De-Escalating Critical Incidents (podcast)

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

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

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

In the News

Sugar, not Salt may be Causing Hypertension

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

Violence Against Nurses Continues

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

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

Correctional Nurse Legal Briefs: Common Areas of Nursing Malpractice Claims

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

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

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

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

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

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

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

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

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

Photo Credit: @ Matthew Benoit – Fotolia.com

November 2014 News Round-Up (podcast)

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

Ohio Prison Inmate Being Treated for Leprosy

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

Restraints Cited in Three Deaths at Bridgewater

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

 Ethical Issues for Nurses in Force-Feeding Guantánamo Bay Detainees

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

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

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

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

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

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

October 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurse experts Mari Knight, Johnnie Lambert, Denise Rahaman, and Sue Smith join Lorry to discuss the hot topics in correctional healthcare news in this monthly round-up.

Ohio prisons credit $10M savings to Medicaid changes

Our first story comes from the Ohio prison system where they are reporting saving $10 million dollars in medical expenses this fiscal year through maximum use of the Medicaid system and Affordable Care Act. Frankly, the various ways prison and jail systems cover inmate medical expenses can be confusing. Of note is the enrollment of inmates in Medicaid for better continuity of care and access to medications.

How Gangs Took Over Prisons

Our next news item is an extensive article in the Atlantic about how gangs took over prisons. The information is fascinating. The article mainly focused on gang activity in the California Prisons System – Pelican Bay State Prison, in particular – and relied heavily on a book by David Skarbek called “The Social Order of the Underworld”. It can be helpful for nurses to understand their patient’s culture. Information from this article and the book may be of particular interest for nurses working in facilities with major gang activity.

NLN Recognizes the Role of the LPN/LVN

This next item is a document published by the National League for Nursing on the recognition of the role of Licensed Practical/Vocational Nurses in advancing the nation’s health. This is of particular importance in our practice setting as we have a high percentage of nursing care delivered by LPNs/LVNs. Based on surveying the changing employment characteristics of LPNs, the NLN is recommending curriculum revisions to meet healthcare system needs – such as adding geriatric and culturally relevant care. The paper reports movement of LPN practice into long term care and community settings where they are dealing with predictable chronic conditions. Of note is a section on Scope of Practice variability and what they call “the growing disconnect between scope of practice standards and the reality of practice”.

Nursing Student’s Program Helps Save Lives in State Prison

Our final story discusses a nursing graduate student who is positively affecting patient care in the California Prison System. The student is Kelly Ranson, chief nurse executive, at Kern Valley State Prison, a high security prison in the state system. She gained approval to implement her Health Promotion and Disease Prevention course project in the facility. This involved diabetic self-management among the male inmate population. The article noted collaboration with security administration and a team approach with mental health staff, dieticians, medical staff and peer support. This report provides a model for implementing health care innovations in a correctional setting.

Clinical Judgment: A Vital Correctional Nurse Competency

decisionsRhonda has been called to the booking area to medically screen a 44 year old man brought by the police on charges of driving a stolen vehicle and drinking while driving. On the way to jail he hit his head on the window of the squad car. Approaching the area she sees an obese white male, hands cuffed behind his back, leaning facedown on the booking counter, propped up by two police. The man is yelling that he is going to faint and can’t breathe.  A chair is brought so he can sit and Rhonda notes that he is diaphoretic and flushed in the face. He reports that he has prescriptions for two inhalers but otherwise has no medical problems. His voice tone is belligerent and he is dressed in shorts, a t-shirt and sandals;  inappropriate for the winter weather. Rhonda can see that his legs and feet are mottled and swollen. He also has a swollen area over his eyebrow on the right side and the eye on that side is swollen shut. There are four policemen waiting for the nurse to screen the arrestee and another six custody officers waiting to proceed with booking. 

Christine Tanner, a nurse researcher, has studied expert nurses to determine components of clinical judgment and when it is most specifically needed. She found that clinical judgment skills were particularly important when

  • The clinical problem or concern is undetermined;
  • The presenting data is ambiguous; and
  • When the situation presents conflicts among individuals with competing interests

Our case above has all three elements. Rhonda has a problem to solve and she needs to do it quickly amidst competing interests – the patient’s, the police, and the correctional officers. The patient condition is undetermined at the moment. Rhonda cannot merely review the patient’s medical record for a list of diagnoses. His presenting data is ambiguous and non-specific. The clock is ticking and the pressure is on.

Tanner reviewed 200 studies on clinical judgment in nursing practice. From this review she concluded that a nursing clinical judgment involved the following components:

  • Gaining a grasp of the situation holistically
  • Seeking an understanding of the situation which is beyond just the objective findings on assessment
  • Considering factors contributing to the presentation
  • Attending to the patient’s response to the nurse
  • Deciding an appropriate course of action
  • Reviewing outcomes and making changes as needed

What clinical judgment do you think Rhonda made in this situation? Even though there was pressure to book the man, she was concerned about a concussion and his respiratory condition. She did not approve him medically for booking and he was sent on to the hospital emergency room. There it was discovered that, although he was intoxicated, he did have a mild concussion, and, more importantly, was discovered to have moderate congestive heart failure. He was in the hospital for over a week.

Have you had a challenging patient presentation that seemed ambiguous at the time or had competing interests to consider? Share your story in the comments section of this post.

Photo Credit: © mstanley13 – Fotolia.com

Correctional Nursing Peer Review (podcast)

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cnt-podcast_cover_art-1400x1400Peer Review for Nurses? Many correctional health care settings are gearing up for correctional nursing peer review as NCCHC implements new accreditation standards this month. In this episode correctional nurse experts Catherine Knox, Kathy Page, Becky Pinney, and Pat Voermans join Lorry to discuss correctional nursing peer review and changes in the NCCHC accreditation standards for standard C-02 – Performance Enhancement.

The performance enhancement standard has been around for many years and focused on peer review for medical providers. This latest revision now includes all licensed staff; thus adding RN and LPN team members to the peer review process.

Panelists discuss the importance of this change for correctional nurses and nurse leaders. They also dispel some common misconceptions about nursing peer review; differentiating peer review from annual performance review and competency evaluation. Practical ways to perform nursing peer review are also described.

A series of blog posts about correctional nursing peer review can be found on the Essentials of Correctional Nursing blog.

In The Nursing News

How is Ebola Transmitted?

Lots in the news about the Ebola virus hitting US soil. Since much is still unknown about the virus and no vaccine or medication treatment is yet available, it is important to be careful around anyone who may be infected. Nurses, in particular, spend time in close contact with patients so we need to know about transmission and protection. On October 15 the CDC increased their caregiver protection barriers to more closely match World Health Organization recommendations. Standard precautions for droplet and body fluid contamination were enhanced with double gloving and full body coverage, including head and neck. Important points:

  1. Ebola has been detected in blood and many body fluids. Body fluids include saliva, mucus, vomit, feces, sweat, tears, breast milk, urine, and semen.
  2. The virus is spread by direct contact; meaning that body fluids (blood, saliva, mucus, vomit, urine, or feces) from an infected person (alive or dead) have touched someone’s eyes, nose, or mouth or an open cut, wound, or abrasion.
  3. Ebola is killed with hospital-grade disinfectants (such as household bleach). Ebola on dried on surfaces such as doorknobs and countertops can survive for several hours; however, virus in body fluids (such as blood) can survive up to several days at room temperature.
  4. Although coughing and sneezing are not common symptoms of Ebola, if a symptomatic patient with Ebola coughs or sneezes on someone, and saliva or mucus come into contact with that person’s eyes, nose or mouth, these fluids may transmit the disease.

Would your health care unit have the equipment necessary to protect you should you need to isolate a patient for evaluation for Ebola infection? Think about this now and have the conversation. Be prepared.

Men with Osteoporosis are Neglected

The International Osteoporosis Foundation has published a report on osteoporosis in men. Although we tend to think about osteoporosis as an elderly female condition, a third of all hip fractures occur in men. Men are prone to brittle bones as they age; particularly after the age of 70 when testosterone reduces significantly. Other factors contributing to osteoporosis in men include smoking, drinking more than 2 drinks per day, low vitamin D levels, a family history and taking certain medication such as cortisone, antiepileptic drugs and SSRI antidepressives. If you care for elderly male inmates, consider osteoporosis and concern for falls.

USPSTF: Screen Everyone 45 and Older for Abnormal Glucose

The US Preventive Services Task Force drafted new diabetes screening guidelines recommending that everyone 45 years and older should be screened for abnormal blood glucose and type 2 diabetes. They hope to identify those with abnormal glucose levels to initiate lifestyle interventions before the condition progresses to diabetes. The guidelines are open for comment until early November, 2014.

Patients Listen More to Female Doctors

An interesting French study suggests that patients heed guidance more regularly from female providers than from male. The study design hypothesized that patients would listen more to a physician of the same gender but it turns out that both male and female patients were more disposed to listen to a female physician. Based on this and prior research the authors suggest that female doctors may be more collaborative with patients and male doctors more dominant. Also, earlier studies have shown that women doctors report feeling more comfortable discussing personal and sensitive issues. It would be interesting to see a similar study regarding nurse-patient relationships.

Making Ends Meet: The Blunt End and Sharp End of Clinical Error

A 33 year old male inmate from a maximum security state prison was admitted to a community hospital with flank pain and hematuria. His Arrow Chamber Funnel ChartINR was discovered to be 8.2 (therapeutic range 2-3). His medical history included deep vein thrombus resulting from Protein S deficiency. A medication error investigation revealed that the patient had been receiving three times the amount of the current order of warfarin (Coumadin) and no INR diagnostic tests had been completed for the last 2 weeks.

Investigating What Went Wrong

Hundreds of doses of medication are administered every day in most correctional facilities so it is not surprising that medication errors are some of the most common to emerge in practice. Investigating errors can lead to information necessary to make improvements to reduce future risk. An error can result from poor decisions and actions along the entire medication use system: ordering, transcribing, dispensing, administering and monitoring. Often poor practices are found in several areas that result in an incident.

Blunt End/Sharp End Evaluation of Clinical Errors

A helpful model of error causation looks at the various components of a clinical error as an inverted triangle with the point of care being at the sharp end and the various complexities of organizational structure, system, and process being at the blunt end; removed from the actual error episode. Blunt end components, then, contribute to an environment that either encourages or does not prevent the error under consideration.

Case Analysis by Blunt End/Sharp End

Figure 1.2The Blunt End/Sharp End model provides a framework for evaluating a clinical error like the one described above.

Sharp End: Investigating the sharp end of the error focuses on the actions of the clinicians in direct contact with the patient. Here are some sharp end investigation questions for this case:

  • Did the nurse follow standard medication administration safety steps when administering the recent doses of warfarin?
  • Were there multiple strengths of the medication in the medication cart and did the nurse administer an incorrect dose?
  • Did the prescribing provider order the strength of the doses administered?
  • Did the prescribing provider order INR lab tests?
  • Were the tests completed but not reviewed or documented in the medical record?

Blunt End: Investigating the blunt end of the error focuses on the policies, procedures, systems, resources, and constraints surrounding the incident. Here are some blunt end investigation questions for this case:

  • What are the policies regarding INR evaluation while on warfarin?
  • What tracking systems are in place for patients on anticoagulation medication?
  • Is there an adequate process for discontinuing previous medication dosing when new dosing is ordered?
  • Are nurses working in this area appropriately oriented to the medication administration process?
  • What percentage of the nursing staff are new, float, or agency staff?
  • How much overtime or double shifts are nurses in this unit working?
  • What communication system is in place for nurses to question medication orders?

Always Look Upstream

When investigating significant errors such as the one above, it is easy to fall into several mental biases.

Attribution error bias: It is easy to pin an error on a character flaw or defect of the clinician at the sharp end of the error. Rather than look for all issues, evaluators stop at the shortcomings of staff members involved in the incident.

Confirmation bias: Making a quick judgment of the cause of an error can lead to accepting evidence that supports that judgment while neglecting evidence that would favor other causes. If an organization is prone to evaluating only the sharp end of a clinical event, evidence supporting this view would encourage investigators to stop looking elsewhere.

Hindsight bias: Actions and outcomes viewed after the fact show an ‘obvious’ path of cause and effect. At the time of the actual event, however, multiple possibilities vie for attention, making the future less apparent. Investigators must consider the event from a perspective of an unsure outcome.

By intentionally looking upstream to the blunt end of a clinical situation, the full picture is able to be evaluated and meaningful process and system corrections can be made; leading to reduced risk of future error.

In the case presented above, faulty medication discontinuation practices, poor interdisciplinary communication (both written and verbal), along with inconsistent medication validation at the point of administration contributed to the poor patient outcome.

How do you evaluate clinical error in your setting? Share your process in the comments section of this post.

Information from this post comes from Chapter 1 of my new book: Correctional Health Care Patient Safety Handbook: Reduce Clinical Error, Manage Risk, and Improve Quality (affiliate link). Click on the link to purchase a print or ebook version. Or, enter my raffle for your own free copy – 3 winners. Hurry, raffle ends November 1: Raffle for a Free Copy of the Patient Safety Handbook

Photo Credit: © John Takai – Fotolia.com

September 2014 News Round Up (podcast)

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cnt-podcast_cover_art-1400x1400Correctional nurses Margaret Collatt, Jeannie Chesney, and Susan Laffan, join Lorry to discuss the latest correctional health care news in this podcast.

Briefing Paper: The Dangerous Use of Solitary Confinement in the US

The ACLU recently published a briefing paper on the dangers of solitary confinement in US prisons. This has been a topic of interest for some time in corrections news as more and more evidence of the effects of long term confinement emerge. This paper reports that more than 80,000 prisoners are likely held in some form of solitary confinement, be it administrative segregation, disciplinary segregation or protective custody. Panelists discuss the variable nature of what constitutes solitary confinement and the effects as reported in the paper. Sadly, many in solitary confinement are juveniles or have severe mental illness or cognitive disabilities that led to not understanding or following prison rules. The effects of confinement can’t be helping them. What can correctional nurses do about solitary confinement practices is also discussed.

Excited Delirium and the Dual Response: Preventing In-Custody Deaths

Excited delirium is the topic discussed in a recent issue of the FBI Law Enforcement Bulletin. This poorly understood medical emergency is seen fairly frequently in the criminal justice system, particularly involving young males who have drug intoxication or mental illness. If not recognized and treated, respiratory arrest can result in death; often during a take-down situation. I’ve been involved in reviewing several correctional legal cases that involved possible excited delirium and know it can be hard to diagnose, even after the fact. It must be very difficult to recognize and manage in the midst of trying to manage a young, strong, agitated and hallucinating male. Panelists describe their experiences with this condition.

Clinic geared toward health needs of ex-offenders opens in Philly

Philadelphia has opened a city health clinic geared toward ex-offenders and people leaving jail or prison. It is a response to the need for health care for our patient population once released. Most of us know that incarceration is often the first health care experience for many of our patients and chronic diseases end up being identified and treated. Then, once released to the community, follow-up is difficult. Panelists agree that this is a good idea that will hopefully be replicated elsewhere.

Oregon prison tackles solitary confinement with Blue Room experiment

Oregon Live is reporting on the use of nature imagery as a therapy to reduce the mental health effects of solitary confinement at the Snake River Correctional Institute in Oregon. A forest ecologist from the University of Utah, Nalina Nadkarni, suggested the use of images of nature such as beaches, rain forests, and waterfalls could help reorient prisoners in isolation and decrease the mental illness, self-harm, and escalating agitation that emerges with continued isolation.

The therapy was picked up by administration at Snake River in early 2013. They used one of their recreation rooms to play nature videos and were able to convert the room for about $1500. They are seeing some positive results including some reductions in disciplinary infractions. The University of Utah hopes to research the effects of the intervention later this fall.

 

Correctional Nurse Guide to the Code of Ethics: The Nature of Health Problems

North East South West Signpost Showing Travel Or DirectionThis post is part of a continuing series applying the Code of Ethics for Nurses to correctional nursing practice. Find other posts in the series here.

Kim was not happy with her assignment in the large city jail infirmary where she worked. The patient load was manageable but she didn’t want to deal with the patient in cell B-5. Kim was a new mother with an eight month old baby girl. She had done everything right during her pregnancy; strictly following medical advice and not drinking at all. Her baby was born with a slight esophageal defect that required surgery in the early days. Although her baby was doing well, it was a continual concern for her. Now she is struggling with bad feelings toward the pregnant woman in cell B-5 who is six months pregnant and going through alcohol withdrawal while being maintained on methadone for her heroin addiction. How could this woman have so little regard for her child’s future? Kim did not know how she would be able to make it through the shift.

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

Kim definitely has an ethical dilemma. She cannot get past the nature of her patient’s health problem. She is unable to provide nursing care in this situation with compassion and respect for the inherent dignity, worth, and uniqueness of this patient. What are her options?

Gift Exchange

An easy option would be for Kim to broker an assignment exchange. Another nurse who is less sensitive to these concerns may be willing to care for this patient and get beyond the ethical matter. This exchange provides Kim with the gift of time to work through her ethical dilemma. Smaller facilities may not have enough staff on shift to provide this option or nursing leadership may be unwilling to juggle assignments. Best for Kim to approach a fellow staff member with the idea and then present a plan to the nurse manager for consideration. This can only be a short-term solution, though.

Shifting Perspective

Kim needs to both objectively and subjectively analyze her feelings toward this patient. It may, in fact, be true that this woman is totally disregarding the health of her unborn baby, however, providing appropriate infirmary care is reversing this disregard. Managing the withdrawal of alcohol in this situation may be of great benefit to the baby, as well as the mother. This shift in perspective may allow Kim to engage in an appropriate therapeutic nurse-patient relationship. Caring concern might be what this patient needs to make a life change. Even if this doesn’t happen, Kim’s nursing care will be of benefit to the unborn child.

Out of Body Experience

Kim does not respect or value the actions of this patient. This is true for many of our incarcerated patients. They have made poor life decisions that most nurses would disagree with. Kim is able to overlook this when dealing with other patients. Why is this one a problem? This is the heart of the ethical issue that Kim must struggle through. This patient’s decisions hit close to home as Kim has a young child and is sensitive to how the life choices of this patient are affecting her unborn child. Kim may benefit from considering the situation from a third-party perspective. This practice (sometimes called bracketing) involves consciously setting aside personal feelings or biases in a situation. No doubt, if she has strong feelings about this patient’s seeming disregard for her baby, bracketing will be challenging.

Most important is that Kim actively engage in working through her ethical dilemma rather than respond poorly to this patient or deny that she is having difficulty.

Have you struggled with a similar situation in providing correctional nursing care? Share your thoughts in the comment section of this post.

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