Are You Thinking Clearly? Rooting Out Biases in Clinical Evaluations

Jigsaw puzzleI was raised on Agatha Christie and Arthur Conan Doyle novels and still find shows like Elementary and Sherlock captivating. In fact, it is the detective work inherent in nursing assessment and diagnosis that drew me to the nursing profession and still keeps me interested some 3 decades later. Oh, for the clarity of mind of Hercules Poirot and Sherlock Holmes when tracking down the cause of a patient’s erratic behavior or unexplainable loss of function!

Unlike these fictional characters, though, we mere humans can be burdened by unconscious biases of thought that cloud our judgement and send us toward wrong conclusions. Improving clinical judgement, then, involves intentionally looking for and rooting out these mental biases in our evaluative practices.

Here is a chart of common cognitive biases I developed for my book The Correctional Health Care Patient Safety Handbook.  Let’s take a look at a few of them as they may emerge in a typical nursing sick call encounter.

Bias Definition Corrective Strategy
Availability Determination based on ease of recalling past cases Verify with legitimate statistics
Premature Closure Relying  too heavily on initial impressions Reconsider determination in light of new data or a second opinion, consider extremes
Framing Effects Being swayed by the description of the  problem Examine the case from alternative perspectives
Blind Obedience Showing undue deference to authority or technology Reconsider when authority is more remote; assess test accuracy
Confirmation Seeking data to confirm, rather than refute, a favored hypothesis Consciously seek both confirming and refuting data
Representativeness Guided by typical features of a disease and missing atypical variants Take into account typical and atypical findings before settling on a diagnosis
Sunk Costs Difficulty considering alternative diagnoses once significant time, effort, and resources have been invested in a particular diagnosis Consider involving a second practitioner free of attachment to the favored diagnosis

 

Remember the patient encounter discussed in the Diabetes Primer post? Here it is again.

A 42 year old female inmate submits a sick call request about her ankle. She thinks she sprained it when she stumbled while walking to the exercise yard one morning a couple days ago. A chart review indicates she is a Type II diabetic and is on a combination of metformin and glipizide. She was recently treated for a vaginal yeast infection with fluconazole (Monostat). She has no other acute or chronic conditions of note. Her ankle is only slightly swollen and painful when she bears weight.

The nurse in that situation analyzed all the information and came to an astute conclusion. What might have happened if a few of the common mental biases had been active?

  • Availability: If the pavement is, in fact, uneven on the way to the exercise yard and the nurse has had other patients stumble or fall, it might be easy to conclude that this is a safety issue rather than a medication issue.
  • Premature Closure: Availability bias might then lead to a premature closure of investigation before seeking out all possible causes. Here, the nurse would focus entirely on the ankle and not bring in any additional evaluation data.
  • Framing Effect: If the patient framed the injury in such a way that being dizzy did not enter into the description, the effect might also be to focus only on the safety issue and musculoskeletal injury.
  • Confirmation: Once favoring a focus on the musculoskeletal injury, the nurse might limit the assessment to the ankle and not pursue any medical causes of the stumble.

Clinical evaluation is a highly specialized skill in professional nursing practice that is of particular need in nursing sick call and emergency man-down situations. Intentionally rooting out mental biases in our assessment and nursing diagnosis practices can avoid error and improve patient outcomes.

Have you struggled with any of these common mental biases in your clinical practice? Share your thoughts in the comments section of this post.

Photo Credit: © Tsiumpa

Time Crunch: What to Do When Med Pass is Cancelled

Time of medicineConsider this scenario: Just as you are preparing for morning med pass at a large city jail a man-down alarm is sounded. Your partner is assigned to emergencies today and she grabs the emergency bag and heads to the announced floor. You continue your preparations, making note that you may be handling both passes this morning if your partner is tied up for very long. A few minutes later, as you are rolling the cart out of the medication room, a call comes in. The man-down is an officer assault, the entire facility is in lockdown, and morning medication rounds are cancelled. Now what?

In traditional health care settings, emergencies may delay some services but accommodations are made to overcome resource limitations to keep care delivery on schedule. Delivering health care is the prime mission of these organizations so plans for emergency need are ever present. In a correctional setting, health care is a support service and not the primary organizational mission. Safety trumps health care needs at all times. Yet, nurses working in secure settings have an obligation to make sure needed medical care, including medication, is provided in a timely manner. It definitely takes determination and creativity to pull this off.

To be effective, many medications must be delivered during specific times related to meals or blood levels of prior doses. Yet, medication timing may be affected by any number of security needs in a correctional setting. Security administration does not often consider the implications of delays or cancellation of medication administration processes when making security decisions. It is often left to health care staff to determine ways to provide the required medication in a timely manner to remain effective in treating the patient condition.

Making Choices

Therefore, it is important to establish a working relationship with security administration and develop a mutual understanding of the therapeutic nature of medication administration and the implication of timing in that therapy. Often a mutually agreeable solution can be reached when medication administration must be delayed or cancelled for a security reason. Here are steps to take when normal medication administration processes are halted.

  • Review medications for the particular timing delay/cancellation to determine if any are time-critical (see table below).
  • Shifting non-time critical medications to the next administration time frame. For example, daily or weekly medication can be moved to a later medication administration time.
  • Consult with prescribers for any gray areas. For example, a stable patient on an anticoagulant may be able to have their medication moved to the evening administration time while a patient with fluctuating INR levels may not be able to delay a dose.
  • Negotiating a method for delivering time-critical medications. Methods can include
    • Cell-side administration: A nurse takes the medication directly to the inmate in the housing unit.
    • Officer escort to the medical unit: Specific patients needing time-critical medications are brought to health care for their doses.

Some settings also allow officer-delivered medication. This requires a clear policy and procedure in addition to a review of the state nurse practice act regarding medication delivery and medication administration. There are many safety concerns with this approach and it is not the best option, if it can be avoided.

In all cases, the process for response to medication administration delay should be written into a policy and procedure that is approved by both security and health care leadership. That way there will be no surprises when an emergency situation like the scenario above arises.

Time Critical and Non-Time Critical Medications

The following listing provided by the Institute of Safe Medication Practice is a helpful guide for making determinations when normal medication administration processes are interrupted.

Time Critical Medications

  • Antibiotics
  • Anticoagulants
  • Insulin
  • Anticonvulsants
  • Immunosuppressive agents
  • Pain medication
  • Medications prescribed to be administered within a specific time period
  • Medications that must be administered apart from other medications for optimal therapeutic effect
  • Medications prescribed more frequently than every 4 hours
  • Medications that require administration related to before, after, or with meals

Non Time Critical Medications

  • Daily, weekly, or monthly medications
  • Medications prescribed more frequently than daily but less than every 4 hours (bid, tid) if not in the time critical listing

How do you handle cancelled medication passes? Share your procedures in the comments section of this post.

Photo Credit: © peerayot – Fotolia.com

Are You Imprisoned by a Messy Med Room?

Cupboard with opened drawerThe medication room is one of the most complex areas of a jail or prison health unit. The set up and maintenance of a medication room can make or break the medication administration process and eat up hours of nursing time every shift. Medication administration can take up to 40% of a nurse’s time in traditional settings. Some correctional nurses spend the majority of their time preparing for, administering, and then documenting medication administration.  Organizing the layout and management of a medication room can smooth the process and reduce error.

Patient Need and Delivery Method

When first organizing a medication room, analyze the needs of the patient population – both size and make-up. For example, a mixed gender population such as that in a large jail will require a wider variety of medication classes than a male-only prison. A large facility with an older patient population will have expanded need for medication delivery and, therefore, larger storage space.

The type of facility, jail or prison, may also dictate medication room needs. A busy jail has a high rate of intake and release meaning many medications are coming in with the patients and awaiting disposal or pick up at release. Storage of these medications can take up space and require an organized system for management.

The method of medication delivery is also a consideration in creating a medication room. If pill line is centralized, a distribution window is often located within the room and medications need to be easily accessed from that location.  A dispersed system where nurses take carts out to housing areas requires room in the medication room to lock the carts when not in use.

The numbers of people working in the room at the same time is also a factor in medication room management. Sufficient space is needed to prepare for medication administration such as supplying the medication cart and organizing equipment.

Room Layout

Many facilities must make due with the room that is available. Fortunate, indeed, are nurses working in facilities with spacious medication rooms. Some facilities merely have a few cupboards in the corner of a clinical room for medications. It is ideal for the room to be laid out according to function. If space is available, a medication room can have areas for the following functions.

  • Ordering, receiving, scanning in and putting stock away
  • Area for the medication carts in easy reach of stock and supplies
  • Locked areas for narcotics and locked box/cabinet with expired or discontinued medication awaiting pick up or shipment to the source pharmacy

Storage Conditions

Consideration should be given to the storage of medications for efficiency and to maintain potency.

  • Bubble packs work well in containers allowing them to stand up so patient and drug name are easy to read
  • Creams, lotions, inhalers, and liquids require separate storage; away from oral preparations to avoid wrong route errors
  • A reliable refrigerator is needed to maintain chilled temperatures for some medications
  • If intravenous services are provided in an infirmary, an additional area for storing IV supplies and solutions may be needed
  • Emergency medications are also kept in the locked medication room and need to be quickly accessible to take to a man-down situation
  • Sharps for medication administration, such as needles and lancets, are also often secured in the medication room

Standardized Processes

The following maintenance systems should be in place to ensure that medications are available when needed for chronic care, acute conditions, and emergency situations.

  • Check in and storage of new medications arriving from the pharmacy vendor
  • Filing of paperwork and order manifests
  • Inspection of expiration dates and stock rotation (esp. emergency medications)
  • Inventory par levels for stock medications, over-the-counter, and protocol medications with standard ordering process
  • Medication return process with pharmacy vendor
  • Monitoring narcotic control
  • Monitoring storage temperatures for room and refrigeration
  • Processing of new prescription orders
  • Reordering of keep-on-person/self-administered medications
  • Shift counts of controlled substances and sharps
  • Turning over the MARs for a new month

Stable Staffing

Consistent staffing in the medication room is a safety factor.  The complexity of the standard medication room processes needs an in-depth understanding of pharmacy processes and patient needs. This requires an individual who values safety and efficiency. Some sites have a pharmacy technician while others have a med room nurse. If “Everyone” is responsible for med room organization, The result is most often a messy med room.

Principles for Medication Room Systems

Here is a summary of key medication room system principles to maintain organization and safety.

Category Principles
Security
  • Keep the medication room locked at all times
  • Reduce the number of staff with key access to the medication room
  • Do not allow food in the medication room
Layout
  • Minimize what is stored in the medication room since access is limited
  • Keep only medications, medication preparation equipment, and controlled items like sharps locked in the medication room to avoid key control issues
Staffing
  • Limit the number of staff who receive, organize, store, maintain, and dispose of medications
  • Have consistent, knowledgeable staff managing the medication room
Storage
  • Keep topical medication clearly labeled and stored separate from oral medications
  • A quality refrigerator and thermometer are needed to maintain proper temperature and humidity for some medications and vaccines
Medication Intake Processing
  • Check medication delivered to the medication room against the delivery manifest and ordering records
  • Report any missing medications to the pharmacy
  • Process and organize new medications such as on medication delivery carts, baskets, or shelves
Medication Organization
  • Organize medication by inmate name or number
  • Medication may also be organized by housing unit or medication rounding system
Medication Disposal
  • Regularly review and rotate stock based on expiration dates
  • Follow environmental regulations when disposing of expired or contaminated medications.
  • Do not flush medication into the septic system
Medication Security
  • Do not allow patients  in the medication room
  • Avoid using inmate porters for medication room cleaning
  • Staff must monitor inmate porters at all times when they are in the medication room
Medication Administration Equipment and supplies
  • Have necessary medication storage and administration equipment and supplies available in the room
  • Supplies can include pill slicers and crushers, disposable pill cups, sharps containers, and drug book

How are you managing the medication room at your jail or prison? Share your tips and tricks in the comments section of this post.

Gayle Burrow, long-time correctional nurse administrator in Portland, OR and frequent Correctional Nursing Today news panelist, contributed significantly to this post. Thanks, Gayle!

Photo Credit: © Oliver Sved – Fotolia.com

Diabetes Primer for the Correctional Nurse

Lori Roscoe, PhD, MSN, CCHP-RN, is a Nurse Practitioner and Correctional Health Consultant in Atlanta, GA. This post is based on her session “Diabetes Primer for the Correctional Nurse” taking place at the Spring 2015 NCCHC Spring Conference on Correctional Health Care in New Orleans, April 11-14, 2015. Learn more about the conference and register HERE.

Stethoscope and device for measuring blood sugar levelIf you have been in correctional nursing for a while, you may have noticed an increase in the number of diabetic patients you are managing. The recently released BJS Special Report on Medical Problems of State and Federal Prisoners and Jail Inmates provides national statistics on the medical conditions of our patent population. It compares this data with that found in 2004 (the last time this information was collected). Diabetes Mellitus (DM) doubled in our patient population in that span of years. That means it is more important than ever to understand this chronic condition and the various treatment modalities available. Consider this nursing sick call situation.

A 42 year old female inmate submits a sick call request about her ankle. She thinks she sprained it when she stumbled while walking to the exercise yard one morning a couple days ago. A chart review indicates she is a Type II diabetic and is on a combination of metformin and glipizide. She was recently treated for a vaginal yeast infection with fluconazole (Monostat). She has no other acute or chronic conditions of note. Her ankle is only slightly swollen and painful when she bears weight.

What Type Is It?

As nurses we learned long ago about Type I and Type II Diabetes. However, we may have an outdated mental shorthand about the differences. For example, you may categorize diabetes by those who need insulin and those who do not. You might also, then, categorize your diabetic patients by those that could be hypoglycemic because of too much insulin and those that couldn’t because they don’t take insulin. But, these categories can be unhelpful. Better is a differentiation based on physiology.

Type I Diabetes – No or Low Insulin Production. In Type I DM the body either stops making insulin or makes too little to effectively manage glucose. Therefore, it is a lack of insulin production.

Type II Diabetes – Inability to Use Insulin. In Type II DM the body loses the ability to use insulin to manage glucose. In this case, insulin is being produced by the body but is not metabolizing the glucose. There also may be inadequate insulin production over time.

Med Madness

Understanding insulin production and use in the body is one part of diabetes management. Another part is understanding the complexity of medication options. Over the past few years, new types of insulin and new medication classes have made the treatment of diabetes complex. Our patients may now be entering the correctional system with unusual insulin regimens and unfamiliar oral medications or medication combinations for maintaining a glucose equilibrium.

Although correctional nurses do not prescribe medications, an understanding of their effect/side effect is necessary to administer these newer preparations. In addition, we may be called upon to interpret a regimen change to a patient; this can be especially true in settings where a limited formulary requires that generic substitution be made to standard treatment while the patient is incarcerated.

Besides effects and side effects, nurses need to be aware of any interactions among medications or with food. Medication timing with or between meals can affect drug absorption and can be difficult to manage in the secure setting where our patients do not have control over when they eat or the type of food available.

Go to the Head of the Class

Categorizing medications by therapeutic class provides an organizing framework for better recall of important information in a clinical situation. A therapeutic class is determined by the drug’s mechanism of action and resulting effects/side effects, and interactions. While Biguanides (like Metformin/Glucophage©) and Sulfonylureas (like Glipizide/Glucotrol©) are common therapeutic classes of antidiabetics, you may be seeing other, newer, classes arrive with patients on intake or being added to the standard formulary. Meglitinides (Repaglinide/Prandin©), D-Phenylalanine Derivatives (Nateglinide/Starlix©),  Thiazolidinediones (Pioglitazone/Actos©), DDP-4 Inhibitors (Sitagliptin/Januvia©), Alpha-Glucosidase Inhibitors (Acarbose/Precose©), and Bile Acid Sequestrants (Colesevelam/Welchol©) are being prescribed more frequently in our setting.

Then, there are the combination antidiabetic medications. These combination pills are often non-formulary for a correctional setting and must be switched to the singular medications once the patient is incarcerated. The patient in the above-mentioned sick call situation was originally taking Metaglip©, which is a combination pill containing both metformin and glipizide. After incarceration, she was switched to the equivalent medications as generic single-medication pills.

Confused? The Joslin Diabetes Center provides a handy table of antidiabetic drug classes and combination pills HERE. You might want to print one out and post on your unit (hint, hint).

How to Get Up to Speed

So, how do you stay up-to-date on diabetes treatment, or, for that matter any of the myriad of new medications and therapies becoming available? Here are a few ideas to incorporate into your professional development plan.

  • Think diabetes (and hypertension) in nursing sick call as both these conditions are on the increase in our patient population according to the BJS report. Our patients may be on new medication regimens or may be suffering from lack of treatment or, even, have undiagnosed conditions.
  • Have a current and easy-to-read drug book handy in the sick call and medication administration areas. No one can keep all that information in active memory.
  • Look up new medications when you first hear of them or begin seeing them on the MAR.
  • Categorize medication knowledge into drug classes and add new classes or new medications to your current mental structure as they become prevalent in your setting.
  • Ask prescribers to provide information about new medications coming into use in your setting. You may want to have an informal education session or have someone from the medical staff speak at a monthly staff meeting.

Chronic Disease and Sick Call Evaluation

Back to that sick call patient with a swollen ankle. The astute nurse, after reviewing the chart and examining the ankle, asked the patient these follow-up questions:

  • Have you been feeling dizzy at all?
  • When does it usually happen?
  • What do you do about it?
  • Have the episodes increased since you started treating the yeast infection?

Once asked, the patient offered that she occasionally feels dizzy but just eats a honeybun from the commissary when that happens. Once she thought about it, she realized that her tumble coincided with just such a dizzy spell and that, yes, she has been getting dizzy more frequently of late. Based on a full assessment of both the acute ankle injury and her diabetes management, this patient had her ankle wrapped and was set up for a provider visit later that day to have her medications adjusted. Glipizide is one Type II oral antidiabetic that can cause hypoglycemia and this side effect is potentiated when taken in combination with fluconazole (Monostat).

How do you keep up with the latest changes in diabetes management? Share your tips in the comments section of this post.

This post is part of a series discussing topics that are addressed during sessions of the 2015 NCCHC Spring Conference on Correctional Health Care. All posts in this series can be found HERE.

Photo Credit: © maya – Fotolia.com

February 2015 Correctional Health Care News Round Up (Podcast Episode 92)

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cnt-podcast_cover_art-1400x1400Gayle Burrow and Denise Rahaman return to talk about this month’s correctional health care news items*.

Medical Problems Of State And Federal Prisoners And Jail Inmates, 2011-12

Our first news item is the publication of a US Department of Justice special report on the Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. This is a long awaited update to their prior reports over a decade ago. The report validates what correctional nurses know to be true: inmates are more likely to have a chronic or infectious condition than the general population and female prisoners have more chronic conditions than males. A few interesting findings:

Clallam County working to avoid measles outbreak in jail

The Clallam county jail in Port Angeles, Washington is now providing measles vaccination for inmates. They are concerned about an outbreak after their Department of Health confirmed the state’s fourth active case of measles recently. As you may know, a measles outbreak has hit California traced to an active case in Disneyland. Will jails and prisons be ramping up measles vaccination?

When Prisoners Are Patients

Next up is an opinion piece that hit the New York Times about dealing with prisoners as patients in traditional settings. Nurse Teresa Brown shares her experiences caring for one prisoner for several weeks. She talks about giving ‘needed, accessible care to the most despised and potentially violent among us’. That surely sums up what correctional nurses do. Insights from the article helpful to correctional nurses include a need to separate the patient from their crimes, maintaining a different perspective than officers, and wondering why necessary health care isn’t provided to all citizens, not just incarcerated ones.

Long-running public service project sends Johns Hopkins students behind prison walls

The Johns Hopkins Gazette tells the story of Hopkin’s students tutoring inmates at the Baltimore City Detention Center. The University’s Jail Tutoring Project currently has 36 undergrads tutoring inmates from the general population, substance abusers working to maintain sobriety and some with mental health issues. The program has been in place for 40 years and stories from the students and the inmates indicate that it is changing lives.

What are your thoughts on this month’s news? Do you agree with our panelists? Share your comments below.

* Views of the panelists are their own and do not necessarily reflect the views of their employers, their clients, or their families.

Botulism and Prison Brew

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

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

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

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

Signs that Trouble is Brewing

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

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

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

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

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

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

Photo Credit: © gekaskr – Fotolia.com

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

Top 5 Posts of 2014

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.