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?

Photo Credit: © Maurizio Milanesio – Fotolia.com

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.

Photo credit: © vladimirfloyd – Fotolia.com

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.

Photo Credit: © victorpr – Fotolia.com

Top 5 Posts of 2014

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Top 5Thank you for being a part of CorrectionalNurse.Net this past year! Your comments and suggestions make this blog a helpful resource for nurses new to the specialty and those interested in keeping abreast of the latest news and information important to working in jails and prisons. In fact, my goal for this blog is:

Informing, encouraging, and inspiring nurses who care for vulnerable, marginalized patients in the low resourced, ethically challenging criminal justice system.

We have been around now for more than 5 years and there are over 300 informational posts in a variety of categories. Search by key word using the search field in the upper right or by category using the drop-down menu on the right sidebar.

Here are the five most popular posts in 2014. Surprisingly, three of these posts made the list in 2013; an indication of the staying power of the topics. Check them out if you missed them when they originally aired. Stay tuned for more great information in the year ahead. I hope you visit often and include your views by commenting frequently.

#5 Correctional Nurses Always on Guard

Nurses learn quickly to be watchful for their personal safety when working in a jail or prison. This post shares important points about guarding our bodies, our minds, and our hearts when we start our shifts.

#4 Dental Issues for Correctional Nurses

By far, dental issues were the greatest learning curve for me in entering this specialty. This post has some great pictures provided by Dr. Stephen Mitchell and is a big help for nurses who need to know what is routine and what is a possible emergency when dealing with dental conditions. This post was the top post of 2013 and is still valuable and popular information.

#3 Interview Guide: Part I   Part II

Many nurses discover this blog while looking for help in preparing for their first interview for a correctional nursing position. This 2-part series shares tips for determining if a correctional setting will be a safe work environment along with questions that may be asked during the interview. A perennial favorite, these posts made the number 2 spot in 2013

#2 8 Medication Rights – Not 5?

Just when you think you are up-to-date something changes. That is life as a practicing nurse. This post adds three new ‘rights’ to the classic 5-rights of medication administration and is actually reposted from the blog of a fellow nurse. A great review! This post made the top five category in 2013, as well (number 3)

#1 Five Mistakes New Correctional Nurses Make

It is easy to start off wrong in this specialty. As a correctional nurse educator, I have helped many staff nurses and nurse managers get oriented to the specialty. In my experience, I have found several common mistakes new nurses can make when they start their career behind bars. This post resonated with many readers.

What was your favorite post of 2014? Share your thoughts in the comments below.

Photo Credit: © md3d – Fotolia.com

December 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts Gayle Burrow and Catherine Knox take a break from their busy holiday schedules to talk with Lorry about the latest correctional health care news.

News Items

WHO Preventing overdose deaths in the criminal-justice system – 2014 Update

The World Health Organization updated a white paper on preventing overdose deaths in the criminal justice system. This 30-page report examines the effect of the prison experience on post-release drug-related outcomes and focuses particularly on opioid addiction treatment. The report affirms what we see in our patient population – opioid addiction is a chronic disorder and has a high relapse rate. There are some key points to consider:

  • Drug treatment services should be similar to what is available in the community
  • Opioid dependent prisoners should be given the opportunity to start or continue substitution therapy if it is available in the community
  • Building partnerships and networks among agencies and within the community is important for success

Legal Issues Unique to Female Offenders

Our second story is a post on the corrections.com website about legal issues unique to female offenders. Not surprising, the three mentioned are health care related – actually pregnancy related. About 5% of women coming into the criminal justice system are pregnant so if you have women in the system you are dealing with pregnancy issues.

The first issue discussed is the use of restraints with pregnant inmates. Medical, legal, and human rights organizations have come out against shackling pregnant inmates. The United Nations even stating that employing restraints during childbirth violates the United Nations Convention Against Torture. Yet, according to this post, less than half of state prison systems have set policies on prohibiting restraints for pregnant inmates.

The second legal issue for female offenders is prenatal care. There have been both news items and legal case reviews on lack of prenatal care or early intervention for miscarriages or initiation of labor, so this is definitely an important issue.

The final legal issue addressed in this post is the availability of non-therapeutic abortion. Non-incarcerated women have free access to abortion. This, however, can be greatly hindered in the correctional system.

Prison Infirmary Failed to Secure Medical Records

The next story is a short piece on confidential medical records being accessed by an infirmary inmate worker and then used against the patient during an altercation. Patient confidentiality is an issue in all settings but this news item is a good reminder that we can’t become complacent about having inmates in the medical unit.

Why one Alaska nurse prefers the jailhouse to the hospital

Our last news item is actually a video posted by the NBC network affiliate in Anchorage, AK. The short video chronicles the work life of Ashten Glaves, a 27 year old nurse working in the Anchorage Correctional Complex. Department of Corrections is the largest provider of medical and mental health services in Alaska. Eighty percent of the patients in the Anchorage Correctional Complex are substance involved and 65% have a diagnosable mental illness. Ashten describes herself as an accidental correctional nurse, landing a job at the jail as a new graduate. This reminds me of a guest blog post by student nurse, Sarah Medved, who was excited to discover correctional nursing while in school and will be looking for work in our specialty when she graduates in the spring.

The video emphasizes many good and accurate aspects of correctional nursing:

  • The complexity and variety of health care situations and how patient education is so important.
  • That crime should make no difference to the care provided. This nurse doesn’t want to know the patient’s charges as it doesn’t affect the job she does as a nurse.
  • That the specialty is not for everyone. Especially if you can’t disconnect your nursing care from the crimes committed.

What do you think about these news items? Share your comments below.

De-Escalating Critical Incidents (podcast)

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cnt-podcast_cover_art-1400x1400Melissa Caldwell, PhD, a clinical psychologist and Director of Mental Health Services for Advanced Correctional Healthcare in Peoria, IL, shares tips for dealing with escalating patient anger or frustration. Do you practice Mental Health Standard Precautions at work? Dr. Caldwell relates this concept in the podcast as being continually aware that any patient situation could become volatile and prepare accordingly. Good advice! We are working with patients who are confined because they are a risk to the public yet we forget that they continue to be a risk while in the facility. That risk has not been neutralized. It should always be in the back of our mind that any patient could become unexpectedly volatile; initiated in some unanticipated way. Don’t be caught unaware.

Here are some other tips from Dr. Caldwell’s discussion on this podcast:

  • Anger and frustration can come from both our patients and ourselves in a patient encounter. Monitoring our own professional approaches to our patient population can help us manage critical incidents.
  • Think of your therapeutic approach as a tool in the health care tool box. Develop your ability just as you would any other nursing skill.
  • Hold unconditional positive regard for the patient. See your patient as a person deserving appropriate care. Maintain a climate of mutual respect. You can respect someone even if you don’t like them.
  • Verbalizing what you are seeing can help the patient see that you understand. This does not necessarily mean you are saying that how they are responding is appropriate. That is an important difference.
  • Listen without interruption. Allow the patient to fully express themselves before responding.
  • Confrontation has little to do with you; but you can make it worse or better by how you respond. Be aware when a patient is getting under your skin.
  • Express empathy with the patient’s perspective. You can empathize with someone even if you don’t agree with them.
  • Have congruency between what you say and what you do. Words and actions must match. For example, don’t make promises that can’t be kept. If you say something, do it. If you can’t do something explain the reasons.
  • Center yourself before a patient interaction. Assess your own mindset. Be particularly attentive if you are having a bad time in your personal life or are ill.
  • Be mindful of your peers in their responses to patients. Help each other to reduce confrontations.
  • Sometimes just letting the person calm down is all that is needed. If there is space and everyone is safe, let the patient run out of steam before responding.
  • Sometimes the best tool we have is to sit calmly and listen with a calm facial expression and head nodding.
  • You don’t necessarily need to be directive. It is better to help the patient discover the way to solve their own issue. We can give support and guidance rather than give them the solution to their problem.
  • Have an exit plan if the patient continues to be volatile. Be sure you know where the officer is and how to activate their involvement.
  • If you know that you are going to deliver bad news (can’t provide medication or treatment desired) you may need to alert the officer on duty to be available for an escalated situation.

In the News

Sugar, not Salt may be Causing Hypertension

The British Medical Journal published an article suggesting that we have been focusing attention on reducing salt intake to reduce hypertension when it may be the sugar in highly processed foods that is the culprit. The article lays out a defense of this proposition based on epidemiology studies. The author concludes that reducing high sugar over-processed foods can be of benefit in reducing hypertension. Correctional nurses can advocate for healthier menus and commissary options for our patients.

Violence Against Nurses Continues

Violence against nurses in hospitals across the country is chronicled in this article from Medscape. Reported violence against nurses is on the increase – up over 6% – according to the Bureau of Labor Statistics. The specialty cited as experiencing the greatest number of incidents is emergency nursing. I wonder if nurses in correctional settings were even a part of that study. It would be interesting to compare violent incidents toward emergency and correctional nurses. I’m thinking that the greater availability of security officers in our setting might bring our numbers down below those in the emergency setting. What do you think?

Have you ever been in a volatile situation with a patient? How did you handle it? Share your thoughts in the comments section of this post.

Correctional Nurse Legal Briefs: Common Areas of Nursing Malpractice Claims

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Medical LawsuitA study of nursing liability claims by a major nursing malpractice insurance provider grouped common allegations by the amount of paid indemnity (money paid out by the insurance company for the case) as well as frequency of the claim. Although this data cuts across all nursing specialties, the top categories of malpractice claims have application in the correctional nursing specialty. Let’s review these as they relate to the particular perils of correctional nursing practice.

Scope of Practice: Scope of practice claims brought the highest payouts. The insurance provider proposed that this is due to a perception that practicing outside of a nurse’s professional license is considered to be of high concern. Correctional nurses have high risk of practicing outside the scope of licensure. Our specialty practice has few boundaries. Correctional peers may have little understanding of what nurses can and can not be asked to do. There may be pressure to limit the involvement of costly outside resources. Wanting to be helpful in a difficult situation, nurses may slip into poor practice outside licensure limits. All nurses must understand the limits of their licensure, but correctional nurses, in particular, must also be willing to speak up when asked to perform outside the boundaries.

Patient Assessment: Claims in this category are frequent. Patient assessment is a major component of correctional nursing practice as nurses are most likely the first to see the patient and a timely assessment indicates need for monitoring, treatment, or referral to another professional such as a provider, dentist, or mental health specialist. The most frequent successful claims in this category were failure to properly or fully complete a patient assessment and failure to assess the need for medical intervention. Of note is a category of claims related to failure to consider or assess the patient’s expressed complaints or symptoms. Correctional nurses can easily slip into a pattern of considering patient complaints to be malingering, manipulation, or attention-seeking. Yet, all patient complaints and expressed symptoms must be objectively evaluated as a part of professional nursing practice.

Patient Monitoring: Once again, correctional nurses, as the primary health care staff in a correctional setting are required to monitor patient conditions and alert providers if changes warrant treatment alterations. The highest percentage of closed claims in this category were related to monitor and report changes in the patient’s medical or emotional condition to the practitioner.

Treatment/Care: This was a broad category in the nursing malpractice data. It included not completing orders for patient treatment as well as delays in completing orders. Mentioned in the report was the need for effective communication among practitioners as many claims were the result of communication failures. Correctional nurses often work with providers who are only minimally on-site and must be contacted by phone for orders or evaluations. Broken communication systems or delays in communication are frequent in an on-call situation. In addition, staff nurses and providers may be unfamiliar with each other, leading to judgment concerns and unfamiliarity with style and perspective. If a provider or nurse is known to be hostile or uncivil, hesitation and delay in communication can result.

Medication Administration: Drug-related errors figure prominently in this evaluation of nursing malpractice claims. The most frequent cause of medication administration claims was giving the wrong dose of medication followed by using improper technique, and administering the wrong medication. Authors of this report noted, once again, the importance of communication, particularly in clarification of confusing medication orders before administration. Medication administration in the correctional setting has additional challenges that increase risk. Pill lines are often long and nurses can be pressured to complete medication administration quickly due to other security concerns. Cell-side medication delivery in high-risk areas such as administrative segregation can lead to pre-pouring medication; an increased error risk.

Documentation Deficiencies: As expected, poor documentation of nursing care contributed to many of the closed malpractice claims against nurses. Incomplete documentation was a factor in many of the above categories and bears mention as a liability risk. Correctional nurses are often called upon to maintain patient record documentation in less-than-ideal situations. If a physical charting system is in use the single chart may be unavailable at the time and location of care delivery. Even electronic medical records require computer availability (great enough number) and accessibility (located where care is delivered). Nurses delivering care in a disseminated system may not be able to chart until returning to the medical unit many hours later.

There are many legal risks to working in a correctional setting, but nurses can greatly reduce the chance of a malpractice claim by attending to the above areas of vulnerability.

Have you experienced any of these liabilities in your practice setting? Share your thoughts in the comments section of this post.

Photo Credit: @ Matthew Benoit – Fotolia.com

November 2014 News Round-Up (podcast)

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

Ohio Prison Inmate Being Treated for Leprosy

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

Restraints Cited in Three Deaths at Bridgewater

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

 Ethical Issues for Nurses in Force-Feeding Guantánamo Bay Detainees

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

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

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

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

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