Post Traumatic Stress Disorder Behind Bars

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

Survivor Response to Trauma

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

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

Emotional and Psychological Support Interventions

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

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

Counseling and Crisis Intervention

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

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

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

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

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

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

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

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

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

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

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Diabetic Self Care in Corrections (Podcast Episode 91)

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

Tips for Making Change Happen

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

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

Nursing News

AAP Updates Measles Recommendations

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

Fatal Smoking Risks May Be Higher Than Thought

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

No Evidence to Support Dietary Fat Recommendations

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

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

Botulism and Prison Brew

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

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

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

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

Signs that Trouble is Brewing

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

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

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

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

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

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

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Correctional Nursing – Staying True to Yourself in a Strange Land

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mummers masks of market in Romania 2013.Just about every correctional nurse will tell you it is very difference from traditional nursing. You can feel like you have been dropped into a foreign country where people are in strange outfits and speaking a strange language. Here’s the challenge of correctional nursing – stripped of the many supports that are standard in traditional settings such as a nursing administration or a team of like-minded staff members, many correctional nurses must carve their own path to professional practice behind bars. This is when it is most important to understand the boundaries of your license and the Nurse Practice Act for your state or jurisdiction (Here is a handy directory of State NPAs). This is also when an understanding of the professional Code of Ethics for Nurses is important. The principles that guide professional practice such as patient autonomy, human dignity, and patient-centered care, are challenged every day in a correctional setting.

For many nurses, this is the first time they have been confronted with defining their own practice boundaries or needing to speak out when a request is made that is beyond their scope of practice or is unethical. Here are some recommendations to help you remain true to your professional licensure and ethical responsibilities.

  • Know your role and responsibilities. Don’t wait for a situation to arise that seems wrong to you. Review your nurse practice act and how it practically applies to your correctional nursing position. For example, if you are a licensed practical/vocational nurse (LPN/LVN), are you able to assess and determine interventions for a patient condition? If not, do not accept a sick call assignment.
  • Know your job description, policies and procedures. As with your professional role and responsibilities, know your role and responsibilities to your employer. Determine, before a situation happens, if there are any elements of these documents that don’t seem appropriate to your licensure or ethical responsibilities.
  • Talk to your supervisor. If you have concerns about what you are being asked to do, follow the chain of command and address the issues with your supervisor. Ask about a mechanism for refusing assignments that are not consistent with the nurse practice act. Always work toward a positive resolution to the issue.
  • Prepare a good response to an officer request. Have a well-thought-out response for when you are asked by an officer or security administrator to perform a function that is outside your professional or ethical boundaries. Remember, these folks may not know they are asking you to do something unlawful or unethical. Give them the benefit of the doubt. Here is an example to get you started thinking about how you can respond respectfully and collegially” “I’d really like to help you out with this issue but what you are asking me to do is beyond what my nursing license allows (or is not considered ethical for a nurse to do). Let’s see if we can come up with a solution that works for all of us.”

All of the recommendations above address the issue of being asked to work outside the boundaries of professional nursing practice, but there is another concern that you need to be ever alert for – leaving your nursing license at the door when you walk in. Only you can maintain that mental attitude of who you are as a nurse and what your goals are for professional practice. The definition of correctional nursing found in the ANA’s Correctional Nursing Scope and Standards of Practice is a good place to start for creating your own mission statement for your work as a correctional nurse.

Correctional nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, advocacy, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system.

Using this definition as a guide, you can be reminded of what you do, how you do it and where we are practicing.

What I Do

  • Protect and promote health
  • Prevent illness and injury
  • Alleviate suffering

How I Do It

  • Through the nursing process
  • By being a patient advocate

Where I Do It

  • In the criminal justice system

As different as nursing may seem inside the security perimeter, being a nurse does not change. But it is up to us to keep it that way.

Have you had to carve out your own path in your correctional nursing practice? Share your thoughts in the comments section of this post.

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Help! I’m Not a Mental Health Nurse – Part V: The Officers are Using the Restraint Chair

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dottori mattiCrystal was called to the holding area of the large city jail she worked in to evaluate an inmate that was just put into a restraint chair after refusing to follow the direction of the deputies and continually beating his head against the concrete wall of his cell. She arrives to find the man secured to a padded metal chair with belts around shoulders, forearms, lower legs, and torso. He has on a ‘spit mask’ as the officers reported that he was spitting at them while they restrained him. It was a distressing sight and she stopped for a moment to take a deep breath and organize her thoughts.

Physical restraints are still used in the criminal justice system to manage unruly inmates; most often mentally ill or substance-involved individuals who are not willing or able to follow instruction or control themselves in custody. The risk of self-harm or the harm to others may be valid reasons for a limited use of physical restraint, but the least restrictive options are recommended. Restraint such as this example, especially when it follows a violent take-down or the use of pepper spray, can result in death.  Cases in Florida, South Carolina, and Georgia emphasize the concern over the use and misuse of physical restraint in corrections.

However, sometimes a restraint chair is necessary to keep both the inmate and staff safe for a short period of time, say, to be able to administer chemical restraint or to get a handle on a situation before moving forward. Most problems with the use of restraint chairs come from use as the solution to a problem rather than a short-term intervention in a larger treatment plan.

Restraint Risks

The use of force necessary to establish control of a violent and combative person, especially if this person is large, can result in broken bones or back injury. Death from physical restraint can result from asphyxiation, aspiration, cardiac arrest and other reasons. That is why continuous monitoring of a restrained inmate’s health status is important early in the process.

Immediate Nursing Action Needed!

Correctional nurses are called upon to evaluate the health status of inmates once they are restrained, such as the situation above. It can be extremely distressing to come upon a fully restrained person like this. However, nurses can disagree with the choice of action taken while still needing to provide necessary health care in the situation. Crystal needs to act now in the best interest of her patient. Here are the immediate actions she needed to take:

  • Determine if the patient is in distress – take initial vital signs; especially respirations, heart rate and consciousness.
  • Check that restraints are not so tight as to restrict normal chest expansion
  • Check that limb and shoulder restraints do not have the body is a poor alignment that could cause avoidable injury
  • Check for any body injury that may have resulted from the takedown. Get a report from the officer in charge about the pre-restraint experience to determine if there are any particular body areas that need specific attention.
  • Establish that the patient is being continually monitored by custody staff while in restraint – this can be by video but should also include direct visualization every 15 minutes. Respirations and consciousness should be monitored
  • Establish that the patient is not accessible by other inmates who could harm him.
  • Set up a regular schedule of nursing visits – every 2 hours, at a minimum.

Ongoing Nursing Actions

All the problems of immobility descend upon a fully restrained patient. Even after immediate injury is avoided there remains increasing risk of other perils as time goes on. Just like bed rest, restraint can lead to these conditions:

  • Dehydration
  • Deep venous thrombosis (DVT)
  • Pulmonary embolism
  • Pressure ulcers
  • Urinary tract infections
  • Neuropathy
  • Muscle wasting
  • Constipation

To help avoid the hazards of immobility, then, Crystal and the other nurses need to do the following at each 2 hour check:

  • Monitor vital signs
  • Release limbs one at a time and move each through a normal range of motion
  • Checked each limb for circulation and neurovascular status
  • Offer fluids and toileting

All of these interventions will likely require officer assistance.

Intervene to Reduce Time in Restraint – Mental Health Consult Stat!

Crystal is doing her part in monitoring the patient’s health status and preventing physical injury while in restraints, but she has an opportunity to do so much more for this patient. As a patient advocate, correctional nurses can establish rapport with officer colleagues to make suggestions and encourage interventions on behalf of the patient. Even though this inmate was restrained by order of custody, suggest a mental health consult for a treatment and management plan to deal with the behaviors that initiated the need for physical restraint. Agreement is likely if suggested in a collegial manner focused on the needs of both the patient and the officer (who will want to end continual observation as soon as possible).

In the case above, though, Crystal was unable to convince the officers of the need for a mental health evaluation. She then contacted her supervisor on call and her supervisor directed Crystal to contact the on-call mental health provider while she contacted the jail’s shift commander to broker an arrangement. By the end of the shift the inmate had been started on lorazepam (Ativan ©) and was released from restraint after being moved to a seclusion cell in the protective unit. A positive outcome to a risky patient situation.

Have you had to deal with a physically restrained patient in your correctional setting? What did you do?

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Help! I’m Not a Mental Health Nurse – Part IV: My Patient is Not Eating or Sleeping

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frowning doctor holding a stethoscope and listens to her thoughtCarrie is passing medications for the morning pill line in a large medium security state prison. One of the inmates shuffles to the window looking tired and ill. She asks the inmate “How are you doing?” as she prepares his prescribed medication and he says he can’t eat or sleep since he got here 3 weeks ago because the others on the unit are so noisy and the food is terrible. Carrie knows both those things to be true but she is concerned about how ill this patient is looking and schedules him for Mental Health Clinic later that afternoon. After completing pill line she lets the mental health nurse know that she is concerned about this patient’s mental state and thinks he should be evaluated for a medical or mental health condition that might be causing his symptoms.

Being incarcerated is a downer in and of itself, but Carrie is wise to have this patient evaluated for something more. There are medical conditions that can lead to lack of appetite and insomnia that need ruled out. In addition, this patient might have a mood disorder.

Mood disorders are alterations in emotions that are expressed as depression, mania or both. They interfere with a person’s life, troubling him or her with severe long-term sadness, agitation, or elation. The accompanying guilt, anger, self-doubt leads to altered life activities and relationships. The primary mood disorders are bipolar disorder and depression.

Few nurses are surprised to find so many incarcerated patients struggling with depression. This mental health diagnosis is common in the general patient population but even more so in the inmate population with 20-30% reporting symptoms of major depression according to a Bureau of Justice report. Like depression, bipolar disorder is common among the inmate patient population with that same report indicating that more than half of interviewed inmates reported symptoms of mania in the last year. So, if you work behind bars, it is likely that you will frequently deal with patients showing symptoms of or being in active treatment for a mood disorder.

Rule Out Medical Conditions First

A constant theme in dealing with mental health disorders is to rule out a medical cause for the symptoms. One study of admissions to a VA psychiatric unit found that about 3% of admissions were incorrect diagnoses of symptoms as mental illness that was actually caused by a medical condition. The top misdiagnosed medical condition in this study was hyperglycemia/diabetes, however many other medical conditions can cause depression-like symptoms such as hypothyroidism, liver disease, and anemia. This study also found that these misdiagnoses had incomplete medical histories. It is especially easy to jump right to a mental illness diagnosis if the patient already has a past history of psychiatric care. Correctional nurses can assist with the accurate diagnosis of a condition by obtaining a full medical history along with thorough documentation of subjective and objective assessment findings.

Rule Out Self-Harm

Another constant theme in dealing with mental health disorders is to consider the likelihood of patient self-harm. Suicide ideations should be considered when a mood disorder is being evaluated. In fact, depression in implicated in more suicides behind bars than any other mental health condition.

Is it Depression or Bipolar?

If your patient presents with depression symptoms, it could also be the down side of a bipolar disorder. With this condition, the patient has excessive mood swings between periods of high activity, racing thoughts, and poor impulse control (mania) and periods of intense feelings of loss and hopelessness (depression). It is important, then, to ask a potentially depressed patient about past seasons of manic activity. For example, any of the following:

  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative than usual or pressure to keep talking
  • Racing thoughts
  • Attention easily drawn to unimportant or irrelevant external stimuli
  • Excessive activity such as unrestrained buying sprees, gambling, or foolish investments

Anticipate Treatment Options

Effective treatment for mood disorders combines medication and therapy to reduce symptoms and develop responses to the condition that will return the patient to a normal level of function. Here is a handy guide to various mental health medications from the National Institute of Mental Health (NIMH).

Medication. Antidepressants are likely to be prescribed for depression while mood stabilizers are initiated for those with a bipolar condition.      

Antidepressants.The most common anti-depressant medication categories are tricyclic (TCAs), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).  Each have a specific side effect profile but here are common ones for all classes:

  • Slow start: Most antidepressants have a slow start up for symptom relief – up to 4 weeks. Counsel patients to persevere through the side effects for depression relief. If there is no response in a month, a medication change may be warranted.
  • Dry mouth: Make sure the patient has access to liquids
  • Sedation: If sedation is an issue, consider moving the medication to the last dose of the day. SSRIs and SRIs can cause insomnia. In this case, consider moving the medication to the morning dose.
  • Nausea: Try to provide medication near meal time if this is an issue.
  • Discontinuation syndrome : The abrupt discontinuation of most antidepressants can lead to dizziness, lethargy, headache, and nausea. Therefore, there should be adequate bridging of antidepressants at intake and patients new to these medications need instruction on the importance of therapy continuation.

Mood Stabilizers. Lithium is still the most popular mood stabilizing medication for a bipolar disorder, although others in use include atypical antipsychotics such as Olanzapine (Zyprexa), Aripiprazole (Abilify), and Risperidone (Risperdal).  Lithium toxicity is a real issue for these patients and can be difficult to manage in a jail or prison. Lithium levels should be closely monitored with at least weekly laboratory work. The medication should be held and the provider contacted for levels of 1.5 mEq/L or above. At these levels the following symptoms may be noted:

  • Blurred vision
  • Ringing ears
  • Nausea and vomiting
  • Severe diarrhea
  • Mental confusion

Lithium levels of 3.5 can lead to seizures, coma, and cardiovascular collapse so monitoring lithium levels is vital for patient safety.

Therapy

Group and cognitive therapy can be helpful for patients with a mood disorder.  Group therapy can provide a supportive environment to gain perspective on the condition while cognitive therapy can help a patient control the thought distortions and expectations that potentiate disordered moods.

The inmate Carrie was concerned about did have an elevated blood glucose and is being worked up for Type II Diabetes. He was evaluated for suicide potential and obtained a low score on the screening. A mood disorder was ruled out by the psychiatrist at his monthly clinic and he was entered into an inmate diabetes support group that was being piloted in the facility.

How do you deal with mood disorders like depression and bipolar disorder in your setting? Share your thoughts in the comments section of this post.

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Correctional Nursing From Within (podcast)

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cnt-podcast_cover_art-1400x1400Elizabeth Scala, a registered nurse and author of the book “Nursing From Within: A Fresh Alternative to Putting Out Fires and Self-Care Workarounds”, talks with Lorry about the challenges of maintaining a positive mental perspective in nursing. Elizabeth is a former psychiatric nurse who worked on one of the most acute inpatient units in the state of Maryland before starting her work as a keynote speaker and Reiki Master Teacher. She talks about the principles from her book and how they  might apply to correctional nursing practice.

A key concept for a fulfilling nursing career is to run toward your true heart’s desire and ideal work setting rather than away from what you don’t want. Listen to this podcast episode to revitalize your correctional nursing practice in the New Year. Think about connecting with your inner nurse this year – the reasons you went into nursing in the first place, who you are, and what you enjoy about nursing.

In the News

We are all about getting in shape in the New Year and so we have a couple studies here looking at the benefit of exercise. Although exercise programs can be difficult to arrange behind bars, maybe you can develop some options for your patients this year.

Exercise Helps Menopause Symptoms and Quality of Life

Researchers in Finland looked into the benefits of exercise for managing menopause symptoms and quality of life. They surveyed 2606 women about exercise habits and their self-perceived health. Less active women had higher scores for anxiety and depression while those more active reported greater self-perceived health and less hot flashes. Although these correlations are significant, the increased activity may not be the cause of the improved health but the result of it. Still, there is mounting evidence that moderate activity (2.5 hours per week) has health benefits and moderates menopause symptoms.

Arthritis: Self-directed Exercise Program Shows Benefits

A self-directed exercise program for those with arthritis was the intervention in another study on exercise and health published recently in the American Journal of Preventive Medicine. Exercise has been found to be of benefit to those with arthritis but most do not exercise as they should. One reason is due to accessability of exercise classes such as those recommended by the CDC. To combat this difficulty, a self-directed program called The First Step to Active Health created by the American College of Sports Medicine was provided to around 200 participants who were directed to follow the program at their own pace. They were provided with arthritis-specific recommendations, logs for reporting progress to the study coordinator and an expectations calendar. After 12 weeks participants were found to have improvement in strength, functional exercise capacity, flexibility, pain, fatigue, and stiffness. What I like about this program is it looks adaptable to the limitations of an incarceration environment. I could not find where it has been used in a prison setting but would love to try it. Let me know if you are interested in trying this program for your arthritic patients.

Influenza Hospitalizing Twice as Many as Last Year

The CDC is reporting a heavy flu season this year with hospitalizations more than double that of a year ago. They think this is due to the principal virus strain A(H3N2) and that the strain circulating is mutated from the strain used to create the current vaccine, making it less effective.

What are you doing in your facility to reduce infection spread? Are you limiting visitors, increasing hygiene, monitoring staff illness? Share your actions in the comments section of this post.

Help! I’m Not a Mental Health Nurse! Part III – My Patient is Lying and Manipulative

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stressPersonality is the emotional and behavioral characteristics that make up a person. Personality traits are said to be present at birth or develop early in life. Personality influences the way we see and relate to the world. Correctional patients often have disordered personalities that have led to criminality and incarceration. Although there are many forms of personality disorders such as paranoid, narcissistic, and obsessive-compulsive, the most common forms in the correctional patient populations are antisocial personality disorders. Prisoners are ten times as likely to have an antisocial personality disorder as the general population. So, correctional nurses need to understand how to recognize and respond to these conditions. Consider this patient situation:

Lynn is a new nurse in a medium security state prison. One morning on treatment rounds in one of the housing units she gets distracted while George is using the nail clippers. Clippers are available for use by inmates in the presence of a nurse. When she returns her attention to George the clippers are nowhere to be found and George responds “What clippers? You must have left them somewhere.” He smiles charmingly at Lynn as she frantically searches for the missing implement. Although afraid of losing her job for carelessness, Lynn reports the situation to the housing officer who initiates a lock down and cell search. The clippers are found in George’s shoe and he is placed in administrative segregation. Later it is discovered that George owed another inmate a large gambling debt and wanted moved out of general population for protection.

Antisocial Personality Disorders (ASPD)

Antisocial personality disorders involve characteristics of social irresponsibility, exploitation of others, and lack of guilt or shame in these behaviors. These traits make ASPD patients dangerous to the emotional and psychological well-being of nurses who care for them.

What to Look For

Here is a list of common ASPD characteristics. How many of them describe patients arriving at your sick call or medication line?

  • Superficial charm
  • Self-centered & self-important
  • Need for stimulation & prone to boredom
  • Deceptive behavior & lying
  • Conning & manipulative
  • Little remorse or guilt
  • Shallow emotional response
  • Callous with a lack of empathy
  • Living off others or predatory attitude
  • Poor self-control
  • Promiscuous sexual behavior
  • Early behavioral problems
  • Lack of realistic long term goals
  • Impulsive lifestyle
  • Irresponsible behavior
  • Blaming others for their actions
  • Short term relationships

George demonstrated several of these characteristics in the situation with Lynn. He took advantage of her and felt no shame or guilt about it. He was superficially charming while being deceptive and lying about the situation.

A patient with antisocial personality disorder, then, is manipulative, irresponsible, deceitful, and guiltless. Nurses must be careful to protect themselves while setting clear behavioral boundaries for the nurse-patient relationship.

Protect Yourself from Manipulation

Unless you are working the mental health side, your job is not to ‘treat’ the antisocial behavior, but to be aware of it and protect yourself. These patients will use every interaction to their advantage. They are astute at discerning another person’s vulnerabilities and they prey on people who are hurting. Staff members who are lonely, insecure, or self-involved are good candidates for the manipulation of an inmate with an antisocial personality disorder. Nursing careers have ended when nurses have been drawn into sexual relationships or nefarious activities such as smuggling contraband or diverting narcotics for these individuals. Guard yourself. Know the characteristics. Keep yourself and your teammates accountable to stop potential issues before they move to a dangerous level.

Protect yourself from manipulation by treating all inmate-patients with consistant professional behavior and demeanor. Follow all security rules of conduct. Here are a few tips.

  • Don’t get personal. If an inmate comments about your hair or your figure, call them on it. If the comments continue, report them.
  • Do not perform even the smallest ‘extra’ activity for an inmate. That cotton ball or paperclip is the first step down a slippery slope.
  • Treat all inmates with equal respect and professional distance. Do not show any favoritism and do not allow any in return.
  • If you think you may have already been compromised, report it immediately to your supervisor and take actions to halt the progression. This may include reassignment to another care unit to break the connection.

Control the Situation

When working with ASPD patients it is important to maintain control of the situation.

  • Keep your distance: A somewhat detached therapeutic stance will help establish the professional nature of the interaction. This patient will not appropriately respond to empathy or compassion.
  • Keep control of the relationship: Set clear limits about your availability, frequency of encounters, and appropriate patient behavior during medical visits.
  • Keep your cool: Monitor your own feelings when entering into a patient encounter with an ASPD patient. Be mindful of words and actions. For example, avoid responding in kind to verbal attacks or manipulation.

Establish Behavior Accountability

All patients, but those with ASPD in particular, need to be held accountable for their behavior. While it is difficult to maintain positive regard for a patient who is deceitful or manipulative, it can be done. Here are some ways to remain therapeutic in patient encounters with ASPD patients.

  • Maintain an attitude that projects that it is not the patient but the patient’s behavior that is unacceptable.
  • When the patient exhibits unacceptable behavior, identify it as such and redirect the patient to appropriate behavior.
  • Do not attempt to convince the patient to do the right thing. Instead of saying “You should” or “You shouldn’t”, say “You are expected to”. This establishes normative behavior and depersonalizes required actions.

Interacting with patients who have ASPD can be the most frustrating part of your correctional nursing practice. However, with mindfulness toward self-protection and behavioral boundary setting, you can feel confident that you have done your best to provide quality healthcare in a difficult situation.

Have you struggled with a difficult patient like Lynn’s? Share your experience in the comments section of this post.

Photo credit: © © crystal kirk – Fotolia.com

Help! I’m Not a Mental Health Nurse! Part II: My Patient is Hearing Voices

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crazy doctorPsychotic patients have lost touch with reality and have unusual thought disturbances such as hallucinations and delusions. The most common psychotic disorder is schizophrenia, but patients can manifest any variety of psychotic symptoms without having this diagnosis. The Bureau of Justice reports that 15% of those in prison and 24% of those in jail reported having thought disturbances such as hallucinations or delusions. So, correctional nurses are likely to provide nursing care to psychotic patients. Consider this scenario:

Melinda is conducting nursing sick call in a local jail. Her next patient submitted a slip indicating right ankle pain. She interviews the patient; asking about the initiation, duration, and quality of the pain while examining the patient’s ankle. The patient explains that he hears voices at night talking about the tracking device implanted in his ankle. When it is turned on he gets a sharp pain that lasts for about 20 minutes. He knows that his movements are being tracked by the government. This patient has been in the jail for 5 days. The initial screening form only indicates that the patient is not suicidal and has no history of medical or mental health treatment.

Auditory hallucinations are one of the most common types of psychiatric symptoms. Most often these false perceptions manifest as voices but they can also be clicks, music, or other sounds. Like this patient’s presentation, psychotic disorders can include both hallucinations and delusions. A delusion involves a false personal belief that the patient continues to believe even after proof to the contrary. Here is a short list of common delusion types:

  • Control: Belief that objects or persons have control over him. This patient has a control delusion.
  • Grandeur: An exaggerated sense of importance or power. This delusion can be combined with religiosity. (“I am Jesus Christ”).
  • Persecution: Belief that others intend the patient harm. This patient also expresses a persecution-type delusion.
  • Reference: Irrational belief that all objects and actions refer to the patient. “All the articles in this magazine are talking about me in code.”
  • Somatic: Delusions based on body function. A 65 year old woman saying “I know I am pregnant even though the Dr. says I am not.”

Labeling the delusion, however, is not as important as accurately describing what the patient is hearing and experiencing.

An earlier post discussed ruling out medical conditions that might cause psychiatric symptoms – particularly delirium. Melinda plans to discuss this with the on-call physician once she has gathered all the data. She knows this patient will likely need a referral to a mental health professional. The mental health nurse practitioner sees patients two afternoons a week. She won’t be in until tomorrow afternoon, though, so what should Melinda do to help this patient right now?

Subjective and Objective Findings

Melinda still needs to perform a physical assessment and document subjective and objective findings. Although it is unlikely that the patient has a tracking device implanted in his ankle, he may actually be feeling pain and may have an injury.  Always fully evaluate a patient concern.

In addition, exposure to medications or drugs and medical conditions such as hepatic disease or electrolyte imbalance can cause psychotic symptoms. There is little known about this patient’s history. Melinda may be able to obtain helpful background information from the patient or, if available, the patient’s family.

Determine Harm to Self or Others

When a patient reports hearing voices, the underlying cause can be variable: auditory hallucinations, thoughts characterized erroneously as “voices,” or an indicator of malingering. Regardless, if a patient reports hearing voices, it is important to fully evaluate how this might affect the patient’s safety and the safety of those around him. Ask the patient what the voices are saying and attempt to get a full range of the content. If there is any indication that the voices instruct the patient to harm himself, perform a full suicide evaluation. If the voices instruct the patient to harm others the patient needs to be isolated from other inmates until there is a full mental health evaluation and therapy is active.

General Tips for Working with Psychotic Patients

It can be challenging to handle a patient interaction with someone who is not in touch with reality. There are a few things that Melinda was keeping in mind when communicating with this patient.

  • Avoid touching the patient without warning. Although we avoid touching anyway in corrections, touch happens during assessment and vital sign readings.
  • Maintain an attitude of acceptance to encourage the patient to fully share the delusion or hallucination.
  • Do not reinforce the hallucination. For example, refer to an auditory hallucination as ‘the voices’ rather than ‘they’.
  • If appropriate, as when a patient is hearing the hallucination in your presence, respond truthfully in an affirming tone. Such as “Even though the voices are real to you, I do not hear them.”
  • Do not argue or deny a false belief. Instead, present a ‘reasonable doubt’ position such as “I understand that you believe this, but I am personally having a hard time accepting it.”
  • Avoid laughing, whispering, or talking quietly to other staff around the patient.
  • Maintain an assertive, matter-of-fact, and genuine approach.

Therapy Options

Once Melinda fully evaluated the patient she contacted his mother who was indicated on the intake form as an emergency contact. With the patient’s permission, she asked his mother about his prior medical history and discovered that the patient had, indeed, been under psychiatric care in the past and had been taking Risperdal (risperidone). The patient had left home several months ago and his mother was no longer able to encourage compliance.

Armed with this information, the on-call provider was contacted and an order was obtained for this medication. Risperidone is an atypical antipsychotic agent (also called second generation) often prescribed for schizophrenia. Other drugs in this class include Clozapine (Clozaril), Olanzapine (Zyprexa, and Quetiapine (Seraquel).

Medication is not the total answer for a psychotic condition and this patient will likely need some type of therapy such as behavioral therapy, group therapy, or individual psychotherapy. Unfortunately, many settings like Melinda’s have limited resources for these mental health services.

Have you had a sick call episode with a patient hearing voices? Share your experience in the comments section of this post.

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