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
The 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.