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

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

Correctional Nursing From Within (podcast)

Play

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

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

December 2014 News Round Up (podcast)

Play

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.

Thinking About Our Patient’s Families This Christmas

Christmas living roomI had some opportunity to think about inmate families over this last year and my heart goes out to them this Christmas season. So much of the holiday is about family and relationship. Yet, with around 2.4 million Americans spending Christmas behind bars, there are plenty of empty seats at Christmas dinner and many a child, parent, and even grandparent missing from holiday traditions. I think today of those who are spending Christmas without their incarcerated family members.

People end up behind bars for many reasons. Families remember the little girl who grew into a confused teen; falling in with a rowdy group of misfits who ended up taking a car on a joyride. A young father turns to drugs and soon abandons his family to chase his demons. An uncle controls his alcohol for decades before it starts controlling him and leads to a drunken car crash and manslaughter conviction.

This year I was in touch with fellow nurses with spouses or children in or entering the prison system. They were afraid for the ones they loved and felt unable to help them. Using what resources I had, I gave them what support I could to help them navigate the system. I know this wouldn’t happen where you work, but I was told about nursing staff that were less than helpful when contacted by these family members. Some were defensive and some rude or dismissive of concerns shared by family members on the outside. These were disappointing to hear and I hope few in number compared with more positive interactions.

In fact, these stories were tempered by hearing from correctional nurse colleagues about ways they have reached out to patient family members in efforts to help manage an inmate health situation. While writing the chapter on patient and family involvement for my recently published book – The Correctional Health Care Patient Safety Handbook (affiliate link)- I was delighted to hear stories from correctional nurses about how they engaged family members to provide input and understanding in a difficult patient situation.

Although some of our patients are estranged from their families due to their life choices and histories, many are not. Consider these ways to engage family members in health care situations in your correctional setting:

  • Use a positive family relationship to motivate a reluctant patient to participate in the care plan.
  • Obtain missing family and health history information necessary for the development of an effective treatment plan.
  • Gain access to prior health records and provider contact information.
  • Assist in continuity of care after incarceration.

Having a family member away during the holiday season can be difficult. Having a family member behind bars during the holiday season can be distressing. If you have all (or even some) of your family with you this Christmas – hold them close and spend a moment thinking about the children, spouses, parents, and grandparents who have a loved one behind bars right now.

PS – A special thanks to those of you pulling a shift this holiday. You are, indeed, a special nurse!

Do you have a positive experience of involving patient family in care? Share it in the comments section of this post.

Photo Credit: © Paul Maguire – Fotolia.com

De-Escalating Critical Incidents (podcast)

Play

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

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)

Play

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.

Eight Ways to Improve Clinical Judgment

医者の表情Although every nursing specialty has its challenges, correctional nursing involves complex situations that can appear simple, but aren’t. There are many unknown factors in sizing up a situation. Correctional nurses are most-often the first healthcare provider to see the patient situation. As a gatekeeper, the nurse must make a fairly autonomous judgment on what needs to be done and who needs to be involved. Therefore, clinical judgment skills are absolutely essential for nurses working behind bars. Recent posts have discussed the vital role of clinical judgment, reasons correctional nurses need clinical judgment, and clinical judgment booby traps to avoid. In this final post of the series, we are turning to ways to improve clinical judgment. Incorporate these methods from traditional clinical settings and educational programs to improve your clinical judgment and that of nurses you work with.

Clinical Practices

 Case Review

Case review is one of the best ways to develop clinical judgment, especially with nurses new to the specialty. Although you can use cases developed purposefully it may be even better to include review of actual cases as a regular part of the process of unit management. For example, reviewing actions, reactions, and interactions of a recent complex or emergent patient situation can allow nursing staff an opportunity to learn from the experience and from each other. Much can be gained by providing an opportunity for staff to dialog about clinical judgment and reflect on their practice and the practice of others. Of course, this dialog must be carefully facilitated so that team members develop abilities to critically review a case without being critical of each other. You want this to be an empowering experience rather than a disempowering one. Careful guidance is needed until staff develop the skills necessary to be encouraging, purposeful, and thoughtful in their dialog.

Peer Review

Guided peer review is another way in which staff can develop clinical judgment skills. Similar to traditional physician peer-review, nursing peer review is a analysis of written documentation of past patient care on an individual practice basis. This process, by the way, is also helpful to encourage more thorough documentation. Learn more about nursing peer review in corrections from this series.

Reflection

Reflective practice is another clinical activity encouraging development of clinical judgment. Reflection on an actual significant clinical experience such as an unexpected death or near-miss experience can yield a wealth of wisdom for the nurses involved. By guiding the discussion toward analysis and synthesis of information, the experience can expand both individual and group learning. New staff members can be asked to keep a journal of their patient experiences that is reviewed periodically with the nurse manager or a senior staff member. The journal activity helps with reflection and the documentation can guide discussion into deeper meanings of assessments or a better understanding of facility processes.

Simulation

Another clinical activity that builds clinical judgment is simulation. Simulation allows a safe practice experience while developing procedural skill and team kills in collaboration and coordination of care. Use the disaster drill and man-down simulations to encourage clinical judgment development. Debrief the simulations as you would an actual experience and guide staff to truly think about why various decisions were made.

Educational Practices

Clinical judgment development can also be infused into standard educational programming. Many in-services involve a lot of information with little application. Instead, a better way is to provide foundational information and then engage staff in a dialog about how to apply this information in practical and realistic situations. An example of how not to do this is an inservice I taught on dealing with chest pain in correctional settings. It had a ton of information about assessment, interventions, and facility policy. We even talked about how to deal with the on-call physician. Participants left with a head full of what and how but not much application or critical thinking about dealing with chest pain. Here are some ways this program could have been improved to help develop clinical judgment.

Dialogue

Adding interaction and dialog to a learning experience engages the learners in thinking and applying the information. Providing real life examples and cases is an excellent way to encourage discussion.

Probing Questions

Probing questions combine with interactive dialogue to fully engage participants. A probing questions looks beyond yes or no and moves the thinker from reaction to reflection. Questions such as “What do you think would happen if……” or “Why do you think that might happen?” encourage learners to analyze a situation and work through possible solutions.

Mind Mapping

Mind mapping, also called concept mapping, is a creative method of displaying information and how it connects together. This process is gaining popularity in undergraduate nursing programs to help students think about the various elements of a clinical situation. Why not use it with practicing nurses? A mind map is a visual organization around a core concept. Here is an example of a mind map developed during a presentation on chest trauma.

mindmap

Algorhythms

An algorhythm is a decision tree that guides through a particular situation. While a mind map is based on relationship of information, an algorhythm is a decision tree and is expressed in a linear fashion, often answering questions of yes or no and then moving on. This example is from an ACLS course on responding to bradycardia. For the chest pain inservice I described earlier, I might have asked participants to develop algorhythms for respond to chest pain.

algorhythm

The key to clinical judgment development in an educational setting is to engage the learner with the thinking processes and to reflect on their own practice and how they might incorporate this new knowledge into their practice.

Do you have ideas for how to apply these eight processes in clinical and educational practices in your setting?

Photo Credit: © ぶぶたん – Fotolia.com

Three Clinical Judgment Booby Traps to Avoid

Risk concept. Sign question on bear trap.Over time, as we develop our practice, we store up clinical reasoning helps that can speed our decision-making for commonly reoccurring scenarios. We begin, for example, to develop rules of thumb and analogies resulting from common pattern recognition that originate from past successes. The formal term for this is heuristics. In fact, clinicians rarely use formal computations to make patient care decisions in day-to-day practice. Rather, we develop an intuitive understanding of probabilities combined with a concoction of rules of thumb, educated guesses, or mental shortcuts.

Without care, other factors can cloud our thinking. In particular, we must be mindful of our biases, cultural background, and assumptions when making clinical judgments.

Biases

Biases are rooted in our human nature and hard to avoid. We can, however, mindfully consider them as we reflect to improve practice. A few biases of importance to avoid when making clinical judgment are described here.

Premature closure is one of the most common errors. In this bias clinicians make a quick diagnosis (often based on pattern recognition), fail to consider other possible diagnoses, and stop collecting data (jump to conclusions). In fact, even the suspected diagnosis is not always confirmed by appropriate testing. A premature closure issue common in correctional nursing might be “I know this patient-he is faking this condition to get attention”.

Confirmation bias occurs when clinicians selectively accept clinical data that support a desired hypothesis and ignore data that do not. Clinicians who rely heavily on pattern recognition and become overconfident in diagnostic abilities can fall prey to premature closure and confirmation biases. If a patient is acting erratically and an officer shares a high breathalyzer reading, a nurse may settle on an alcohol intoxication diagnosis when there are also signs of a head injury.

Availability bias results in overweighing evidence that comes easily to mind. This could be recent evidence or what we perceive as meaningful events. For example, if you have ever had a legal claim against you for a particular diagnoses or clinical action, you have had heightened awareness of that diagnoses for some time afterward.

Assumptions

Assumptions about what is and isn’t present can also affect our thinking and judgment. A simple example can underscore how assumptions can get us tripped up. Consider this puzzle that you must solve. A donkey is tied to a 6 foot rope. A bale of hay is 8 feet away from the donkey. Without biting through the rope, how can the donkey get to the bale of hay? Answer: He just walks over to it. There is not mention that the rope is anchored to the ground. Most people hearing this story, though, assume that the donkey is tethered. Sometimes we need to see what isn’t there as well as what is there when evaluating a patient, too.

Culture

Our culture can lead to unconscious ‘habits of the mind’ that affect clinical judgment. Repeated personal experiences and cultural socialization are absorbed into our ways of thinking about the world around us. For example, over time, correctional clinicians may absorb a jaded view of inmate intentionality or the surrounding security culture of the facility. Attitudes about patient motivation can cloud our judgment and alter subjective interpretation of symptoms.

Sometimes getting over our biases, assumptions, and culture in clinical judgment is as easy as changing the questions we ask ourselves. Imagine seeing a drawing of 2 triangles a square and a circle. If you ask yourself the question “What is this?” You may answer – 2 triangles, 1 square, and 1 circle. How might that change if you ask yourself “What could this be?” Maybe the answer now is – a jack-o-lantern or a clown face. Sometimes self-questioning can break us out of our biases, assumptions, and cultural norms.

How have you seen biases, assumptions, and culture affect clinical judgment? Share your experiences in the comments section of this post.

Photo Credit: © valentinT – Fotolia.com