Correctional Nursing Peer Review: Some Examples

cocheAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the fourth in a 4-part series of posts on correctional nursing peer review. Find other posts on this topic here.

Recently I queried correctional nurse leaders around the country about what they were doing regarding nursing peer review. Many responded that they were researching the process and just getting started. Here are examples of what some systems have developed thus far. They may help you determine what would be best for your purposes.

The Washington state prison system is using a form to document peer review of these practice factors:

  • MAR Completion
  • Completion of Assessments
  • Nurse Care Plan & documented follow-up
  • Documentation
  • Seeks Consultation Appropriately
  • Appropriate Application of Guidelines
  • Clinical Knowledge Base
  • Interest in Improving Skills
  • Patient-oriented Care
  • Professionalism
  • Professional Ethics
  • Patient Education
  • Observed Clinical Skills
  • Critical thinking skills
  • Delegates tasks appropriately

Armor Correctional Health Services, Inc. is using a system that follows the nursing process, reviewing documentation for these practice factors:

  • Legibility of notes
  • Each entry includes date, time, signature and printed name
  • Sufficient information to understand the condition
  • Appropriate assessment includes objective information about the condition
  • Appropriate format and documentation (ie: soap v. incidental note, abbreviations)
  • Ordering of medication (from the right vendor, right medication, right dose)
  • Documentation on the medication administration record
  • Completion of referrals as appropriate

The Ohio state prison system has had a nursing peer review program in place since 2007. They review nursing documentation for each nurse every 2 years. Ten charts are selected – 5 by the reviewer and 5 by the nurse being reviewed. Their policy specifically states that results of the nursing peer review are never used as grounds for disciplinary or punitive action. Instead, a remediation plan may be initiated, if appropriate.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © lculig – Fotolia.com

Correctional Nursing Peer Review: Making It Practical

Peer Review written in white chalkAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the third in a 4-part series of posts on correctional nursing peer review. Find other posts on this topic here.

Building a nursing peer review program from the ground up can be a daunting task. Here are some practical ideas for how to have a successful nursing peer review process that is efficient and effective.

Create Links to Current Programs

Although nursing peer review is different from continuous quality improvement, nursing competency reviews, or performance evaluations, these programs can be linked to the nursing peer review process in several ways.

  • Trending in CQI studies can help in prioritizing which professional standards to review in any given time period. If studies are showing that withdrawal protocols are not being initiated as expected in a jail setting, assessment and decision-making on intake might be a priority professional standard for nursing peer review.
  • Likewise, if competency evaluation of new orientees shows deficits in differentiating dental urgencies and emergencies, this can become a peer review priority.
  • Because performance evaluations often involve compensation and employment behavior, it is best to have a clear separation between the performance evaluation and the nursing peer review process. However, if trends in clinical issues emerge during the performance evaluation process, these issues might help make determinations of which professional standards will be the focus of upcoming peer reviews.
  • Other clinical data can also inform a nursing peer review program. Information from risk management, medication errors, mortality reviews, and emergency room visit trending may indicate a particular focus for evaluating clinical performance.

Involve Everyone

Involving front-line nurses in the creation of the program and prioritization of the standards used for the review will encourage maximum participation. The challenge of peer review is maintaining a climate of professional development rather than one of evaluation and criticism. It may be tempting for a nurse manager to complete the nursing peer review on all nurse employees. A team effort, instead, can provide professional growth among the staff. Properly managed, nursing peer review can be a supportive and encouraging professional process. Poorly managed nursing peer review can seem punitive and discouraging.

Create Forms

Forms provide structure to any process, especially new ones. If a form is used for peer reviews there is more opportunity for consistency. In addition, a form can operate as a checklist to prompt a reviewer on  elements requiring attention. Staff are more likely to get involved if they have a written format to follow. NCCHC also recommends the use of a standard form in the discussion of the C-02 standard.

Spread Reviews Across the Calendar

Work out a program for peer review throughout the year rather than trying to do it all at once. Make it a monthly or quarterly activity; possibly attached to an existing quality improvement or meeting structure. The important point is to keep nursing peer review as an active and ongoing process rather than a periodic disconnected project.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © lculig – Fotolia.com

Correctional Nursing Peer Review: Determining Discipline-Specific and Community Standards

Peer review whiteboardAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the second in a 4-part series of posts on correctional nursing peer review. Find other posts on this topic here.

There are four key components to the ANA definition of nursing peer review according to their published  Guidelines.

  • Practicing Registered Nurses
  • Assess, monitor, and make judgments about
  • Nursing care provided
  • Measured against professional standards of practice

Accepted professional standards of practice for correctional nurses, then, provide the basis for a nursing peer review program. The NCCHC standard C-02 focuses attention on the competence of the individual under review. The ANA places peer review centers on the complementary goals of quality and safety. Thus, a peer review process for correctional nurses that encompasses competent, quality, and safe care provision is recommended.  Three primary sources of community and discipline-specific standards for nursing peer review programs are outlined below.

ANA Correctional Nursing Scope and Standards of Practice

The American Nurses Association Correctional Nursing Scope and Standards of Practice (affiliate link) provide key professional nursing standards focused on the unique nature of the correctional nursing specialty. Therefore, they provide an excellent foundation for a nursing peer review program. The six Standards of Practice, in particular, provide competency statements appropriate for use in peer review. These standards follow the nursing process and include:

  • Assessment
  • Diagnosis
  • Outcomes Identification
  • Planning
  • Implementation: Coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment (Advanced Practice Nurses)
  • Evaluation

State Boards of Nursing – Nurse Practice Acts

Nursing practice is governed by state legislation. State boards of nursing then provide the guidance for the nursing profession through interpretation of the nurse practice act and by developing administrative rules or regulations that clarify practice act components. Although they vary among the states, nurse practice acts all contain the standards and scope of nursing practice under their jurisdiction. Here are some examples of practice standards common to most Nurse Practice Acts and follow the key elements of the nursing process

  • Nursing Assessment
  • Patient-centered Health Care Plans
  • Independent Nursing Judgments
  • Provision of Care (as ordered or prescribed by authorized health care providers)
  • Evaluation of Interventions
  • Patient Teaching
  • Delegation of Nursing Interventions
  • Patient Advocacy

Links to state nurse practice acts can be found on the National Council of State Boards of Nursing website along with a helpful article describing the standard factors of nurse practice acts.

Accreditation Standards that Address Nursing Clinical Practice

Many NCCHC accreditation standards address organizational structure and process but some address individual professional practice. Most come from Section E: Patient Care and Treatment. Those standards can be incorporated into a nursing peer review program. Here are a few examples of appropriate accreditation standards to consider:

  • Receiving Screening
  • Transfer Screening
  • Initial Health Assessment
  • Mental Health Screening and Evaluation
  • Nonemergency Health Care Requests and Services
  • Nursing Assessment Protocols
  • Discharge Planning
  • Infirmary Care
  • Intoxication and Withdrawal

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

Photo Credit: © lculig – Fotolia.com

Correctional Nursing Peer Review: What It Is and What It Isn’t

Frau mit Lupe vor dem GesichtAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the first in a 4-part series on correctional nursing peer review.

Peer review is a familiar program to providers (physician, nurse practitioner, physician assistant) as a means of evaluating the quality of care provision by individual practitioners. Nurses, however, can have difficulty applying this concept to their own clinical practice. The American Nurses Association’s (ANA) Nursing Peer Review Guidelines provides a definition and set of principles for the nursing peer review process that are applicable in the correctional setting.

What It Is

The original ANA definition of nursing peer review stands today as an appropriate description of the process:

“Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice”

Breaking down the components of this definition supplies key concepts for a nursing peer review program in corrections:

Practicing Registered Nurses

Peer review should be performed by nurses who are practicing in a similar context. Thus, it would not be appropriate to have critical care nurses evaluate the nursing care of correctional nurses or for emergency nurses to evaluate the care of neonatal nurses. Nurses practicing in a similar context understand the environment of care, the patient population, and the standard processes for accomplishing care that would not be familiar to a nurse from another context.

Assess, Monitor, Make Judgments

Peer review is an evaluative judgment about the actions of another staff member from the same profession. The primary objective is to determine the quality and safety of care provided by an individual staff member.

Nursing Care Provided

A major component of the definition of nursing peer review is that it is a judgment of actual care provided. This is often done as a chart review but could also be performed as direct observation. However, the evaluation is of actual nursing care provided rather than a nurse’s ability to provide care.

Measured against Professional Standards of Practice

Accepted professional standards of practice are used to determine the quality and safety of care in a peer review. These accepted standards should be known to all members of the peer review process. For correctional nurses, professional standards of practice can come from

  • ANA Correctional Nursing Scope and Standards of Practice
  • State Board of Nursing Practice Act
  • Accreditation Standards that Address Clinical Practice

What it Isn’t

There can be misconceptions about what constitutes nursing peer reviews. Based on the above defining qualities of a nursing peer review, these are not nursing peer review processes:

Annual Performance Evaluation

An annual performance evaluation is a judgment of an employee’s work as it relates to their hired status and job description. Although clinical practice is a part of a nurse’s job performance, it is often not the primary focus of the performance evaluation.

Nursing Competency Checklists

Competency checklists or skills reviews evaluate a nurse’s ability to perform various skills and functions. They do not evaluation actual nursing care provided.

Simulations Such as Man-Down or Disaster Drills

As with competency or skill evaluations, simulations such as man-down or disaster drills evaluate staff ability to perform in an emergency situation but do not evaluate actual nursing care in a real clinical situation.

Continuous Quality Improvement Projects

Continuous quality improvement projects look aggregately at clinical care provided while nursing peer review evaluates a specific clinician’s actual care provision.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Correctional Nursing: How to Improve the Practice Environment

Nursing background concept

The first examination of the qualities of professional practice in correctional nursing was done recently in Ontario, Canada. Conclusions from the surveys and interviews of 297 nurses and nurse managers were that the work environment was characterized as understaffed with significant role overload. These nurses also reported limited access to resources, significant autonomy but limited control over practice and experienced significantly higher levels of emotional abuse, conflict and bullying than nurses in other studies. The source of emotional abuse, conflict and bullying most often originated from custody staff followed by other nursing staff (Almost et.al. 2013a). These results support earlier publications about the practice challenges in correctional nursing including limited access to resources and education (Flanagan and Flanagan 2001, Maroney 2005, Smith 2005) , pressure to conform to the values of the custodial subculture (Holmes 2005), and challenges to clinical decision making authority (Smith 2005, Weiskopf 2005).

Reasons to improve the quality of the work environment include the ability to attract and retain nurses, increased productivity, improved organizational performance and better patient outcomes (Almost et.al 2013a, Sherman & Pross 2010, Dall et.al 2009, Needleman et.al 2006). Focusing on improving the professional work environment yields significant results even in the absence of increased staffing (Flynn et.al 2012, Aiken et.al. 2011, Friese et.al. 2008).

The following paragraphs discuss five factors in work environments that can be modified or enhanced to support professional nursing practice.

  1. Control over practice
    • Accurate interpretation and clarification of the state nurse practice act and its guidance in job descriptions, work assignments and policies and procedures (Knox, West, Pinney & Blair 2014, White & O’Sullivan 2012). Workplace directives should also incorporate or reference relevant aspects of the ANA standards of professional practice for correctional nurses (Knox & Schoenly 2014).
    • Work flow should be examined so that barriers to effective practice can be eliminated including system gaps that increase work complexity and work that is not related to patient care (Knox, West, Pinney & Blair 2014, Ebright 2010, Schoenly 2013). An example of the former is locating supplies used for nursing treatments in multiple locations. An example of the later is when nurses are expected to gather and report data on service volume or for quality assurance audits (number of sick call visits, number of clinic appointments, and number of incomplete MARs etc.).
    • Increase nursing participation on committees such as pharmacy and therapeutics, morbidity and mortality review, mental health, utilization review, and medical administration (Aiken et. al. 2011, Flynn et. al. 2012, Almost et.al. 2013a). Staff meetings also should be reviewed to see if meaningful two way dialogue can be increased to involve nurses in identification and early resolution of practice problems.
    • Consider assignment models that emphasize use of nursing process and clinical judgment rather than task completion; where registered nurses provide a greater proportion of direct care themselves while actively supervising care delegated to others (Corrazini et.al 2013a; MacMurdo, Thorpe & Morgan 2013). Staffing takes thoughtful preparation and legacy staffing practices may no longer work as complexity in health care delivery increases (Knox, West, Pinney & Blair 2013, Ebright 2010, MacMurdo, Thorpe & Morgan 2013).
  2. Autonomy in clinical practice
    • Considered one of the hallmarks of correctional nursing it is also an Achilles heel in the absence of appropriate clinical guidelines and support in their use (ANA 2013, Smith 2013, Smith 2005). Protocols should be based upon nursing process and coordination of care rather than reaching a medical diagnoses and rushing to treatment conclusions.
    • Nurses must be appropriately qualified and experienced in assessment and clinical reasoning as well as skilled in surveillance related to the variety of clinical situations encountered in the correctional setting to use protocols.
    • Provide access to information and tools that enhances recognition of clinical patterns and deviations necessary for good clinical judgment (Ebright 2010).
    • Assist nurses to prioritize and coordinate care with daily briefings, debriefings, huddles and work flow tracking to provide real time information about the availability and assignments of other members of the health care team (including primary care and mental health staff).
  3. Positive workplace relationships
    • Establish clear expectations for a respectful workplace in policy, procedure and other written directive. These instructions should define behaviors consistent and inconsistent with professional behavior in the workplace; describe what to do in the presence of unprofessional behavior and how to report these incidents (Almost et.al. 2013a).
    • Joint meetings and interdisciplinary training can be the vehicle to demonstrate support for the goals of both health care and custody (Almost et.al. 2013a, Weiskopf 2005).
    • Nurses may benefit from additional development in the area of conflict resolution because they have such a prominent role negotiating coordination of patient care with custody operations (Schoenly 2013, Weiskopf 2005).
    • Increase communication about patient care between registered nurses and LPN/LVNs (Corrazini et. al. 2013).
  4. Support education and certification
    • Orientation also needs to be tailored to the needs of each individual based upon education, licensure and an assessment of competency (Knox, West, Pinney & Blair 2014; Shelton, Weiskopf & Nicholson 2010). The ANA scope and standards of professional practice should also be incorporated into new employee orientation so that nurses develop institution specific skills consistent with the expectation of the professional discipline (Knox & Schoenly 2014).
    • Mentoring and coaching of new employees should be emphasized in development of expertise in clinical reasoning (Schoenly 2013, Ebright 2010).
    • Use creative, simple approaches to continuing education including self-study, reflective exercises, on-line web based seminars, facilitated case review and discussion, and a journal club (Almost et.al. 2013b, Schoenly 2013). Staff with superior knowledge and skill in a subject area can be asked to assist in developing relevant continuing education material (Knox, West, Pinney & Blair 2014).
    • Certification in correctional nursing is available through both the American Corrections Association and the National Commission on Correctional Health Care. These exams are offered regionally and can be administered at the place of employment if there are enough people taking the exam.
  5. Adequate resources
    • Includes staffing, equipment and supplies as well as access to leadership. Examining the work of first line managers may reveal sources of role overload (scheduling, meetings, payroll data gathering etc.) that impede their availability to line staff and can be reassigned to increase the availability of clinical leadership to line staff(Almost et.al. 2013a).
    • Review legacy staffing practices and work flow to identify opportunities to adjust assignments that result in more appropriate or effective use of existing resources (Knox, West, Pinney & Blair 2013, Ebright 2010).
    • Involve nurses in evaluation of equipment and technology decisions to prevent acquisition of products that complicate rather than improve delivery of patient care (Ebright 2010). For example decisions about how patient specific prescriptions were packaged have impacted timeliness and accuracy of medication administration in some correctional facilities because the packaging was cumbersome and time consuming for nurses to use.

Conclusion: Attention to the work environment of nurses (control over nursing practice, autonomy without isolation, positive working relationships, support for education and specialty certification, and adequate resources) has a profound effect on nursing practice, the ability to recruit and retain nursing personnel and on patient outcomes. More resources about work environments that support professional nursing practice can be found at the sites listed in the resources section below.

What do you think can be done to improve the professional practice work environment for correctional nurses? Are there resources or solutions not discussed here that should be? Please share your opinions by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources

 

References

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., Neff, D.F. (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care 49(12): 1047-1053.

Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., Rose, D.N., Squires, M., Lee, C., Bookey-Bassett, S. (2013a) Exploring work-life issues in provincial corrections settings. Journal of Forensic Nursing 9:1

Almost, J., Gifford, W.A., Doran, D., Ogilvie, L., Miller, C., Rose, D.N., Squires, M. (2013 b) Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context. Implementation Science 8:71

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org

Corrazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.

Dall, T.M., Chen, Y.J., Seifert, R.F., Maddox, P.J., Hogan, P.F. (2009). The economic value of professional nursing. Medical Care 47 (1):97-104.

Ebright, P.R. (2010). The complex work of RNs: Implications for a healthy work environment. Online Journal of Issues in Nursing. 15(1).

Flanagan, N. & Flanagan, T. (2001) Correctional nurses’ perceptions of their role, training requirements and prisoner health care needs. The Journal of Correctional Health Care 8:67-85.

Flynn, L., Liang, Y., Dickson, G., Xie, M., Suh, D.C. (2012) Nurse’s practice environments, error interception practices, and inpatient medication errors. The Journal of Nursing Scholarship. 44(2):180-186.

Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J. (2008) Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research. 43(4): 1145-1162.

Holmes, D. (2005) Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care 41(1):3-13.

Knox, C.M., Schoenly, L. (2014) Correctional nursing: A new scope and standards of practice. Correct Care, 28 (1) 12-14.

Knox, C.M., West, K., Pinney, B., Blair, P. (2014) Work environments that support professional nursing practice. Presentation at Spring Conference on Correctional Health Care, National Commission on Correctional Health Care. April 8, 2014. Nashville, TN.

MacMurdo, V., Thorpe, G., & Morgan, R. (2013) Partners in practice: Engaging front-line nursing staff as change agents. Presentation at Custody & Caring, 13th Biennial International Conference on the Nurse’s Role in the criminal Justice System. October 2-4, 2013. Saskatoon, SK.

Maroney, M.K. (2005) Caring and custody: Two faces of the same reality. Journal of Correctional Health Care. 11:157-169.

Needleman, J., Buerhaus, P.I., Stewart, M., Zelevinsky, K. Matke, S. (2006) Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 25(1):204-211.

Shelton, D., Weiskopf, C., Nicholson, M. (2010). Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care. 16 (4). 38-47.

Sherman, R. & Pross, E. (2010) Growing future nurse leaders to build and sustain healthy work environments. Online Journal of Issues in Nursing. 15(1).

Schoenly, L. (2013) Management and Leadership. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2013) Nursing Sick Call. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2005) Stepping through the looking glass: Professional autonomy in correctional nursing. Corrections Today 67(1):54-56.

Weiskopf, C.S. (2005) Nurse’s experience of caring for inmate patients. Journal of Advanced Nursing 49(4):336-343.

White, K. & O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD: Nursebooks.org.

Photo credit: © Kheng Guan Toh – Fotolia.com

 

Minimizing liability in correctional nursing

Overburdened doctor at the hospital in the stressLitigation has been a major catalyst in the reform of the criminal justice system, including the delivery of health care. Correctional nurses can expect to be involved in litigation involving health care during their professional career in this specialty practice area. Being familiar with the legal system particular to correctional health care, regulations and other information about the nurse practice act, as well as the profession’s code of ethics assist nurses in steering through the liability landscape (Moore 2013).

I recently reviewed an article describing a study of nurses practice insurance claims. What really caught my attention was that correctional health was one of the specialty areas included in the analysis. The results were very interesting and are summarized here.

CNA HealthPro and Nurses Service Organization (NSO) analyzed nurses professional liability claims which had been closed between 2006 and 2010 to identify patterns or trends in liability and to make recommendations to both minimize exposure and promote patient safety (Benton & Flynn 2013). This analysis included 516 liability claims and another 1,127 claims for defense against allegations made to regulatory boards. Finally, a survey was conducted of 1,617 nurses who had experienced a liability claim loss between 2006 and 2010 and a random matched sample of nurses who had never had a claim to identify demographic and workplace factors that affect risk exposure. The analysis was limited to registered nurses (RNs) and licensed practical or vocational nurses (LPN/LVN). Please note that a similar analysis was completed in 2012 for advanced registered nurse practitioners (ARNPs) and can be obtained at their website.

Professional liability claims involving nurses in correctional health care are a small proportion of total closed claims and the average indemnity cost in this field was less than the average for all claims. The table below depicts how nurses’ liability in correctional health compares to other practice specialties in terms of closed claim experience.

Nursing specialty % of closed claims Average paid indemnity
Correctional health 3.1 $144,701
Obstetrics 10.3 $382,353
Behavioral health 1.7 $151,944
Adult med/surg 40.1 $143,969
Emergent/urgent care 9.7 $141,832
Community health/hospice 8.9 $138,452
Gerontology 18 $100,294
Overall 100 $161,501

Claims involving scope of practice, assessment and monitoring had the highest average indemnity payments consistent with the significant effects these aspects of practice have on patient safety. Closed claims regarding nursing care or treatment were more prevalent but had a lower average payout. The work profile survey showed that lower indemnity payments were associated with nurses who reported more continuing education, working in an organization that had a policy for disclosing errors and who were comfortable asking managers for help.

The risk control recommendations made as a result of the analysis are similar to those made by Jacqueline Moore in Chapter Three of the Essentials of Correctional Nursing. The recommendations from both these sources are consolidated here:

1. Make sure your individual practice is consistent with the state nurse practice act and the organization’s policies and procedures.

  • Request and review a copy of the nurse practice act from the state regulatory board.
  • Review your organization’s policies and procedures regularly.
  • If the organization’s policy and procedure differ from the state nurse practice act bring this to the attention of your manager. Until clarified follow the directive which is the most restrictive. In other words, the organization can limit your practice in the work setting but cannot assign responsibilities that are broader than the nurse practice act.
  • Know the steps you are to take within your organization if you are given an assignment outside the lawful scope of practice or your personal competence to perform.
  • Do not accept assignments that you are not competent to perform.

2. Ensure communication is professional, accurate, respectful, inclusive, complete, appropriate and timely.

  • Determine the patient’s primary language or communication preferences and arrange translation or other accommodations to ensure the patient understands and agrees with the plan of care.
  • Exchange key information whenever responsibility for the patient is transferred from one caregiver to another or from one setting to another.
  • Do not criticize a provider in the presence of a patient or in documentation in the health record.

3. Maintain clinical competencies relevant to the needs of the population served and standards of practice for correctional nursing.

  • Attend relevant classes, in-service and continuing education. Maintain copies of certificates or other evidence of attendance.
  • Participate in peer review and reflective practice exercises.
  • Subscribe to journals, websites and other means to stay up to date with the literature that pertains to correctional nursing such as this blog post and Correctional Nurse.net.
  • Join professional organizations such as the American Nurses Association, the International Association of Forensic Nurses, the American Correctional Health Services Association, the Academy of Correctional Health Professionals, and the American Corrections Association.

4. Nurses are in the prime position to prevent harm to the patient and are expected to advocate for the patient’s wellbeing.

  • Invoke the chain of command as necessary to focus attention on the patient’s status or when there is a change in condition.
  • Ensure timely attention to patient needs and implementation of the plan of care.
  • Persist in communication and follow-up regarding the patient until a satisfactory resolution is achieved.
  • Address communication issues that deter use of the chain of command including identification of individuals who ignore, bully, retaliate or intimidate when chain of command is accessed.

Kathy Page, a colleague of ours, summed this subject up in a quote from the Essentials of Correctional Nursing “During the years reviewing malpractice cases that took place in correctional settings, most of the litigation was due to nurses not advocating for the patient, resulting in a delay in treatment. This includes nurses being judgmental in their charting (e.g. “malingering, drug seeking”), resulting in lack of access to care. Also, nurses’ failure to follow the provider’s orders for medications and treatments resulted in withholding or lack of care” (page 53).

In publishing the results of this claims analysis, the authors suggest that nurses be inspired to examine their practice to identify the recommendations for change most likely to reduce liability risk using this self-assessment tool developed as part of the full report.

Are these the results you expected? What recommendations do you have to reduce liability for nursing practice in the correctional setting? Please share your thoughts by replying in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References

Benton, J.H. & Flynn, J. (2013) Identifying and minimizing risk exposures affecting nursing practice to enhance patient safety. Journal of nursing Regulation 3(4):4-9.

Moore, J. (2013) Legal considerations in correctional nursing in Schoenly, L. and Knox, C.M. (eds.) Essentials of Correctional Nursing. New York, NY: Springer Publishing.

 

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Alcohol Withdrawal: Special Issues

Danger signEven with an effective screening process, a solid treatment plan, and regular monitoring, patients withdrawing from alcohol can be in danger. Seizures and Delirium Tremens (DTs) can derail an otherwise effective withdrawal program. That is why it is also important to consider patient safety when making management decisions.

Safe Housing

Withdrawing patients are prone to falls and injury. Decreased liver functioning from long alcohol use causes increased bleeding tendencies that lead to hematoma formation, making head injury dangerous. Hallucinations and delirium can lead to erratic behavior and friction with officers and other inmates. Officers need to be aware of any inmates they are monitoring who are withdrawing. Those with potential for confusion, agitation, seizures, or delirium should be housed in the most protective manner possible.

Complicating Circumstances

Chronic conditions and past injuries can make alcohol withdrawal even more perilous than usual. According to Federal Bureau of Prison guidelines, withdrawing patients who have any of these additional conditions should have even close monitoring and additional safety precautions.

  • Cardiac Conditions: Sympathetic hyperactivity, common as high levels of alcohol are withdrawn, can agitate a weakened heart. A slower taper of benzodiazepine therapy is recommended for this group of patients.
  • Elderly: Older alcoholics may not show the usual signs of sympathetic hyperactivity so they may progress to severe withdrawal symptoms without any warning. Higher levels of chronic diseases and greater use of prescription drugs in this patient population increases chances of co-morbid complications and drug interactions. Aging causes decreased drug metabolism that can affect the adjustment of medications during the treatment tapering process.
  • History of Traumatic Brain Injury (TBI): Past brain injury increases the likelihood of seizures or DTs.
  • Liver or Kidney Disease: Chronic liver or kidney disease leads to poor metabolism of medication that requires closer monitoring as treatments are tapered.
  • Pre-existing Psychiatric Conditions: Alcohol can ameliorate psychiatric conditions. Mental illness symptoms may re-emerge once alcohol is no longer in the system. Severe depression, in particular, can lead to attempts at self-harm and suicide. Another reason for close monitoring.
  • Pregnant Inmates: Pregnancy complicates the withdrawal process by adding a second patient. Coordination of alcohol withdrawal with an obstetrical specialist is highly recommended, especially if there is also concern about drug use. Many correctional settings are not equipped or staffed to manage complex situations so transfer to an acute care facility is often the best option.
  • Seizure Disorders: A history of seizure disorders or already being under medical management for seizures increases the potential for withdrawal seizures. This history should be considered when tapering from benzodiazepine treatment. A slower taper is recommended for these patients.

How do you handle alcohol withdrawal for patients with these additional considerations? Share your tips in the comments section of this post.

To read more about alcohol and drug withdrawal in the correctional setting see Chapter 5 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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