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


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

Here are some key tips:

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

In the Nursing News

Sounding the Alarm – Patient Safety and Quality Healthcare

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

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

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

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

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

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

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

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

More than the Tasks

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

Three Choices

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

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

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

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

How to Show You Care in Corrections

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

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

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

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

Photo Credit: © Stuart Miles –

Three Ways to Use Inmate Grievances to Improve Health Care

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

Fix System Problems

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

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

Resolve Staff Issues

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

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

Correct Communication Concerns

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

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

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

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

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

o   Capacity Issues: Staffing/Supplies

o   Communication

o   Patient Information/Understanding

o   Staff Issues: Knowledge, Accountability, Skill

o   System/Process Issues

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

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

PS – You still have time to get a free downloadable copy of my new ebook – The Correctional Nurse Manifesto - by signing up for my email list. Use this link Hurry! Offer ends July 5!

Photo Credit: © puje –

Art Therapy in the Prison Setting (podcast)


cnt-podcast_cover_art-1400x1400Sue Ethridge, an art therapist from North Carolina with over 25 years of experience working with a variety of patient populations, talks about the advantages of art for incarcerated patients. For many years she provided art therapy at the medical facility at the federal prison in Butner, North Carolina. Currently, Sue works with the incarcerated at Central Prison in Raleigh, NC.

A goal of art therapy are to reduce symptoms of mental illness. For example, art materials can help schizophrenic patients connect with reality. A depressed patient with feelings of hopelessness might find a long term art project to be helpful in giving them a future outcome. Art therapy objectives are incorporated into the overall treatment goals. Art therapists are part of the treatment team. Most prisoners, not just those with mental illness, can benefit from creative work. It allows some freedom of choice in a life situation with very little freedom.

During the interview Sue explains benefits of art therapy including

  • Providing an acceptable outlet for expressing feelings and emotions
  • Creating an opportunity to create something meaningful
  • Fostering self-expression and individual decision-making
  • Socialization and teamwork is enhanced through a group project
  • Helping with self-esteem
  • Enhancing social and family connections if the art product is sent out to the community such as a greeting card

How can nurses working in facilities without the luxury of an art therapist incorporate art therapy into practice? Even though art therapy is a masters level position and requires expertise for appropriate interventions, a nurse could encourage the use of art and even provide basic art materials in some settings. Simple themes like seasons and holidays could be considered. Both patients and staff can benefit from the use of art in the correctional setting.

In the Nursing News

Stress In Pregnancy Linked To Autism-Like Traits

First up is a study on the effect of extreme stress during pregnancy on the baby’s later development of autism-like traits. This study from Canada caught my eye because prison is a real stress for our already at-risk pregnant women. Researcher tracked 150 pregnant women who had experience extremely stressful living conditions during severe weather in early 1998 and following the progression of pregnancy and child development. They found that at by age 6 ½ the children were more likely to have austism-connected traits like difficulty making friends, exhibiting odd speech patterns or clumsiness. The researchers are quick to note that these are traits connected to autism but the children had not necessarily developed the diagnosis.

Suicides More Likely After Midnight, Study Finds

Healthday reported on a study presented at the Associated Professional Sleep Societies meeting about the more likely times for suicides. Suicide prevention is always an important issue in corrections. The study suggests that nightmares and insomnia are significant risk factors for suicide ideation and being awakened at night by them can contribute to suicide behavior. After analyzing information from the National Violent Death Reporting System, researchers concluded that the peak time for suicide was 2am – 3am. This has implications for our suicide watch processes. We should be particularly watchful during the night hours – which isn’t always easy.

1 in 10 Heart Attack Patients May Have Undiagnosed Diabetes

Finally, a study presented recently at the American Heart Association meeting in Baltimore found that 10% of heart attack patients were found to also have undiagnosed diabetes that likely contributed to the heart disease. In addition they discovered that only a third of these newly diagnosed diabetics received education and medication on discharge. Also, new diagnoses of diabetes were most likely if an A1C was drawn. A possible outcome of this study might be to look at A1C levels for all new MI patients. Those of us in corrections should be thinking about diabetes when a patient returns from the hospital after having an MI.


Five Mistakes New Correctional Nurses Make

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

Not paying attention to security procedure

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

Disrespecting correctional officers

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

Not treating the inmates like patients

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

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

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

Treating the inmates like patients in other settings

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

Leaving the nursing license at the door

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

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

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

Photo Credit: © gosphotodesign –

Scope and Standards: Care Settings

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

Prison interiorThe other day I was trying to explain correctional healthcare to an attorney who was considering taking on a case involving care in a county prison. I was familiar with the facility and told her that although the facility’s name used the word prison, it was really a jail. Thus began an extended conversation about the differences between a prison and a jail and why that might matter to the case and the clinical experts she would want to engage. One of the challenges of correctional nursing advancement is the great diversity of practice settings in which we work.

In an earlier post I discussed the definition of correction nursing, which encompasses the ANA definition of professional nursing tempered by the particular location of the criminal justice system. This location defines our practice being framed by our patient population (discussed here) and our care setting. The care setting is a unique component of correctional nursing and part of our scope of practice.

Where in the Pipeline

Our care location is first defined by where our patients are in the criminal justice process. The two primary areas are jails and prisons but I have also been involved in nursing care consultations that involved courtroom detainment and half-way houses after release. Our correctional patients can also be found in locked hospital units and addiction treatment centers.

Jail – The majority of arrested individuals are brought to a jail. Jail detainees may be awaiting a court hearing, trial, or sentencing. Many jails also hold those sentenced to a term less than one year as transfer into the prison system would not be cost effective and 12 month or less sentences are rarely high security issues. Jail health care, especially in urban areas, involves high concern for drug and alcohol withdrawal. Jails also have higher suicide rates than prisons so this is also a top-of-mind issue in this setting. Jails have a high rate of turnover, with people coming in for short stays before being released or bonded out to await trial. Therefore, it can be difficult to keep track of your patients and manage chronic care issues or diagnostic follow-through.

Prison – Once convicted of a crime and sentenced to longer than 12 months, an inmate is transferred to prison. Depending on the type of crime, this could be a state or federal prison. Each prison system designates intake facilities that evaluate and classify inmates as to security level and, possibly,  healthcare requirements. Security classification is primarily determined by violence potential and escape risk, although some systems also house sex offenders or gang members in separate locations. Health requirements can affect classification if the system has a central hospital facility or a working prison such as a farm or industrial site. Prison health care is generally more stable than jail health care as the patient population is less transient.

Mixture – Smaller states combined the jail and prison system. Delaware, Rhode Island and Massachusetts have combined jail and prison systems where both detainees and sentenced inmates reside.

Who is in Charge?

The government entity in charge of the criminal justice setting also changes based on location within the system. For example, most jails are managed the county government, although some large urban jails are managed by city officials. Prisons are managed by the state or federal government. The chief executive of a jail may be a sheriff or a jail administrator who reports to the sheriff while the chief executive for a prison most often holds the title of warden. A jail may have deputies as officers while a prison may use the term custody officer or correctional officer (CO).

Age Matters

Offenders under the age of 18 are usually held in juvenile or youth facilities. Some youth are also held in adult facilities if they have been sentenced for an adult crime.

Picture This

Here is a graphic representation I like to use to help visually describe the primary components of the criminal justice system.

Location of Care

This is a fairly simple explanation of the criminal justice system – the setting of correctional nursing practice. After talking with the attorney, she decided she needed a jail nurse expert for her case.  Have you ever tried to describe the criminal justice system to another nurse or care provider? How do you do it? Share your tips in the comments section of this post.

Photo Credit: © viperagp –

May 2014 Correctional Healthcare News Round-Up (podcast)


cnt-podcast_cover_art-1400x1400Dig into the correctional healthcare news with Lorry and guests C. J. Young, Gayle Burrow, and Johnnie Lambert. This month’s news items include female inmate growth, shackling pregnant woman, dealing with summer heat, and housing issues.

Female Inmate Growth Outpaces Males in Jails

Our first story is from the National Institutes of Corrections where they posted the lasted Bureau of Justice Statistics on the jail inmate population. They found that while the male inmate population has declined by 4.2% the female population has jumped by almost 11%. Men still make up the majority of inmates – 86%. What do you make of the rising female population? How will healthcare services be affected?

Best Practices for Using Restraints on Pregnant Women and Girls

Keeping with our female inmate theme, our next story is about a Best Practices Guide for using restraints on pregnant women and girls that was recently published by the Bureau of Justice Assistance, a part of the US Department of Justice. Many national advocacy groups have been lobbying for changes in restraint practices with pregnant – particularly laboring – women. Yet many correctional administrations have been slow to make changes. In fact, even with legislation passed to prohibit use of restraints with pregnant inmates change is slow. Recent news out of my home State of Pennsylvania is that this is still taking place despite prohibiting legislation. Why is restraint a health issue for pregnant inmates? Are there things correctional nurses can do to change practice in their setting?

Death in Hot Riker’s Island Jail Cell

Well, summer is right around the corner and that means hot conditions in many of our jails and prisons around the country. Story #3 is about the death of a mentally ill homeless veteran in a Riker’s Island, NY jail cell that was over 100 degrees. We have a lot of temperature issues in some of our older facilities – I can attest to that having worked in the NJ prison system. CJ, this story got some play on the Correctional Nursing LinkedIn group that you facilitate. Overheating is a real health issue for correctional nursing practice, isn’t it?

Companion Article: Inmate Attacks on Civilian Staff Climb at Rikers

Saskatchewan court dismisses appeal of prison inmates who want to live together

This final story is out of Saskatchewan, Canada, where the court system was asked to decide if two men in a relationship could have a request granted to live in the same house in a minimum-security annex of the Saskatchewan Penitentiary. They took the issue to court when prison officials denied the request. With the rapid social change going on around gay and lesbian concerns, do you think this type of request will become more frequent?

Companion Article: Can Gay Prison Inmates Get Married Now? Can They Share a Cell?

In the Nursing News

Systematic Review of Long Term Weight Loss Maintenance

The British Medical Journal just published finding of a systematic review of research into the effectiveness of interventions to support maintenance of weight loss. This is important in correctional practice because nutrition and exercise are common health education topics so we need some evidence as to what we should be recommending.

Forty five studies were reviewed and the meta-analysis indicated that b there is no clear winner in the successful interventions category, leaving us still wondering what is going to work to maintain weight loss. There is small but significant support for interventions such as behavioral modification sessions, weekly dietician sessions, or consistent physical activity. However, one finding was that weight loss maintenance typically peak at 6 months before a gradual regain of weight in most individuals

Iodine Supplementation for Pregnant Women

Many of us are managing pregnant patients. The American Academy of Pediatrics just published a statement regarding the need for adequate iodine for proper brain development of unborn children. They found iodine deficiency to be high among pregnant women. So, if you provide multivitamin supplementation to pregnant women in your jail or prison you will want to check that it contains iodine.

Physical Therapy May Not Be Helpful for Osteoarthritis

The latest issue of JAMA has a report out of the University of Melbourne where 102 patients with hip osteoarthritis were randomized in a placebo-controlled trial of physical therapy for reducing pain and increasing physical function. They found no appreciable difference between the two interventions. What is interesting in this study is that the placebo control intervention was going to see a physical therapist weekly without the active therapy intervention. They did this to control for other factors such as intensive contact with a caring professional, therapeutic environment, and home tasks. Since with or without the physical intervention, the patient saw improvement, it is postulated that active attention to the arthritic condition may not be as important to treatment as the regular attention of a healthcare provider. Arthritis is a top chronic condition among the incarcerated patient population so these findings are relevant for our practice. You may not be able to provide regular formal physical therapy for your arthritic patients, but paying attention to their condition and offering what you can in our limited environment can still make a difference.

Prison Terminal – A Conversation with Edgar Barens (podcast)


cnt-podcast_cover_art-1400x1400In this episode Edgar Barens, an independent film producer from Chicago, talks about prison hospice from the context of his Oscar-nominated documentary “Prison Terminal: The Last Days of Private Jack Hall” that debuted on HBO March 31, 2014. Find out where the film is currently showing by visiting his website: Edgar talks about:

  • How long it took to film and when he starting the project (Hint: A l-o-n-g time!)
  • Stories about the inmate workers and correctional nurses he was in contact with during the weeks he was filming in the Iowa State Penitentiary.
  • Why a prison hospice is good for all the inmates, not just those who need terminal care.
  • Future documentary plans.

Productivity Tip

Go low-tech with pencil and paper to increase your productivity

Behind the Scenes

Its back to the bedside for me as my husband recuperates from hip surgery

In the Nursing News

This week’s info comes from the Academy Insider – a weekly newsletter from the Academy of Correctional Health Practitioners. If you are not a member, you can still get this free newsletter. I’ll link to the subscribe button in the episode notes:

Changes in Hypertension Treatment: Jeff Keller over at his Jail Medicine blog reviews the changes to hypertension treatment guidelines in a recent blog post. You are likely to care for patients with hypertension so you need to keep up with the latest guidelines. His entire post is a valuable read. Here are the high points.

  • In Adults 60 and older, the new BP treatment goal is 150/90 or below.
  • The BP treatment goal for all patients under the age of 60 is 140/90.   This includes patients with diabetes and kidney disease.
  • Use a thiazide diuretic, a calcium channel blocker, an ACE inhibitor or an ARB preferentially to treat hypertension.  Do not routinely use other drugs, including beta-blockers.

High-fiber diet linked to lower death risk after heart attack: Most prison diets are low in fiber. A new study published in the British Medical Journal shows a link between high fiber diets and lower deaths from heart attacks. Once again the findings are from an analysis of data from the Nurses’ Health Study female US RNs and the Health Professional Follow-Up Study of male health professionals. The study found that for those who survived an MI, greater intake of dietary fiber was associated with decreased mortality. In the general population a 20-40% risk reduction in coronary heart disease had consistently been observed among those who consume fiber-rich whole grains. But less than 5% of Americans get the recommended intake of 25 grams of fiber for women and 38 grams for men. So, add increasing fiber intake to your chronic disease teaching for your heart patients and look for ways to encourage increased fiber in the chow line and commissary.

Soy Sauce The Key To HIV Treatment? Flavor Compound 70 Times More Potent Than Tenofovir: HIV Infection is also a common chronic disease managed in jails and prisons so we need to keep up with the latest findings on effective treatment. Many of us are using tenofavir for HIV treatment. News out of the University of Missouri is that a flavor enhancer called EFdA, used in many soy sauce recipes, may actually be more potent than this standard medication. This research is preliminary and it may be some time before EFdA is on the market as a treatment option, but this sounds very promising.

April 2014 Correctional Healthcare News Round-Up (podcast)


cnt-podcast_cover_art-1400x1400In this monthly round-up of correctional healthcare news Lorry is joined by Sue Smith and Denise Rahaman.

Story #1 Hepatitis C Prevalence and Treatment

Communicable disease makes the news this month with research out of Emory University under the direction of Dr. Ann Spaulding; well–known in correctional circles. Her group found that 17.4% of prisoners are infected with HCV – under earlier estimates of 25%.

This finding is coupled with a second story from USA Today questioning whether prisoners should get expensive Hepatitis C treatment. The cost of treating a single person is $65-170,000 per year using recently developed drug treatment. How do we deal with this ethical dilemma of “treat or not treat”?

 Story #2 - Inmates with HIV benefited from treatment in prison

Disease treatment is certainly effective in prisons, as highlighted by our second story out of Infectious Diseases News. Dr. Jaimie Meyer and colleagues from Yale School of Medicine found that the highly structured environment of prison is good for HIV treatment. I think we have all seen that to be true in our own experience, but, would you agree with Dr. Mike Puisis’ response that there is still much more to be done?

Story #3 – New NCCHC Standards Published

Story number 3 is about the much anticipated new accreditation standards from the National Commission on Correctional Health Care (NCCHC). Although education about the standards began last fall, they were unveiled for the first time earlier this month at the spring conference in Atlanta. I have mine on order but am already beginning to digest the changes. Facilities are scrambling to review changes and make program alterations accordingly. The implementation date for the 2014 Standards is October 1, 2014.

According to the NCCHC website

  • Facilities with on-site accreditation surveys scheduled on or before October 1, 2014, will have the choice of being surveyed under the 2008 edition or the 2014 edition of the standards.
  • Facilities surveyed under the 2008 edition would then be required to submit a plan to meet the 2014 standards by October 1, 2014
  • Facilities with on-site accreditation surveys scheduled after October 1, 2014 will be surveyed under the 2014 standards.

The Standards Change also affects those sitting for the Certified Correctional Health Professional (CCHP) exam:

  • Exams conducted before or on October 1 will refer to the 2008 Standards.
  • Exams conducted after October 1 will refer to the 2014 Standards.

Story #4 – Prison Terminal Documentary on HBO

Our last story is some happy news for our friend and independent film producer Edgar Barens. His film, Prison Terminal: The Last Days of Private Jack Hall, was nominated for an Oscar this past month. It has been airing on HBO and providing a public forum to discuss terminal illness and hospice care behind bars. As a note to our listeners, more information about the video can be found at

There are many articles available, I selected one from Newsweek. In this interview Edgar is quoted as saying “We still owe people like Jack a dignified death”. In many ways, I think that sums up a lot of what correctional nursing is all about – no matter the crimes of an individual – By virtue of their humanity, we owe them respectful care.

Also in this episode:

Are Your Correctional Clinical Processes Like Swiss Cheese?

Swiss CheeseI love Swiss Cheese, don’t you? It makes everything taste better, be it a ham sandwich or a spinach omelet. Yes, Swiss cheese is welcome at my table any day of the week. However, one place Swiss cheese is not welcome is in your correctional clinical processes. No, I don’t mean you shouldn’t eat your lunch while doing Nursing Sick Call (although you shouldn’t). I’m talking about your clinical processes not being full of holes like this block of cheese on the right.

The image of a block of Swiss Cheese demonstrating the various ways we safeguard against errors in complex systems like correctional healthcare was first described by James Reason. Reason used the image of the many and varied holes in Swiss cheese to describe the gaps of protection in the safety mechanisms we have created within our various processes. So, a clinical error happens when multiple “holes” line up in the layers of system protection to allow penetration of the safety system resulting in harm. There is a visual example:

Swiss Cheese Reason







Consider some errors from your own experiences. Although it is natural to first think about the person involved in the error (maybe the person was distracted, unskilled, or inexperienced) there are usually system issues, as well. For example, several staff were out with the flu, emergency protocols are not in place, or an important lab result was not communicated. In the correctional setting, issues with security interface, the geography of care settings within the facility, and patient population characteristics can add additional layers to further complicate the process.

The Swiss Cheese Model is a helpful way to debrief a clinical event to learn about patient safety gaps in your system and make course corrections. Here is a hypothetical root cause analysis for a major correctional healthcare clinical incident in the news  – The Case of Courtland Lucas. Let me say right up front that this analysis is in no way a disparagement of the healthcare contractor. In fact, I have worked for this company in the past and know that there are dedicated and caring individuals seeking to deliver quality care in a challenging setting. This case was selected because it provides enough detail about the situation to suggest some Swiss Cheese hole alignments that let the clinical error ball drop through.

Courtland Lucas, a 31 year old inmate in a city jail, collapsed and died in his cell while awaiting transport to the local hospital. The legal system, looking to attribute cause, typically singles out individual error. In this case the news article suggests that staff members willfully disregarded Mr. Lucas’ medical needs. If we apply our Swiss Cheese Model we might also see some system issues that aligned to contribute to this death:

  • The documentation was missing critical information about the patient’s care. How difficult is it for staff to document? For example, must staff deliver care in an outlying area and then ‘remember’ what they did long enough to write in a paper chart later in the shift when they return to the medical unit?
  • What was the system for communication with the physician? What was the on-call process? Was it difficult to obtain physician advisement at 4am?
  • How difficult is it to get transport for an emergency medical situation? Many minutes can be lost moving a paramedic team through various security check points and sally ports if the patient is deep within the security perimeter.
  • What experience did onsite staff have with the overlapping medical conditions present? This patient, though relatively young, was withdrawing from heroin, had elevated blood sugars and a heart condition. The correctional specialty requires significant autonomous assessment and clinical judgment.
  • Was there an organizational culture in custody or medical that was cynical of inmate requests? Culture is pervasive and can be absorbed, even by dedicated and caring staff. Are there ways to overcome and change such a culture?

These are just a few of my thoughts based on the news article. What else did you see? Share your thoughts in the comments section of this post. Also, let me know what you think of the Swiss Cheese analogy in looking to improve clinical processes. Do you have an alignment example to share? Use the comments section to add to the conversation.

Photo Credit: © Meliha Gojak –