Anyone who knows me even a little knows that I don’t like the use of the words faking and feigning and malingering in health record documentation of a patient’s assessment because it may lead to pre-mature closure bias. But, correctional nurses must be aware that there may be a variety of motives behind their patients’ requests for medical or mental health treatment, including medical/mental health chronic conditions, acute conditions and attempts to gain benefits in the correctional environment. Malingering is defined as the falsification or profound exaggeration of illness (physical or mental) to gain external benefits such as avoiding work or responsibility, seeking drugs, avoiding trial (law), seeking attention, avoiding military services, leave from school, paid leave from a job, among others. It is not a psychiatric illness according to DSM-5 (Diagnostic and Statistical Manual of Mental Diseases, Fifth edition). We do see incidences of malingering in jails and prisons.

Reasons to Feign Illness

There are many reasons an incarcerated person may fake a mental or medical condition. The first that usually comes to mind is to be prescribed drugs. Unable to have access to the usual mood enhancers, such as alcohol, opiates and benzodiazepines, that they used in the community, incarcerated persons seek other avenues of relief. Seroquel is an example of a current favorite that may be sought through feigning mental illness or psychosis.

However, secondary gain can also include other, more benign items such as special creams and lotions. Nutritional supplements (such as Ensure/Boost) can bring a high price on the facility black market when they are viewed as a means to “bulk up.”

Illness can also bring desirable housing locations or work release. Trips to the hospital or specialists provide avenues for escape attempts or a chance for a ‘vacation’.

Some incarcerated individuals may exaggerate symptoms because they think they will not get attention in the system unless they are in severe distress. A true medical condition exists but not as intense as it is being portrayed.

A CORRECTIONAL NURSE’S BEST RESPONSE

Always maintain professional objectivity! Follow these suggestions to ensure that you are providing your patient with the consideration required for all possible scenarios:

• Do a complete nursing assessment. Do not disregard any medical complaint as faking. Always respond.
• Thoroughly document all objective and subjective data. Repeated questioning now or later may reveal inconsistencies or validate findings.
• Review prior documentation and history for comparison with current presentation, but be mindful always of potential bias you may have.
• Portray empathy. You do, in fact, want to get to the bottom of the issue and provide correct treatment.
• Ask open ended questions (“Do you have any other symptoms?), rather than asking about patient specific abnormalities that may be present in certain serious conditions (Is your vision blurry with the headache? Are you vomiting or have nausea with the headache? Is it the worst headache you have ever experienced?).
• Err on the side of safety. Provide a period of observation (such as in the infirmary or holding area).
• Always question yourself and ensure your thoughts and actions are free from bias. After 3 negative ‘chest pain’ complaints – this could be the real one.

Remember, determining feigning/malingering is not a nursing function.

Assessment, referral to provider or emergency department, or treatment based on protocol are nursing actions. Stay within your education, training and scope of practice always.

Why It‘s Important

Getting to the bottom of potential malingering is important in order to eliminate the  unnecessary use of valuable resources, including time that could be more effectively spent elsewhere. Correctional nurses can help eliminate malingering by taking detailed histories, conducting thorough and appropriate assessments, documenting the patient’s responses for comparisons over time, and collaborating with medical and mental health staff to develop appropriate interventions.

Please share with your colleagues in the comments section below your experiences.