Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

In the last post I applied Orem’s Self-Care Theory to correctional nursing practice. It fit well in a sick call situation but doesn’t give much attention to the emotional/psychological needs of the patient. So, I have been on the search for a practical theory that might help in that sphere. Thus, I happened upon the classic nursing theory of Interpersonal Relations developed by Hildegard Peplau.

What is attractive about Peplau’s theory of nursing practice is that it focuses on the dynamics of the nurse-patient relationship and sees the nurse’s role as a therapeutic force in that relationship. She also emphasizes the importance of communication and interviewing skills in nursing practice and that nurse-patient interactions promote growth for both the patient and the nurse. Correctional nurses must often quickly develop relationship in brief patient encounters in order to determine the health concern and needed interventions so Peplau’s theory holds promise for application in the criminal justice system. Here are the high points.

Progressing Roles

The Theory of Interpersonal Relations provides a number of roles the nurse plays in a patient relationship depending on immediate needs. These roles can change overtime as the patient progresses through various stages in their health or illness. Here are a few of the common nursing roles identified in the theory.

  • Stranger – Start the relationship with an accepting attitude that will build trust
  • Teacher – Provide information related to the patient’s need or interest
  • Resource Person – Provide information that will assist in better understanding a situation or problem
  • Counselor – Assist the patient to integrate the meaning of the current situation along with guidance and encouragement to adapt to new situations
  • Surrogate – Act on the patient’s behalf as an advocate, when needed
  • Leader – Encourage the patient to take on the responsibility for meeting health care needs

Phases of the Nurse-Patient Relationship

Besides various roles, there are also natural phases that a nurse-patient relationship moves through.

  • Orientation: During this phase of the relationship the nurse identifies the health care problem of concern and moves from a stranger to one or more of the other roles depending on what is discovered.
  • Identification: Here the nurse determines the appropriate professional assistance to provide to the patient. The patient, in turn, begins to feel supported and has decreased feelings of helplessness and hopelessness.
  • Exploitation: In this phase assistance is provided and the nurse supports the patient in ‘exploiting’ all the avenues of help.
  • Resolution: In this final phase the patient leaves the relationship in a healthier emotional balance, no longer needing professional nursing services. The relationship ends.

Applying Peplau’s Theory to Correctional Practice

Will Peplau’s theory work in a correctional nursing interaction? Let’s apply it in this intake screening encounter.

A 34 year old husband and father of 2 is booking in to a small county jail on a 30 day sentence for possession and sale of a controlled substance. A nurse is performing the receiving screening and preparing to place a TST when he states, “I just want to get this over with. I figure if I mind my own business I can stay out of trouble and get on with it. They’ll leave me alone, won’t they?” He looks stiff and nervous.

How might Peplau’s Theory of Personal Interaction help in this patient situation? Let’s walk through the phases of the nurse-patient relationship.

Orientation: Using an accepting tone of voice and open body language the nurse responds, “It’s tough going to jail. Tell me about your concerns. Maybe I have some information for you.”

Identification: The patient is slow to respond but finally shares with the nurse that he has never been in jail before and he is anxious about gangs, violence, and sexual assault. He says he has seen a lot of things on television. The nurse determines that she can take on the role of teacher, resource person, and counselor to this patient.

Exploitation: The nurse acknowledges his anxiety, instructs him on how to access health care and some of the other support services available, including chaplain services. She explains that, fortunately, there is little gang activity or sexual assault in this small jail and counsels him on how to report any sexual advances.

Resolution: The patient is visibly more relaxed after this information is shared and proceeds through the rest of the health screening. At the conclusion of the encounter, the nurse makes direct eye contact with the patient and states, “You can do this. It may be one of the toughest things you have ever done, but you can make it through.” The patient nods and seems to be pondering those words as he heads back out to the booking room.

So, what do you think? Would Peplau’s Theory of Interpersonal Relations work in your setting? Share your thoughts in the comments section of this post.

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Dorothea Orem Would Make a Great Correctional Nurse!

Dorothea Orem Would Make a Great Correctional Nurse

Dorothea Orem Would Make a Great Correctional Nurse

Just having celebrated National Nurses Week, I am reminded of the many great nurses who helped build the nursing profession we have today. Nursing theorists are in this group of trailblazers. I must admit, I was mostly confused during my first go-round with nursing theories. Some of them are downright undecipherable (in my humble opinion!). However, Orem’s theory stood out as both practical and understandable. I came across her theory again in some reading I was doing for a writing project and was struck by how very applicable this nursing theory is to correctional nursing practice. Indeed, Dorothea Orem would make a great correctional nurse!

Self-Care at the Core

Orem’s theory of nursing targets self-care as the primary goal of nursing. After all, self-care and preservation is a human instinct. We naturally seek out adequate air, water, and food at the most basic of levels. Orem’s theory establishes self-care as initiating and performing actions that maintain life, health, and well-being.

Nursing is Meeting a Need

Nursing care is needed when illness, injury, or disease keeps an individual from meeting care needs independently. The condition may be too severe for self-care, such as a broken ankle. Or, the condition might be beyond the understanding or abilities of the individual, such as a complicated medication regimen for uncontrolled hypertension. Orem’s theory identifies five ways that nurses help patients with their self-care.

  • Acting for and doing for others
  • Guiding others
  • Supporting another
  • Providing an environment promoting personal development
  • Teaching another

Nurses help patients in these five ways through three nursing systems.

  • Wholly Compensatory: The nurse performs all self-care requirements and ‘compensates’ for the patient’s inability to perform these functions themselves. Patients in the infirmary may, at times, need wholly compensatory nursing care, as would patients in a man-down situation
  • Partially Compensatory: The patient is able to provide some self-care but needs nursing assistance in other areas. This is the primary mode for nursing sick call, medication administration, and intake screening.
  • Supportive-Education: Here the nurse supports and educates the patient to be able to maintain and enhance their self-care process. Sometimes this system is active in a nursing sick call situation where the condition does not require treatment as much as patient education. This might also be the system in operation when nurses provide general or group education to the patient population such as at intake or at health fairs.

Applying the Orem Theory to Correctional Practice

Orem’s theory is a practical way to apply nursing theory to correctional nursing practice. Here is an example of use in a common nursing sick call situation.

Inmate Drake, age 32, is 10 days into a 30 day stay in a county jail. He comes to nursing sick call having submitted a slip requesting something for constipation. He states he is usually quite regular but has not had a bowel movement for 5 days.

Nursing System: Partially Compensatory. This patient will likely need some help to regain a regular elimination pattern but should be able to return to self-care with support.

  • After a review of systems and an abdominal assessment, the nurse provides an approved OTC medication for constipation.
  • The nurse also asks about his exercise and eating patterns and provides guidance on how to increase fiber, fluid, and activity while incarcerated.
  • She then instructs him on returning to sick call if these interventions are not successful.

So, this sick call nurse met the patient’s needs through several of Orem’s five nursing activities: doing for the patient, guiding, and teaching him about ways to self-care for bowel hygiene.

Although Orem’s theory is practical and easy to apply, critics of the framework say there isn’t enough attention to the emotional needs of the patient or the impact of the environment on the patient. The emotional and psychological health of incarcerated patients and the unique environment of care behind bars may need further attention than can be provided by applying this theory, but it is a good start.

So, what do you think? Would Dorothea Orem’s theory work in your setting? Share your thoughts in the comments section of this post.

Photo Credit: © bbbar – Fotolia.com

Was Florence Nightingale the First Correctional Nurse?

Florence Nightingale statueHappy Nurse’s Week! This week we celebrate nursing and modern nursing’s founder, Florence Nightingale; who’s birthday is May 12. Since 1974, May 12 has been deemed International Nurse’s Day and the week proceeding May 12 was coined National Nurses Week since 1994.

I must admit that I didn’t know much about Florence Nightingale other than a few ‘facts’ from my Nursing History course a couple decades ago. For example, I know she was the ‘Lady with the Lamp’  and attended the British soldiers in the Crimean War. I also remember that she was a great statistician and a determined woman; willing to risk her upper class status to help the suffering. What my recent search discovered, however, is that Florence Nightingale may, in fact, have been the first correctional nurse. Let me explain.

19th Century Work Houses

Workhouses were developed in England in the 1600’s as relief for the poor. In the 1700’s they became more punitive in order to serve as a deterrent; only accessed in desperation. By the mid-1800’s they had become little more than prisons.  Families were separated into dormitories; meals were provided in communal dining rooms; personal clothing replaced by uniforms. Sound familiar? Dickens wrote Oliver Twist during this time period and portrayed life for an orphan in a workhouse.  Here is a fascinating documentary on British Workhouses.

Workhouse Infirmary Overhaul

Nightingale’s Crimean War service in the 1850’s caught the hearts and minds of the British public through news portrayals. However, long before her war experience she expressed her concern for the health of the poor. As an upper-class lady in mid-19th century England, she had visited the work houses of London and later stated:

 “In days long ago, when I visited in one of the largest London workhouse infirmaries [Marylebone], I became fully convinced of this. How gladly would I have become the matron of a workhouse. But, of a visitor’s visits, the only result is to break the visitor’s heart. She sees how much could be done and cannot do it.” (5 February 1864, in Public Health Care)

Teaming up with philanthropist William Rathbone in the mid-1860’s she began to transform the Liverpool Workhouse Infirmary by adding trained nursing staff and establishing standard health care practices.

Be a Correctional Nurse like Flo

Florence Nightingale transformed the healthcare provided in the British Workhouses and therefore improved public health in 19th Century England. As correctional nurses, our work in providing quality health care in US jails and prisons improves the health of our patients and, therefore, the public health of the nation.

Nightingale’s ideas about nursing were captured in her classic work – Notes on Nursing. She said that nursing “…ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet – all at the least expense of vital power to the patient”

Consider how the living conditions of your patients are affecting their health and illness. What ways can you improve these conditions or help your patient overcome them? Here are some ideas

  • Teaching patients to make good food choices in the dining hall and commissary
  • Advocate for healthy food options in the commissary
  • Encourage all patients to exercise according to ability
  • Provide standard exercise plans that work in-cell (such as boot-camp basic drills) or in the exercise yard
  • Customize standard exercise plans with patients during encounters
  • Encourage good sleep hygiene practices whenever possible

Celebrate Nurse’s Week

Some see Nurses Week as a time for giveaways, nice food, and flowery words about the meaning of our work. Other see the week as an opportunity to complain about how unappreciated they are! I would like to suggest that Nurses Week is an opportunity to reignite our mission as correctional nurses.  Let’s all try to be more like Flo in our correctional nursing practice this week!

So, do you think Florence Nightingale was the first correctional nurse? Share your thoughts about being like Flo in the comments section of this post.

Photo Credit: © Tony Baggett

Empathy: A Practice not an Emotion

Young man on reception at psychologistEmpathy has been discussed as a basic component of effective nursing practice since the 1960s. It is important because empathy produces insight into an patient’s experience and coping with illness. These insights facilitate the nurse’s diagnostic accuracy, problem solving and care becomes more patient centered. When patients feel understood they become engaged in a helping relationship with the health care professional and are more likely to adhere to treatment recommendations and advice about healthy lifestyle changes (Wiseman 2007).

Concerns about expression of empathy in correctional settings

Correctional nurses sometimes express concern about being empathetic with inmates. A simple definition of empathy is that it involves the ability to see the world through another person’s eyes. In correctional practice this definition is sometimes misinterpreted to mean that you have to think, feel and act like a criminal or a murderer or a sex offender; an impossible and unethical expectation. Another misunderstanding about empathy in correctional nursing is that the nurse is letting their emotions or feelings guide their actions and they are at risk of being manipulated by the inmate. Empathy in nursing practice is not a subjective emotion or feeling but is instead a professional interaction (Dinkins 2011, Mercer & Reynolds 2002).

If empathy isn’t an emotion, what is it?

A more descriptive definition of empathy is that it is the ability to perceive and understand the meanings, feelings and concerns of another person and to communicate that understanding to the other person. Empathy involves perceiving, thinking and communicating about another person’s experience and concerns. You do not have to think or feel like the other person to practice nursing empathically. There are three parts to empathy in nursing practice, sometimes referred to as the Empathy Cycle, these are:

  1. Listening, reasoning and understanding. Essential skills are the ability to listen attentively and the sensitivity to perceive another person’s experience, concerns or perspective on a subject. Understanding is a cognitive process that involves reflection and the suspension of judgment.
  2. Conveying understanding of the other person and your intention to help. Communication must be patient centered, accurate; not judgmental or blaming.
  3. The patient’s awareness that the nurse has communicated understanding and believes it to be genuine and accurate (Mercer & Reynolds 2002, Wiseman 1996, Wiseman 2007).

An example of empathy in correctional nursing practice

Last week I observed a nurse in sick call. She was seeing a 19 year old man for complaints of headache and acne. During her assessment she checked his medication administration record and noted that he had missed several days of thyroid medication. At first she lectured him about the importance of taking it each day. He looked at his feet and mumbled his understanding and agreement. Next she asked why he wasn’t taking it and he replied that he was still bed when it was time for morning meds. They talked some more about why he couldn’t get up and the impact of not taking the medication. Finally she said “Staying in bed in the morning is more important to you right now, isn’t it?” He nodded yes. Her reply was “I understand; let me see if the doctor will change the medication time to noon or the evening. Would that work better for you?” He nodded and indicated verbally that it would help.

The nurse accurately understood that for this young man, the consequences of not taking the prescribed medication were so remote compared to his desire to stay in bed that he would forgo the medication even after having listened to the information she provided. She acknowledged his reality that staying in bed was more important to him and used the information to problem solve a way to increase his medication adherence.

At this same correctional facility where I observed the nurse conducting sick call, the correctional officers are taught in training academy to offer empathy in their interactions with inmates. The curriculum notes that empathy establishes a dynamic that allows the officer to assist the inmate in problem solving, to feel understood and supported. Empathy is described as the “crown jewel” of active listening technique. The fact that correctional officers are taught in training academy how to use empathy really seems to support correctional nurses’ use of empathy in their interactions with patients.

Empathy and the Standards of Professional Practice in Correctional Nursing

Several of the professional practice standards for correctional nurses published by the American Nurses Association describe empathy among the competencies that nurses must demonstrate to meet the standard. The nurse in the example given above demonstrated all of the competencies in her brief interaction with the patient during sick call. These include:

Standard 1 Assessment: The correctional nurse elicits the patient’s values, preferences, expressed needs, and knowledge of the healthcare situation to utilize such information as appropriate within the context of the correctional setting.

Standard 4 Planning: The correctional nurse develops an individualized plan in partnership with the patient considering the patient’s characteristics or situation, including but not limited to values, beliefs, spiritual and health practice preferences, choices, developmental level, coping style, culture and environment, safety of the patient, and available technology.

Standard 5 Implementation: The correctional nurse advocates for health care that is sensitive to the needs of the patient, with particular emphasis on the needs of diverse populations.

Standard 7 Ethics: The correctional nurse maintains a therapeutic and professional nurse-patient relationship within appropriate professional boundaries.

Standard 13 Collaboration: The correctional nurse promotes conflict management and patient engagement (2014).

Reasons for lack of empathy in nursing practice

The primary factor that has been identified as impacting the practice of empathy among health care professionals is a fixation on the tasks and technology of care coupled with time compression. Other reasons identified as impeding empathic practice include:

Difficult patients Anxiety about patients Feeling belittled or insignificant
Unsympathetic colleagues Lack of role models Fear of making a mistake
Individual nurse’s personality Intimidating environment Pressure on task completion

(Ward, Cody, Schaal, & Hojat 2012)

Every one of these factors could be present in the practice environment of a correctional nurse. How many of them factor into your practice environment and to what extent have they impacted your use of empathy in the delivery of patient care? Empathy is not solely a personality trait; it is a skill that can be taught and developed (Wiseman 2007). Taking a moment to reflect on our practice environment may identify opportunities to improve our empathic response in patient interactions. From there it is possible to create a plan of professional development in this area.

Empathy reminders for our practice

Helen Riess, Associate Professor of Psychiatry at Harvard Medical School gave her TEDx Talk audience (2013) the following mnemonic which she uses to help health care providers develop empathic responses in their patient care encounters.

E              Eye contact – this is first indication that we have acknowledged an individual and it begins the interaction

M            Muscles of facial expression – are the road map of human emotion, notice the patient’s facial expression

P             Posture – an open or closed posture indicates receptivity (or lack thereof) to interaction (both yours and the patients). Maintaining an open posture facilitates the patient’s interaction with the health care provider.

A             Affect – is a term for expressed emotion; try to identify label the patient’s emotion, and listen to the patient with that perspective, it will improve your understanding of what the patient is communicating

T              Tone of voice – is an indicator of emotion, vocal chords are located in the brain close to the same area that activates fight or flight response, changes in tone of voice may be an early indicator of emotion

H             Hearing the whole person – more than the words that are said, understand the context of the patient’s experience, and be non-judgmental in order to comprehend

Y             Your response – pay attention to your feelings; we respond to others all the time; know what you are conveying and manage your part of the relationship professionally.

Are the challenges of using empathy in your professional correctional nursing practice similar to those described here? If so what resources have you found helpful in addressing these challenges? Please reply by responding in the comments section of this post.

For more on the nurses professional practice relationship with patients in the correctional setting see Chapter 2 Ethical Principles for Correctional Nursing as well as Chapter 19 Professional Practice in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.

References

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Dinkins, C. (2011) Ethics: Beyond patient care: Practicing empathy in the workplace. The Online Journal of Issues in Nursing 16(2).

Mercer, S. W. & Reynolds, W.J. (2002) Empathy and quality of care. British Journal of General Practice Quality Supplement 52: S9-S13.

Riess, H. (2013) The power of empathy. TEDxMiddlebury. Accessed 4/25/2015 at https://www.youtube.com/watch?v=baHrcC8B4WM

Ward, J., Cody, J., Schaal, M., & Hojat, M. (2012) The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional Nursing 28 (1) 34-40.

Wiseman, T. (1996) A concept analysis of empathy. Journal of Advanced Nursing 23: 1162-1167.

Wiseman, T. (2007) Toward a holistic conceptualization of empathy for nursing practice. Advances in Nursing Science 2(3): E61-E72.

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Inmate satisfaction with health care services during incarceration

 

Customer SatisfactionLast week’s post summarized the results of the most recent survey of inmates’ health published by the Bureau of Justice Statistics (BJS). This survey also reported on inmates’ experience with the delivery of health care in 606 correctional facilities throughout the U.S. and their satisfaction with services provided. So before we look at those results take a minute to reflect on your encounters with inmates seeking or receiving health care and how they might rate their satisfaction. My experience is that many correctional nursing colleagues think that inmate satisfaction with health care is low, that many inmates fail to appreciate their care and take what care they do receive for granted. What is your opinion about how satisfied inmates are with their care?

What Do Inmates Think? 

According to the over 100,000 inmates surveyed, more than half were satisfied or very satisfied with health care received while incarcerated. In jails, 51% of the inmates in the survey reported being satisfied or very satisfied and in prisons it was 56%of those surveyed (Maruschal, Berzofsky, & Unangst 2015). This information certainly bursts the stereotype that inmates don’t value the health care they receive during incarceration! Most inmates do appreciate it. Further evidence is found in another survey done recently in a maximum security prison; the vast majority of prisoners in poor health prior to prison reported that their health had improved during incarceration (Yu et al. 2015).

Identifying Opportunities for Improvement 

Patient satisfaction has long been recognized as a valid tool in quality improvement. Often it is only through a patient’s eyes that we can see opportunities to improve patient outcomes or make the experience more supportive of health attainment. Information about patient satisfaction can provide insight into the perceptions and expectations of patients, one important part of the larger picture of a program’s performance. For example, in the Oregon DOC, one of the questions we used on a patient satisfaction survey was whether follow up appointments after nursing sick call were timely. We expected that inmates would be dissatisfied when wait times were more than a day and found out we were wrong. Even wait times of up to one week were rated as satisfactory.

The results of a patient satisfaction survey conducted in the Connecticut prison system revealed much the same results as that reported in the national survey by the BJS. Forty-three percent of 2,727 inmates surveyed (or 16% of the total population) reported satisfaction with their health care; this was considered “better than expected” by some of the health care staff in the system (Tanguay, Trestman & Weiskopf 2014). There was no difference in satisfaction scores based upon gender (male or female) or the type of facility (maximum security, work camp etc.).

The survey developed in Connecticut consisted of ten questions derived fundamentally from Crossing the Quality Chasm: A New Health System for the 21st Century published by the Institute of Medicine (IOM). There were ten topics that inmates were asked their opinion about. These are listed below:

General satisfaction with care Respect for privacy
Access to care is satisfactory The provider listened
Waiting time in the clinic is short The provider is competent & well trained
The provider introduced themselves The provider explained their findings
Treated in a friendly & courteous manner The patient knows what to do to get better or take care of themselves

The article pointed out that to ensure a good response rate questions were written at the fourth to fifth grade reading level, were limited to ten in number and used only three response categories (yes, no and unsure). Although the survey was anonymous, inmates were reluctant to participate at first but this changed over time as inmates came to understand that the survey was intended for program improvement, was indeed anonymous and therefore participation was “safe”.

Important Findings From the Feedback 

Feedback on inmate satisfaction was discussed with health care and correctional staff at each facility and at a statewide level. Satisfaction with each of the ten measures varied. The results and the ensuing discussion were used to identify areas for focused program improvement. For example access to care was rated as satisfactory by 45% of the inmates surveyed. Areas that made access to care difficult included appointments that were dropped because of facility to facility transfers which required inmates to re-request services. Automation of inmate scheduling was discussed as a way to eliminate this problem with access. Other areas that were selected for improvement included explanations for the patient about what the problem is and their treatment options and productive use of time spent waiting while in the clinic (Tanguay, Trestman, & Weiskopf 2014).

Correctional Nurses’ Role in Quality Improvement

Standard 10 of the Correctional Nursing Scope and Standards of Professional Practice provides guidance for correctional nurses’ contribution to quality. Competencies include participation in the evaluation of clinical care and service delivery, correcting inefficiencies in the process of care delivery, identifying and weakening barriers to quality patient outcomes (American Nurses Association 2013). Satisfaction surveys can provide useful insight into the experiences and expectations of our patients. Some patients may be receiving very good health care and still be unsatisfied but taken in the aggregate inmates tend to rate health care received during incarceration very positively. Consider conducting patient satisfaction surveys at your facility if you haven’t used this feedback method yet; you and other health care staff are likely to be pleasantly surprised.   Satisfaction survey results also provide information that can help focus on the areas of the patient’s experience that greatly impact health outcomes, as the report from Connecticut illustrated.

What Is Your Experience and Advice? 

Have you sought feedback from inmates at your facility about their satisfaction with health care? If so, was your experience with the results similar to that reported by the BJS and for the Connecticut prison system? Do you have copies of the survey questions that were used and if so will you share by responding in the comments section of this post?

For more on the nurses’ role in quality improvement see Chapter 18 Research Participation and Evidence-Based Practice in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.

References

American Nurses Association (2013) Correctional Nursing: Scope & Standards of Practice. Silver Springs, MD: Nursesbooks.org.

Institute of Medicine (IOM) (2001) Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press.

Maruschal, L. M., Berzofsky, M., & Unangst, J. (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Special Report. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Tanguay, S., Trestman, R., & Weiskopf, C. (2014) Patient Health Satisfaction Survey in Connecticut Correctional Facilities. Journal of Correctional Health Care 20 (2); 127-134.

Yu, S-s. V., Sung, H-E., Mellow, J., Koenigsmann, C.J. (2015) Self-Perceived Health Improvement Among Prison Inmates. Journal of Correctional Health Care 21 (1); 59-61. 

Photo credit: © bahrialtay– Fotolia.com

What does it all mean: New stats on the prevalence of disease among inmates?

Stethoscope, chart, diseases, medical, healthcare, insuranceThe U.S. Department of Justice, Bureau of Justice Statistics (BJS) recently released a report that describes the tremendous burden of disease among inmates in our nation’s correctional systems. See Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12 released February 2015. Over 100,000 adult inmates participated in a survey about their physical health conducted at 606 correctional facilities of all types between February 2011 and May 2012. The following is a summary of the findings and their implications for correctional nursing practice.

Forty percent of the incarcerated population report having a current chronic medical condition with 25 percent reporting two or more chronic diseases. When standardized for comparison, only a third of adults in the “free” community report having a chronic disease. Inmates are more likely than adults in the “free” community to have hypertension, diabetes, cardiovascular problems, asthma and cirrhosis of the liver. Female inmates are more likely to have a chronic condition than men and the likelihood of having a chronic disease increases with age. The prevalence of diabetes among inmates is twice the rate and hypertension is 1.5 times the rate reported in the 2004 survey by the BJS. Two thirds of inmates reporting a chronic condition took prescription medication for it in the 90 days preceding incarceration.

Infectious disease is also more prevalent among incarcerated persons (14.3%) than the “free” community (4.6%). Inmates are twice as likely to have had tuberculosis infection, six times more likely to have hepatitis and twice as likely to have had a sexually transmitted disease. While the rate of HIV among inmates is higher (1.3%) than the general population in the community (0.3%) the overall prevalence of HIV among prisoners has been slowly and steadily declining since 2001.

Mirroring the nationwide epidemic of obesity, nearly three quarters of prisoners and more than 60 percent of jail inmates were either overweight or obese as reported in the 2001-20012 BJS survey. Obesity contributes to the chronic health problems discussed earlier, specifically hypertension, heart disease, stroke and diabetes. Race and gender differences were consistent with those reported for the community at large.

So what does this all mean for correctional nurses?

  1. It is a reminder that we practice “population based” care. In other words we are responsible for the health and wellbeing of a population of people who happen to be incarcerated. We are not just an OB-GYN nurse or the ED nurse or the psych nurse but instead see patients whose health problems are not well established and can include a wide variety of concerns. Rather than view a patient’s problem, headache for example, within narrow parameters and judgmental stereotypes we should consider the high rates of disease in our population and thoroughly evaluate the patient. Our patients do not have the same disease profile as the general community.
  2. Every patient encounter (sick call, med line etc.) is an opportunity to teach and support a healthy lifestyle that encourages the patient’s self-care and quality of life. These conversations should not just be reserved for the visit with the ID nurse or the chronic care visit. The most effective behavior change takes place when patients received the same information and support from multiple sources to make change.
  3. Many of our patients will require coordination of their care as they transition from the community to incarceration, upon transfer to another correctional facility, during off site specialty care and upon return to the community after release from incarceration. This means obtaining records from previous providers, maintaining an up to date problem list, reconciling medication lists, tracking appointments, communicating information to other providers, developing and carrying out release plans.
  4. Managing chronic and infectious disease in prisons, jails and detention facilities also requires advocating for conditions that support attaining a healthier lifestyle during incarceration. The provision of a heart healthy diet, access to aerobic exercise, and clean air are topics that nurses should advocate for if not available at a correctional facility. If these provisions are available nurses should actively include and support use of these resources when working with patients.

Our work is a lot easier if we are taking care of a diabetic who is in good control or an HIV patient whose condition has stabilized. Blaming the patient for being sick or having a disease that is preventable only makes for an adversarial relationship resulting in worse patient care outcomes. Taking steps to identify disease early and get treatment initiated as well as coordinate the patient’s care during incarceration and upon release is a more effective way to manage our practice than waiting until problems arise before taking action.

What does the information from the BJS report on medical conditions of prison and jail inmates mean for your practice? How does your facility address obesity? Are inmates counseled about weight control? Please share your thoughts by responding in the comments section of this post.

For more on the nurses’ role in addressing chronic disease see Chapter 7 in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.

 

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Correctional Nurse Self Care: Resilience

 

 

Peligro, cuerda rotaLast week’s commentary on the burden of moral distress brought forth the concerns and experiences of several more correctional nurses. Each of these courageous nurses described a turning point where they chose to act rather than stay silent and address the needs of their patients; each also paid a price, including termination, depression, failing health and so forth. I too, had to leave a position I had been in for 17 years because I was “in the way” of achieving the cost savings the organization had promised. This past year I witnessed a colleague being walked off the job because while she was trying to improve nursing practice she didn’t have the full support of the facility health authority. These are tremendous consequences for nursing professionals committed to quality patient care. One nurse commented that it is “easy to blame the nurses that are working with the inmates daily” rather than look up the chain of command to the organization itself and the managers responsible for the delivery of services. These experiences and the accompanying reality are the reason resilience has been identified as an essential quality to nurture as part of the caring practice of the nursing profession (Tusaie & Dyer 2004, Hodges et al. 2005, Warelow & Edward 2007).

Resilience refers to the ability to bounce back or recover from adversity (Garcia-Dia et al. 2013). Others describe resilience as the ability to grow and move forward in the face of misfortune or adversity; to adapt to adversity while retaining some sense of control and moving on in a positive manner (Jackson, Firtko & Edenborough 2007). Resilience has been suggested as a strategy for nurses to manage the emotional and physical demands of caring for patients as well as reduce their vulnerability to workplace adversity (excessive workload, organizational restructuring, lack of autonomy, bullying and violence).

The good news is that resilience is not a personality trait, that we either have or not, but instead consists of behaviors, thoughts and actions that can be developed and fostered to strengthen and adapt to our circumstances. Strategies that help build personal resilience include:

Professional relationships which are supportive and nurturing

A key component in the lives of resilient people is positive social support; having one or more people in the profession who are role models and can be called upon for guidance and support when needed. At least some of these individuals need to be from outside the immediate workplace so that support is unbiased and safe to receive, especially when the workplace is laden with tension. Another feature is that the relationship needs to be nurturing and one that fosters offers encouragement, reassurance, and individual professional growth; such as a mentoring relationship. In thinking about this, my professional network was developed among the members of the Oregon Chapter of the American Correctional Health Services Association. We meet twice a year and each meeting includes training, social time and the opportunity to discuss the workplace challenges we each struggle with. The relationships built through this local organization with other correctional nurses over the years have sustained me during many periods of crisis and change.

Maintain positivity

Positive emotions, including laughter, increase energy, change perceptions and help cope with adversity. Positivity comes from optimism or an ability to visualize potential benefits or positive aspects of an adverse situation. Considering a situation in a broader and longer-term perspective can build optimism. Indeed forcing oneself to think positively develops a greater range of resources and broadens the inventory of possible solutions in the midst of adversity (Jackson, Firtko & Edenborough 2007). The readers’ comments about their experiences with moral distress express an optimistic and positive view that reaching out to each other will create a collective voice to improve conditions in correctional health care. Techniques suggested to support positivity include visualizing what one wants rather than what is feared, identifying what brings joy to one’s life, maintaining hope for a positive outcome and laughter.

Develop emotional insight

Emotional insight is the capacity to identify, express, and recognize emotions; to incorporate emotions into thought; and to regulate both positive and negative emotions. When faced with adversity, emotion is inevitable, however we often are focused on the “who, how, what, when and where” of what is happening; unaware of how emotion is effecting us. When we can identify our emotional response to a situation we can switch our parasympathetic nervous system on and respond in a calm and rational manner and not suffer the effects of a “fight or flight” response. Understanding our emotional needs and reactions provides further insight into how we cope and may yield new ideas about how to improve our response in the future. Specific techniques suggested to develop emotional insight are relaxation exercises, guided imagery, meditation, deep breathing, journaling and reflection. See an earlier post about the use of reflection for professional growth.

Achieve life balance and spirituality

Highly resilient persons express existential beliefs, have a cohesive life narrative and appreciate their own uniqueness. This has also been described as having an anchoring force in life. In nursing, we often use the term achieving a work-life balance which is to engage in activities that are physically, emotionally and spiritually nurturing. This includes being clear about our mission in professional life, the reason for being a correctional nurse, so that we aren’t distracted in challenging times. Activities that support a balanced life include getting enough sleep, eating healthy, regular exercise, and maintaining a spiritual practice. You may want to revisit a recent post introducing self-care for correctional nurses. Another suggestion is to write and then send a letter to yourself recognizing your strengths and expressing gratitude for the work that you do.

Reflective practice

Reflection is a way to develop insight and understanding about situations so that knowledge is developed and can be used in subsequent situations. A concrete experience, such as losing one’s job or experiencing an ethical dilemma is used as a catalyst for thinking and learning. Journaling is especially helpful in adult learning because putting an experience into writing ascribes meaning to the people, places and events involved in the experience. Reflection is an opportunity for self-discovery; many people report better relationships, greater personal strength and self-worth, a deeper spirituality and heightened appreciation for life as a result of the self-growth that takes place after adversity. One of our readers said exactly that… “I have learned so much about myself, and systems change, and leaders vs managers.” I have to agree based upon my own experience; I am a stronger, more skilled professional than I ever was and have more to give others as a result of the self-discovery that took place after leaving, so long ago, a job I loved.

 

No one wants to experience workplace adversity and professional burnout and yet we know from our own experience and those of our readers, it is a reality in correctional nursing. Recognizing and building resilience personally and within our organizations is a strategy that is becoming part of the profession’s uniform. Below are several excellent resources for developing nursing resilience:

  1. Resilient Nurses: How health care providers handle their stressful profession. Written and produced for Public Radio. Consists of two ½ hour interviews with several leading nursing experts. The second segment includes techniques used to handle unusual strain as well as everyday stressors in nursing. It also includes a relaxation audio, a booklet, a CD and a list of resources.
  2. How can nurses build resilience and master stress? A summary of a 16 week series on Activating Resilience in Nursing and Leadership by Cynthia Howard. Links are included to other posts in her series on resilience.
  3. University of Virginia School of Nursing, Compassionate Care Initiative, is dedicated to teaching nurses resilience and compassion in health care. The site includes a link to “nurses thrive!” an online community of nurses dedicated to promoting resiliency. Also includes resources for building resilience through guided practice and exercise.

Do you recognize aspects of your own path to professional resiliency in these descriptions? What has helped you adjust or rebound from adversity? Please share your experiences or advice by responding in the comments section of this post.

References:

Garcia-Dia, , J., DiNapoli, J.M., Garcia-Ona, L., Jakubowski, R. & O’Flaherty, D. (2013) Concept Analysis: Resilience. Archives of Psychiatric Nursing 27; 264-270.

Hodges, H.F., Keeley, A.C., & Grier, E.C. (2005) Professional resilience, practice longevity, and Parse’s theory for baccalaureate education. Journal of Nursing Education 44, 548-554.

Jackson, D. , Firtko, A., & Edenborough, M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing.

McGee, E. M. (2006) The Healing Circle: Resiliency in Nurses. Issues in Mental Health Nursing 27; 43-57.

Sieg, D. (2015) 7 Habits of Highly Resilient Nurses. Reflections on Nursing Leadership 41 (1).

Sullivan, P., Bissett, K., Cooper, M., Dearholt, S., Mammen, K, Parks, J., & Pulia, K. (2012) Grace under fire: Surviving and thriving in nursing by cultivating resilience. American Journal of Nursing, 7 (12).

Tusaie K. & Dyer J. (2004) Resilience: a historical review of the construct. Holistic Nursing Practice 18, 3-10.

Warelow, P. & Edward, K-l. (2007) Caring as a resilient practice in mental health nursing. International Journal of Mental Health Nursing 16, 132-135.

 

For more on moral distress and courage see Chapter 2 Ethical Principles for Correctional Nursing in the Essentials of Correctional Nursing. You can order a copy directly from Springer Publishing and receive $15 off as well as free shipping by using this code- AF1209.

Photo credit: Peligro, cuerda rota@alejandro dans- Fotolio.com