Could You Be the Next Joyce Mitchell? 4 Prevention Tips

Could You Be the Next Joyce Michell- (1)Many of us have been closely watching the unfolding events surrounding the NY Prison Break over the last month. Here is a timeline of events, concluding with the death of convicted killer Matt and the shooting and capture of convicted killer Sweat in upstate New York. Early in the story Joyce Mitchell, a prison worker who managed the tailor shop with her husband, was taken into custody for her part is assisting the prisoners.

Those unfamiliar with our patient population find it hard to believe that someone would develop an intimate relationship with a murderer and assist them in this way. Yet, unhealthy inmate relationships are a constant threat and should be a continual concern for anyone working in the criminal justice system. No one is immune to this work hazard. Here are my four prevention tips along with some links to prior posts and podcasts on the topic.

Know Your Patients

Prisoners are ten times more likely than the general population to have an antisocial personality disorder (ASPD). That means many of our patients are sociopaths or psychopaths; individuals who use others to gain what they want without remorse, guilt, or conscience. Among other things, that means that they may appear charming and charismatic in their interactions with you. Unfortunately, that charm is often ‘turned on’ in order to manipulate and deceive. Always be aware that things may not be what they seem in the words and actions of patients. Click here for more information about dealing with lying and manipulative patients.

Know Yourself

Most of us became nurses in order to help people in distress – the injured, ill, and suffering. This motivation can make us prey to antisocial patients. Empathetic people are natural targets for sociopaths. We are even more vulnerable when our emotional lives are in turmoil such as when we are having relationship issues (divorce or break-up), work stress (new job, discipline, understaffed), health issues (illness, pregnancy, new baby) or are under financial stress (foreclosure, credit card debt). Be aware of your emotional and psychological state when dealing with this patient population.

Remember Where You Are

Many of us spend the majority of our time at work. What is unusual for most people (working behind bars) becomes normal and common place for correctional nurses. It can become so normal that you forget where you are and who is nearby. This can result in ‘letting down your guard’ and becoming too familiar with your patients. Talking about your personal life around workmates and patients alike can make you vulnerable to those interested in gaining rapport and influence. Small breaches of professional boundaries can lead to great harm. It is unlikely that Joyce Mitchell woke up one morning determined to help two murderers escape prison. But, she is reported to have been very chummy with at least one of them including bringing in meals.

Help Each Other

Manipulative patients will note any friction among staff members and use that to advantage. One of the best ways to avoid being drawn into an inappropriate patient relationship is to have good working relationships with your team mates. Present a united front before the patient population and keep any friction or personality differences for behind the staff-room doors. Talk openly in staff meetings about professional boundary challenges and be willing to confront team mates who may be slipping into danger. It seems hard to believe that no staff member noticed Joyce Mitchell’s over familiarity with Matt and Sweat. Would life be different for her right now if someone had intervened?

Learn from this News Event

Could you be the next Joyce Mitchell? It is easy to become accustomed to your surroundings and lose sight of the relationship goals of some of your patients. We can all learn from the recent events at Clinton Correctional Facility. Take this opportunity to double down on your professional boundaries with patients and have a conversation with your workmates about how to prevent inappropriate relationships from starting.

Resources to Keep You Safe

Working with Inmate-Patients Series

Podcast Episodes

What tips do you have for avoiding unhealthy patient relationships? Share your thoughts in the comments section on this post.

Photo Credit: © boule1301 –

Understanding Professional Boundaries (podcast)


cnt-podcast_cover_art-1400x1400Cindy Peternelj-Taylor talks about professional boundary violations in this episode of Correctional Nursing Today. Cindy is Professor, College of Nursing, University of Saskatchewan in Saskatoon, Saskatchewan, Canada and Editor-in-Chief for the Journal of Forensic Nursing. She has done extensive research into professional boundaries in the nurse-patient relationship and shares some of her findings in this interview.

Cindy became interested in boundary violations when she saw firsthand boundary crossing and violations in her work in forensic mental health. She shares her story at the beginning of the interview. Later she describes the cardinal signs of trouble in boundary issues and how to spot them in yourself and your colleagues. Correctional nurses are particularly vulnerable to boundary violations and she tells why. She provides advice for how to deal with boundary crossings in our practice and how to support our peers in avoiding violations, including what nurse managers need to do.

Read more about Professional Boundary issues from these past blog posts:

Unhealthy Inmate Relationships: 5 Danger Signs

Sexual Boundary Violations in Correctional Nursing: It Could Happen to You

Maintaining Professional Boundaries: Part I

Maintaining Professional Boundaries: Part II

Thoughts on Under-Involvement with Our Patients

Cindy shares some ways we get overinvolved with our patients in correctional nursing. That is one way we move out of a helpfulness zone of patient relationship. The other way we move out of therapeutic relationship is when we become under-involved with our patients. It is easy to distance ourselves from inmate patients, especially when cynicism or a jaded attitude to the inmate population takes hold. This is a particular struggle to remain objective in practice. Our patient population and care environment can lead us to become skeptical and suspicious of patient complaints. New staff members soon learn that some inmates seek services for reasons other than health needs. The prison culture can value manipulation, deception, and secondary gain. Healthcare staff can unwittingly get caught up in a ‘game’ inmates are playing. Once burned in such a situation, it is easy to assume all inmates are looking for an angle when seeking health care. You can read more about this struggle to remain therapeutic in these blog posts:

Avoiding Cynicism

How to Work with Inmate-Patients: Be Alert for the Con

Legal Risk and the Correctional Nurse


I am excited to again be part of a correctional healthcare risk reduction webinar provided by OmniSure Consulting Group. The Unscheduled Clinical Encounter: Reducing Liability and Risk will be held on Wednesday, December 4, 2013at 1pm Central. Also on the panel are Lori Roscoe and Debra Stewart.  Here is a link to the registration form.  Nursing contact hours are being awarded – so mark your calendars to join us!

Did you know there are three ways to listen to Correctional Nursing Today? You can subscribe on iTunes or use the podcast app Stitcher or click on the podcast tab on the blog and listen using the player at the top of the post about the episode. Take us with you on your commute to work, while walking, or while picking up around the house.

Manifesto Proposition Five: Guarding Physical and Mental Safety

Safe StampIn a prior post, I suggested a Correctional Nurse Manifesto with seven propositions. This post discusses the meaning and importance of the fifth proposition:

Correctional nurses continually guard their own and other’s physical and mental safety

While professional boundaries can help protect a nurse’s safety (See the discussion on professional boundaries in Proposition Four Part I and Part II), correctional nurses must also be vigilant to guard against physical and psychological injury from a variety of sources on a daily basis. Officer, civilian, and healthcare staff must provide a consistent front to protect against injury when dealing with the inmate population.

Physical Safety

Workplace violence concerns are ever-present in the correctional setting. Correctional nurses need to be vigilant for physical injury from inmates, other staff, or visitors. Here are some areas of concern for nurses:

  • Know your facility’s particular security procedures. This might include knowing security codes and procedures for obtaining assistance.
  • Visually scan a work area or travel route for signs of safety threat. Avoid secluded areas or ‘blind spots’ within the facility.
  • Travel in pairs or groups when possible. If you must travel alone, be sure other staff members know your whereabouts and expected return.
  • If you must travel alone, be within sight or sound of an officer at all times when in any inmate area. Know where the next officer station is on your route. Check in by a wave or ‘Hello’ with each officer to be sure they know you are traveling in the area.
  • Dress conservatively to avoid misinterpretation. Choose loose-fitting functional clothing and eliminate jewelry such as necklaces that can be a choking threat.
  • Arrange exam rooms so that you are closest to the door to prevent entrapment.
  • Be careful to keep confidential any security procedures such as pending shack-downs or cell searches.
  • Keep close control of keys to secure areas. Lost keys can result in access to secure areas and physical threats.
  • Do not discuss personal information around patients. Information about family members, schedules, or personal stresses can be used for manipulation.

Mental Safety

Many of our patients have developed patterns of subtle manipulation to gain control in relationships. These skills mean survival in the criminal world and can become a havitual mode of communication – even with healthcare staff. There are common themes to the manipulation patterns of inmate-patients. Been on guard for these manipulation techniques that come from the excellent book – The Art of the Con.

  • Staff Friendship: Comments are personalized to establish a special relationship. “I am so glad you are here today. You are the only one who cares.”
  • Peer Group Alienation: Establishing a ‘we vs. them’ situation. “The night nurse is always complaining about you but I stuck up for you.”
  • Request for Help: A request for sympathy or an action beyond your nursing role. “Could you mail this letter to my 5-year-old son for me?”
  • Nudging: A test to see how far you are willing to go beyond the rules. “Could I have a few alcohol wipes to clean my shaving equipment?”
  • Turnout: Leverages past rules-breaking to request more serious offenses. “If you don’t get me a cell phone I’ll have to report that letter you mailed for me last week.”

Looking Out for Others

Teamwork is a major part of delivering health care. It is also a necessary part of remaining safe in the correctional setting. We all need to be alert for our own safety, but also for the physical and mental safety of our workmates. It is usually easier to engage a peer in physical safety concerns such as a reminder to keep the keys on their person or refrain from discussing personal information in a public area. However, it can be difficult to speak up when a fellow staff member is dressing provocatively or engaging in personal conversation with patients. Courage is needed. Your interventions in these areas, though, improves safety for everyone.

Have you had to come to the aid of another staff member to protect them from physical or mental harm? Share your story in the comments section of this post.

Photo Credit: © kentoh – 


Manifesto Proposition Four: Maintaining Professional Boundaries-Part II

Post and Rail FenceIn a prior post, I suggested a Correctional Nurse Manifesto with seven propositions. We are in the midst of discussing Proposition Four:

Correctional nurses hold themselves and their peers to the professional boundaries of practice

My last post discussed why we need boundaries and signs that boundaries are being crossed. This post talks about the broken fences of boundary violation and what to do to avoid boundary crossing or violations in your own practice or that of your peers.

Broken Fences – Boundary Violations

Unfortunately, I see it again and again – correctional nurses crossing the boundary into sexual relationships, providing contraband, or drugs to inmate-patients. How does it happen? Boundaries are violated when a professional relationship moves to a social relationship. In a professional relationship the nurse provides care and service based on using expert knowledge. The relationship is therapeutic and focused on the needs of the patient. A social relationship shifts this focus to personal needs and desires, thus distorting goals and intentions of communication and actions. At a minimum this can be confusing to the patient and undermine therapeutic efforts. At worst, this can be exploitative and personally dangerous.

Boundary crossings, described in Part I, lead to boundary violations. The line between a boundary crossing and a boundary violation can be blurred. Boundary crossings are single events in a nurse-patient relationship that may be by error or lack of awareness. A boundary violation, however, is a persistent relationship characterized by indulging in actions of a personal nature. In the correctional setting, this often involves affectionate communication – both verbal and written (love letters); sexual interaction – touch, oral sex, intercourse; or providing contraband – drugs, cell phones, alcohol.

Identifying Inappropriate Professional Behavior

We serve ourselves, our colleagues, and our patients by being alert for and responding to any indication of professional boundary crossing or violation. The College of Registered Nurses of Nova Scotia provides a decision-making framework with 5 quick questions to ask to determine if a behavior you are considering or one you observe in a colleague is within professional nursing boundaries. I have modified these questions to reflect American correctional nursing practice:

  • Is the behavior consistent with the Nursing Code of Ethics?
  • Is the behavior consistent with the Correctional Nursing Scope and Standards of Practice?
  • Is the behavior consistent with your duty to always act in the best interest of your patient?
  • Does the behavior promote patient autonomy and self-determination?
  • Is this a behavior you would want other people to know you have engaged in with a patient?

If the answer to any of these questions is ‘No’ – DON’T DO IT!!!

Mending Fences

Even if there have not been any boundary crossings or violations, good fence mending is in order. We all need to keep our professional fences in good repair and encourage our peers to do the same. Here are some recommendations from a recent nursing journal article on the subject:

  • Openly discuss the challenge of professional boundaries with correctional nursing peers
  • Make a pact with your peers to ‘watch their back’ when it comes to observed boundary crossing. Look out for each other
  • Be particularly sensitive to stressful seasons in your personal life as this increases vulnerability to boundary violations in practice
  • Do not discuss intimate or personal issues with a patient
  • Do not keep secrets for or with patients
  • Treat all patients with dignity and respect (See Manifesto Proposition One)
  • Speak, act, and dress professionally to inspire professional conduct in yourself and others
  • Be firm, fair, and consistent with all patients
  • Do not engage in behavior that can be misinterpreted as flirting – touch, personal compliments

Have you seen indications of professional boundary violations in your correctional nursing practice or the practice of your peers? What did you do about it? Share your thoughts in the comments section of this post.

Manifesto Proposition Four: Maintaining Professional Boundaries-Part I

In a prior post, I suggested a Correctional Nurse Manifesto with seven propositions. This post is Part 1 of a 2-part series discussing the meaning and importance of the fourth proposition:

Correctional nurses hold themselves and their peers to the professional boundaries of practice

Fence in a fieldI live in a rural community of dairy farms. In fact, on every side of our property and across the road are cattle pastures. They all have fences around the boundaries of each field. Mostly, the cows are pleasant and stay within their territory. Once in a while, however, a fence falls into disrepair and Bessie wanders out into our yard. What trouble that can cause! These placid animals may not be violent, but they can plod through flower beds, randomly plop ‘fertilizer’ where it isn’t needed, and chew up the shrubbery.

The idiom that ‘good fences make good neighbors’ can also be applied to our nursing practice. Good fences make good nurses – especially in corrections. Setting boundaries in your interactions with patients protects both you and the inmates in your care.

Why Good Nurses (Like Good Neighbors) Need Fences

Zone of HelpfulnessProfessional boundaries separate therapeutic behavior in a nurse-patient relationship from other behaviors which may be well-intentioned but are not therapeutic or part of professional nursing practice. The National Council of State Boards of Nursing provides a helpful graphic of a continuum of relationship with boundaries for nursing practice. Correctional nurses must find ways to remain within the bounds of the Zone of Helpfulness in order to remain safe and provide appropriate nursing care. Out-of-bounds relationship could include under-involvement or over-involvement in the relationship.

In every nurse-patient relationship there is a power differential between the nurse’s authority and the patient’s vulnerability. This differential is accentuated when the patient is also an inmate with limited freedom or rights. For example, in a traditional health care situation, a patient could request a different care provider or change practices if there was discomfort or dissatisfaction. Inmates are limited to the assigned care provider’s treatment.

Since nursing care provision is inherently personal in nature, the foundation of the nurse-patient relationship must always be for the purposes of preventing illness, alleviating suffering, and protecting, promoting, and restoring the health of the patient. These are, in fact, the defining elements of nursing practice. The challenge comes in maintaining this core purpose in the nurse-patient relationship while being authentic and caring in perspective.

Straddling the Fence – Boundary Crossing

Correctional nurses can find themselves, or their peers, under-involved in patient relationships when cynicism or a jaded attitude to the inmate population takes hold. Under-involvement was discussed in Manifesto Proposition Three. Boundary blurring in correctional nursing practice can also lead to over-involvement in a patient relationship; moving toward a personal relationship that goes beyond the therapeutic role. Establishing a personal relationship with a patient is inappropriate, at best. It can be dangerous and illegal, as well.

The Association of Registered Nurses of Alberta Canada published a helpful guide for the nurse patient relationship that lists indications of boundary crossing.

  • Frequently thinking of the patient while away from work
  • Planning your day around the care of this patient
  • Sharing personal information or work concerns with the patient
  • Favoring this patient’s care at the expense of others
  • Keeping secrets with the patient
  • Selectively reporting the client’s behaviors (negative or positive)
  • Changing dress style for work when working with this patient
  • Acting or feeling possessive about the patient
  • Swapping assignments in order to be with the patient
  • Feeling responsible for the patient if progress is limited

These are the signs to look for in your own nurse-patient relationships and those of your peers. Make a pact with those you work with to call each other out if you see this behavior. Support each other in maintaining good fences in your correctional nursing practice.

In my next post, I’ll continue this discussion and describe the broken fences of boundary violations and how to mend the fences and return to the Zone of Helpfulness.

Have you seen indications of professional boundary crossing in your correctional nursing practice or the practice of your peers? What did you do about it? Share your thoughts in the comments section of this post.

Photo Credit: © victorgrow –

Manifesto Proposition Three: Avoiding Cynicism

In a prior post, I suggested a Correctional Nurse Manifesto with seven propositions. This post discusses the meaning and importance of the third proposition:

Correctional nurses do not become cynical to the health requests of their patients

Values word cloudThe night nurse was called to a housing unit because one of the inmates seemed to be seizing. When the nurse arrived, the patient was seen on the floor passed out. Her cellmate had called for help. The officers arrived to see the patient flailing about and babbling before passing out.

Correctional nurses have a particular struggle to remain objective in practice. Our patient population and care environment can lead us to become jaded and cynical. New nurses soon learn that some inmates seek services for reasons other than health needs. The prison culture can value manipulation, deception, and secondary gain. Nurses can unwittingly get caught up in a ‘game’ inmates are playing. Once burned in such a situation, a nurse can assume all inmates are looking for an angle when seeking health care.

Yet, many a correctional nurses has also been burned by assuming a patient is ‘faking it’ or being deceptive only to find that their health need was very real. What can correctional nurses do to protect themselves from manipulation while also guarding against jaded cynicism?

Reasons to be Skeptical

There are several reasons why cynicism so easily develops when dealing with our patient population.

1.  Manipulation is a way of life: By the time many of our patients arrive in the facility, they have lived a life based on distrust, manipulation, and deception. It is how they view the world and how they have used their skills to obtain what they want.

2.  Care may not be given if the symptoms are not severe: Some of our patients don’t think they will get the attention of officers or health care staff unless they exaggerate their symptoms. There may be a basis for their health care request but it may not be as severe as described or presented.

3.  Health care is a way out of the facility: Other patients see health care as an opportunity to travel to the free world for hospital visits or specialty appointments. Every outside visit has the potential for contact with family and friends, or even an opportunity for escape.

4.  Special treatment can bring status: In the stripped down prison society, health passes for lower bunks, special shoes, or lighter work details can bring status. Special food, like evening snacks for diabetics, or desirable medications, can be used for trade or barter in the prison black market.

5.  Special treatment can bring safety: Many inmates feel vulnerable and unsafe in general housing units. A medical or mental health diagnosis may bring a more secure housing assignment and greater safety.

Ways to Remain Objectively Caring

Nurses working in correctional settings must understand the very real potential of deception in the patient population while maintaining a professional perspective on the nurse-patient relationship and the need to deliver appropriate health care. Here are several ways to remain objective when dealing with inmate-patient requests.

1. Listen to the patient: Keep an open mind when listening to your patient. Truly hear what they are saying about their symptoms. Listen for full descriptions. Be sure to objectively document these symptom descriptions and the circumstances of their emergence. This documentation has at least two uses. First, it validates the actions you will take during this encounter. Second, it provides a history for use with ongoing encounters. If a patient is ‘working the system’ it can become clear over time with solid documentation of symptoms. Good communication among the health care team is important. Listening to the patient also validates concern to the patient. This may encourage accurate description of the symptom if exaggeration is an issue. Listening can help determine if safety is a concern.

2. Observe and document: Good observation and assessment skills are required in corrections. Document all observations with a keen eye toward those that validate or invalidate the patient’s stated symptoms. Accurate and thorough observations can help the healthcare team ‘get to the bottom’ of the symptoms, whether actual or fabricated.

3. Seek corroborating evidence: Validation of symptoms can also be obtained from others. Officers may observe patient activities in the housing unit and the exercise yard. Other team members such as social services, psychology, or medical staff may have corroborating evidence. This is why an integrated medical record can be so important. Be careful, however, to limit observations to objective data. Opinions and attitudes about motivations such as ‘drug seeking’ or ‘malingering’ have no place in the medical record.

4. Do not make assumptions: Even a patient who has invented illness in the past may have a serious medical need in a future encounter. It is unwise to assume that a patient is contriving the current symptoms. Every nurse-patient encounter deserves an objective evaluation.

Why Avoid Cynicism?

Wouldn’t it be easier to just assume patients are being manipulative and deceptive when they seek out healthcare? Some nurses think so. However, we forfeit our professional nursing values when we see every patient in this light. We are also risking missing important medical conditions and delivering substandard care that would be indefensible should a legal claim be brought. It is in our own best professional interests and in the best interests of our patients to develop skills in remaining both realistic about the characteristics of our patient population while remaining objective in our delivery of nursing care.

Have you struggled with cynicism in your correctional nursing practice? How did you pull out of it? Share your experiences in the comments section of this post.

Manifesto Proposition Two: Staying Within the Scope of Practice

In a prior post, I suggested a Correctional Nurse Manifesto with seven propositions. This post discusses the meaning and importance of the second proposition:

Correctional nurses work within their scope of practice at all times

Values word cloudDo any of these situations sound familiar?

  • An RN in a small jail is asked by an officer to ‘clear’ one of the inmates for take-done into a restraint chair because he has been kicking at his cell door for two hours.
  • An LPN/LVN is assigned to complete intake physical assessments because the RN who usually has that assignment is on maternity leave.
  • A medication technician gives an inmate an antihypertensive from another patient’s card because he can’t find the inmate’s supply in the medication cart during a busy pill line in a housing unit.

These are just a few examples where nurses (and others) can wander into territory beyond the scope of their licensure in corrections. Unlike traditional settings, jails and prisons can seem like the Wild West where the law can be unclear and licenses can be on the line. Most nurses working in traditional settings have the protection of clearly defined boundaries of practice. A hospital, for example, is organized around the practice of health care and an organizational structure bounded by licensure. Nurses work within these boundaries and know what they can and cannot do based on policy, procedure, and operating guidelines.

In the correctional setting, however, nurses can work among those who are less familiar with the boundaries of licensure and have misconceptions about the knowledge and experience of the health care staff they work with. In a command and control environment things can get out of hand. In the first situation, the nurse is certainly able to determine if the inmate has a condition that should be taken into consideration in a forced restraint such as a prosthetic hip, a serious heart condition, or severe asthma. The nurse, however, is not in a position to medically approve the use of a restraint chair and must make this clear to the requesting officer. In addition, depending on the context, the nurse may have an obligation to request mental health intervention prior to use of force. This is a sensitive issue, especially in a jail setting.

Health care provision in a correctional setting can be under-funded and under-staffed. Managers struggle to provide required care with the staff available. This can lead to breaches in judgment about licensure boundaries. Differences between LPN/LVN and RN licensure can be blurred. This is particularly true regarding assessment. Although experienced LPN/LVN’s may have the skill to perform physical assessments, licensure may limit the legal ability to do so. Placing an LPN/LVN in a position to work beyond their licensure places them at high risk and may require clinical judgment beyond their training or experience. In the second situation, the LPN/LVN should question the assignment based on a knowledge of licensure requirement.

Correctional facilities rarely have onsite pharmacy dispensing. Many rely on mail-order or fax-and-fill systems to obtain patient medications. The medication administration process is complicated by security issues and remote locations for delivery. Some systems allow trained but unlicensed technicians to deliver routine medications to the patient population. However, even licensed staff are tempted to create work-arounds when delivering a high volume of medications over a short period of time. One common work-around in medication administration is borrowing medication from one patient for administration to another. Although seemingly harmless, making choices like this is equivalent to pharmacy dispensing and beyond the scope of nursing or unlicensed staff. In the third example, the medication technician should either provide the missing medication from stock in the exact dosage ordered, or delay administration until the situation is cleared up upon return to the medical unit.

Correctional nurses care for patients in an environment that can be unfamiliar and unappreciative of the legal boundaries of licensure. We have a responsibility to fully understand our own scope of practice and practice safely within that scope at all times.

Have you seen correctional nurses placed in situations beyond their scope of practice? Share your experiences in the comments section of this post.

Photo Credit: © ojka –

5 More Ways Correctional Nurses Can Land in Court

This is a continuation of a list started in an earlier post. Correctional nurse experts Kathy Wild, RN, MPA, CCHP and Royanne Schissel, RN, CCHP, offered advice to correctional nurses during the 2013 NCCHC Spring Conference.  Here are five more ways you can land in court.

#1- Treat your patient as an inmate – It is easy to slide into a punative perspective in dealings with inmates. After all, some of them have learned that they can get what they want through manipulation and deceit. Yet, according to Earl Nightingale, our attitude toward others determines their attitude towards us. As nurses we are called to treat all patients with respect and dignity. We cannot disrespect or abuse the patients that we are responsible to treat.

#2-Don’t share critical health care information with others – HIPAA release forms are not needed for every situation. Check out this earlier post about sharing confidential patient information in the correctional setting. We often need to share important health information with custody officers. Officers, especially housing officers, are part of the treatment team and need to be aware of significant medical conditions that may need early medical attention.  Communication is important.

#3- Don’t follow up on something because “It’s not your job” – Nurses are responsible for positive patient outcomes. Yet, in some correctional cultures, staff are willing to do specific tasks and no more. Some correctional settings still ascribe to a functional care delivery pattern where some nurses only perform sick call while others only perform medication administration activities. “It’s not my job” is not an appropriate response where patient outcomes are concerned and does not absolve nurses from responsibility in a bad outcome where something could have been done to improve a patient outcome.

#4-Don’t follow current protocols – Protocols often guide nursing actions in the correctional setting. They are particularly important for nursing sick call and emergency responses. Written protocols should be available at all times and staff should know where protocols can be found. For example, the only copy of clinical protocols should not be locked in a supervisor’s office. Skipping protocol steps is a frequent problem in legal cases. Referring to the protocols frequently will ensure that this does not happen. Relying on memory is not good practice. Another legal concern with protocols is keeping them updated with any new changes in practice. At a minimum nursing protocols need to be reviewed and updated annually.

#5-Don’t look for other employment when you are not happy with your job – Correctional nursing is not for everyone. The environment can be unfriendly and the patient population challenging. If you don’t enjoy your work you can fall into practice patterns that can land you in court. Indications that you don’t like your job can include calling inmates names, calling other staff members names, having a bad attitude, or taking shortcuts with patient and staff safety. Some nurses are unable to overcome concerns that inmate patients are dangerous. Yet, you can’t help a patient when you are afraid. If you see these indications in yourself, consider other nursing options. Maybe correctional nursing is not a good match for you.

What do you think of this list of risky practices? Have you been tempted or pressured to let your guard down in any of these areas? Share your thoughts in the comments section of this post.

Sexual Boundary Violations in Correctional Nursing: It Could Happen to You

This past fall I participated in a session on sexual boundary violations presented by Cindy Peternelj-Taylor at the International Association of Forensic Nurses Scientific Assembly. Her research into this concept in Canada is fascinating and has much for us to apply in our own practice settings. Here are my notes and thoughts from her session.

Cindy interviewed seven registered nurses working in secure settings who had observed or experienced sexual boundary violations in their nursing practice. Spending a lot of time with a patient, such as can happen in correctional settings, can make this a hotbed for potential problems.

What does it mean to cross the line? She identified this as behaving in a way that is socially unacceptable or behaving in a disreputable or inappropriate manner. In professional practice, this can mean nurses who are professionally irresponsible; having crossed the bounds of an appropriate nurse-patient relationship to a romantic or sexual relationship. When has a nurse-patient relationship crossed the line? Peternelj-Taylor’s research revealed these indicators:

  • Starting to look forward to seeing that person the next day.
  • Keeping secrets in the relationship
  • Not allowing others into the relationship
  • Exchanging messages

Relationship should always be for the benefit of the patient, not for self-gratification or personal gain. Yet, therapeutic relationship can be very intimate and confusing to the patient.  In fact, it is not uncommon for a patient to misinterpret therapy. For example, how would you respond to a patient who says, “I want to kiss you?” How would you respond in a way that would realign the relationship and not cause the patient to withdraw from therapy? Our inmate-patients often misinterpret  interactions with nurses; both words and gestures.

Nurses have an ethical responsibility to maintain the therapeutic environment no matter the actions of the patient.  Caution is needed. We can lose sight of professional roles and responsibilities in the midst of a situation and can be blindsided. Therefore, we have responsibility to our peers to point out when we see potential boundary violations.

Questions to ask in a potential improper nurse-patient relationship:

  • Would this relationship really work out in the real world?
  • Would I say or do this in front of my peers or my supervisor?
  • Am I keeping secrets or not talking to my peer group about my conversations or actions with this patient?

Peternilj-Taylor’s research also suggests that managers can reduce sexual boundary violations. One way is to investigate any indication of improper relationship in the medical unit. Training, especially the use of case vignettes, can help nurses to overcome temptation and develop skills in responding to potential violation opportunities.

Do you think sexual boundary violations are of greater potential in correctional nursing practice? Share your opinions and experiences in the comments section of this post.

Photo Credit: © Oleksandr Moroz –

Courage in Correctional Nursing

I’m at the International Association of Forensic Nursing Annual Scientific Assembly this week drinking in the sunshine of lovely Puerto Rico (It IS an international association, after all!) and absorbing lots of information of importance to correctional nurses. As I pause to contemplate and apply what I’ve heard today, I am struck by the brief, but powerful, words of President Elect Polly Campbell at the Annual Meeting Luncheon. She spoke of the need for courage in our practice of nursing. How true that is. Did you know you were courageous in accepting the challenge to work with our patient population and in our work environment? Many nurses are not that bold. They do not seek out experiences that involve security escorts, the clanging of automatic barred doors or the need to have their personal belongings searched when entering and leaving the workplace. Yes, you are a courageous nurse!

Polly suggests three categories of courage needed for our profession. These come from the courage to be a great leader. Let’s apply them to our work:

TRY Courage: The courage of initiative and action— making first attempts, pursuing pioneering efforts and stepping up to the plate

TRY Courage motivates us to act when needed – even if it is hard. Have you had to advocate for the needs of one of your patient? Have you had to confront cruel or disrespectful actions of a staff member? Have you had to address inappropriate patient behavior? It takes courage.

TRUST Courage: The courage of confidence in others— letting go of the need to control situations or outcomes, having faith in people and being open to direction and change

TRUST Courage allows us to let go of controlling the outcomes of what we do. We are responsible for right action, but can’t control the outcomes of those actions. Do you have the courage to take a right action and let go of the outcome? You are a courageous nurse.

TELL Courage: The courage of voice— raising difficult issues, providing tough feedback and sharing unpopular opinions

TELL Courage is the courage to speak up when the issue is difficult or you are the only one in the situation who is disturbed. Correctional nurses are sometimes put in situations where there are no other health professionals available for consultation. Social pressure might be applied to ‘go along’ with the situation. Have you spoken up in a difficult situation? You are a courageous nurse.

How can you be courageous for your patients or your fellow staff members in your work this week? Are you willing to meet the challenge? Share your stories of courage in the comments section of this post.

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