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.

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.