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.

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Patient Safety and Correctional Nursing Care

Traffic cones and hardhat. Road sign. Icon isolated on white bacAccording to the Wall Street Journal, enough Americans are kills by medical errors each week to fill four jumbo jets. Patients are rarely told of errors made during their care and the same errors often happen over and over again. A third of hospitalized patients experience a medical error and 7% are permanently harmed or die as a result of an error. The annual cost of medical errors has been reported to be upwards of 17 billion. How about in our own specialty? How can we reduce errors to improve our patient outcomes and reduce costs?

Correctional nurses have the most contact with the correctional patient population and, therefore, improvements in the way nursing care is delivered can improve patient safety in our setting.  A good place to start is by considering the application of patient safety principles developed for traditional health care settings to the organization and delivery of nursing care in our setting.

The Institute of Medicine (IOM) commissioned a consensus report on nurse activities toward patient safety in 2003. KEEPING PATIENTS SAFE: Transforming the Work Environment of Nurses provides expert recommendations for nurse-workforce efforts toward patient safety that can be applied in the correctional setting. Here are some key recommendations that apply to our specialty:

  • Fatigue leads to errors: Nurses should not work longer than 12 hours in a 24-hour period and in excess of 60 hours per 7-day period. Airplane pilots have a limit on number of hours in the air. Nurses make decisions that affect the health and safety of their patients. Limiting mental and physical fatigue is just as important in our field.
  • Busyness leads to errors: Nurses should have limited involvement in non–value-added activities, such as locating and obtaining supplies, looking for personnel, completing redundant and unnecessary documentation, and compensating for poor communication systems. Improving systems to reduce nurse involvement in these activities will free up time for important patient safety functions.
  • Communication reduces errors: Systems for communication among and between health care disciplines will reduce communication gaps and increase patient safety.
  • Orientation and training reduces errors: The onboarding and ongoing education of nursing staff is vital to increase patient safety in the fast-paced changes of health care. Attention to the development of all new and incumbent staff members will reduce error.

Can we improve patient safety in correctional healthcare? This short list is a good place to start. What is your facility doing to reduce medical errors? Share your thoughts in the comment section of this post.

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

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Encouraging Patients to Participate in Self-Care

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

Paternalistic Culture

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

Patient Preparation

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

Practitioners Behaving Badly

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

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

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

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

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Verbal Order Safety Tips

Old-fashioned phone on white isolated backgroundDo you use verbal orders in your correctional facility? I bet you do…..and probably more frequently than traditional settings as prescribers are often less accessible in our secure environment. Orders communicated verbally are common in all clinical settings with estimates as high as 20% of all inpatient ordering.

A Verbal Order (VO) has the following characteristics:

  • communicated orally by telephone, digital device, or face-to-face
  • requires transcription by an approved individual
  • requires the prescriber to follow-up with review and signature of the transcribed order

Did I Hear That Right?

The most common VO errors involve misinterpretation of the dose or the medication name. For example VO errors reported in the literature include misinterpreting the number fifteen (15) as being fifty (50) and the number two (2) as being ten (10). Besides dosage confusion, sound-alike medications have also caused VO errors. Examples cited include mistaking azithromycin for erythromycin and Klonopin for clonidine.

Verbal information among care providers can also lead to error. Verbal communication of blood glucose readings without confirmation have resulted in administration of overdoses of insulin, as when the nurse heard a verbal report of the patient’s blood glucose reading being 353 when the reading was actually reported as 85.

Could You Repeat That?

For these reasons, patient safety experts recommend a standing policy that all verbal orders be stated back (or read back) to the prescriber before implementation. Besides verbal orders, this state-back policy should include high-risk clinical information that results in medication administration such as blood glucose levels or patient assessment information during a code.

One pediatric hospital reduced VO errors from 9% to zero by implementing this process. The read-back process requires the staff member who receives a verbal order to read-back the order information and obtain affirmation from the prescriber that the information is accurate. The read-back process includes the following components:

The receiving staff member writes down the order as it is verbalized by the prescriber.

  • The receiving staff member repeats the order back to the prescriber – reading directly from the written dictation.
  • To reduce sound-alike errors in medication and dosage, the reader spells out the medication name and dosage amount, for example, t-w-o – 2 mg.
  • A verbal affirmation is obtained from the prescriber before initiating the order.
  • A second staff member qualified to accept VOs listen in on highly risky communications such as insulin, anticoagulants, and narcotics

Who Are You?

We are surprisingly trusting when taking patient orders by phone. One study found that few smaller institutions asked for identification when prescribers called with patient orders. With the rapid turnover of staff and covering providers, it can be risky to rely on voice recognition to confirm identification. Many large academic institutions use provider identification numbers for verbal orders. Several incidents of individuals posing as providers have fooled staff into taking and implementing verbal orders for patients. The correctional setting has opportunity for nefarious use of telephone communication. Do you know who is on the other end of the line when you take verbal orders?

Know Your Limits

The high risk of error with VO’s requires limits on use. Here are some standard limits placed on VO’s that should be considered in our setting:

  • Limit VO’s to urgent patient care needs and not as a routine practice or for convenience purposes.
  • Limit the number of staff who can take verbal orders.
  • Limit the type of medication that can be ordered to formulary medications that are more likely to be familiar to staff members.
  • Do not use verbal orders for complex medication schemes such as chemotherapy.

What is your practice regarding verbal orders? Share your thoughts and tips in the comments section of this post.

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Checklists in Corrections

doctor working with  tablet,

My husband was, for many years, a private pilot. Although I could never get comfortable flying in such small compartments, I did travel with him many times and every time he went through a page of equipment checks before take off. Occasionally on business travel I have peeked in to the open door of the cockpit to find commercial pilots using a similar list to work through standard system checks before taxiing to the runway. After thousands of hours in the air, why would professional pilots need to review a list of checks? In the risky business of air travel, nothing can be left to chance or memory. Requiring pilots to work through a list of standard safety checks before every flight has saved many lives and reduced inflight emergencies.

The patient safety movement has embraced the use of checklists in the clinical setting since Gawande published research on the use of checklists to reduce clinical error in the book “The Checklist Manifesto”.  Working with the World Health Organization (WHO), Gawande implemented a simple pre-surgical checklist in 8 hospitals and found a 36% decrease in major post-operative complications and a 47% decrease in post-op mortality. Since then WHO has developed checklists for safe childbirth, trauma, and H1N1. The Agency for Health Care Research and Quality (AHRQ) provides a clearinghouse of evidence for the positive outcomes of checklist use in health care.

Checklists improve safety in highly specialized and technical settings where repetitive functions lead to complacency. Fragmented and chaotic care environments are filled with interruptions and distractions that can generate omissions of important steps in a clinical process. How might checklists help us stay on track in the correctional healthcare setting? Here are a few of my thoughts:

  • Suicide Watch Release: What are the steps to clear an inmate from suicide watch? Who needs notified and who needs to sign-off on the release?
  • Chronic Care Visit Prep: What should be available for a chronic care visit? Are the labs back? How about specialty consults and diagnostic studies? What patient teaching materials are needed?
  • Post Emergency Response: What forms need completed? What needs documented in the chart? How about replacement of medications used during the event? Who needs contacted? What is the disposition of the patient?
  • Return from an Outside Appointment: Was the medical record returned? Did the specialist send instructions? Does the provider need contacted? Is there a follow-up visit requested?

We can learn much from the patient safety movement. By evaluating and applying successful strategies from traditional settings, we can improve the effectiveness and efficiency of our care behind bars.

Do you use checklists to stay on track in your clinical setting? Share your experiences in the comments section of this post.

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Sexual Boundary Violations in Correctional Nursing: It Could Happen to You

This past fall I participated in a session on sexual boundary violations presented by Cindy Peternelj-Taylor at the International Association of Forensic Nurses Scientific Assembly. Her research into this concept in Canada is fascinating and has much for us to apply in our own practice settings. Here are my notes and thoughts from her session.

Cindy interviewed seven registered nurses working in secure settings who had observed or experienced sexual boundary violations in their nursing practice. Spending a lot of time with a patient, such as can happen in correctional settings, can make this a hotbed for potential problems.

What does it mean to cross the line? She identified this as behaving in a way that is socially unacceptable or behaving in a disreputable or inappropriate manner. In professional practice, this can mean nurses who are professionally irresponsible; having crossed the bounds of an appropriate nurse-patient relationship to a romantic or sexual relationship. When has a nurse-patient relationship crossed the line? Peternelj-Taylor’s research revealed these indicators:

  • Starting to look forward to seeing that person the next day.
  • Keeping secrets in the relationship
  • Not allowing others into the relationship
  • Exchanging messages

Relationship should always be for the benefit of the patient, not for self-gratification or personal gain. Yet, therapeutic relationship can be very intimate and confusing to the patient.  In fact, it is not uncommon for a patient to misinterpret therapy. For example, how would you respond to a patient who says, “I want to kiss you?” How would you respond in a way that would realign the relationship and not cause the patient to withdraw from therapy? Our inmate-patients often misinterpret  interactions with nurses; both words and gestures.

Nurses have an ethical responsibility to maintain the therapeutic environment no matter the actions of the patient.  Caution is needed. We can lose sight of professional roles and responsibilities in the midst of a situation and can be blindsided. Therefore, we have responsibility to our peers to point out when we see potential boundary violations.

Questions to ask in a potential improper nurse-patient relationship:

  • Would this relationship really work out in the real world?
  • Would I say or do this in front of my peers or my supervisor?
  • Am I keeping secrets or not talking to my peer group about my conversations or actions with this patient?

Peternilj-Taylor’s research also suggests that managers can reduce sexual boundary violations. One way is to investigate any indication of improper relationship in the medical unit. Training, especially the use of case vignettes, can help nurses to overcome temptation and develop skills in responding to potential violation opportunities.

Do you think sexual boundary violations are of greater potential in correctional nursing practice? Share your opinions and experiences in the comments section of this post.

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Danger Will Robinson! Christmas Week in Corrections

We are moving into one of the most dangerous weeks of the year in our specialty. We need a robot flailing his arms and shouting “Danger” as we head into our facilities these next few days. Here is a reminder post from last December to help you keep on your toes. The Merriest of Christmas’ to all my blog readers. Looking forward to a great year ahead.

The week between Christmas and New Year is traditionally one of feasting, family and fun as we celebrate the season and the start of a new year. However, there are many reasons why this time of year is dangerous in our workplace. Correctional nurses need to be on high alert in the days ahead. Here are my three reasons for concern this week.

Reason #1: We lose our focus

The last month of the year is busy with many things. You and your colleagues are taking that final stretch of vacation time. Kids have holiday and end-of-year school activities. Work sites have holiday parties and extra treats in the break room. It is easy to lose focus on personal safety or to be working short-staffed. Those who might do you harm take advantage of opportunity. In addition, your own emotions might be swinging between elation and despair as the holidays approach. Emotional turmoil is a magnet for  inmate psychopaths or sociopaths. Therefore, this is a time of year with increased vulnerability to inappropriate relationship. Check out my prior posts on dealing with psychopaths andsigns of unhealthy relationships.

Reason #2: Our patients are not merry

For inmates, the lack of family support and distance from children or spouse is accentuated during the holidays. Guilt over not being able to provide gifts for children and family estrangement can be acute. The holidays can lead to deeper depression, anger and aggressive behavior. Be particularly alert for increased evidence of suicide potential during the holiday season.

Reason #3: Our co-workers and managers are with their families

On occasion I review medical charts in cases involving inmate plaintiffs. A common scenario involves lack of treatment or inaction during a weekend or holiday. Reduced staffing and vacant management offices leave staff with few resources to deal with emergent issues. Be sure to know all administrative contacts when working weekends and holidays. Policy manuals and treatment guides should also be accessible to staff. It is not unusual to find these important materials locked in a manager’s office; unavailable to those who need their guidance in an urgent situation.

Do you have some other reasons to add? Have you had some dangerous Christmas Week experiences in your setting? Share your thoughts in the comment section below.


Hand Hygiene Challenges for Correctional Nurses

What exciting thing can be said about washing your hands? Even before becoming nurses, we heard this admonishment as youngsters in households across the fruited plain. Our Infection Control 101 lecture started with: Hand washing is the single most important infection control principle we have.

Infection is rampant in most correctional facilities. Our work settings were created for purposes other than healthcare and hold a population with known propensity for a variety of infectious conditions.

Yet, with all this knowledge and all this evidence before us, handwashing frequency is abysmally below standard requirement. I couldn’t find a study of handwashing in correctional settings, but a multihospital study cited by the CDC found only 36-59% of health care workers washing their hands where and when they should.

Nurse leaders from the Mayo clinic suggest that what we really need is not more knowledge but a culture change and environmental accommodations to improve hand washing frequency. In an article in the November, 2011 issue of Nursing2011, authors Johnson, Kachler, and SIska offer the following interventions to improve hand washing:

• Keep it simple: Create simple message about hand hygiene, using protective equipment and cleaning clinical equipment. Find resources on the CDC site.

• Place hand-hygiene products where they are needed: Like at the door of the nurse’s station, the medication room, and clinic rooms used for patient care.

• Integrate hand hygiene into the workflow: Make it easy and convenient. Keep hand sanitizer locked in the medication or treatment cart for use when delivering care in the housing unit.

• Role model: Medical, nursing and administrative leaders should ‘walk the talk’ on hand hygiene and other infection control responsibilities.

But wait, correctional nurses encounter many unique barriers to increasing hand hygiene practices. Here are some of our challenges according to Joseph Bick, a correctional physician:

• Many areas in which clinical care is provided lack hand washing stations. Our facilities were not designed for health care practices.

• Soap and soap dispensers are valuable commodities and may be stolen by inmates

• Alcohol based hand washes burn with a clear flame and may raise concerns with custody staff.

An additional peculiarity of the correctional setting is our patient population’s propensity to take advantage of available resource for their benefit. To wit, inmates have been known to drink alcohol-based hand sanitizer. A recent event landed 4 inmates in the emergency room in Shelby County, AL. []. Although the CDC has not officially supported alcohol-free hand sanitizers, they are growing in popularity in school and correctional settings.

Are you using alcohol-free hand sanitizers? How are you making it easier to “Wash Your Hands!” in your clinical setting? Share your experiences in the comments section.

Here’s a fun video from Jefferson Hospital about hand hygiene:

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June News Round-Up (Podcast)


Regular panelist, Sue Smith, MSN, RN, CCHP-RN, and guest panelist Sue Lane, RN, CCHP, join host Lorry Schoenly in a discussion of recent infection outbreaks in the news this month. Our first story comes from Oklahoma, where the State Department of Corrections reports the need to make contact with about 60 former inmates who are believed to have had contact with two inmates found to have active TB at one of the correctional facilities in the state.

In the Oklahoma article, the physician interviewed stated that TB is so controlled in the US public that medical professionals now often miss the signs. Our next news story involves an even less prevalent infectious disease – leprosy. This story comes from Minnesota, where the department of health reports an inmate with likely leprosy – now more commonly referred to as Hansen’s disease – was not managed appropriately and continued in general population for a couple months before being isolated. The inmate is Burmese and had spent a significant amount of time in a Thailand refugee camp. Have either of you had experience with Hansen’s disease in the correctional setting?

After discussing two serious issues – Tuberculosis and Leprosy, we end on a lighter note – inmate creative uses of antibiotic ointment. A research study reported at the annual APIC conference this month found that inmates are using antibiotic ointment for other purposes such as dry skin, lip balm, hair grease and shaving. The researcher and current APIC president suggest this practice may contribute to antimicrobial resistance. and we need more education and awareness. What are your thoughts on this research and how does it compare to what you have seen in your own practices.

Infectious Disease Management Resources

Centers for Disease Control. Health Providers and TB Program Materials By Topic
Centers for Disease Control. Regional Training and Consultation Centers
Federal Bureau of Prisons Clinical Practice Guidelines: Management of Methicillin-Resistant Staphylococcus Aureas (MRSA) infections


How to Deal with Inmate Anger

Workplace violence is an increasing concern in all care settings. Jails and prisons are full of angry people with poor impulse control. Correctional nurses need skills in deflating potentially violent situations in their clinical practice.

Preventing anger from escalating to violence is a primary tool to increase personal safety in this setting. The nurse’s demeanor in a nurse-patient interaction can diffuse potential anger from developing. A positive assertive presence can help reduce anger escalation in a tense patient situation. Being neither aggressive nor servile in responding to an angry patient has been shown to assist in keeping the situation from getting out of hand. Three possible types of responses to anger are aggressive, assertive, or servile. Aggressive and servile are on opposite ends of the spectrum and should be avoided, but it takes practice.

Aggressive responses to an angry patient can be risky. Aggressive responses are arrogant and make the patient feel insecure. Aggressive communication shows indifference to the causes of the situation, is commanding and uncompromising. It shows a lack of concern for the patient.

On the other end of the continuum, servile responses to anger are over-cautious. A servile response seeks to placate the angry person by seeming to do what they want. This can include making unrealistic promises or unreasonable concessions. A nurse might respond to anger in this fashion when feeling intimidated. This type of response can encourage an angry patient to escalate the anger further.

A positive, assertive stance is more likely to de-escalate an anger situation.  This response values the patient and aims to reduce fear. The nurse provides guidance to the patient about the situation, attempting to negotiate a workable solution. This can have a calming effect and lead to resolution.

Tips for dealing with angry patients

  • Give extra personal space, double the usual handshake distance. This is not only calming but provides a safety buffer should things get physical.
  • Listening is an action that can reduce anger. Show by both body language and conversation that you are concerned about what is causing the anger.
  • Respond to the concerns of the individual using a calm tone and demeanor.
  • Use mutual negotiation and shared problem solving if dealing with a rational patient
  • In all cases, engage the assistance of available corrections officers if the patient is irrational continues to be agitated or shows any signs of physical violence.

Have you had to deal with an angry patient? Share your tips in the comments section of this post.

Information in this post was adapted from:

Nau, J., Halfens, R., Needham, I., Dassen, T., (2009). The de-escalating aggressive behavior scale: development and psychometric testing. Journal of Advanced Nursing, 65(4), 1956-1964.

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