In a prior post, we 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

Do 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-down 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 a patient 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 a place where the rules 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 with whom they work. 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 their 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 procurement and administration processes are complicated by security issues and remote locations for delivery. Some states 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 and 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 when he returns to the medical unit.

Correctional nurses care for patients in an environment that is perhaps unfamiliar with and unappreciative of the legal boundaries of nursing licensure. We have a responsibility to fully understand our own scope of practice and practice safely within that scope at all times. We also may need to educate our custody colleagues about this very important aspect of correctional nursing.

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