Keep Your Cool: Heat Injury Alert

keep your coolIt’s that time of year again-Summertime. Time to be hot and bothered at work if you are one of many correctional nurses working in a setting that lacks air conditioning. Jails and prisons were not built for comfort and many older ones are without air conditioning or even good ventilation. Heat injuries such as heat exhaustion and heat stroke should be on our minds when evaluating vague patient symptoms during the summer months; especially when the weather is both hot and humid, like many of our southern states. For example, as identified in a recent lawsuit, most of the Texas state prisons are without air conditioning, although some have climate control in the medical unit. So, what should you do to identify and treat heat injuries?

Vulnerable Conditions

Although anyone can succumb to heat and humidity, the young and old have fewer reserves to overcome heat stress. If possible, move patients with the following conditions to special housing or provide with additional monitoring and fluids during high heat alerts.

  • Elderly
  • Heart disease
  • Pulmonary disease
  • Mental illness

A main reason those with the above conditions are prone to heat-related illness is the medication they are likely prescribed. The following medications or substances increase heat injury risk.

  • Anticholinergics (Atrovent, Chlor-Trimeton, Cogentin, Spiriva)
  • Antihistamines (Allegra, Benadryl, Zyrtec)
  • Benzodiazepines (Klonopin, Librium, Valium, Xanax)
  • Beta blockers (Atenolol, Corgard, Lopressor)
  • Calcium channel blockers (Cardizem, Norvasc, Procardia)
  • Diuretics (Chlorothalidone, Diuril, Lasix)
  • Neuroleptics/Phenothiazines (Haldol, Mellaril, Prolixin)
  • Tricyclic antidepressants (Pamelor, Tofranil, Vivactil)

Rapid Cooling and Hydration for Heat Injury

Heat exhaustion and heat stroke are the two most common heat injuries, although sunburn and heat cramps are also often listed.  In heat exhaustion, the body is decompensating having difficulty maintaining normal body temperature in an extended high heat situation. Heat stroke begins when the body becomes unable to keep internal temperatures in a livable range. Without intervention, heat exhaustion can progress to life-threatening heat stroke. Here is a quick comparison of the presentation and treatment of heat exhaustion and stroke.

Heat Exhaustion Presentation

  • Body temperature under 104 degrees F
  • Heavy sweating
  • Muscle and stomach cramps
  • Headache
  • Nausea or vomiting
  • Tiredness, weakness
  • Dizziness and fainting

Heat Stroke Presentation

  • Body temperature above 104 degrees F
  • Hot, dry skin
  • Confusion, strange behavior, seizures, or unconsciousness
  • Rapid pulse
  • Throbbing headache
  • Nausea

As you can see, many of the symptoms are similar as heat stroke is an intensification of heat exhaustion. A differentiating factor is the change from heavy sweating to hot, dry skin. In both cases, treatment focuses on rapidly cooling and hydrating the body. Heat stoke definitely requires hospitalization while heat exhaustion, if mild, can be treated at the facility and may require infirmary monitoring.

Heat Exhaustion Treatment

  • Move to a cool area (Shade, AC)
  • Remove or loosen restrictive clothing
  • Rehydrate with fluids
  • Use evaporation methods
    • Spraying water on the body and fan the air
    • Sponge body with cool water
  • Rest
  • Monitor until body temperature returns to normal

Heat Stroke Treatment

  • Move to a cool area (shade, AC)
  • Removal of restrictive clothing
  • Use evaporation methods
    • Spraying water on the body and fan the air
    • Sponge body with cool water
    • Covering the patient with cold water–soaked sheets
    • Place ice packs in the axillae and groin
  • Supplemental oxygen, if available
  • Prepare for possible initiation of IV therapy
  • Prepare for transfer to acute care

Patient Education for Prevention

Helping patients to manage heat and humidity can prevent heat injury. These reminders are important for officer staff, as well.

  • Keep hydrated. This can be difficult where bad-tasting water and fruit-flavored Kool-Aid are the only options. Advocate for healthy fluid options for your patients when possible. Ask about fluid intake during your subjective assessments.
  • Reducing physical exertion. Now is not the time for basketball competitions or lifting challenges. Many inmates are on outdoor work duty with many hours in the sun. Be mindful of the work status of inmates coming to sick call with symptoms of dizziness, weakness, headache, and general body tiredness. Instruct patients to take frequent rest breaks and seek out shaded areas at work and recreation sites.
  • Use available cooling methods. Teach patients evaporation heat reduction methods to stay cool such as sponging body areas with cool water and body fanning.

Personal Safety in the Heat

Don’t forget yourself in your summer heat preparations. You are also vulnerable to heat injury. Even if the medical unit is air conditioned, many health care activities take place outdoors or in housing units. Be sure to follow all the instructions provided to patients. Stay hydrated and monitor your mental and physical status regularly. Urine output and characteristics can be a good indication of adequate hydration. If you are basically healthy, pale urine is an indication of appropriate bodily fluid volume and generally good kidney function. Concentrated darker urine or decreased urine output can indicate a need to increased fluids. Double up on the fluids you bring on shift. Water is always a better option than sweet or caffeinated drinks.

Do you work in a high-heat setting? How do you keep your cool and manage your patient’s heat regulation during the summer? Share your thoughts in the comments section of this post.

Photo Credit: © OlegDoroshin

Could You Be the Next Joyce Mitchell? 4 Prevention Tips

Could You Be the Next Joyce Michell- (1)Many of us have been closely watching the unfolding events surrounding the NY Prison Break over the last month. Here is a timeline of events, concluding with the death of convicted killer Matt and the shooting and capture of convicted killer Sweat in upstate New York. Early in the story Joyce Mitchell, a prison worker who managed the tailor shop with her husband, was taken into custody for her part is assisting the prisoners.

Those unfamiliar with our patient population find it hard to believe that someone would develop an intimate relationship with a murderer and assist them in this way. Yet, unhealthy inmate relationships are a constant threat and should be a continual concern for anyone working in the criminal justice system. No one is immune to this work hazard. Here are my four prevention tips along with some links to prior posts and podcasts on the topic.

Know Your Patients

Prisoners are ten times more likely than the general population to have an antisocial personality disorder (ASPD). That means many of our patients are sociopaths or psychopaths; individuals who use others to gain what they want without remorse, guilt, or conscience. Among other things, that means that they may appear charming and charismatic in their interactions with you. Unfortunately, that charm is often ‘turned on’ in order to manipulate and deceive. Always be aware that things may not be what they seem in the words and actions of patients. Click here for more information about dealing with lying and manipulative patients.

Know Yourself

Most of us became nurses in order to help people in distress – the injured, ill, and suffering. This motivation can make us prey to antisocial patients. Empathetic people are natural targets for sociopaths. We are even more vulnerable when our emotional lives are in turmoil such as when we are having relationship issues (divorce or break-up), work stress (new job, discipline, understaffed), health issues (illness, pregnancy, new baby) or are under financial stress (foreclosure, credit card debt). Be aware of your emotional and psychological state when dealing with this patient population.

Remember Where You Are

Many of us spend the majority of our time at work. What is unusual for most people (working behind bars) becomes normal and common place for correctional nurses. It can become so normal that you forget where you are and who is nearby. This can result in ‘letting down your guard’ and becoming too familiar with your patients. Talking about your personal life around workmates and patients alike can make you vulnerable to those interested in gaining rapport and influence. Small breaches of professional boundaries can lead to great harm. It is unlikely that Joyce Mitchell woke up one morning determined to help two murderers escape prison. But, she is reported to have been very chummy with at least one of them including bringing in meals.

Help Each Other

Manipulative patients will note any friction among staff members and use that to advantage. One of the best ways to avoid being drawn into an inappropriate patient relationship is to have good working relationships with your team mates. Present a united front before the patient population and keep any friction or personality differences for behind the staff-room doors. Talk openly in staff meetings about professional boundary challenges and be willing to confront team mates who may be slipping into danger. It seems hard to believe that no staff member noticed Joyce Mitchell’s over familiarity with Matt and Sweat. Would life be different for her right now if someone had intervened?

Learn from this News Event

Could you be the next Joyce Mitchell? It is easy to become accustomed to your surroundings and lose sight of the relationship goals of some of your patients. We can all learn from the recent events at Clinton Correctional Facility. Take this opportunity to double down on your professional boundaries with patients and have a conversation with your workmates about how to prevent inappropriate relationships from starting.

Resources to Keep You Safe

Working with Inmate-Patients Series

Podcast Episodes

What tips do you have for avoiding unhealthy patient relationships? Share your thoughts in the comments section on this post.

Photo Credit: © boule1301 – Fotolia.com

Are You Thinking Clearly? Rooting Out Biases in Clinical Evaluations

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

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

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

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

 

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

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

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

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

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

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

Photo Credit: © Tsiumpa

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.

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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

I Found Correctional Nursing and I Love it!

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

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

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

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

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

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

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

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

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

Photo Credit: © pathdoc

November 2014 News Round-Up (podcast)

Play

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

Ohio Prison Inmate Being Treated for Leprosy

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

Restraints Cited in Three Deaths at Bridgewater

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

 Ethical Issues for Nurses in Force-Feeding Guantánamo Bay Detainees

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

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

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

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

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

Eight Ways to Improve Clinical Judgment

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

Clinical Practices

 Case Review

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

Peer Review

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

Reflection

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

Simulation

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

Educational Practices

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

Dialogue

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

Probing Questions

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

Mind Mapping

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

mindmap

Algorhythms

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

algorhythm

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

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

Photo Credit: © ぶぶたん – Fotolia.com

Three Clinical Judgment Booby Traps to Avoid

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

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

Biases

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

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

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

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

Assumptions

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

Culture

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

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

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

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Five Reasons Correctional Nurses Need Clinical Judgment Skill

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

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

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

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

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

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

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