Correctional Nursing Research Priorities

Research PrioritiesI was excited to see my correctional nurse research published in the October, 2015, issue of Journal of Correctional Health Care (JCHC) for several reasons. Of course, it is always professionally fulfilling to see your writing in print; especially in a peer-reviewed scholarly journal such as JCHC. Performing nursing research, in itself, is a rewarding and difficult enterprise, so just completing the study was satisfying. But, the top reason for my pleasure in seeing this research in print is the promise that it might spur meaningful research in our specialty. This is much needed as we move forward to establish professional correctional nursing practice. I encourage you to read the full article, if you are able. However, here is a summary of the key points of the study.

The Delphi Method

The Delphi research method is a survey of expert in a particular discipline. It has been used to determine research priorities in a number of nursing specialties and was familiar to me as I used it to determine research priorities for the nursing staff development specialty many years ago. In the Delphi approach a group of experts in a field of study are asked to list, from their perspective, top priorities for a particular area of study. It could be research or it could be priorities for competencies or even components of a practice guideline or standard of care.

For my study, I put out an email call for participation to a large group of correctional nursing experts I had met in my various activities in the field. Those who responded included their resume to confirm expertise and background. Eighteen experts were included in the Delphi panel.

A three-round Delphi method was used and included these rounds:

  • The first round asked the question – What are the most significant problems or questions affecting correctional nursing practice that can be solved or answered through nursing research?
  • The second round had panelists rate the list of research questions obtained from the first round.
  • The third round allowed panelists to see the second round mean rating of each question and have an opportunity to rate the research questions using that feedback.

Top Correctional Nursing Research Needs

Here are the key areas of correctional nursing research needs as determined by this expert group.

  • Critical Thinking/Clinical Judgment: How are critical thinking and clinical judgment affected by our unique environment and the particulars of our patient population?
  • Competency/Educational Level: What are the core competencies for correctional nursing practice?
  • Assessment: How can nurses rapidly, yet effectively, assess correctional patients?
  • Nursing Protocols: What are the best formats and methods for nursing protocols that stay within scope of practice?
  • Effect on Patient Outcomes: What are correctional nurse-sensitive patient outcomes?
  • Environment of Care: In what ways does the care environment affect correctional nursing practice?

Now What?

How can this study be used to increase correctional nursing research? Here are some ideas.

  • Determine the theme of a thesis or dissertation when pursuing an advanced degree.
  • Determine areas for best practice development for a site or correctional system.
  • Establish research topics for a grant proposal.
  • Gather a collaborative group across systems to pursue an understanding of one of the themes.
  • Topics for conference presentations.
  • Topics for journal manuscripts.

So what do you think? Are there other ways to apply correctional nursing research priorities? Share your ideas in the comments section of this post.

Responding to Angry Inmates

During a sick call visit for lower back pain, a patient begins shouting at the nurse that no one is helping him with his pain. “I need something stronger than these baby pills!”, he shouts as he stands up and puts his face in front of the nurse.

Dealing with angry patients is a challenge, especially when you have a patient population prone to anger management issues like many of our inmate patients. Successfully managing anger in others is mostly about your own response to the anger as Dr. Melissa Caldwell discusses in the Correctional Nursing Today Podcast “De-Escalating Critical Incidents”. A while back I wrote a post on dealing with inmate anger and recently came across some new research on response to anger that may help make your work life calmer. Neuroscience is providing some helpful direction for those of us confronted with angry patients. Much of the findings noted here come from the books Handbook of Emotional Regulation and Crisis Negotiations: Managing Critical Incidents and Hostage Situations in Law Enforcement and Corrections.

Stay Calm

Dealing with a tense and angry patient can easily make you react in kind. It is natural to reflect a similar emotion yet if you stay calm the patient is less likely to escalate. This takes practice and self-awareness. Studies in neuroscience show that the answer is not to suppress your own anger, though. Suppressed emotions don’t help the situation and can actually continue to escalate the confrontation. Venting your angry response, of course, doesn’t help either. Distracting yourself from the emotion was actually found to be the most helpful method for staying calm. How would that work in a patient interaction like the case above?

It’s Not About You

Neuroscientists found that reappraising the situation was of the most benefit. Reappraisal is the consideration of alternative explanations of a situation. Reconsider the situation from the patient’s perspective: he is in pain; he is under a lot of stress. In other words, focus on the underlying cause of the anger.

Smart parents do this all the time with toddler temper tantrums. Rather than confronting the emotion, they ignore the tantrum and consider possible causes such as overstimulation. Sometimes a brief time-out is all a child needs to regain control. This concept can work for out-of-control adults, too.

Slow Things Down

Crisis negotiators advocate slowing down the conversation to help the angry person get control of their emotions and to show a desire to actively listen to them. Your response can be as simple as stating that you would like to help but need them to speak slowly so that you can understand. Slowing down the conversation helps the person gain control of their emotions while you get organized to respond effectively.

Response Toolkit

Crisis negotiators use active listening techniques to diffuse emotional situations. Active listening is established through body language and verbal response.  Here are some verbal responses that show an angry patient that you are listening to them.

  • Acknowledge: “It sounds like you are frustrated with your treatment.”
  • Paraphrase: “The medications you are now taking are not helping your back pain.”
  • Open-ended Questioning: “Let’s work on this. Tell me more about your back pain.”

The Texas Medical Association has a resource for handling patient confrontations with some verbal communication techniques that can help with an angry patient. Here are three techniques they recommend:

  • Wish I Could: “I wish I could give you stronger pain medication, but we first need to establish the cause of your back pain.”
  • Agree in Principle: “I agree that we need to get your back pain under control. Although I can’t give you other pain medication, here is what we can do.”
  • Broken Record: If the patient continues to try to get their way, don’t come up with new reasons why you can’t do it. Instead, restate the same response with slight variation.

Oh, by the way, these techniques work well in all areas of practice and life. Try them when communicating with angry coworkers or family members, too!

Have you had success dealing with an angry inmate? Share your experience in the comments section of this post.

Photo Credit: @master1305

July 2015 Correctional Health Care News Round Up (Podcast Episode 103)


Ep103Gail Normandin-Carpio and Denise Rahaman join Lorry to talk about top correctional health care news items for July, 2015.

Callous and Cruel: Use of Force against Inmates with Mental Disabilities in US Jails and Prisons

Our first story is a report out of Human Rights Watch about the use of force against inmates with mental disabilities in US Jails and Prisons. We have been discussing the plight of the mentally ill in the criminal justice system for some time. Our jails and prisons are not organized to effectively treat mental illness, yet growing numbers of inmates have serious mental illness such as schizophrenia and bipolar disorder. The mentally ill are less likely to adjust to conditions of confinement and have difficulty following all the rules that must govern life behind bars. That puts them into confrontational situations with officers who must keep order and control. This report paints a grim picture but also provides some hopeful recommendations.

Bill would give inmates’ families access to prison medical records

New York has passed a bill that would require the State Department of Correction and Community Supervision to provide medical information disclosure forms as a routine procedure for all incoming or transferring inmates. This would give inmates the option of appointing a family member or other person to receive their medical information.

Dating a prisoner: What attracts people on the outside to fall in love with convicted criminals?

This next story is about dating prisoners and comes from a British news source. The recent NY Prison Escape story and follow-on investigation as brought to light something we see in practice all too often – staff getting intimately involved with criminals. Hybristophilia is described as a condition whereby women are sexually aroused by and responsive to men who commit heinous crimes. Often referred to as the ‘Bonnie & Clyde Syndrome’, the person who is the focus of the sexual desire can be someone who is in prison. In some cases, the hybristophile may urge and coerce their partner to commit a crime. This may somewhat explain staff attraction to our patient population.

Florida prisoners train therapy dogs to help veterans

In our final story, a group of Florida prisoners are training therapy dogs for veterans suffering from Post-Traumatic Stress Disorder as part of a new program. Prisoners from the Blackwater River Correctional Facility will train three puppies for America’s Vet Dogs Veteran’s K-9 Corps with plans to expand to 10 dogs by the end of the year. The training program will teach the K-9s to do everything from retrieving medication, to turning lights on and off, to waking veterans from nightmares. Sounds like a nice idea for both the veterans and the inmates.

What is your take on these news items? Share your thoughts in the comments section of this post.

Four Ways Your Patient Can Help You Avoid A Medication Error

Four Ways Your Patient Can Help You Avoid a Medication ErrorA well-informed patient can be a great assistance in reducing medication error. The more patients understand about the medications they are taking, the better they can assist with monitoring treatment practices and questioning when unfamiliar medication is offered. Here are four ways to engage your correctional patient in the medication process to avoid error.

  1. Be Sure Your Patients Know the Important Stuff

Patients are best able to contribute to medication safety by having both general and specific knowledge of their medication program. Low general health literacy contributes to misunderstanding and gaps in patient medication. The level of understanding of the medical process, and specifically the medications ordered for treatment, affects medication adherence, whether provided by direct observation or through a self-administration process.

  • Medication allergy. General knowledge includes an understanding of any medication allergies a patient has and the symptoms they see when taking these medications. Indeed, understanding the difference between side effects and allergies are of particular importance for proper treatment. For example, a patient may state that they are allergic to aspirin when what they have experienced is stomach burning when they have taken aspirin on an empty stomach. Therefore, it is important to obtain descriptive information about medication allergies when documenting a health history.
  • Medication effect and side effect. Even when patients come into the criminal justice system on long-term chronic medications they may have misconceptions about why they are taking the medication, the expected effects of the medication on their condition, and what side effects they should be monitoring. There is even greater need for this information if new medications are added to the regimen.
  • Self-administration practices. Self-administration practices such as dosing and timing of medication self-administration can be an added challenge for patients, especially those with low literacy skills. It may take more than mere labeling instructions to be sure patients are appropriately self-administering medications allowed in the keep-on-person program. Besides basic information about medication effect, side effect, dosing, and timing, patients should be able to identify an interactions with food or other medications as well as any precautions that need to be taken such as avoiding direct sunlight or not stopping the medication abruptly. Because incarceration can restrict movement and meals, health care staff should also be sure self-administration practices are adapted to the particular situation of the patient.
  1. Give Them a Way to Communicate Directly with You

A knowledgeable patient is particularly important in a correctional setting where security barriers can cause medication delay or omission. A direct communication process between the patient and the health care staff assist in allowing patients to speak up when they have concerns about medication administration schedules. Many inmates use the sick call slip process for communication with health care staff, although other systems may need to be initiated if this is burdensome to the sick call process. For example, some settings have electronic communication through a kiosk system and others have a phone message system for inmate/health care communication.

  1. Help Them Understand Their Role

Incarcerated patients may need to be directly told to speak up about their medical condition and to question medication administration that does not fit with their understanding of their medical treatment. The power-over structures within a correctional setting does not encourage proactivity or self-efficacy in the patient population. Health care staff need to encourage and support patient participation in the care plan, including actively addressing unfamiliar medication administration.  Staff administering medications must be willing to explain any changes in the regimen. Here are a few common times when medications may be unfamiliar to a patient.

  • New patients may have medications switched from non-formulary brands to generic equivalents on intake into the facility.
  • Patients may not understand the information provided by a prescriber regarding a dosage change.
  • A new medication formulation including a change in size or color of the pill may be used while patient-specific medication is shipped from the pharmacy.
  1. Create a Solid Medication Self-Administration System

Involving the patient in administering their own medications can improve patient safety and assist with developing independent health habits. As identified earlier, patient education on drug and food interactions is important; so is information about medication effects and side effects. Confirm that the patient understands what situations require medical attention and the process for obtaining more medication when the supply is dwindling. Here are some tips for a safe and effective keep-on-person (KOP) medication program.

  • Establish a system for distributing and reordering KOP medications. Be sure patients understand the system and their responsibilities. Many medical units ask that patients show up at a treatment or pill line to reorder medications when there are about 10 doses left. This allows time for order filling.
  • Incorporate KOP medication into the Medication Administration Record (MAR) process. All medications provided to the patient should be documented in a single place to assist in communication among care providers and decrease confusion in the treatment plan.
  • Be sure every medication card has the patient’s name and ID, as well as medication and prescription information. During cell sweeps, medications will be confiscated if not in the possession of the person whose name is on the card.
  • If providers give out medications during medical sick call, sometimes called ‘Provider Packs’, the medication cards should have the inmate’s name and ID written on them by the provider along with date and signature.
  • In like fashion, over-the-counter medication distributed by nurses during sick call should be labeled for the individual inmate with date and nurse signature.
  • Security staff should be able to confirm the rightful owner of any medication found in the general prison population.
  • A regular spot-check process for patient compliance with KOP medications is helpful. Randomly check KOP cards in mid-cycle to determine proper use. For example, twice a week, a number of inmates with KOP medications could be called to report to the medical unit with all KOP cards. Nurses can use this time to validate proper use and reinforce patient teaching.

How do you involve your patients in monitoring their medications? Share your tips in the comments section of this post.

Photo Credit: © Vera Kuttelvaserova

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 –

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
  • 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
  • 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
  • Limit the number of staff who receive, organize, store, maintain, and dispose of medications
  • Have consistent, knowledgeable staff managing the medication room
  • 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 –

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 –

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


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 –