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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Clinical Judgment: A Vital Correctional Nurse Competency

decisionsRhonda has been called to the booking area to medically screen a 44 year old man brought by the police on charges of driving a stolen vehicle and drinking while driving. On the way to jail he hit his head on the window of the squad car. Approaching the area she sees an obese white male, hands cuffed behind his back, leaning facedown on the booking counter, propped up by two police. The man is yelling that he is going to faint and can’t breathe.  A chair is brought so he can sit and Rhonda notes that he is diaphoretic and flushed in the face. He reports that he has prescriptions for two inhalers but otherwise has no medical problems. His voice tone is belligerent and he is dressed in shorts, a t-shirt and sandals;  inappropriate for the winter weather. Rhonda can see that his legs and feet are mottled and swollen. He also has a swollen area over his eyebrow on the right side and the eye on that side is swollen shut. There are four policemen waiting for the nurse to screen the arrestee and another six custody officers waiting to proceed with booking. 

Christine Tanner, a nurse researcher, has studied expert nurses to determine components of clinical judgment and when it is most specifically needed. She found that clinical judgment skills were particularly important when

  • The clinical problem or concern is undetermined;
  • The presenting data is ambiguous; and
  • When the situation presents conflicts among individuals with competing interests

Our case above has all three elements. Rhonda has a problem to solve and she needs to do it quickly amidst competing interests – the patient’s, the police, and the correctional officers. The patient condition is undetermined at the moment. Rhonda cannot merely review the patient’s medical record for a list of diagnoses. His presenting data is ambiguous and non-specific. The clock is ticking and the pressure is on.

Tanner reviewed 200 studies on clinical judgment in nursing practice. From this review she concluded that a nursing clinical judgment involved the following components:

  • Gaining a grasp of the situation holistically
  • Seeking an understanding of the situation which is beyond just the objective findings on assessment
  • Considering factors contributing to the presentation
  • Attending to the patient’s response to the nurse
  • Deciding an appropriate course of action
  • Reviewing outcomes and making changes as needed

What clinical judgment do you think Rhonda made in this situation? Even though there was pressure to book the man, she was concerned about a concussion and his respiratory condition. She did not approve him medically for booking and he was sent on to the hospital emergency room. There it was discovered that, although he was intoxicated, he did have a mild concussion, and, more importantly, was discovered to have moderate congestive heart failure. He was in the hospital for over a week.

Have you had a challenging patient presentation that seemed ambiguous at the time or had competing interests to consider? Share your story in the comments section of this post.

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What is Your Correctional Nurse Work Style?

Many different beautiful butterfliesA major challenge for many in correctional nursing is adjusting to the work environment. A correctional facility is not run like a hospital and health care is not the primary mission. Correctional officers often have different goals and worldviews than healthcare staff. Nurses can have difficulty assimilating into the organizational culture while maintaining a professional nursing perspective. That’s why I found this research about the work styles of jail nurses so interesting.

Hardesty, Champion, and Champion interviewed 26 registered and licensed practical nurses working in jails in three northern states. Patterns and themes emerged as the transcribed interviews were analyzed. One interesting finding was a proposed typology of jail nurse work styles. This typology chronicles the adjustment of a new nurse to the correctional culture and the effect of that adjustment on their ability to function successfully. The categories are based primarily on the balance the nurse is able to gain practicing professionally while understanding the security perspective and organizational culture.

Check out this continuum of jail nurse work styles and see if you can find yourself, or some of your nurse colleagues, in the descriptions.

Idealist

  • Rejects or fails to understand the security perspective
  • Nursing perspective is the primary consideration
  • Poorly socialized to the custody staff culture

Realist

  • Acknowledges and respects the security perspective
  • Nursing perspective remains the primary consideration
  • Socialized to the custody staff culture

Situationalist

  • Alternates between the security and the nursing perspective
  • Nursing perspective is optional
  • Not yet socialized to the custody staff culture

Acceptor

  • Accepts the security perspective
  • Minimally acknowledges the nursing perspective
  • Socialized to the custody staff culture

Identifier

  • Extreme acceptance of and identification with the security perspective
  • Considers nursing perspective not applicable in a jail environment
  • Well socialized to custody staff culture

So, what is the optimum work style? The researchers do not clearly note the best work style and suggest that more research is needed. My vote is for the Realist style as this nurse is able to maintain a professional nursing perspective while understanding the perspective of correctional officers and socializing to the correctional culture. This provides an atmosphere of respect and understanding among peers while allowing for professional nursing practice.

So, what do you think? Which work style is the most favorable for correctional nursing practice? Do you see examples of these work styles in your facility? How does it affect patient outcomes? Share your thoughts in the comments section of this post.

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Four Sources of Fast Correctional Nursing CE for Recertification or Relicensure

Stack of papers and clock isolated on whiteDoes this sound familiar? Notice arrives that your CCHP or CCHP-RN certification or your nursing license is due next month. Plenty of time to get the required continuing education (CE), right? The notice is set aside (if you are like me it gets printed and set on the pile on the right side of my desk) and the next time the paper shows up, submission is due tomorrow. Not that this has ever happened to me (well, alright, it did happen just last month….). So, just in case this might happen to you (I’m sure it won’t, but just in case) here is my list of four quick sources of correctional nursing continuing education that you can access online and complete immediately. First, though, is a clarification of requirements:

License Renewal

States vary as to the number of contact hours needed for a 2 year licensure period. Most states ask the licensee to maintain the official documentation (CE certificates) and attest to having completed the required number of hours. Documentation may be requested in a random audit of licensees. Here is a handy list of current state nursing board CE requirements for relicensure from nurse.com:

Nursing Continuing Education Requirements by State

Some states have specific content requirements as part of the total CE needed. For example, Florida RNs are required to complete 24 hours of appropriate continuing education (CE) during each renewal period, including two (2) hours relating to prevention of medical errors. In addition to these 24 hours of general CE, each RN must complete two (2) hours of domestic violence CE every third renewal for a total of 26 hours. Specific requirements are addressed by state in the link above.

CCHP and CCHP-RN Recertification

CCHP and CCHP-RN certifications have yearly CE requirements.

CCHP CE Recertification Requirements: Participation in 18 hours of continuing education (at least six of which are specific to correctional health care).

CCHP-RN Recertification Requirements: Completion of at least 18 nursing contact hours, with six specific to correctional health care.

If you have an excellent benefits package at work that includes an education allowance, try to get a National Commission on Correctional Health Care conference. You won’t regret it. However, that won’t work for a looming due date. Looming due dates require immediate results. Here are four go-to places for correctional nursing online CE.

Sources of Correctional Nursing Continuing Education

  • Pedagogy Correctional Health Care Campus: I’m a bit biased on this source since I develop the correctional healthcare specific continuing education here. The modules specific to corrections are in video format and have application checkpoints to hold your attention. Here are the ones available so far with more on the way:

o   The Correctional Health Care Patient and Environment

o   Correctional Health Care Processes

o   Safety in the Correctional Setting

o   Chronic Illness in the Correctional Setting

o   Control and Management of Infectious Diseases in the Correctional Setting

o   Legal Origins and Issues Behind Correctional Nursing

o   Psychiatric Nursing in the Correctional Setting

o   Women in Prison

  • Correctional Nurse Educator: Our friends over at Correctional Nurse Educator have some fantastic courses available, as well. Topics include Asthma, Chronic Care, Inmate Manipulation, Suicide Prevention, and much more. All are focused on correctional nursing practice.

That’s it for my quick list of correctional healthcare continuing education. Do you have a favorite online source that I missed? Share your secrets in the comments section of this post.

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Struggling to Define Caring in Correctional Nursing

rock climbingCorrectional nurses face a daily struggle to care for their patients while delivering much-needed healthcare in a restricted environment where they may also fear for their own personal safety. How can nurses truly care for and care about their inmate patient population? This is a question many of us in the specialty grapple with as we try to elevate the professional status of correctional nursing. Caring has been described as the essence of professional nursing practice, therefore we must establish the characteristics of this concept as it is enacted in the criminal justice system.

Weiskopf studied nurses’ experience of caring for inmate patients and discovered a number of limitations in our setting .  Nurses in this study described the need to negotiate boundaries between the culture of caring and the culture of custody to establish relationship with custody staff in order to be effective. One surprising finding of the study was the extent to which the negative attitudes and behaviors of other nursing staff affected nurses who were attempting to provide compassionate nursing care.

Many nurses working behind bars feel an obligation to care and often struggle to find ways to do this in a hostile environment. Yet, developing a structure and process for caring may be the core defining characteristic of our specialty. Here are some suggested ways nurses enact caring behaviors in corrections:

  • Educating patients about their health conditions and self-care principles
  • Maintaining a nurse-patient relationship that is within the helpful zone of professional boundaries
  • Advocating for the health care needs of a patient when necessary
  • Showing compassion and respect
  • Presenting a non-judgmental manner
  • Listening to what the patient is saying
  • Helping patients through a difficult situation

Correctional nurses are confronted daily with a struggle against a tidal wave of organizational culture convinced that we should not be caring ‘too much’ for our patients. Caring for murderers, rapists, and criminals takes true grit and a more serious definition than a superficial application of a warm positive emotional response or empathetic word. We are the ‘Tough Love’ folks on the nursing caring continuum.

Consider these unusual ways that a correctional nurses cares for patients:

  • Not accepting a gift from a patient
  • Letting a patient know that you know the rules and they should not ask you to violate them
  • Asking the patient to complete a sick call request for their rash that they want treated during pill line
  • Being diligent with mouth checks during pill line

All of the examples above constitute an action or activity that is helpful for the patient; whether it avoids penalties, provides boundaries, or prevents self-harm. Caring seeks the best for the other in any situation.

Have you found it difficult to care for patients in the criminal justice system? Share your thoughts in the comments section of this post.

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The foundation of this post originally appeared in the Essentials of Correctional Nursing blog

Correctional Nurses: Always on Guard

Stasi-Gefängnis HohenschönhausenPersonal safety is a growing concern in all nursing specialties. Patient violence can take place in the emergency room, on inpatient psychiatric units, and dementia wards. Correctional nurses are no strangers to the need for personal safety. We have visible proof all around us that our patients may turn violent. Officers often escort nurses around the compound and many locked doors must be negotiated to gain access to deliver care. The routine nature of security operations can blunt our continuing vigilance, however. I like to consider personal safety as multi-dimensional with the very basic start being physical safety. Here are some tips in three areas of safety concern for correctional nurses.

Guard Your Body

• Be aware of your surroundings and the location of the nearest security officer.
• Travel in pairs whenever possible. Always tell others in your unit where you are going and when you expect to return.
• Observe all security procedures. Wait for clearance before entering any area, including when responding to an emergency.
• Do not leave sharps and other potential weapons out on surfaces. Keep equipment locked and maintain counts of all potential contraband items.
• Be careful to limit personal conversation or discussion of facility procedures when patients are present.

Guard Your Mind

• Our patient population can be a difficult one to care about. Patients may have cruel or violent histories. To avoid developing a judgmental attitude, do not seek out information about the crimes of your patients. Focus your mind on nursing care provision and the health care issue at hand.
• Our patients can also seek health care for secondary gain such as a privileged status, more comfortable accommodations or items to fuel the underground prison economy. Guard your mind toward manipulative behaviors while maintaining a professional nurse-patient relationship.
• Because inmate patients can try to con you or game the system, it is easy to become jaded or cynical. Guard your mind against these attitudes that decrease your ability to deliver care.

Guard Your Heart

• Regular contact with the inmate population can lead to professional boundary crossing in relationships. Some patients may seek additional ‘favors’ from nursing staff. Be firm, fair, and consistent in all patient interaction. Immediately report any such requests to your manager.
• Guard your heart toward flattery or flirtatious comments and actions by inmates. Respond firmly and initiate security procedures with the slightest indication of personal contact. You are guarding yourself from harm and protecting the patient from disciplinary action.
• Agree with your fellow nurses to watch out for each other. Comment on observations of inappropriate conversations or behavior toward patients.

Do you have additional safety tips to add to this post? Use the comments section to expand on these points.

This post originally appeared in the Essentials of Correctional Nursing blog.

Five Mistakes New Correctional Nurses Make

Mujer  arrepentida equivocada cubriendo sus ojos.I’ve worked with a lot of new correctional nurses over the years; many of them succeeded and embraced the unique nature of our specialty. Some, however, quickly abandoned their positions even before they gave themselves time to adjust to their new role. Sometimes it is just not a good fit. For example, some nurses just can’t bear to hear the bars click shut behind them when they enter the sally port after security clearance. However, many times nurses make preventable mistakes that land them in trouble on the ‘inside’. Based on my experiences, here is a list of common mistakes nurses can make in their first correctional position.

Not paying attention to security procedure

Many seasoned correctional nurses will tell you that working behind bars is one of the safest jobs aroung. In fact, correctional nurses have more security presence than most emergency rooms or mental health units in traditional settings. That being said, nurses must know the security procedures and follow them. For example, nurses need to know where officers are located and how to activate the alarm system. We also need to let others know where we are headed and when we expect to return when moving within the various facility areas. And, whenever possible, travel with someone else. Nurses who don’t pay attention to security procedure can find themselves vulnerable to injury or assault.

Disrespecting correctional officers

Correctional officers are professionals, too, and deserve civil and respectful treatment. Nurses who are arrogant or act superior to their correctional colleagues don’t last in the specialty. We may come from different worldviews and we may have differing opinions, but both professions have a vital role in the facility. The happiest correctional nurses are those who build collegial relationships with the officers with whom they work.

Not treating the inmates like patients

Some nurses enter the correctional setting and find affinity with the officer role, even identifying with it. These nurses easily absorb the jail culture and abandon their nursing perspective. In a poor environment, this can easily degenerate into a cynical and punitive attitude toward the patient population. Research into correctional nurse working styles identified four types:

  • Idealist: Nursing perspective is a primary consideration and does not understand the security perspective
  • Realist: Respects the security perspective while continuing to function from a nursing perspective
  • Situationalist: Alternates between a security orientation and a nursing perspective depending on the situation
  • Acceptor: Identification with the security perspective with no application of nursing perspective while in the correctional setting

By focusing on becoming a realist, new correctional nurses can successfully navigate in the criminal justice system while providing substantive nursing care to their patients.

Treating the inmates like patients in other settings

This one sounds contradictory of the previous mistake but hear me out. While we must treat inmates like patients, nurses make mistakes when they treat incarcerated patients like they might a frail elderly hospitalized patient. What I mean is that the common signs of compassion and care provided in a traditional setting such as a shoulder squeeze or other touch can be misinterpreted in the correctional setting. Successful correctional nurses find other avenues to show care or concern.

Leaving the nursing license at the door

I know it can be hard to believe but I have seen this more than once. Nurses start working in a correctional facility and fall into practices that are definitely unsupportable to a licensing board. These practices can be as mundane as poor or missing documentation. They can also be as egregious as participating in a use of force against an inmate. A nursing license governs every employment setting, no matter how untraditional it might be.  New correctional nurses are successful when they practice within their licensure requirements when ‘behind the wall’.

Do any of these sound familiar? What advice do you give new correctional nurses? Share your thoughts in the comments section of this post.

PS – For a short time, you can get a free downloadable copy of my new ebook – The Correctional Nurse Manifesto by signing up for my email list. Use this link

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Where to Find Clinical Guidelines for Your Chronic Care Clinic

Guidelines Key Shows Guidance Rules Or PolicyChronic disease is common among our patients. In fact, 38.5% of federal inmates, 42.8% of state inmates, and 38.7% of local jail inmates have at least one chronic condition. Our patients have more diabetes, hypertension, prior myocardial infarction, and persistent asthma than the general population. This means all of us are managing chronic care clinics. Although often considered a provider’s domain, nurses play a significant role in chronic care management through

  •  Patient teaching
  • Medication administration
  • Symptom management
  • Lifestyle adjustment

Accreditation standards and best practices call for the use of national clinical practice guidelines in managing chronic conditions. Here is a quick-start list of resources for guidelines that work well in a correctional setting.

 Generic Sources

Arthritis 

 Corrections-Specific Sources

Federal Bureau of Prisons (FBOP) Clinical Practice Guidelines

National Commission on Correctional Health Care (NCCHC) Guidelines for Disease Management

Asthma 

Diabetes 

Hypertension 

HIV Infection Management 

What sources do you have for clinical practice guidelines? Did I miss any? Share your links in the comments section of this post so we develop a full resource.

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Nursing Care of End-Stage Liver Disease (podcast)

Play

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.

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.

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