Nursing Care of End-Stage Liver Disease (podcast)

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cnt-podcast_cover_art-1400x1400Richmond James Rada, MSN, RN, CCHP, a nurse consultant with the California Correctional Health Care Services in Sacramento, CA, talks about managing end-stage liver disease (ESLD) in a correctional setting. Richmond recently published an article on nursing care of end-stage liver disease in CorrectCare, the magazine of the National Commission on Correctional Health Care (NCCHC). Here is a link to the online issue in which his article appears. Richmond became interested in ESLD while doing death reviews for the state. He saw how important nursing management of the condition was to patient outcomes.

Although liver disease can be caused by many conditions such as chronic heart failure, obstruction, or metabolic conditions, our patient population most often develops ESLD due to chronic alcoholism and infection (especially Hepatitis C).

ESLD is not curable – liver transplant is the only cure and that is not an option for the majority of inmates. So, symptom management is the primary plan of action.

Nurses can be challenged to understand the clinical manifestations of liver pathology. Just a few of these include:

  • Upper GI Bleed due to back pressure in the vessels of the lower esophagus and upper stomach
  • Ascites due to portal hypertension causing fluid leak into the abdominal cavity
  • Ammonia build up causing confusion, disorientation, and behavior changes

Medication management is a key nursing management role. For example, lactulose is a common treatment for high ammonia build-up from a failing liver. It causes frequent bowel movements that is difficult to manage in the cell block. Nurses need to help patients develop a plan for working with the side effects of important ESLD medications.

Patient teaching is also an important nursing function. Our patient population needs information that is focused on their level of understanding. Richmond recommends that the patients bring their medications to chronic care visits and explain to the nurse how they are taking the medication, what the side effects might be, and what the medication is for.

Nurses can advocate for ESLD patients by recommending higher levels of care when deterioration is noted. This requires collaboration with medical and custody staff. Sensitivity to end-of-life wishes is vital, but talking about dying in prison is difficult. Family and friends may not be in contact or difficult to engage in this type of discussion.

Medical appointments, dietary needs, and activity restriction can cause conflict with officer peers. CO’s also need information to understand ESLD implications for security operations.

Finally, nurses are the hub for managing ELSD treatment complexities. This means coordinating outside appointments, dietary restrictions and pharmacy communication. ESLD treatment is costly. By managing symptoms and adherence to the medical regimen, correctional nurses are able to improve patient outcomes while reducing costly hospitalizations.

Scope and Standards: Population Served

ANA StandardsThis post is part of an ongoing series discussing key components of the Correctional Nursing Scope and Standard of Practice, 2nd Ed. Review prior posts in this series here. Purchase your own copy of this highly recommended book through Amazon.

Many of us entered the nursing profession to help those in need. I can’t think of a needier patient population than those in correctional facilities. The demographic make-up and specific health needs of our patient population contribute to what makes correctional nursing a specialty. Because our patient population is defined by location and jurisdiction, rather than disease or health need (as in most traditional settings), correctional nurses must be proficient in a broad array of conditions and, often, a variety of ages and genders. For example, a small jail may house detained men, women, and juveniles. While, larger systems such as a state or federal prison system have the volume and support necessary to separate populations by gender and age.

Although the majority of prisoners in the US criminal justice system are white, there is a disproportionate number of minorities behind bars. Therefore, conditions found more frequently in black and Hispanic populations are prevalent in the inmate patient population. According to the CDC, blacks are three times more likely to have diabetes and strokes and have a higher death rate from HIV disease. Likewise, the CDC reports Hispanics having higher rates of death from these conditions along with higher rates of chronic liver disease. Therefore correctional nurses must be proficient in assessing for and treating these conditions.

Coming from disadvantaged backgrounds, with less access to regular healthcare services, the incarcerated patient population has many untreated conditions and a high burden of chronic disease. A study of jail and prison inmates found higher rates of diabetes, hypertension, asthma, and prior MI than the general population. The correctional nurse may be a first contact with the healthcare system. Therefore, correctional nurses must be proficient in evaluating symptoms that might indicate an undiagnosed chronic condition. For example, I have seen newly diagnosed diabetes and asthma in the correctional setting.

Our patients are also prone to infectious disease with high rates of sexually transmitted infections, tuberculosis, and blood-borne infections such as HIV, HCV, and HBV. Many have poor hygiene practices and a cramped correctional environment can contribute to the spread of infection, like norovirus, throughout a facility. Correctional nurses often become infection control specialists; containing a varicella outbreak, reporting food poisoning to the health department, and educating patients to reduce transmission.

The inmate patient population has high rates of mental illness. Every correctional nurse is a mental health nurse! Among the mental conditions over-represented in the incarcerated are mania, major depression, psychotic disorders, and borderline personality disorder. Not only must correctional nurses understand the assessment and treatment of these conditions but must be aware of the implications of personality disorder, sociopathic, and psychopathic tendencies on the nurse-patient relationship.

The often violent and abusive backgrounds of the correctional patient population means higher rates of traumatic brain injury, post-traumatic stress disorder, and suicidality. Correctional nurses must be astute in detecting the potential for self-harm and seeking to prevent it. Histories of abuse require sensitivity in nurse-patient interactions to avoid triggering panic, anxiety, or suspicion. An understanding of the effects of traumatic brain injury is needed when providing patient instruction.

Finally, our patient population is highly substance involved. Drugs and alcohol are a way of life for so many under our care. An extensive study found nearly 85% of all U.S. inmates involved with alcohol or illegal drugs. You can bet that means withdrawal concerns when they enter the criminal justice system. Our patients are also willing to coerce others (including you!) to obtain drugs for them while they are ‘inside’. Their desire for alcohol can lead to hooch-making from spoiled fruit and potato peels – that can be deadly. Amazingly, alcohol –based hand sanitizer has also been ingested in the correctional setting.

In summary, it is clear that correctional nurses work with a unique patient population that requires specialized knowledge, skills, and attitudes. Did you see your patient population in this description? Share your thoughts in the comments section of this post.

The Correctional Nurses’ Guide to the Code of Ethics

code of ethics in wood typeLast fall I was appointed to the American Nurses Association advisory committee to the distinguished panel of nurses who will be revising the Code of Ethics for Nurses. I am honored to represent the correctional nursing perspective and provide input to the panel as they update the 2001 version of the Code. I’d like you to come along with me on the journey as I consider how the Code of Ethics for Nurses applies to our specialty practice.

It All Started with Flo

All professions have codes of ethics that govern practice. The nursing code of ethics has a long history reaching back to the original Florence Nightingale pledge of 1893. Until researching the pledge for this post, I never realized that it wasn’t written by Florence Nightingale but, instead, was named after her when developed by a nurse training school in Michigan. Many nursing schools still use the pledge in graduation ceremonies. Did yours? I graduated from an associate degree program of a small community college in Wisconsin in 1984. We did not say the pledge that I remember. However, like the Hippocratic Oath often recited by graduating medical students, it provides an ethical basis and common foundation to guide practice.

It wasn’t until 1950 that a formal professional code of ethics was developed and approved by a large group of nurses through the American Nurses Association.  The current 2001 code is the sixth revision to the document. Most revisions involve variation in the way nurse duties to the patient and professional values are described in light of the changing social context. However, it is clear that the primary values of the profession are unchanged.

Professional Nursing Values

The values embedded in the code have stood the test of time. Within the 9 provisions are the values of

  • Altruism – concern for the welfare of others
  • Patient Autonomy – the right of self-determination
  • Human Dignity – the inherent worth of every individual
  • Integrity – consistent honesty of action
  • Social Justice – fair treatment regardless of the status of the individual

Duty to Self and Others

Although nursing practice is definitely altruistic, the code clearly identifies that nurses have a duty to themselves as well as the patient. It reminds me of the flight attendant instruction to put on your own oxygen mask first before helping others. If we do not pay attention to our own health and well-being, we are not fully able to engage in a therapeutic patient relationship.

The duty we have to others extends beyond the patient to include other team members. This duty includes respectful interactions and peer support.

Over the course of this year, I will be regularly blogging through the current Code of Ethics for Nurses using correctional nursing situations to help us apply the code to our unique environment. I hope you will join me in the dialogue and help make the nursing code practical for the work we do.

Photo Credit: © Marek – Fotolia.com

Chronic Care: Are You Really Making Sense?

Plastic English letters isolated on white backgroundManaging chronic conditions is a major process in every correctional setting. The chronic care visit is an ideal time for patient teaching and reinforcement. Correctional nurses often provide a large part of patient teaching in a collaborative chronic care clinic. Areas of teaching include

  • The disease process
  • Lifestyle adjustments
  • Medication effects and side effects
  • Self-care activities

Unfortunately, there are few ready-made patient educational materials that suit the correctional setting. Most materials must be adapted to the restrictions of a secure facility and the limitations of diet and exercise imposed on our patients. As described in an earlier post, many of our patients have learning disabilities or little formal education. For all these reasons, correctional nurses need to be sure written materials are adapted to our environment, easy to understand, and make sense to our patients.

Even the general population has trouble understanding most patient education materials, as this Institutes of Medicine paper indicates. Therefore, we need to improve the readability of any patient handout used in our setting. Fortunately, there are free resources available to help us – like this guide created by the Centers for Disease Control.

Back to Basics

Here are some basic principles for creating clear and understandable patient education materials for low literacy patients taken from the CDC guide:

  • Include graphics and pictures to demonstrate important principles
  • Limit text to need-to-know information that uses action terms to directly tell the patient what they need to do
  • Use a  positive, friendly, and conversational writing style
  • Use simple words with limited use of medical and scientific jargon.
  • Limit statistics and use general terms, such as many or few, instead.
  • Format the teaching material for maximum understanding – font size of text should be as large as possible to improve readability – at least 12 points

Readability

Once materials are written and formatted, readability should be tested. The best test is to pilot with a sample of your patients; however, readability can also be factored using MSWord functions or online readability services. A very simple test of readability is the number of multiple-syllable words in the document. The Simple Measure of Gobbledygook (SMOG) is a quick online option.  The test counts the multiple-syllable words in three strings of 10 sentences within the document and then comparing the count to a table to determine reading level.

Culture and Language

Once you have your basic material together, check it for cultural appropriateness. Are the visuals representative of your patient population? Are there any trigger words that might be offensive to members of your patient community? Are there familiar terms that need to be added for clarity? Again, you may want to pilot test with key members of your patient groups. Also consider whether translation is needed; for example some settings have a large Spanish-speaking population.

Start with a Good Foundation

As you can see, writing patient education materials that make sense is hard work. You may want to start with some foundational materials created by experts. In that case, there are plenty of materials from national associations and government sites that can be adapted for the criminal justice setting. Here are a few links to get you started:

How do you teach patients in your setting? Share your thoughts in the comments section of this post. 

Photo Credit: © Vladimir Voronin – Fotolia.com

Managing Nursing Sick Call Requests (podcast)

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cnt-podcast_cover_art-1400x1400Jessica D. Lee MSN CCHP, Vice President of Nursing Support Services for Corizon Health, shares key components of a well-managed nursing sick call process. She should know! In her position, Jessica manages policy and procedure development and implementation for nursing care provision in over 500 jails and prisons. She has helped many jails and prisons improve sick call delivery.

Nursing sick call is one of the key ways ambulatory care is delivered in a correctional setting. This process allows inmates to request to be seen for a medical condition. Here are some of the basic elements of nursing sick call from the episode:

  • Each patient needs education on procedures for requesting medical attention. This usually happens at intake and needs to be provided in understandable terms.
  • The request process can take various forms and may be through a written request or a daily walk-in system.
  • Triaging requests is also a key component. Unlike emergency care, in the correction it is the review and prioritization of the request so that there is a disposition or decision. The patient may need to be seen immediately or routinely. Requests may be referred out to another professional such as a dental visit. Whatever the outcome of the triage process, the patient needs to be informed. Other requests may be informational, such as finding out the results of a diagnostic test or the need for refill of a medication.
  • Protocols are also important. Usually there are written guidelines telling the nurse to obtain assessment data based on the health history and initiating concern. Protocols also provide direction for the interventions to take based on the data collected.
  • Appropriate referrals are also needed for an effective sick call process. These are based on assessment findings when treatment indicated is beyond the nurse’s scope of practice.
  • Timeframe is important. Nurses must determine if the patient needs to be seen by another provider immediately or if the referral can be merely routine.
  • Patient education is a priority for every nursing encounter. This is certainly true for nursing sick call. In particular, the nurse needs to be sure the patient understands the outcome of the sick call visit and steps they need to take after the visit.

Nursing sick call is central to good correctional health care. Nurses are very often gate-keepers to other medical care in the correctional setting. It can be a good indication of weaknesses in other areas of the program such as intake and chronic care.

Sick call can also be a risky part of correctional healthcare with some common problems. Listen to this episode of Correctional Nursing Today for Jennifer’s take on common problems for nursing staff and nurse managers.

What do you find most challenging when delivering nursing sick call in your setting? Share your thoughts in the comments section of this post.

Other News on the Podcast:

  • In this podcast I comment on my recent CorrectionsOne column on restraint chairs. Link:  CorrectionsOne column on Restraint Chairs.
  • Also, I am traveling south for some sun the end of March so there will be no March 2014 Correctional News Round-Up.
  • Keep up with correctional healthcare news by following me on twitter, facebook, or linkedin.

Encouraging Patients to Participate in Self-Care

TrappedOne of the challenges of correctional nursing is engaging patients as full participants in their healthcare. Depending on the organizational culture, you may have limited opportunity to encourage your patients to manage their healthcare needs. Yet, the majority of our patients will be released to the community and they need to take on the responsibility for their health and well-being. Here are a few barriers we must overcome to be able to involve our inmate-patients in their healthcare.

Paternalistic Culture

Some correctional settings have a culture that devalues the patient and discourages patient input in other areas of life. A correctional culture based on order, control, and discipline could stall efforts to actively engage patients in care decisions and therapy monitoring.  A paternalistic culture can develop in a correctional setting where inmates are controlled and are not expected to make personal decisions. This hinders patient engagement in their healthcare and reduces motivation toward self-care activities.

Patient Preparation

The patient population can be ill-prepared to actively participate in their own health care. Limited English proficiency and low literacy levels can make self-care difficult. The inmate patient population is less educated than the general population and is twice as likely to have learning disabilities. It is also difficult to get an accurate evaluation of literacy from the patient’s self-report as inmates are more likely to over-estimate their reading and comprehension abilities. The patient’s unwillingness to participate in their own care can also be a barrier.

Practitioners Behaving Badly

Practitioner behaviors can also inhibit patient involvement. Involving patients in care provision involves a time-commitment that clinicians may be unwilling or unable to make. In addition, a continuing paternalistic medical culture combine with pervasive attitudes about the correctional patient population can result in an authoritarian stance toward the patient that inhibits involvement. Here are some practitioner behaviors that block patient involvement. Have you seen any of these behaviors in your setting?

  • Defending an action and blocking continued expression of concern
  • Interrupting and finishing sentences for the patient
  • Deliberately changing the subject when uncomfortable
  • Citing policy as a reason for an action
  • Minimizing patient’s concerns
  • Condescending comments about patient concerns
  • Not following through on promises

A primary role of the nursing profession is that of patient advocate. Correctional nurses can advocate for patient involvement in their healthcare. Even small changes can make a difference.

How do you involve patients in self-care in your setting? Share your thoughts in the comments section of this post. 

Photo Credit: © Stocksnapper – Fotolia.com

Scope and Standards: Prevalence of Correctional Nurses

foule de pélerins à lourdesBefore I accidentally became a correctional nurse, I didn’t even know the specialty existed. However, I soon learned that, although we work in a hidden practice setting, there are many correctional nurses. Unfortunately, we are almost invisible to the larger profession. Take any nursing survey that asks for your specialty area and you will see what I mean. I have never seen a place to check for correctional nursing. Most often we are filling in the open space next to ‘other’.

The taskforce revising the Correctional Nursing Scope and Standards of Practice had quite a time searching for verifiable information on the number of correctional nurses working in American jails and prisons. We finally settled on reporting numbers from the Health Resources and Services Administration (HRSA) data from the National Sample Survey of Registered Nurses. This survey estimated a total of 20,772 registered nurses working in correctional settings. That is almost 1% of all nurses working in the US (0.08%).

To those of us active in the profession, however, this seems a low number. Could it be that more nurses work in criminal justice? The way nurses are employed to work in a correctional setting may skew survey findings. For example, correctional nurses may be employed by a university medical system (like those working in Connecticut and New Jersey prison systems. Many jails are staffed by nurses working for the public health department. Nurses may provide care to inmates but work for private companies such as those who manage dialysis units within prison systems.

Maddie LaMarre, in a chapter on nursing practice for Clinical Practice in Correctional Medicine (2006), cited an estimated 2-3% of US nurses work in corrections. With Bureau of Labor Statistics of over 2.6 million employed registered nurses in 2008, this would suggest between 52,374 and 78,561 correctional nurses. The figure does not include the many LPN/LVN nurses practicing in the specialty.

Also not reflected in the National Sample Survey are nurses who work in correctional settings in a part time or per diem capacity. Some prison settings in remote areas must rely on traveling nurses to meet healthcare needs. Many settings regularly employ agency nurses to fill gaps in the schedule.

Without a professional association specifically dedicated to correctional nursing practice, there is no reliable collection on information on the number and characteristics of correctional nurses. More the pity.  Correctional nursing might be more visible with an accurate idea of the number and strength of the specialty.

How many correctional nurses do you think there are in the country? Share your thoughts in the comments section of this post.

The full Correctional Nursing Scope and Standards of Practice, 2nd Ed. Is available through Amazon.

Photo Credit: © piccaya – Fotolia.com

February 2014 Correctional Healthcare News Round-Up (podcast)

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cnt-podcast_cover_art-1400x1400Sue Smith and Gail Normandin-Carpio join Lorry Schoenly in discussing correctional healthcare news stories from the past month.

Story #1: Nevada Prison Begins Charging for Services

Our first story comes from Nevada where the Elk County Sherriff has started charging prisoners $10 per day for meals and $6 for doctor visits. Inmate co-pay for some health services. This is a fairly common practice across the country. Charging for meals is something different though. Is this a coming trend or a local oddity?

Story #2: More on California Prison Physician linked to Sterilizations

About 6 months ago the story broke on a California prison physician performing unapproved sterilizations on women in Valley State Prison in Chowchilla, CA. It seems that over a hundred sterilizations were performed without first being reviewed and approved by an oversight committee – as is DOC policy. This situation is still under medical board and state auditor investigation but it is a good opportunity to look at some of the systems issues in corrections that can lead to something like this happening.

  • What is the ethical concern here and why does the California DOC have an oversight committee for approving such elective procedures?
  • This article alleges that the doctor has a history of medical controversies and expensive malpractice settlements. Is correctional practice a haven for poor practitioners or is that a misnomer?
  • This doctor is accused of some pretty inappropriate behavior such as eating popcorn while examining patients. Can some settings have a lax attitude toward healthcare delivery since the setting is not acute care?
  • Finally, this physician was evaluated for two newborn deaths. One related to failing to perform some routine prenatal testing. In a written summary of the case, this doctor stated that the patient had numerous unscheduled emergencies during her pregnancy that required immediate attention and resulted in the oversight. This situation highlights the fragmented and episodic nature of correctional healthcare that can lead to missed tests and poor follow-through. But aren’t there standard ways to deal with standard testing, even in a prison?

Story #3: Managing Justice Involved Women

Our third story is an article from the recent issue of American Jails magazine on managing justice-involved women. This article focuses on the particular challenges of women inmates in the jail setting. Jails have shorter stays than prisons and are basically organized to manage a male inmate population. This article supports a gender-responsive approach to incarcerated women. The differences that justify a gender-responsive approach include

  • Women have a lower level of risk compared to the majority of male offenders
  • Women are either pregnant or parents of minority children
  • Women have a more frequent history of physical and sexual abuse compared to men
  • Women have a higher level of mental illness, behavioral health challenges, and substance abuse that directly caused the criminal behavior

Story #4: Colorado Prison-trained dog Turns Autistic Boy’s Life Around

Ending on a positive note, our final story comes from the Denver post, reporting on a Colorado prison program to train service dogs. This piece shares the story of an autistic child whose life is transformed by a service dog that was trained by an inmate from Trinidad Correctional Facility, where he is serving time for a second degree murder charge. At the end of the video that accompanies the story, the boy’s mother says, “Who would have thought that a prisoner could have changed my son’s life?”

Do you have thoughts on this month’s correctional healthcare news items?

Under the Influence: Impaired Nurses in Corrections

pill on a hookOne in ten doctors and nurses abuse drugs or alcohol. Is this surprising to you? It is to me. Although this number (10-15%) is equivalent to abuse rates in the general public, those of us in healthcare have a special responsibility to be able to think and act clearly as we are responsible for providing safe patient care. Drug abuse is particularly concerning in healthcare as there is increased access to addicting substances. This can be especially true in correctional healthcare, a low tech setting with fewer barriers to access. For example, very few correctional systems have electronic lockout systems such as pyxis.

Some impaired healthcare professionals gravitate to a correctional setting with the perception that the system has fewer safeguards than a traditional setting; so drug diversion is less likely to be detected. Unfortunately, this may be an accurate appraisal, especially in smaller or disorganized settings where strong narcotics security is not in place. Even well-managed settings can become lax about shift narcotics counts or double-lock systems. Here are a couple successful diversion methods from my own correctional management experience. Could any of these happen in your setting?

  • The foil backing of a bubble pack of oxycontin was slit. Pills were replaced with a similar looking over-the-counter medication and taped back in place. Bubble packs of the same medication were banded together and the middle pack was tampered with. Nurses were only counting the number of packs each shift.
  • An entire page of a narcotics ‘red book’ was sliced from the book along with the full pack of medication. Nurses were counting based on what was in the drawer rather than what was in the book index so it was unclear when the theft took place.
  • A hospice patient was on liquid morphine at fairly high doses. A sealed box of multiple bottles was double locked in the long-term inventory. When active stock was depleted, the sealed box was opened to find that it no longer contained all the original bottles. The count had been done for some time by just looking to see that the box was still in long-term inventory so it was unclear when it had been tampered with.

According to the National Council of State Boards of Nursing, there are four risk factors for narcotic diversion. How does your setting line up with these risks:

  • Access:  Relatively easy access to narcotics in the clinical area
  • Attitude: A relaxed attitude toward narcotics security in the setting
  • Stress: A high stress work environment including shift rotation and frequent short staffing
  • Lack of Education: Staff members are not regularly educated or warned of narcotic diversion concerns

One of the greatest ethical challenges you may face as a nurse is confronting a workmate who appears to be abusing substances. An atmosphere of suspicion and feelings of betrayal can poison work relationships. Many nurses would rather look the other way than deal with the after math of talking to a colleague or reporting suspicious behavior. An article from American Nurse Today has some helpful information on signs and symptoms of a substance abusing nurse:

Physical Signs

  • Tremors
  • Slurred speech
  • Watery eyes
  • Sweating
  • Unsteady gait
  • Runny nose
  • Change in grooming

Behavioral Changes

  • Frequent mood changes
  • Angry outbursts
  • Defensiveness
  • Lack of concentration
  • Blackout periods
  • Frequent lying
  • Poor judgment

Actions

  • Wearing long sleeves even when it is hot
  • Unexplained absences from the nursing unit
  • Medication errors
  • Reports of lack of pain relief from assigned patients
  • Offering to medicate co-worker patients
  • Increased narcotic sign-outs

Being aware of drug diversion or of staff members working impaired is both an ethical and legal concern. We have a responsibility to our patients and other team members to address concerns about a colleague’s substance abuse behaviors. In fact, we have a responsibility to our impaired colleague to initiate action so that they get the help they need to overcome their addition.

Have you witnessed drug diversion or impaired nurse behavior in your setting? Share your insights in the comments section of this post.

Photo Credit: © Photobank – Fotolia.com

Nurse Perceptions of Correctional Health Care (podcast)

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cnt-podcast_cover_art-1400x1400In this episode of Correctional Nursing Today Karen Marchand-Singleton discusses her research involving nurse perceptions of correctional healthcare. Karen performed this research as part of her master’s degree program and hopes to expand her sample in future research. Karen’s entry into correctional practice started when her son, who has hemophilia, was detained at a local jail. She had not been exposed to correctional nursing before and was unsure of the medical treatment her son would be receiving. She took a position at a nearby jail to find out and discovered she loved the specialty.

As a nurse manager at that same facility, Karen found it difficult to recruit nurses into the correctional setting. This led her to pursue this research topic to find out what the perception was of correctional nursing in the healthcare community. Her research sample was based on her South Carolina locale where she did live interviews with 20 nurses. These nurses had backgrounds in acute care, home care, hospice, and corrections. Her structured interview involved 10 questions about their understanding and exposure to correctional nursing.

Her results indicate that we have a ways to go to improve the awareness and image of correctional nursing. Few study participants had a clear understanding of the specialty and only one had been exposed to the field during initial schooling. Her findings indicate a need for more dialog in the general nursing community about correctional nursing practice. Correctional nurses need to interact with nurses outside the specialty at general conferences and become a part of the larger nursing community.

Do you think the correctional nursing specialty is invisible? Share your thoughts in the comments section of this post.