Scope and Standards: Five Correctional Nurse Roles

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

I love helping nurses discover the invisible specialty that is correctional nursing. In fact, that was my original purpose in starting this blog over 5 years ago. I was sure that if more nurses knew about our specialty then more would join our ranks. From my own experience I know that few nurses get exposure to incarcerated patients during their education. There are practical reason why student nurses don’t have clinical rotations in the local jail, but it hampers the ability for new nurses to consider entering our challenging specialty. Regularly I am asked by new nurses if they should apply for a correctional nursing position. Although I enthusiastically encourage these individuals; I also caution them to be careful in selecting their first correctional nursing position if they are a new graduate. Here is why: Correctional nurses have so many roles and must often do them with little support and resources. This can be overwhelming for a new nurse; who may need a good bit more structure to get a solid foundation for their nursing career.

Based on the Correctional Nursing Scope and Standards of Practice, here are the five leading roles of a correctional nurse.

Primary Care

Correctional nurses are most often the first point of contact for incarcerated patients with healthcare needs. They manage access to all other aspects of healthcare and make determinations of appropriate level and type of care needed. In this way they coordinate ambulatory care provision to the patient population.

Emergency Care

Correctional nurses also provide immediate treatment of injury and acute illness while determining if a life-threatening injury exists that would warrant emergency transport to an emergency room. Patients are stabilized for transport with the provision of first aid and basic life support.

Health Promotion

The inmate patient population is often underserved with limited healthcare access in the community. They enter the correctional system having made poor lifestyle choices and often have little knowledge of how to manage chronic conditions.  Therefore, correctional nurses have a major role in promoting heathy lifestyle choices while educating the patient population at every encounter.

Patient Advocacy

Healthcare is not the primary mission of correctional institutions. Security concerns and community safety may vie with an individual patient’s healthcare needs. Correctional nurses negotiate the security system and collaborate with officer peers to meet patient health needs within system constraints. They act as patient advocates through these efforts.

Care Coordination

Correctional nurses coordinate patient care within a system arranged for other purposes. Barriers to care must often be overcome. Standard security constraints such as restricted movement or limited personal items can inhibit continuity of care. Correctional nurses must creatively navigate the system to coordinate appropriate care.

Along with the above roles, correctional nursing practice is a merger of multiple nursing specialties: Occupational health, emergency nursing, acute care, community health, psychiatric care, geriatrics, women’s health, adolescent health, palliative and end-of-life care.  A correctional nurse must be prepared to deliver a full menu of assessment and interventions within the security perimeter; knowing when a patient needs to be transported to an advanced level of care or specialty. This can be a daunting task for even the experienced professional.

Although I caution new nurse graduates to pick their first correctional nursing position with care; it can be done. With an extended orientation and good management support, many new nurses have made correctional nursing their first specialty.

Do you have a story about the various roles of correctional nursing? Share your thoughts in the comments section of this post.

*Affiliate Disclosure: I am grateful to be of service and bring you content free of charge. In order to do this, please note that when you click links and purchase items, in most (not all) cases I will receive a referral commission. Your support in purchasing through these links enables me to keep this blog going. Thank you!

Avoiding Patient Manipulation (podcast)

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cnt-podcast_cover_art-1400x1400Corrections expert and author, Gary Cornelius, joins Lorry to talk about the best ways to deal with manipulative patients. He shares highlights from his excellent book Art of the Con  which was instrumental in developing the chapter on staff safety in the Essentials of Correctional Nursing book.

He provides a helpful 3-part description of manipulation as 1) wanting to control or change things 2) by artful and unfair means 3) to achieve a desired end.

Key concepts from the interview:

  • Everyone is a target. You have what the manipulator wants – access to the outside.
  • Stressed out people are vulnerable. Financial problems, emotional stress, or marital discord can be used by some inmates to manipulate staff to do their bidding.
  • If a request is made that you are not sure about – talk to your supervisor first.
  • The schemes will start small and seem innocent. The idea being, if you bend the rules for small things what else will you do?

Try the C-H-U-M-P-S approach when dealing with correctional patients:

  • C-Control rather than complacency. Be the master of your assignment. Assert your rightful authority. This can also mean saying ‘No’. Always avoid becoming complacent.
  • H- Help inmates to help themselves. Instead of doing things for them, explain how they can do it for themselves through the system.
  • U- Understand the inmate culture and demographics of your patient population.  For example, it is common for inmates to lack stable relationships in their lives and be involved with excessive drug or alcohol use.
  • M- Maintain a safe professional distance. Keep the patient’s knowledge about you at a minimum. Don’t accept gifts from patients.
  • P- Stay professional and adhere to policies and procedures. Know what your agency expects of you. Be well-groomed and professional looking.
  • S- Stressed out staff are vulnerable. Work stress, home stress, or financial stress can lead to manipulation.

Additional Resources on Patient Manipulation in Corrections:

How to Work with Inmate-Patients Part 1: Be Alert for the Con

How to Work with Inmate-Patients Part 2: Are You a Target

How to Work with Inmate Patients Part III: Watch for These Techniques

How to Work with Inmate Patients Part IV: Protecting Yourself

In the Nursing News

Pharmacological interventions for sleepiness and sleep disturbances caused by shift work

Published this month in the Cochrane Database of Systematic Reviews is a thorough review of sleepiness and sleep disturbances related to shift work with findings that 1-10 mg of melatonin may increase sleep length during the day after a night shift by 24 minutes. They also found that caffeine plus pre-shift napping decreased sleepiness.

Idaho Reports Alarming Rise in Whooping Cough Cases

Although more dangerous for infants and children, the CDC reports that adults frequently contract the infection and then pass it along to children. They recommend a vaccination booster for whooping cough for all adult. This is combined with tetanus and diphtheria and often called the TDAP. So check that out for yourself. We come in contact with a lot of infections in our facilities

Cocaine Use and Risk of Strokes

The National Center of Epidemiology performed a systematic review of previously published research and concluded that cocaine use increases stroke risk. If cocaine is a drug of choice for your patient population, be on the lookout for stroke symptoms in even your younger patients with a drug history.

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.

Photo Credit: © Aleksandr Bedrin – Fotolia.com

Multi-Dose Vials: Risk and Reality in Corrections

Syringe and vialsCheri was delighted to land her first nursing job in the county detention center close to home. She was an LPN and the only nurse on night shift for an average population of 300 mostly-male inmates. The night shift nurse gives the morning insulin for any diabetic inmates at 5am just prior to breakfast. This is always a time-pressed situation. The line officer is eager to get to shift report and the inmates don’t want to miss the best selections in the chow line. Cheri hadn’t much experience with drawing insulin from vials as her school clinicals were in LTC facilities and they used insulin pens. The new patient in the line had an order for both Regular and NPH insulin that required mixing. She picked up the Regular insulin and noted that the label indicated U-100. She interpreted that to mean there were 100 units of Regular insulin in the small vial and began to draw up the patient’s dose…..

If you are a long-time nurse, especially in the correctional setting, you may be surprised to learn that drawing up insulin from multi-dose vials and mixing insulins in a single syringe are no longer as common a practice in traditional health care settings. Individual insulin pens and premixed pre-measured syringes have frequently replaced nurse calculations in administering insulin for diabetic management. Nurses new to our specialty may have little experience with what we consider a common practice. Fewer safeguards and, often, minimal oversight of staff practices can lead to a variety of clinical errors.

The Institute for Safe Medical Practices (ISMP) reviewed errors in using insulin vials. They fell into the following categories. Consider your own setting and multi-dose vial practices and evaluate how many risks are currently present:

  • Dosing errors: In the example above, Cheryl assumed that U-100 was the total number of units in the 3ml insulin vial. This can happen when staff are not familiar with insulin characteristics and standard concentrations. Dosing errors can also result from using a syringe labeled in ml rather than units (mixing insulin syringes with parenteral syringes).
  • Look-alike vials: Vials of different medications can appear similar-especially if the nurse is distracted or time-pressured, as Cheryl was.
  • Unlabeled syringes: In some settings nurses may draw up medication in syringes prior to direct administration. If syringes are not labeled, a mix-up can result in medication given to the wrong patient.
  • Beyond expiration: If expiration dates are not written on an opened multi-use vial once it is punctured it may be used when it is no longer safe or potent.
  • Cross-contamination: Because a vial can be accessed by multiple practitioners for many different patients over several weeks, there is great chance for contamination. This is more common that you might think. One study found that 25% of practitioners have re-entered a vial with a contaminated needle. Recent news from the Arizona and Connecticut show that this continues to be an issue in the correctional setting.

Multi-dose vials, in general, are a source of considerable medication error. The most common uses for multi-dose vials in the correctional setting are insulin, PPD solution, and vaccine. Here are some standard protocols for multi-dose vial use in any setting:

  • NEVER reinsert a used needle into a multi-dose vial.
  • Whenever possible, have a separate vial for each patient. Clearly label with the patient name and organize vial storage to maximize easy identification.
  • Medication in vials are good for 28 days and should be labeled with the expiration date once opened for use (unless the manufacturer information specifically states otherwise).
  • Cleanse the access diaphragm of multidose vials with 70% alcohol before inserting a device into the vial.
  • Discard multi-dose vials if sterility is compromised.
  • Many medications provided in multi-dose vials also need refrigeration. Be sure that the medication refrigerator is kept at the proper temperature. “Vaccine clinics” can be of particular concern as vials may be removed from refrigeration for extended periods of time which can jeopardize the integrity of the vaccines.
  • Follow facility regulations regarding sharp movement, if a pre drawn syringe, and multi-dose vials are used, they should be transported in a locked container with access to a disposal system at the point of administration.

Unfortunately, safeguards were missing in Cheri’s insulin administration situation. Although her new patient received an overdose of insulin, he recovered from a significant hypoglycemic event with quick treatment and a day of evaluation in the infirmary. Could this situation happen in your facility?

Share your thoughts on the dangers of insulin administration from multi-dose vials in the comments section of this post.

Photo Credit: © antpkr – Fotolia.com

Summer Correctional News Round-Up (podcast)

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cnt-podcast_cover_art-1400x1400Regular panelists Johnnie Lambert and Gayle Burrow join Lorry to talk about the latest correctional healthcare news stories. Even amidst some busy summer plans, they pause to share their thoughts on unfolding events.

Ohio Stops Putting Kids in Isolation

Mental health management is a key issue in corrections in this era. We have seen many a story about the need for more mental health services and also the need to curtail solitary confinement in managing mentally ill inmates. Ohio’s Department of Youth Services has reached an agreement with the Justice Department to stop using solitary confinement in their youth prisons. Placing kids in solitary confinement just doesn’t seem like a good idea. There are some startling revelations about youth treatment in this article and accompanying audio interview from Ohio Public Radio.

Ammonia Capsules for Seizure Evaluation? 

Our next story comes from Dr. Jeff Keller’s Jail Medicine Blog. A recent post recommends using ammonia capsules for assessing seizures (particularly determining true unconsciousness). Many acute care, emergency, and correctional settings have actually banned the use of ammonia capsules as dangerous. Could the use of ammonia capsules also be considered unethical? Panelists weigh in on what they are seeing in other correctional settings.

Causes of Stress for Correctional Officer (and Correctional Nurse) 

This third story shares results of dissertation research on the causes of correctional officer stress. Correctional nurses can experience similar stresses working with the same population and many of the same work environment conditions. This was a survey of 197 officers working in minimum, medium, and maximum security settings. The two most common causes of stress were insufficient salaries and overtime demands. Other stressors included lack of input into decision making, prison security level, and lack of support from administration. The most popular methods for coping with this stress were exercising, seeking religion, support from family, and participating in social activities.

Farm to Table Program

This last story has so many good things to offer us. A Farm-to-Table program was recently started at San Diego’s Richard. J. Donovan Correctional Facility. They have 20 inmate farmers working 3 acres of farmland with the goals of teaching them community gardening, composting, and water-wise gardening using raised bed gardens. A nice addition to this story is that the idea was conceived and initiated by a California Correctional Health Care Services Executive. Many advantages accrue from such a program. Recidivism is only 5-10% with farm prison reentry vs the average of 61% in California.

Personal Safety During Medication Administration

Packs of pillsJennifer didn’t expect to be the patient in the clinic room this morning getting her ankle evaluated. Just a short time ago, she was administering medications from a cart on one of the housing pods at a county jail as she did most weekday mornings for the last 14 months. This pod was for protective housing where those with mental illness or who had a vulnerability such as a severe learning disability were managed. She stationed her medication cart next to the officer desk, as usual, and started through the line in her standard process, checking arm bands and bantering with the men while she delivered the medications and watched them swallow their pills. A new detainee became angry when he found out Jennifer did not have the clonipin he thought the doctor had ordered for him. He shoved the cart forward, toppling Jennifer and catching her left ankle under the wheels.

Medication administration is a primary nursing function in corrections.  Even with a keep-on-person system in place, there are a number of medications that still need administered in a watch-take (direct observation) process. Often called pill lines, direct administration of medications can take place in two primary ways. Inmates may come to a central area like the yard or the medical unit for their medication doses at designated times. This is a more common practice in prisons. Decentralized pill lines, more common in jails, involve the nurse coming to the inmate living areas to administer medication. In lower security settings this can mean standing behind a medication cart in the housing unit open area with inmates lining up for their medication. In higher security areas, this may mean rolling a cart from cell to cell to administer medication. Unfortunately, many high security settings have narrow walkways that necessitate pre-packaging medications for administeration through the cell bars.

Stay Alert

Personal safety during the medication administration process is an important concern in corrections. Emotional control can be a scarce commodity behind bars.  Patients can become volatile when medication request are declined, such as in Jennifer’s situation above. Especially in a jail setting, patients can be coming off various self-medication schemes, such as a variety of street drugs and alcohol, making them edgy and irritable. They can be overloaded with entry information for living in this confined setting and may not have registered what was told them about medication changes or start-up delays. Jennifer was comfortable, maybe even complacent, with the medication delivery process and was not alert to her personal safety that morning.

Cart Placement

Cart placement is a very important part of personal safety. Unfortunately, this is sometimes out of a nurse’s control based on the layout of the facility. However, make every effort to work out an agreeable process that maintains personal safety as much as possible. Here are some questions to ask:

  • Can the patient forcefully shove the cart toward the nurse, causing injury?
  • Are there brakes on the cart and are they locked prior to the start of the line?
  • How far from the cart top are patients standing?
  • Could a heavy object, like a pill crusher, be taken from the top of the cart and use as a weapon?
  • Is an officer actively engaged in the medication administration process or focusing on other duties at that time?

Possibly the safest situation is for a barrier to exist between the nurse and the inmate such as the use of a pill window behind a locked door.  It would also be safest for an officer to be located on the same side of the cart as the patient. In Jennifer’s situation, the officer was behind a desk that was next to the medication cart. He was watching monitors while she worked.

Self-Check

Personal safety can also be compromised by a nurse’s own medication practices. Jennifer has seasonal allergies and was taking an antihistamine that works well for allergy symptoms but make her brain a bit foggy for the first few hours after she takes it. Having forgotten to take it when she awoke this morning, she took the medication just before she started organizing for the morning pill pass. Thus, she was not as alert to safety issues as she might have been.

Nurses often focus on patient safety when administering medications as this standard task has great error potential. Personal safety, however, is also a key concern when administering medications in the criminal justice system. Do you have personal safety tips for medication administration? Share them in the comments section of this post.

Photo credit: © Nikolai Sorokin – Fotolia.com

Correctional Officers are from Mars; Nurses are from Venus –Communication in Corrections (podcast)

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cnt-podcast_cover_art-1400x1400Do you feel like you are working in another world when you enter your correctional facility? Then this episode is for you. Art Beeler, former Warden of the Federal Medical Center in Butner, NC, shares his unique perspective on good communication between officers and nurses. Art has some great advice for working with officers. As correctional nurses we are continually walking the balance between custody and caring to do our jobs.

Here are some key tips:

  • Understand and acknowledge the different perspectives between security and health care. Everyone has a role to play in every situation.
  • Good communication is role modeled from the top. First line managers, especially, must show respect and collaboration among the disciplines.
  • Don’t dismiss officer health concerns of inmates. When an officer contacts health care staff about an inmate, even if the issue seems unfounded, the patient still warrants an evaluation.
  • Courtesy and respect among the staff is important. The correctional environment, by its nature, can be negative.
  • Don’t ignore name-calling or disrespectful communication. Address it directly when it happens.

In the Nursing News

Sounding the Alarm – Patient Safety and Quality Healthcare

Unattended alarms ranks as a top safety issues in acute care settings. An article in the online journal Patient Safety and Quality Healthcare outlines strategies to attend to healthcare alarms. Correctional healthcare may generally have less alarms, but those working in large infirmaries may find this article useful. A four tenet approach is advocated for tackling alarm issues.

  • First, address the culture around the safety issue. An organization may find that over-riding alarms or ignoring them is condoned in the culture of a particular unit or the entire facility.
  • Next deal with the infrastructure supporting the unsafe practice. This can include the layout of the unit or staffing patterns.
  • The third tenet is to consider practices. Here is it best to engage front-line staff in developing a process for alarm notification, verification, and response. What alarms, for example, can be changed from the default to better meet the needs of an individual patient?
  • The final tenet is technology. Questions to investigate in this area include whether staff are correctly using the monitor technology – both as intended and to the full extent.

These tenets are also helpful to guide improvement processes for other safety issues. Consider poor documentation of sick call visits. Using the four tenets, consider how the department culture is affecting this issue and what infrastructure could be implemented to support good documentation during sick call visits.  Involve the staff in providing information about practices that leads to a policy revision to support good practice, and then, see if there is any technology that could help capture sick call visits.

Antipsychotics: Adverse Events That Send Patients to the ED (requires free Medscape Account Login)

An editorial by Dr. Lee Hampton, a medical officer at the CDC, cites antipsychotics as having the highest emergency room visits for adverse effects of other primary categories of psychiatric medications. The antipsychotic drug class includes medication such as haloperidol (Haldol), quetiapine (Seroquel), and risperidone (Risperdal). A study using ER visits at 63 US hospitals over the course of three years found antipsychotic adverse events to be three times more common than anti-anxiety medication, four times more common than stimulants, and five times more common than antidepressants. Of course, the implications for correctional nurses are that patients will be initiating sick call visits for antipsychotic side effects, so it is important to be knowledgeable about how they present. The most common adverse effects noted in the study were movement disorders like trismus (jaw spasms), dystonias (sustained muscle contractions cause twisting and repetitive movements or abnormal postures), and extrapyramidal symptoms such as the lip smacking of tardive dyskinesia or the inability to initiate movement or remain motionless. Also, the atypical antipsychotics such as Seroquel and Risperdal can lead to hyperglycemia and new onset diabetes. Take into consideration the use of antipsychotic medication when evaluating your sick call patients. An appointment with a mental health provider for medication management may be in order.

Summer Fun: Top 5 Reasons You Know You Are A Correctional Nurse

two little girls  sitting in the carHope you are including some fun in your summer. Correctional nursing is stressful. Relaxation, humor, and entertainment go a long way to keeping us sane in our crazy world. Nurses have a wild sense of humor, probably generated from a need to break the intensity of our work helping those who are suffering. It can sometimes be misinterpreted by outsiders as being unkind or unfeeling, that is true. With that in mind, I wanted to take the idea of the “You Know You Are….” List and clean it up a bit for public consumption. There are a couple lists making the rounds for correctional nurses – here is one from a ways back on Scrubs Magazine and a recent one that was published on CorrectionsOne. With a hat-tip to these lists and my own good-natured spin, here is my list of reasons you know you are a correctional nurse. In true Letterman fashion, I have listed them in a countdown:

You Know You Are A Correctional Nurse because

#5 – Your Patients are the Ones in Color-Coded Uniforms

When I started as a nurse in the 1980’s it was fashionable in hospitals to have the staff where scrubs based on the unit they were working in. I was in Telemetry/Critical Care and we all wore tan and peach scrubs and lab coats. I guess that was supposed to be soothing. In corrections, our patients are the ones whering designated colors and staff members are more likely to get a list of colors they are not to wear. This might be, for example, khaki or denim.

#4 – Your Patients Make Up Reasons to See You and Don’t Want to Leave

When I worked in the hospital we had many an AMA Discharge (against medical advice). Even patients interested in the treatment plan were eager to depart the unit and move on with their lives. Correctional patients, however, often see the medical unit as a safe refuge or entertaining diversion. This can mean increased requests and access.

#3 – Shift Count includes Every Sharp Item in the Unit

I cringe when I think about some of my past practices with sharps in a community hospital setting. Things are probably tighter now, but leaving needles and syringes lying about was not of great concern in years past in my ‘free world’ practice settings. You can know you are a correctional nurse if you are acutely aware of the location of every sharp item in your work area. It is important to your own safety and the safety of your colleagues and patients.

#2 – You Get a Police Escort When Making ‘House’ Calls

Having officer colleagues is one of my favorite advantages of being a correctional nurse. Many of my emergency nurse colleagues wish they had more security in their world; especially in major urban settings. Our custody peers watch out for our safety and provide an escort when we are working in the housing area or making segregation rounds.

#1 – When You Look at a Patient Who has Done Cruel and Violent Things, You See a Human Being in Need of Nursing Care

Yes, this is the number one way you know you are truly a correctional nurse. We don’t have the luxury, as in some other nursing settings, to be unaware of the character or background of our patients. If you are working in a supermax setting, for example, you can try to ignore it, but your patients have a violent background. Gaining the ability to look past that and see the inner patient in need of your professional service – that is when you truly know you are a correctional nurse!

Christmas in July  – Add to My List and Grab a Correctional Nurse.Net Coaster

Just to increase the summer fun, I will be sending a CorrectionalNurse.Net Coaster to the first 10 readers who add to my list of 5 reasons. Keep it clean, now!

Photo Credit: © altanaka – Fotolia.com

Correctional Nurse Guide to the Code of Ethics: Relationship to Patients

North East South West Signpost Showing Travel Or DirectionJason has been working intake screening at a county jail for over a year now. He has seen some unusual conditions and participated in many an emergency situation, especially when he is on night shift. This Saturday night is uneventful and he finds himself, once again, performing an intake screening on a homeless man who was picked up on a street sweep. This gentleman is unkempt and has a strong body odor. Jason finds it hard to keep from covering his nose as the man shuffles into the screening room. Already familiar with his medical history from prior frequent detainments, Jason rushes through the screening questions making no eye contact.

Code of Ethics Proposition 1: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems.

More than the Tasks

Most correctional nurses have experienced Jason’s situation. He did his job according to protocol and adequately screened this man for medical conditions that need attention. But, has Jason provided ethical nursing care? Provision 1 of the Code proposes that we provide compassionate and respectful care to all patients; a difficult matter in many correctional nursing patient encounters. Without continual attention to our ethical grounding, we can easily drift into disrespectful practices with our patients.

Three Choices

In discussing the application of Provision 1 in the Guide to the Code of Ethics for Nurses, Taylor suggests that we have three choices in how we interact in every patient encounter we have.

1) Go Away: Unfortunately, this may be the message Jason was sending that Saturday night by his body language, facial expression, and lack of eye contact. The ‘Go Away’ message shouts to our patients that we do not care about them as a fellow human in need and we don’t think they are worthy of our care and attention.

2) You are an Object: We treat our patients as objects when we strip them of their humanity. This can happen both intentionally and unintentionally. How many patients have become the “Broken Leg” in Cell 2 or the “Rule Out TB” in Cell 5 of the Infirmary? Dehumanization is rampant in our institutions as incarceration can lead to individuals becoming ID numbers or classification status’s. Nurses working in the criminal justice system struggle to maintain equilibrium in the midst of the pull to objectify the patient population.

3) I Care About You: Of course, the ideal patient-focused encounter in our nursing practice is to convey the message of care. This message can be as simple as making eye contact and listening to what the patient is saying. In a correctional setting, it is often conveyed by taking the patient’s concern seriously and following through on treatment actions.

How to Show You Care in Corrections

Correctional nurses can feel wedged between a rock and a hard place when it comes to showing care for patients. Compassion and respect may not be valued commodities in many correctional settings. Caring behaviors common in other health care settings, such as hand holding or shoulder squeezing can be misinterpreted by our patient population. Jean Watson, a nurse theorist who has focused on caring, suggests some objective way to care as nurses that can easily be implemented in the criminal justice system:

  • Sustain eye contact during patient interactions
  • Verbally respond to an expressed concern
  • Explain procedures before initiating them
  • Verbally validate a patient’s emotional status
  • Discuss topics of concern to a patient other than the current health problem

Jason was not practicing up to Code in his patient encounter that Saturday night, even though he performed all the necessary tasks. The Code of Ethics for Nurses provides guidance for ethical practice that helps us find our way in the criminal justice system.

How to you focus on relationship with your patient population? Share your thoughts in the comment section of this post.

Photo Credit: © Stuart Miles – Fotolia.com

Three Ways to Use Inmate Grievances to Improve Health Care

Frau mit DosentelefonInmate grievances are a standard mechanism for prisoners to request changes and express discontent with a variety of conditions of confinement such as housing, officer treatment, and inadequate medical care.  Although many in correctional health care see the grievance process as a tedious necessity, inmate medical grievances can be a rich source of information for uncovering system flaws. This patient feedback can actually help improve the quality of your patient outcomes, reduce clinical error, and avoid legal liability. Here are three important ways to use inmate grievances to help provide quality correctional health care.

Fix System Problems

“Last month Doc said I was going for tests about my liver. I haven’t seen my name on the call out list yet. Please help!”

Grievances can sometime unearth major system troubles. A common area of weak systems is the process for outside diagnostic testing. No doubt about it, there is no easy way to get our patients scheduled for a liver biopsy, coordinate officer transport, and the various other arrangements necessary for a successful procedure. The investigation of this grievance revealed that several patient tests had dropped off the log during an extended family leave for the medical unit clerk. Staff turnover can lead to system issues if there are no cross-trained staff to keep processes going. This issue was revealed and resolved through an inmate grievance.

Resolve Staff Issues

“I keep turning in sick call slips but no one will see me in medical. I need some attention right now!”

Sometimes inmate grievances are the result of unreasonable expectations and, after investigation, result in educating the patient about the process of requesting and receiving health care. This request, however, resulted in the discovery that the evening shift nurse, whose post duties included rounding to collect sick call slips, was discarding some slips that she determined were unnecessary to process. Resolving the cause of this grievance may have prevented future patient harm by identifying poor staff behaviors. The immediate result of the investigation was termination of the staff member.

Correct Communication Concerns

“My toe is swollen and infected. I was told I would get better shoes months ago. No one is listening to me.”

This older diabetic inmate rightly needed special foot wear and the state prison system he was in had a good process set up for providing them when necessary. However, the communication between medical and procurement in this particular prison was faulty. Good investigation of this medical grievance revealed the disconnect and initiated a change in communication among facility departments that resulted in faster procurement of medically necessary items such as these shoes.

It can be easy to become tone-deaf to complaints of our patients generated through the inmate grievance process. This is a mistake. Granted, some complaints may be unfounded, but all complaints deserve to be investigated.

To use inmate grievances effectively, a system is needed for investigating grievances, answering them, and tabulating any trends. Here are some tips for a smooth-running grievance process:

  • Have a designated individual handle all medical grievances. If you are a one-person department, that would be you; however, if more options are available, pick someone who has a genuine interest in patient satisfaction or quality improvement. A single communication point for grievances means relationships can be built among those in the facility most likely to be regularly handling inmate complaints; thus speeding results. This also provides a consistent contact point when addressing issues with the patient population.
  • Make sure your system is set up to address grievances promptly. Consider grievances like sick call request and turn around a first response in 48-72 hours. A complicated issue may take more time to resolve but you patients should to know they are being heard and that the wheels are in motion.
  • Categorize grievances related to common quality issues once an investigation of the situation indicates a primary cause. Here are some suggested categories:

o   Capacity Issues: Staffing/Supplies

o   Communication

o   Patient Information/Understanding

o   Staff Issues: Knowledge, Accountability, Skill

o   System/Process Issues

  • Tabulate grievance themes in your quality improvement program and investigate trending issues with a formal process or outcome study. Once a trend is seen, a quality improvement study will validate a quality problem and provide baseline data for tracking the outcome of system changes.

Inmate grievances can be a useful source of information about your clinical program. How are you using inmate grievances? Share your experiences in the comments section of this post.

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