment of Adult Literacy, 14% of Americans do not have even basic health literacy skills. This number is even higher in the incarcerated population due to several factors.

  • Cultural challenges – language barriers and culturally-unique interpretations of information can hinder understanding
  • Low educational status – those with less education are also less health literate
  • Low general literacy – the ability to functionally read and write
  • Low social and economic status – those in poor social and economic conditions struggle more with literacy issues

More Need than Ever

There is an ever increasing need for health literacy among our patients due to increasing demands for their participation in health care. Inmate Franken must participate in a complicated treatment plan for his new diagnosis and must evaluation complex information about his condition in order to make healthy lifestyle changes. Patients need to be health literate in order to meet our expectations for their participation in the following health functions.

  • Prevention and healthy living such as nutrition, exercise, and dental care
  • Immunization awareness
  • Self-assessment of health status such as peak flow meter or glucose testing
  • Self-treatment such as insulin adjustments
  • Health care use such as when to go to the clinic, when to seek referrals, and follow-up care

Low Literacy Indicators

Inmate Franken was showing some low literacy indicators when meeting with the infection control nurse. One in particular was nodding in agreement without indicating that he understood the information. In fact, one seasoned practitioner considers three straight ‘yes’ responses as an indication that it is time to stop and get some true feedback on understanding. Here are some other indications that your patient may have literacy issues.

  • Asking few questions
  • Frequently missed appointments
  • Identifying pills by looking at them, not reading the label
  • Incomplete forms
  • Lack of follow-through on tests or referrals
  • Noncompliance with medication
  • Unable to give a coherence, sequential medical history
  • Unable to name medications or explain purpose or dosing

Timing Affects Literacy

Inmate Franken has just heard some devastating news. If the news is unexpected or life-threatening, patients need time to adjust to their new status before they are able to adequately make decisions or digest information. It may have been better to keep the information simple and schedule a return appointment at a more teachable time.

Intake is another time we provide a great deal of health information about accessing the system, medications, and schedules. Yet, our patients are often drunk, drugged, or scared to death about entering the jail or prison. Although we may need to provide this information at intake, consider ways to repeat health care information later in the incarceration period when your patient is more likely to be sober and acclimated.

Improving Comprehension

Here are some quick tips to immediately improve your communication with literacy-challenged patients.

  • Use plain language – simplify medical-speak to shorter words and brief sentences
  • Limit information – think fact sheet rather than encyclopedia when providing complicated information
  • Be specific and concrete – general and vague information lacks clarity
  • Demonstrate, draw pictures, use models – a picture is worth a thousand complex medical terms
  • Repeat/summarize – circle back to the most important take-home message at the conclusion
  • Have the patient teach-back the information to you in their own words to check for understanding. Clarify any incorrect interpretations.
  • Be positive, hopeful, empowering – show your support for the patient

Do you have to share complicated health information in your correctional position? Share your tips in the comments section of this post.

* I’ve just returned from the National Commission on Correctional Health C (NCCHC) 2015 Fall Conference where fantastic correctional clinicians presented on the latest trends, issues, and best practices in correctional health care. This post was inspired by the session “Understanding the Ties Between Cultural Literacy, Understanding, and Patient Safety” presented by Jessica Lee and Elmeada Frias. A while ago I also tackled patient literacy in the post “Are Your Education Materials Inmate-Friendly?”

Responding to Angry Inmates

During a sick call visit for lower back pain, a patient begins shouting at the nurse that no one is helping him with his pain. “I need something stronger than these baby pills!”, he shouts as he stands up and puts his face in front of the nurse.

Dealing with angry patients is a challenge, especially when you have a patient population prone to anger management issues like many of our inmate patients. Successfully managing anger in others is mostly about your own response to the anger as Dr. Melissa Caldwell discusses in the Correctional Nursing Today Podcast “De-Escalating Critical Incidents”. A while back I wrote a post on dealing with inmate anger and recently came across some new research on response to anger that may help make your work life calmer. Neuroscience is providing some helpful direction for those of us confronted with angry patients. Much of the findings noted here come from the books Handbook of Emotional Regulation and Crisis Negotiations: Managing Critical Incidents and Hostage Situations in Law Enforcement and Corrections.

Stay Calm

Dealing with a tense and angry patient can easily make you react in kind. It is natural to reflect a similar emotion yet if you stay calm the patient is less likely to escalate. This takes practice and self-awareness. Studies in neuroscience show that the answer is not to suppress your own anger, though. Suppressed emotions don’t help the situation and can actually continue to escalate the confrontation. Venting your angry response, of course, doesn’t help either. Distracting yourself from the emotion was actually found to be the most helpful method for staying calm. How would that work in a patient interaction like the case above?

It’s Not About You

Neuroscientists found that reappraising the situation was of the most benefit. Reappraisal is the consideration of alternative explanations of a situation. Reconsider the situation from the patient’s perspective: he is in pain; he is under a lot of stress. In other words, focus on the underlying cause of the anger.

Smart parents do this all the time with toddler temper tantrums. Rather than confronting the emotion, they ignore the tantrum and consider possible causes such as overstimulation. Sometimes a brief time-out is all a child needs to regain control. This concept can work for out-of-control adults, too.

Slow Things Down

Crisis negotiators advocate slowing down the conversation to help the angry person get control of their emotions and to show a desire to actively listen to them. Your response can be as simple as stating that you would like to help but need them to speak slowly so that you can understand. Slowing down the conversation helps the person gain control of their emotions while you get organized to respond effectively.

Response Toolkit

Crisis negotiators use active listening techniques to diffuse emotional situations. Active listening is established through body language and verbal response.  Here are some verbal responses that show an angry patient that you are listening to them.

  • Acknowledge: “It sounds like you are frustrated with your treatment.”
  • Paraphrase: “The medications you are now taking are not helping your back pain.”
  • Open-ended Questioning: “Let’s work on this. Tell me more about your back pain.”

The Texas Medical Association has a resource for handling patient confrontations with some verbal communication techniques that can help with an angry patient. Here are three techniques they recommend:

  • Wish I Could: “I wish I could give you stronger pain medication, but we first need to establish the cause of your back pain.”
  • Agree in Principle: “I agree that we need to get your back pain under control. Although I can’t give you other pain medication, here is what we can do.”
  • Broken Record: If the patient continues to try to get their way, don’t come up with new reasons why you can’t do it. Instead, restate the same response with slight variation.

Oh, by the way, these techniques work well in all areas of practice and life. Try them when communicating with angry coworkers or family members, too!

Have you had success dealing with an angry inmate? Share your experience in the comments section of this post.

Photo Credit: @master1305

Who’s Minding Your Patients? Scopes of Practice Issues in Corrections

Fran Tompkins, RN, MS, CCHP, CCN/M, is Nurse Training and Education Supervisor for Correct Care Solutions in Nashville, TN. This post is based on the session “Who’s Minding Your Patients? Understanding Licensed and Unlicensed Scopes of Practice” that she is presenting at the 2015 National Conference on Correctional Health Care in Dallas, TX, October 17-21, 2015. Learn more about the conference and register HERE.

Scope of practice can be described as those activities health care staff are permitted to legally perform based on licensure and training. All nurses need to understand their scope of practice to be able to stay within the boundaries of licensure. Correctional nurses, though, can encounter significant challenges to keep within the bounds. First of all, correctional nurses can have significant autonomy in make care decisions based on the setting. There may be few other health care providers onsite. In addition, officer colleagues may expect nurses to deliver health care beyond licensure limits, unaware that a request is inappropriate.

Nurses have a responsibility to dissect scope of practice as it applies to their particular state of licensure, understand it, and ensure that they are practicing within the boundaries of their license and fulfilling the requirements and conditions of the applicable regulations for the state.

Scope of Practice and Delegation

When using unlicensed assistive personnel (UAP) such as nurses’ aides, medication techs, or emergency medical technicians, it can be difficult to determine what they can legally do. The American Nurses Association and Council of State Boards of Nursing provide some guidance for determining delegated activities within a scope of practice for these individuals. In particular, registered nurses need to uses critical thinking and professional judgment while considering the 5 rights of delegation:

  1. The right task
  2. Under the right circumstances
  3. To the right person
  4. With the right directions and communication; and
  5. Under the right supervision and evaluation

Considerations when deciding to delegate a task include the potential for patient harm, the task complexity, amount of problem-solving needed in the situation, and the predictability of the outcome.

When Delegation is Not a Good Idea

Based on the above considerations, delegation is not always the best decision; especially when the patient situation is acute. For example, first responder events in corrections, like man downs, require nurses to think critically about patients who are acutely injured or become acutely ill. Other nursing processes also require complex evaluation and intervention. Besides emergency response, highly developed assessment skills are needed for intake screening and nursing sick call. In these examples, staff must often make autonomous decisions and intervene based on clinical judgment. Delegation to lesser-licensed staff can be risky.

Nursing staff must be prepared to offer the best care to all patients, recognize those individuals who are critically ill, and determine the best interventions for them; all within the boundaries of their scope of practice.

How do you handle scope of practice issues and delegation in your setting? Share some insights in the comments section of this post.

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


Lateral Violence in Nursing (Podcast Episode 107)


Tara Taylor, BSN, RN, CCHP, Regional Director of Nursing, and Mariann Burnetti-Atwell, PsyD, Director of Operations, Behavior Health Services, for the Missouri State Department of Corrections through Corizon Health, join Lorry to discuss lateral violence and bullying in nursing. They are presenting the session Lateral Violence in Nursing: How to Prevent Bullying and Create a Healthy Work Environment at the National Conference on Correctional Health Care in Dallas, TX, October 17-21, 2015. Learn more about the conference and register HERE.

Lateral violence is also called horizontal violence or workplace bullying. It can happen in any profession but is especially troubling in nursing. This summer the American Nurses Association published a position statement on Incivility, Bullying, and Workplace Violence. The ANA sees these as ethical issues and the statement quotes the Code of Ethics for Nurses with Interpretive Statements that nurses are required to “create an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees, students, and others with dignity and respect” (ANA, 2015a, p. 4).

Affects Staff and Patients

An unhealthy work environment affects both staff and patients. Here are just a few of the effects of bullying on staff morale and patient care.

  • Medication errors: 40% of clinicians “kept quiet” or “ignored” an improper medication due to an intimidating colleague.
  • Staff health issues: Unmanaged anger contributes to hypertension, coronary artery disease, depression, psychological problems or other health problems.
  • Staffing issues: Low staff morale, increased absenteeism, attrition of staff, deterioration in the quality of patient care.
  • High staff turnover: Nurses leave the profession due to lateral violence and bullying contributing to the nursing shortage.

Preventing Lateral Violence

Both employers and staff have opportunities to intervene to prevent lateral violence. Employers can make it clear that bullying will not be tolerated through policy enforcement. Education about and role-modeling of respectful interactions is also important. Poor behavior needs to be addressed rather than ignored. The ANA provides posters graphically representing various prevention mechanisms for use in the clinical setting.

Is lateral violence an issue in your setting? How do you handle it? Share your tips in the comments section of this post.

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

Nursing Assessment of Dental Problems

Julia Buttermore, DMD, is Chief Dental Officer, Federal Medical Center, Carswell, Fort Worth, TX. This post is based on her session “Nurses’ Assessment of Dental Problems” taking place at the 2015 National Conference on Correctional Health Care in Dallas, TX, October 17-21, 2015. Learn more about the conference and register HERE.

Dental conditions can be a great concern for correctional nurses, yet, most received little or no training about dental conditions in nursing school. Most traditional nursing positions don’t involve dental assessments so many nurses enter the correctional specialty unprepared.

What’s the Big Deal?

First of all, a nurse is most often the first person an inmate sees about a dental concern. This is usually at a receiving screening or through the nursing sick call process. So, nurses must be able to determine the nature of the issue and make a decision about urgency of treatment. A dental episode might be remedied with instruction on self-treatment, may need assignment to the next available dental appointment, may need urgent evaluation by a dentist, or may need emergency treatment in the acute care setting. It requires significant clinical judgment abilities to appropriately manage dental issues.

Another reason dental conditions are a concern for correctional nurses is because there are so many of them in our patient population. Our patients are less likely to have received dental care in the past and many have a lifestyle that does not include high levels of dental hygiene. Therefore dental decay and periodontal disease are seen frequently. Our patients come from violent backgrounds that can result in tooth trauma. They also indulge in high levels of alcohol, tobacco, and drug use. All these substances have a negative effect on dental health.  Methamphetamine use, in particular, can cause severe dental erosion and decay. Self-medicating with alcohol and drugs can mask tooth pain. Once incarcerated and withdrawn from these substances, inmates feel increasing mouth pain that leads to dental requests for evaluation and treatment.

Finally, systemic chronic conditions and infections affect dental health. Nurses who understand the relationship of dental conditions to systemic disease can often activate medical evaluation when a dental manifestation is observed. For example, canker sores or herpes can appear on the mouth of an immunosuppressed individual and periodontal infection might exacerbate blood glucose levels in diabetics.

Where to Start

A good assessment starts with an evaluation of the patient’s mouth pain. Here are some important questions to ask.

  • How long has it been hurting? (Just now? 24 hours? 3 months? Years?)
  • Does it hurt spontaneously or when eating, drinking?
  • Does the pain wake you up at night?
  • Describe the pain quality: aching, throbbing, pressure, tingling
  • How long does it hurt? (<1 minute? 30 minutes to 1 hour? all day?)
  • Does anything help the pain?
  • Use the pain scale of 0-10 to determine a baseline level of discomfort

Dental conditions can affect the ability to breathe and swallow. These are two immediate concerns in evaluating any dental condition. Ability to breathe and swallow is affected by infection, traumatic injury, persistent bleeding in the oral cavity, or swelling. Impairment of breathing or swallowing needs immediate emergency treatment. Inspect the mouth for swelling. Take the patient’s temperature.

If this is a traumatic injury, check for a broken jaw. Mandibular fracture is a common injury due to assault or falling. Malocclusion (teeth not fitting together normally) is an indication of a mandibular fracture.

A New Skill

Since most correctional nurses come to the specialty with little training or experience with dental assessment, you may need to develop your own dental training program to develop skill in this important area of nursing practice behind bars. This can involve encouraging your facility dentist to provide in-services and hands-on practice assessing patients under their direction. You may also be able to discuss dental assessments and findings as a debrief of urgent or emergent evaluations. Dental trauma and infections tend to be the most common conditions requiring nursing assessment so these are good places to start.

Do you assess dental conditions in your practice? Share your experience in the comments section of this post.

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

Intensive Medical Management: How to Handle Prisoners Who Self-Mutilate, Slime, Starve, Spit and Scratch (Podcast Episode 106)


Todd Wilcox, MD, MBA, CCHP-A, Medical Director of the Salt Lake County Jail System, joins Lorry to discuss managing some difficult correctional patient situations. He is presenting the session Intensive Medical Management: How to Handle Prisoners Who Self-Mutilate, Slime, Starve, Spit and Scratch at the National Conference on Correctional Health Care in Dallas, TX, October 17-21, 2015. Learn more about the conference and register HERE.

Providing health care in the criminal justice system brings with it some interesting and challenging patient situations. Patients present with unusual medical conditions, for sure, but also have some difficult behavioral and psychological profiles that lead to safety issues for both the patient and the staff. Dr. Wilcox shares insights on dealing with these patients and provides treatment recommendations based on best practices and clinical experience.

Often, disruptive inmates who slime, spit, or scratch incur charges, restricted contact, and lost of privileges. Extreme outbursts and violent behavior can lead to physical restraint. However, treating these individuals punitively rarely has a good outcome; and can sometimes end in injury or death. Things can get out of control with escalation on both sides. A measured approach, focusing on de-escalation and crisis intervention is warranted.

Self-injury, whether mutilation or starvation, are two of the most challenging behaviors to manage successfully. An understanding of mental illness is needed by both healthcare and security staff. While policy and procedure are important to set a framework for managing these behaviors, a one-size-fits-all approach will not work. Often interventions for individual patients must be tested out to determine response. For example, some patients respond well to increased stimuli while others need to be taken away from noise and audience.

Crisis Intervention Training (CIT) is recommended for those who deal with behaviorally challenging inmates. Dr. Wilcox initiated the training for staff working in the Salt Lake County Jail System and they have seen a 95% reduction in the use of force to manage behavioral issues.

How do you handle patients who self-mutilate, slime, starve, spit or scratch? Share your tips in the comments section of this post.

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

Caring for Pregnant Women

Caring for Pregnant WomenDonna Jackson-Kohlin, MSN,CNM, CCHP, is a Certified Nurse Midwife (CNM) providing ob/gyn care at the Western MA Regional Women’s Correctional Center. This post is based on the session “Increasing Staff Comfort Levels in Caring for Pregnant Women” that she is presenting with colleagues Theresa Coley-Kouadio and Carly Detterman; one of many valuable sessions taking place at the 2015 National Conference on Correctional Health Care in Dallas, TX, October 17-21, 2015. Learn more about the conference and register HERE.

If you work with female inmates, you are likely to regularly care for pregnant patients. It is estimated that 6-10% of incarcerated women are pregnant at any time in the criminal justice system as almost 80% of female inmates are of child-bearing age. Many of us enter our correctional practice with little experience caring for pregnant women yet we need to manage prenatal and post-natal care while dealing with women at high-risk for premature labor, ectopic pregnancy, and precipitous delivery.

There are plenty of reasons to be uneasy about caring for pregnant Incarcerated women. Many have had past complicated high-risk pregnancies, with preterm births, multiple emergency cesarean sections, miscarriages, or stillbirths. Then there are the additional concerns of substance abuse, minimal medical or prenatal care, and undiagnosed medical conditions. Chaotic life situations such as homelessness and abuse add to the complications of care. Recovery from substance abuse, regular meals, and a stable living situation during incarceration can decrease the chances for pregnancy problems, especially for women with high-risk histories..

Common Pregnancy Issues

The incarcerated patient population is less likely to have had regular medical care and more likely to be practicing poor health habits such as drug and alcohol use. Here are several common inmate pregnancy issues.

Substance Use: Possibly topping the list of pregnancy risks is substance use. For many reasons, pregnant women can be reluctant to reveal accurate levels of drug and alcohol involvement.

Chronic Medical Conditions: Undiagnosed and untreated chronic conditions such as diabetes and hypertension must be evaluated and managed to minimize risks to the developing fetus.

Mental Health: Undiagnosed depression or mental health diagnoses are common in the general population, and more so for incarcerated women. Many women and many medical staff are hesitant to treat depression and anxiety during pregnancy, but untreated mental health conditions lead to poor outcomes.

Bleeding:  Bleeding can occur at various stages in pregnancy and can be caused by sexually transmitted infections, preterm labor or placental problems.

Be Prepared

“Be prepared” is a good motto for correctional nurses, as well as scouts. Here are some recommended skills and supplies needed for pregnancy care.

Fetal Heart Beat: Be sure to have a fetal doppler in good working order and know how to use it. Check out this prior post on nursing care for pregnant patients for some information links.

Emergency Birth Kit: Know the location and contents of an emergency birth kit. Review the policy and procedure on dealing with a precipitous delivery. This might be a good “man down drill” to practice once or twice a year to make sure all staff are familiar with what to do.

Learn and Practice: Request inservices from your obstetric care providers to better understand normal pregnancy, delivery, and post-partum care. Take advantage of their knowledge and perspective. Ask for hands-on training with any procedure or assessments you will be asked to perform on your own.

Keep ‘Care’ in Your Nursing Care: Listen to your pregnant patients and objectively evaluate their symptoms. Understanding normal and abnormal symptoms is helpful, as is remembering that pregnant inmates may have experienced prior pregnancies numbed by drugs and alcohol. In a drug-free state they may feel increased symptom intensity. Empathy and compassion go a long way in supporting recovery and rehabilitation. In fact, pregnancy and motherhood can be a motivating opportunity for change.

Keep Resources Handy

Have good obstetric resources available for consultation, if at all possible. Here are a couple resources recommended by Jackson-Kohlin for your unit library:

In addition, you can find education and resources such as position statement and patient materials at:

Do you care for pregnant inmates? What tips do you have to help staff feel more comfortable with obstetric patients?

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