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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Avoiding Documentation Pitfalls in an Electronic World

Jackie Griffin-Rednour, RN, BAS, CCHP, is Clinical Nurse Educator for Correctional Health Services in Phoenix, AZ. This post is based on her session “Protecting Your Nursing License: Avoiding Documentation Pitfalls in an Electronic World” 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 laptopThe Electronic Health Record (EHR) in the clinical setting has been hailed as the answer to all our documentation issues. Indeed, EHRs provide many benefits, but correctional nurses can still find themselves in hot water if they don’t follow basic documentation principles…..and, if they don’t consider the risks along with the benefits of documentation technology.

Electronic Health Record – Thumbs Up or Thumbs Down?

There are many benefits to an electronic health record.  A key one being improved patient outcomes.  Improved legibility, efficiency and availability of patient health information allow clinicians to deliver timely, accurate, and relevant care.

HealthIT.gov lists key benefits of electronic health documentation

  • Availability at the point of care
  • Clinical alerts and reminders such as drug-drug incompatibility and patient allergies
  • Improved quality of care screenings

The electronic health record also affords users with the ready availability of clinical decision support (like drug/allergy interactions or best practice guidelines), which has the potential to prevent errors and improve patient outcomes.

Good systems, though, are costly. Initial costs for purchase and maintenance of an electronic health record may seem excessive. However, when compared to the manpower hours involved in maintaining paper records, the cost difference is likely minimal.  Another difficulty can be basic human nature and the reluctance to change.  It requires a shift in paradigm from a paper mentality to a technological one; not to mention the need to change policies and procedures to accommodate new documentation processes.

Do EHRs Improve Nursing Documentation?

It can be difficult to say whether a move to an EHR in the correctional setting improves nursing documentation. Jackie Griffin-Rednour shares her experiences in transitioning to an electronic record within a correctional setting.  “From the point of legibility, the use of an electronic health record has certainly improved the readability of the documentation.  It has certainly improved efficiency and reduced our need to have staff transcribe orders or file loose paperwork.”, she stated. According to Griffin-Rednour, one of the major improvements has been the ability for managers to review and evaluate nurse’s documentation to comply with NCCHC’s standard J-C-02 Clinical Performance Enhancement.  Prior to electronic records, managers had to manually retrieve, review, and in some instances, decipher, the paper documentation.  The use of an electronic record facilitates ready access to patient records for review, allowing timely feedback for staff.

One Size Does Not Fit All

An EHR must be tailored to the specific needs of the clinical setting. A system created for an acute care facility, for example, will not have workflows that accommodate the special processes in correctional health care. So, a first step is to identify current clinical processes before reviewing options.  Though there are many generalities within a correctional environment, each facility has processes that are unique to their particular setting and should be a strong consideration when selecting a product.

Customization is an important feature as every facility will need to alter various processes to accommodate site-specific policies and procedures.  For example, setting vital sign parameters for alerts.

The best system would also integrate with an organization’s custody system and any other outside service providers, such as pharmacy or labs. This improves information integration and streamlines data-sharing.

Lastly, development of an education plan to roll out the new electronic health record is necessary for success. The plan should include an assessment of clinician readiness with evaluation of staff’s technical abilities. Pre-implementation training may be necessary to prepare staff with basic computer skills.

Avoid These EHR Documentation Pitfalls

No matter what type of nursing documentation in use, missing documentation is always a concern. Whether by paper or electronic documentation, if it doesn’t appear on the record, it is legally suspect as to whether it was actually completed. Here are some issues specific to EHR documentation.

  • Cloning information and copying/pasting: The ease of copying information from one part of the record to another can lead to misinformation populating the patient’s record.
  • Over-reliance of templates: Templates are a great time-saver when used correctly but templates can also add in extraneous information not applicable to every patient. Staff need to understand how to customize templates to the patient condition.
  • Ignoring alerts: Flashing or ringing alerts in a documentation system can become background noise much like a touchy IV alarm. Nurses must guard against a tendency to become ‘tone-deaf’ to documentation alerts; thereby, rendering them ineffective.

Staff education and convenient information resources are ways to combat the above pitfalls. These can include a training portal specific to the electronic health record that lists all approved documentation processes as a quick reference.  A specific “Test” environment can be set up that mirrors the electronic production environment.

The EHR must be integrated into staff development programs including:

  • New staff training and practice time prior to orientation in clinical units
  • Reinforcement classes every two to three months to allow staff to refresh skills, learn new features, and practice in the “Test” environment
  • Ongoing information relevant to pertinent changes, emerging trends or problem areas provided to staff in newsletters or emails

What are your experiences with using electronic documentation in your correctional nursing practice? Share your thoughts in the comments section of this post.

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

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Pain Management in Patients with Substance Use Disorders

Aleksander Shalshin, MD, CCHP is the former Deputy Medical Director Correctional Health Services for the City of New York Department of Health currently in private practice. This post is based on his session “Pain Management in Patients with Substance Use Disorders” taking place at the 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14. Learn more about the conference and register HERE.

Addiction wooden sign with a beach on backgroundPain in some form is one of the most common symptoms that bring patients to nursing sick call. Even in traditional practice settings pain is often undertreated and many health care practitioners are particularly concerned about medicating a patient with a history of substance abuse. This is magnified in the correctional setting where substance use disorders are common in the incarcerated patient population. Yet, pain is a legitimate patient concern that we need to manage effectively.

Addiction Complicates Pain Treatment

Substance users present several challenges for pain treatment. First, use of psychoactive drugs results in the development of drug tolerance so pain medication at normal dose levels may be ineffective. Additionally, those with addictions appear to have decreased pain tolerance and, therefore, an increased perception of their pain experience.

The majority of inmates are immediately withdrawn from drugs and alcohol on entry into the criminal justice system. Withdrawal can be intensely uncomfortable, exacerbating any underlying chronic pain. Once withdrawn, practitioners can be concerned that pain treatment may contribute to a relapse.

Finally, pain is subjective, often without any objective confirming characteristics. Clinicians may not trust the patient to accurately describe the level of pain and assume ‘drug seeking’ behavior when patients with a history of substance abuse identify a need for pain treatment.

Pharmacologic Treatment Options

Opiates are the go-to drugs for pain treatment however other drug categories are underutilized and may be good options for this patient population. Nonsteroidal anti-inflammatory drugs (NSAIDs) and even tricyclic antidepressants have been helpful therapies. Depending on the source of pain, topical agents or muscle relaxants may be useful.

When opiates are necessary, they present some concerns in the correctional setting. Security of narcotics must be maintained in the medical unit and precautions against diversion during administration may need to be taken. For example, some settings crush and float narcotics so that the patient is less likely to ‘cheek’ pills for hoarding or barter on the prison black market. Liquid narcotics may also be used for the same reasons. Newer delivery methods such as the dissolving film available for buprenorphine (Suboxone) can also help assure the right patient gets the right dose.

Non Pharmacologic Treatment Options

Non pharmacologic treatments of pain are also often underutilized modalities; but, can play an important role in effectively treating chronic pain for this patient population. Depending on the resources in a particular correctional setting, physical therapy programs and exercise plans can be of benefit. Nurses can play an important role in initiating non pharmacologic treatment options for chronic pain. Treatments are discussed in more depth in this post on chronic pain and this post on managing arthritis behind bars.

Overcoming Resistance in the Correctional Setting

There can be significant resistance to pain management in the correctional setting. Officers and administration may harbor fear of diversion or manipulation in obtaining narcotics from health care staff. Even providers and nurses can have biases against pain treatment for patients with a history of a substance disorder. It takes a multidisciplinary process to be most effective. It also takes organization-wide education about pain treatment and how it is managed for this patient population. A good relationship among the disciplines of security and health care is a must.

Online Resources

American Society for Pain Management Nursing Position Statement: Pain Management in Patients with Substance Use Disorders

Pain Management in Patients with Substance-Use Disorders (American College of Clinical Pharmacology)

This is the first of a series of posts discussing topics addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. Find all posts and podcasts on conference sessions HERE.

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What have been your experiences with pain management for inmate-patients with history of a substance use disorder? Share your thoughts in the comments section of this post.

Photo Credit: © gustavofrazao – Fotolia.com

You Are A Courageous Nurse!

little girl wearing a superhero costumeDid you know you were courageous in accepting the challenge to work with our incarcerated patient population and in our locked-in work environment? Many nurses are not that bold. They do not seek out experiences that involve security escorts, the clanging of automatic barred doors, or the need to have their personal belongings searched when entering and leaving the workplace. Yes, you are a courageous nurse!

Three Types of Courage

Courage is key to effective correctional nursing. Bill Treasurer, in his book Courage Goes to Work: How to Build Backbones, Boost Performance, and Get Results, describes three types of courage we need to develop.

TRY Courage

TRY Courage is described by Treasurer as “the courage of initiating an action— making first attempts, pursuing pioneering efforts, and stepping up to the plate”. TRY Courage motivates us to act when needed – even if it is hard. Have you had to advocate for the needs of one of your patients? Have you had to confront cruel or disrespectful actions of a staff member? Have you had to address inappropriate patient behavior? It takes courage. You are a courageous nurse.

TRUST Courage

TRUST Courage is described by Treasurer as “the courage of confidence in others— letting go of the need to control situations or outcomes, having faith in people, and being open to direction and change”. TRUST Courage allows us to let go of controlling the outcomes of what we do. We are responsible for right action, but can’t control the outcomes of those actions. Do you have the courage to take a right action and let go of the outcome? You are a courageous nurse.

TELL Courage

TELL Courage is described by Treasurer as “the courage of voice— raising difficult issues, providing tough feedback, and sharing unpopular opinions”. TELL Courage is the courage to speak up when the issue is difficult or you are the only one in the situation who is disturbed. Correctional nurses are sometimes put in situations where there are no other health professionals available for consultation. Social pressure might be applied to ‘go along’ with the situation. Have you spoken up in a difficult situation? You are a courageous nurse.

What Are You Afraid Of?

Navy SEAL, Brent Gleesen, knows a bit about overcoming fears and addresses some common fears of leaders in a Forbes article. Using this list as a basis, here are my suggestions for common fears correctional nurses may need to face.

Fear of Criticism

Most people have some concern over being criticized, even if the criticism is delivered gently. Correctional nurses can find themselves working in a very negative work culture where any new idea is ‘shot down’ before it can even take flight. Nurses can also work in facilities where any act of care or concern gets labeled by colleagues as ‘Inmate Loving’ or ‘Hug a Thug’ activity. Overcoming fear of criticism is necessary to fully engage in professional nursing activity behind bars.

Fear of Consequences

The militaristic organizational structure of some correctional settings makes the negative consequences of words and actions very real. Correctional nurses have been banned from facilities for questioning an unethical practices or taking action on behalf of a patient. Words and actions need careful consideration in light of this possibility.

Fear of Failure

Sometimes it is just easier not to try at all rather than risk the chance for failure. Like fear of criticism, this fear is concerned with the acceptance of others whose regard we value. Fear of failure can cause correctional nurses to avoid addressing system issues that are affecting health care delivery.

Fear of Responsibility

Surprisingly, the possibility of success can also lead to fear. What if an idea is accepted and now needs implemented? The responsibility for making a change often rests on the one who suggests it. Like fear of failure, fear of responsibility can lead to inaction.

Take the First Step

Are you afraid to be courageous? The good news is, you have the capacity for gaining more courage. Fear is an invitation to courage – accept that invitation!  Yes, you can build your courage. It is a learnable skill like all your other nursing abilities.  “The important thing is to take the first step. Bravely overcoming one small fear gives you courage to take on the next” – Daisku Ikeda

FEAR1 The-important-thing-is-to

What courageous thing have you done recently in your correctional profession? Share your experience in the comments section of this post.

Photo Credit: © xavier gallego morel – Fotolia.com

February 2015 Correctional Health Care News Round Up (Podcast Episode 92)

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cnt-podcast_cover_art-1400x1400Gayle Burrow and Denise Rahaman return to talk about this month’s correctional health care news items*.

Medical Problems Of State And Federal Prisoners And Jail Inmates, 2011-12

Our first news item is the publication of a US Department of Justice special report on the Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. This is a long awaited update to their prior reports over a decade ago. The report validates what correctional nurses know to be true: inmates are more likely to have a chronic or infectious condition than the general population and female prisoners have more chronic conditions than males. A few interesting findings:

Clallam County working to avoid measles outbreak in jail

The Clallam county jail in Port Angeles, Washington is now providing measles vaccination for inmates. They are concerned about an outbreak after their Department of Health confirmed the state’s fourth active case of measles recently. As you may know, a measles outbreak has hit California traced to an active case in Disneyland. Will jails and prisons be ramping up measles vaccination?

When Prisoners Are Patients

Next up is an opinion piece that hit the New York Times about dealing with prisoners as patients in traditional settings. Nurse Teresa Brown shares her experiences caring for one prisoner for several weeks. She talks about giving ‘needed, accessible care to the most despised and potentially violent among us’. That surely sums up what correctional nurses do. Insights from the article helpful to correctional nurses include a need to separate the patient from their crimes, maintaining a different perspective than officers, and wondering why necessary health care isn’t provided to all citizens, not just incarcerated ones.

Long-running public service project sends Johns Hopkins students behind prison walls

The Johns Hopkins Gazette tells the story of Hopkin’s students tutoring inmates at the Baltimore City Detention Center. The University’s Jail Tutoring Project currently has 36 undergrads tutoring inmates from the general population, substance abusers working to maintain sobriety and some with mental health issues. The program has been in place for 40 years and stories from the students and the inmates indicate that it is changing lives.

What are your thoughts on this month’s news? Do you agree with our panelists? Share your comments below.

* Views of the panelists are their own and do not necessarily reflect the views of their employers, their clients, or their families.

Post Traumatic Stress Disorder Behind Bars

PTSD signsThe past life experiences of many incarcerated patients lead to post traumatic stress disorder (PTSD). According to the National Institutes of Mental Health, PTSD develops after a terrifying event or when a person is regularly put in danger or in a deadly situation. Inmate patient histories frequently include physical or sexual abuse and many have been involved in violent crime. Incarcerated military veterans can also exhibit signs of PTSD. Imprisonment can intensify the PTSD experience as some facilities have an inmate culture of intimidation, coercion, and victimization.

Survivor Response to Trauma

Individuals respond to trauma in various ways based on their own background, developmental phase and the type of trauma inflicted. Like the pain experience, a survivor’s response to trauma is unique. However, there are commonalities among these responses. Here are three main categories of symptoms related to post traumatic stress disorder (PTSD):

  • Reexperiencing the event. Your patient may experience nightmares and flashbacks of a traumatic event. For example, a woman who had been sexually assaulted as a child may have difficulty sleeping as memories of the assault flood into her mind when she tries to relax.
  • Avoidance. You patient may become anxious when confronted with objects or activities that can be associated with the trauma. For example, a stern command from an officer may trigger domestic violence memories. Severe manifestations of avoidance can lead to social isolation and even psychological dissociation.
  • Hyperarrousal. Victims of trauma can also exhibit increased irritability and exaggerated responses to environmental danger signals. For example, the patient described above may run for the corner of the room screaming when given the command by the officer.

Emotional and Psychological Support Interventions

With these survivor responses in mind, you can provide emotional and psychological support for your patients who are dealing with PTSD. It can be challenging to balance objectivity and empathy when dealing with victims of violence.

  • Establish rapport. A patient can pick up a caring attitude and interest by facial expression and body language. Eye contact and listening show concern and establish rapport without getting personal with the patient.
  • Respect and patience. As you listen to the patient, actively attend to being respectful and patient. This provides emotional support.
  • Help the patient express their feelings. Traumatized patients will have difficulty finding words to communicate their distress and the details of their experience. Fear, sadness, or rage is hard to describe when the feelings are present. Helping victims give words to their feelings can be very therapeutic. Don’t impose your own words on the experience, but, rather, help your patient find their own words.

Counseling and Crisis Intervention

A traumatized patient will, most likely, need professional support beyond what you can provide in a brief nursing encounter. Seek out other possible interventions available in your setting. Mental health services, group therapy, peer-to-peer support, or outside resources may be part of support services that can be provided for patients with severe PTSD.

Do you see signs of PTSD in your incarcerated patients? How do you handle it? Share your thoughts in the comments section of this post.

Photo Credit: © jacquimoo – Fotolia.com

My Story: Making the Right Turn to Corrections in My Journey to Public Health

This guest post by Mary Loos, BSN, MPH, shares her story of correctional nursing. Mary spent her correctional nursing career in the Multnomah County Health Department, providing care in the Multnomah County Jail System.

Detour sign - old orange and black  road signEvery person who discovers Corrections Health as a career has their own story to tell about how they got there.  Mine? It started with a right turn in my path to work in the Public Health arena. After earning my BSN, I decided to get RN experience for a year or two.  Before I knew it, I had spent 14 years in hospital nursing, working my way up from staff nurse to hospital nursing supervisor.  My clinical experience provided me with a wealth of experience in pediatrics, general and vascular surgery, post-op open heart / telemetry, quick decision-making and working with many different disciplines.

In 1985, I realized that I didn’t want to work in a hospital anymore.  The first time I looked in the local newspaper for a nursing position, I saw an ad for a Nurse Manager position in our county’s Corrections Health program within the Public Health Department.  My mind started making the connection right away – the public’s health includes all sectors of the population.  I immediately completed an application for this position, toured facilities and had several interviews.  I was hired to work with a person I soon realized was a visionary and a national leader in the Corrections Health professional arena.

At last, I was in public health!  And that is the way my Program Director and I, along with our entire team carried our mission out.  We grew from three facilities to six, doubling our census of patients between the years I was there.  We dealt with the onset of AIDS and the corresponding issues of confidentiality and safety precautions, which was an extremely sensitive issue with custody and program staff.  Our infirmaries grew along with higher complexity patients, our funding cycles went up and down, and threats of litigation motivated all staff to chart precisely and timely.  Interdisciplinary challenges aside, I found working in this environment stimulating, educational, and truly worthwhile.

We established many joint public health programs within the jail facilities.  Among these was our participation in a joint project with community corrections and community health, ensuring that drug-addicted pregnant women in custody were connected with community health nurses both in and out of custody.  We also set up an official Food Handler Certificate program for inmates, putting them one step closer to a job on release.  Corrections Health has evolved over the years into a high technology program that provides basic and complex care to a population that rotates in and out rapidly, and often arrive in booking with unstable and/or acute symptoms.  The staff is incredible – experienced, knowledgeable, skilled, compassionate yet limit-setting, and they juggle a patient load that no other health care personnel face.

And yes, I’ve had people ask why I’m not working as a “real nurse”, and why am I working with “those people”.  My response was unswerving: that I’ve chosen to work with a microcosm of our county population that is sicker due to lack of consistent medical and mental health care.  They, like us, need and deserve health care.  This has led to some interesting conversations, I assure you.  Corrections Health is Public Health at its best. Once you enter the field, it’s easy to get hooked, and longevity in this elite field is common.  You either hate it and leave, or you love it and stay.   To this day, the years I worked with jail inmates are the highlight of my 42 year nursing career.

Do you have an uplifting story to share about your correctional nurse experience? Send your thoughts to lorry@correctionalnurse.net

Photo Credit: © Michael Flippo – Fotolia.com

Diabetic Self Care in Corrections (Podcast Episode 91)

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cnt-podcast_cover_art-1400x1400Kelly Ranson, MSN, PHN, CCHP, Chief Nurse Executive at Kern Valley State Prison in Delano, CA joins Lorry to discuss implementing diabetic self-care at her facility. Kelly recently graduated from the California State University MSN program. This project was part of her graduate studies.

Tips for Making Change Happen

It is not easy to change practice in traditional clinical settings but there are added barriers to health care innovations in a correctional setting. Kelly provides a real-life perspective on how she went about initiating her diabetic self-care project.

  • Pick something you are passionate about. It will keep you motivated when the going gets rough. Kelly has a personal connection with diabetes in her own family as well as having a graduate school class project requirement related to chronic diseases.
  • Seize an opportunity when it comes along, no matter the original reason. Kelly took advantage of an institutional decision for inmates to carry glucometers that originated as a staff work-reduction action.
  • Research the evidence to support the change you want to make. Kelly researched national diabetes standards but also included World Health Organization information for 3rd world countries as the prison environment has many similarities.
  • Consider what the facility leadership is interested in and link to that. Kelly connected the innovation with fiscal savings in reducing late-stage diabetes health care costs.
  • Consider the down-side of the innovation and make accommodations. Kelly and the Warden disassembled the glucometers and lancets to determine if they could be used to create a weapon.
  • Start it as a trial. Administration may be willing to trial a change knowing that it can be pulled back if unsurmountable difficulties arise.
  • Be a hero on the patient side and the taxpayer side. Kelly linked improving patient care to reducing costs to gain management engagement.
  • Include some of the nay-sayers into the implementation team. Kelly involved the nurses who were skeptical about the success of the program with lifer inmates. They became the champions of the program through their early involvement.
  • Involve the patient population early on. Kelly and her team met with the inmate advisory group and got their support before implementation.

Nursing News

AAP Updates Measles Recommendations

The recent measles outbreak is the largest in the US since the vaccine became universally available. The American Academy of Pediatrics recently released updated measles guidelines in response to this national outbreak. Of importance for correctional practice is the recommendation for vaccination of unvaccinated adults born after 1957 who have not had the disease. If you are in an outbreak state, your facility may be considering measles vaccination in the near future.

Fatal Smoking Risks May Be Higher Than Thought

A study recently published in the New England Journal of Medicine found 17% more fatalities caused by smoking than originally noted in an examination of five large databases of over 180,000 fatalities. Twenty one common diseases are associated with cigarette smoking but previously unrecognized smoking-related deaths were discovered. Some interesting findings from this study were that death from infection was 2.3 times higher in smokers and cirrhosis of the liver was 3.1 times higher. The good news is that the elevated risks decrease over time if a smoker quits. So, the move to smoke-free correctional facilities is definitely a positive health move for our patients.

No Evidence to Support Dietary Fat Recommendations

A new meta-analysis of 6 dietary trials involving over 2000 participants was published in OpenHeart, an imprint of the British Medical Journal in partnership with the British Cardiovascular Society. Turns out those dietary guidelines we’ve been using to teach our patients and guide medical diets are not evidence-based. In fact, there is no data to support the recommendations to keep dietary fat less than 30% and saturated fats less than 10%. In this age of evidence-based medicine, it is interesting that so much of our practice is built on a shaky foundation.

What is your take on these news items? Share your thoughts in the comments section of this post.

Botulism and Prison Brew

PotatoSeveral inmates from the same housing unit have come to nursing sick call with complaints of feeling generally unwell, blurred vision, and some difficulty breathing. Since they are all from the same unit an infectious condition is considered. This is flu season so it could be the flu virus….but maybe something else?

Ours is a clever patient population. When confined in a secure setting with little in the way of resources, they are able to manufacture a wide array of items for personal use or barter on the prison underground market.

Homemade alcohol is one such commodity and is fairly common in the US prison system. Local names for prison alcohol products include hooch, pruno, juice, buck, chalk, brew, raisin jack, and jump. The brew is most often made from fermented fruit but any food source will work.

The Centers for Disease Control (CDC) reported on five outbreaks of deadly botulism from prison hooch in the Arizona, California, and Utah prison systems. Although the botulism bacteria can be introduced through any fresh food item, potato peels were identified as the source in several of the CDC investigated outbreaks. Botulism is caused by a toxin produced when a bacteria commonly found in soil is placed in an oxygen-deprived environment – like the closed containers used for DIY alcohol production. The toxin is produced during the fermentation process if no heat is applied to kill the bacteria.

Signs that Trouble is Brewing

Correctional nurses must be aware of the symptoms for botulism if their patients have a propensity to create their own moonshine.

It is important to act on early signs of botulism as the nerve paralysis caused by the bacterial toxin can quickly move to the respiratory muscles and lead to death. Often the first signs involve the eyes with double vision, blurred vision, or drooping eyelids. Slurred speech and dry mouth can follow along with general muscle weakness and difficulty swallowing. Botulism can quickly progress to respiratory failure.

Poisoning from botulism toxins through prison hooch can happen in a few hours or take up to 10 days to appear. A medical evaluation of symptoms is necessary to rule out other possible causes of progressing paralysis. Information about the potential of drinking homemade alcohol is important for a quick diagnosis and response. Question the patient and housing officers in a suspicious situation.

So, if home-brewing is a popular hobby at your facility, be particularly alert for signs of botulism poisoning among those who make and partake of this beverage. It may seem like a harmless way to keep the prisoners peaceful and preoccupied – but it also has potential to brew up some trouble.

Do inmates in your facility create their own drinking alcohol? Share your experiences in the comments section of this post.

Some material for this post was originally published for my health care column over at CorrectionsOne.Com.

Photo Credit: © gekaskr – Fotolia.com