On Being Thankful

Be thankful for what you have; you’ll end up having more. If you concentrate on what you don’t have, you will never, ever have enough.” – Oprah Winfrey

Heart shape hands on the blue sky

As a reforming whiner, I often need reminding to be thankful. Yes, given the choice between appreciating a situation and complaining about it, I will regularly choose the later. That’s why I so appreciate having a holiday every year that focuses on gratitude and thankfulness. What better way to re-center our thoughts on the good in our lives and the contributions of others?

With that in mind, I’d like to offer my Thanksgiving gratitude list (not in any particular order):

  • Correctional Nurses: Frankly, I didn’t know correctional nurses existed 10 years ago. When I discovered this invisible nursing specialty, I know I found a home. It has been a blast getting to know so many nurses who work in difficult environments with often-difficult patients. Our patient population is marginalized and vulnerable, frequently forgotten by society and the traditional healthcare system. I am grateful for your work on behalf of our patients and delighted to have meet so many of you in my travels and through this blog.
  • Blog Readers: Speaking of blogs, Catherine and I are energized by the number of visits and comments on our posts over the years. You are our inspiration and the focus of our efforts.
  • Professional Associations: I am truly thankful for professional associations like National Commission on Correctional Health Care and the American Correctional Health Services Association. These organizations do great work in advancing correctional nursing practice and providing a wonderful venue for networking and communication. I enjoyed meeting many of you at NCCHC and ACHSA conferences this fall.
  • Correctional Officer Colleagues: This Thanksgiving season I have been pondering the great contribution of correctional officers to both public safety and the personal safety of correctional nurses throughout the criminal justice system. Our CO colleagues live with similar social stigma and feelings of invisibility. We are all in this together and need to support each other.
  • Family and Friends: Without the support of my husband, family, and friends I could not do what I do. Those I know who have much family stress and drama have no energy left to create new things. I often forget that I am free to write and speak and learn new things because I have a great support system.
  • A God Who Cares: Having a caring God who made me unique and expects me to use the gifts He gave me is also a cause to be thankful. Even when everything is ‘going wrong’ there is a comfort in knowing there is a plan in play and I don’t necessarily need to know what it is. I do need to do my part, though, by making a difference where I am with what I have been given.

Cultivating Gratitude in the Year Ahead                      

I am inspired to renew my efforts to reduce whining and increase appreciation this coming year. Are you with me on this? Here are two ways I’m going to increase my gratitude and decrease my whining:

  • Count My Blessings: Spend regular time meditating on the simple blessings of life such as a roof over my head and food on the table.
  • Say Thanks: Consciously sharing gratitude for friendship, support, assistance, and information provided by others in day-to-day living.

Will you join me in my efforts to ‘keep on the sunny side’ in the days ahead? Rather than concentrating on what is missing, as Oprah states, we can focus on what we have and end up having more!

Leave your suggestions and encouragement in the comments section of this post.

An earlier version of this post first appeared on CorrectionalNurse.Net

Why do we stay in correctional nursing?

Model isolated on plain background in studio puzzled

The last several posts have described the challenges and distinguishing features of correctional nursing. Well what are the reasons nurses stay in the field? I thought that I would be in the field about five years before moving on to something new and that was 31 years ago! What is it about correctional nursing that keeps us?

Here are some of the reasons that I am aware of…maybe some of these will resonate with you.

  • We can see our patients every day, for years and years, and so have time and opportunity to establish a strong, therapeutic alliance. This is especially true of prisons where an inmate may spend their lifetime. In jails and detention facilities offenders may not stay very long, but a relationship can be built here also because most of them come back again, again, and again for repeated offenses. The amount of time we can spend with our patients, facilitates teaching and coaching them to manage disease and live healthier lifestyles. They are dealing with loss, grief, in some cases death, and at some point will seek redemption, meaning and purpose in life. A nurse may be the one contact that initiates and supports that change. I remember a prisoner who cried at a ceremony we held at the end of eight weeks of psychoeducational classes. He told us that he had never finished anything before, didn’t think he could finish and now realized he was capable of more. It wasn’t “a con”; he went on to get his GED and learn a trade.
  • Prisons and jails may be considered somber and inhospitable places but for many it is a better environment than how they lived in the “free” community; perhaps homeless, unemployed, sought after by the police or other criminals, high on drugs or alcohol. By contrast, a correctional facility is a highly controlled environment. Advantages here are that disease can easily be detected and treated, and sometimes as in the case of tuberculosis and STDs, the public benefits as well. Lifestyle behaviors that contribute to chronic disease can also be modified during imprisonment. Examples include smoking cessation programs, diabetic education, medication adherence and harm reduction. In some ways it is a perfect place to promote change; the patients are available and easy to interest, their progress can be monitored and outcomes measured. When our patients relapse, as inevitably happens when making lifestyle change, they can re-enroll in the program and do it all again, each time making incremental but positive improvement.
  • A related advantage is that this controlled environment is “safe”; a safe place to work. A light hearted way we express this is when we say that at least in prison we know who the criminals are; they all wear the same uniform. We have custody staff monitoring our every movement and every one going in and out is searched for contraband. The only time I have ever been threatened with a weapon was when I worked in an emergency room at a university hospital and the only time I have been hit, I was working on a med-surg unit in a community hospital. After 31 years of experience I would say that a correctional facility offers a very safe and controlled environment in which to provide health care.
  • Lastly, it is a fascinating field. Here is an example from my experience. One day a nurse is seeing patients who have requested health care attention, for complaints typically seen in an ambulatory care clinic, (low back pain, skin irritation, sore throat, and nasal congestion) and then along comes a patient with mild CNS symptoms and gives a history of GI upset and myalgia. He has escaped from civil warfare in Nicaragua and was picked up in the U.S. recently without immigration papers. Given this description what medical problems would you be considering might be the cause of his symptoms? Ultimately the patient was diagnosed with a severe case of trichinosis that has infected his brain, undoubtedly from eating undercooked infected meat on his desperate travel to America. He recovered fully in the capable care of correctional nurses. The range of clinical problems we see in our day to day practice is a marvel.

Why are you still a correctional nurse? What is it about the field that keeps you coming back to work each day? Is it because it is so different from every other specialty, or is it that you can see how much good you can do and the satisfaction of making a difference? Maybe take a moment and give thanks for the things that make you proud to be a correctional nurse. Let us know about your experiences in the comments field in this post.

If you would like to read more about correctional nursing go to Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

Lorry Schoenly, co-contributor at this site, has published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting. If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing, by Lorry Schoenly go to Correctionalnurse.net and order it through Amazon.

Photo credit: © bruno135_406  – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 3

Tonia FaustThe last two weeks we explored two of the challenges in becoming a correctional nurse and how once mastered, the results are practices that distinguish correctional nursing from other areas of nursing practice. A final cultural challenge for nurses in the land of correctional Oz, a phrase Lorry coined for nurses new to the specialty, is to develop a caring practice, consistent with professional principles. Many correctional nurses lament “how can I be caring when the place where I work exists for the purpose of punishment?” In correctional settings, staff are cautioned against touching an offender, unless it is necessary to perform some task, such as a pat down search. Some places go as far as considering touch, an act for which staff can be disciplined.

Common expressions of caring in nursing such as therapeutic touch or an empathic disclosure of personal information are often prohibited or extremely limited in the correctional setting. These acts earn a nurse derision from other staff, particularly custody staff, and they will be taunted as a “chocolate heart”, “hug-a-thug” or “convict lover.” Correctional officers will not trust nurses who violate the facility’s expectations about maintaining boundaries, to act professionally in other encounters.

Caring however remains a central tenet of correctional nursing and is vital to the therapeutic relationship. Another distinguishing characteristic of the specialty, is that the expression of caring, emphasizes interpersonal communication rather than physical contact and use of self to convey empathy. Correctional nurses express caring when their interactions with patients convey respect, are nonjudgmental, acknowledge the validity of the patient’s subjective experience, are not rushed and are done in the genuine interest of the patient (ANA 2013).

Correctional nurses have described how, it is first, necessary to establish a professional relationship with custody staff before they can negotiate delivery of compassionate nursing care. This means having acting, behaving and speaking in a ways that are consistent with professional practice standards. The most recent version of the Scope and Standards of Practice for Correctional Nursing were published in 2013 and now are identical to those of nursing generally. So a correctional nurse practices as any nurse does; it is only the place and population served that differ.

An example of how a professional relationship with custody staff is established, is in accounting, not just for controlled substances, but for all the sharp instruments as well. This is usually done at the beginning and end of every shift. This means all of the instruments, including those in the dental clinic, those kept in the inpatient and outpatient medical areas, and the lab as well plus every needle on site…it can be an arduous task. This degree of accountability is necessary because sharps can be used as weapons, to do tattooing and to shoot drugs, all dangerous and prohibited activities in a correctional facility. Nurses count sharps because it is necessary for security, not as part of health care delivery. A missing sharp means that the whole facility will be locked down and searched until the item is found. I have experienced an entire facility being locked facility down, for hours on end, because a single insulin syringe could not be accounted for. No other work, even delivery of health care takes place, until the “sharp” is accounted for. Sometimes nurses balk at the requirement for counting or act as though it isn’t as important as patient care. However, failure to account for sharps is not only dangerous, but it undermines the professional relationship with custody staff.

The ANA standards for professional practice are also important because they help to define and protect the role of nurses in the correctional setting. We provide health care in a setting where custody staff, facility commanders and correctional administrators have little or no knowledge of the standards for nursing care, let alone much appreciation for the limits of nursing practice in state law, unlike traditional health care settings. A nurse cannot rely on the correctional facility to have practices and procedures that are compliant with state law or professional practice standards. They may be the only nurse for a small facility and have no other health care professional to provide advice, other than a part time visiting physician. Even in large correctional facilities with many nurses, including nurses in management, practice creep can occur for an individual nurse whose primary interaction during a shift is with correctional officers and inmates who don’t know or appreciate the nurse’s scope of practice. Individual nurses must therefore establish these boundaries on their own, or risk violation of the law and the potential for action on their license.

There are many examples where nurses are asked to perform work that is outside the scope of practice or not consistent with professional standards. A nurse may be asked to approve use of pepper spray or endorse the use of a restraint chair and hood; decisions which are not in the interest of the patient or their health care. For example, another friend of mine, Lynda Bronson, was threatened with insubordination for refusing a direct order from the Warden to forcibly medicate an inmate who was in segregation and screaming obscenities at the officers.

The Warden threatened Lynda three times with insubordination and yet she stood her ground and explained that she did not have a medical order that would allow her to forcibly medicate the inmate. These are tough situations to be in and correctional nurses must be experts in communication, collaboration, and problem solving, with Wardens as well as correctional officers. These skills are necessary to arrive at compromises that solve problems, like screaming obscenities and gravely disordered behavior, while keeping the patient and staff safe.

Well done, this is experienced as practice autonomy, one of the most preferred and distinguishing characteristics of correctional nursing. Nurses who are clear about the standards and boundaries of their practice in correctional settings earn the respect of custody staff and are able to negotiate better outcomes for their patients.

To sum up, correctional nurses provide health care from within the justice system, to a disparate population of prisoners with great disease burden. These features; the location and population served, along with the nurse’s independent negotiation for care, define and characterize correctional nursing.

They say that once a nurse has resolved these cultural challenges, he or she will stay in the Land of Correctional Oz forever. As Tonia Faust, the nurse from the Louisiana State Penitentiary said in The American Nurse “There is a purpose for me here”. Those that don’t survive the transition, leave, usually within the first year.

Do the challenges portrayed over the last three weeks fit the experience you had transitioning into the field of correctional nursing? Are there aspects of your practice in correctional nursing that are different from other nursing fields that have not been highlighted in this series? Please share your thoughts about these questions by responding in the comments section of this post.

If you would like to read more about caring and professional practice in correctional nursing see Chapter 2 on the ethical principles of correctional nursing and chapter that discusses the elements of professional correctional nursing practice in our book, Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

Photo credit: Jaka Vinsek, Cinematographer The American Nurse

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

Illustration - Woman in jailLast week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at www.hamiltonproject.org).

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!


Photo credit: © Helder Sousa – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 1

00000001What career did you want for yourself when you graduated from nursing school? Did know you wanted to be a correctional nurse? You probably never heard of it, right? This is me back in 1973 and I had never heard of correctional nursing either. Most correctional nurses will tell you that they never planned to be in this field. The reasons they give for trying it out included:

Wanting to try something different.

It was close to home and convenient.

They knew someone else who was a correctional nurse and suggested it.

I made the change because I was bored with hospital-based psychiatric care. The opportunity to develop a health care program for offenders in state prisons came at the perfect time and I took on the challenge and have had a chance to make a difference in the lives of those who could not do so for themselves. I thought I would stay about five years and move on, but it has been 31 years now. The next several posts will explore the challenges of becoming a correctional nursing specialist, the features that distinguish the specialty and explore why nurses stay in the field.

Nurses have advocated for the health and well-being of prisoners practically since the beginning of time. These include Florence Nightingale, who did some of her best work in England’s poor houses in the mid-nineteenth century as well prisoners during the Crimean war, Clara Barton, who cared for prisoners of war in the Civil War, and Dorothea Dix who was responsible for prison reform in the 1800s. The American Nurses Association has considered correctional nursing a specialty since 1985 and publishes standards for the scope of professional practice in correctional nursing.

The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) acknowledges correctional nursing when commenting on diversity in the nursing profession, stating that nurses will be present anywhere there are people who have healthcare needs. Those of you who watched the movie, The American Nurse, met Tonia Faust, a correctional nurse, and hospice coordinator at the Louisiana State Penitentiary. Four of the 75 nurses portrayed in the book, The American Nurse, were providing health care in correctional facilities at the time they were interviewed. We don’t really know how many correctional nurses there are because many state boards of nursing don’t include this as an option when indicating your place of employment or area of practice.

My co-contributor, Lorry Schoenly, likens the transition to correctional nursing to the popular tale, The Wizard of Oz when Dorothy Gale, walks out into the Land of Oz, after her prairie home landed on the Wicked Witch of the East, following a tornado ride from Kansas. Our first experiences with correctional officers, handcuffs, sally ports, metal detectors, crossing the yard and pop counts brings to mind Dorothy’s admonition to her little dog “This isn’t Kansas anymore, Toto!” In fact Lorry, published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting.

Well the first cultural challenge for nurses after they have arrived in the Land of Correctional Oz is the realization and understanding that our services are secondary to enforcing the law and protecting the public. This is the primary purpose of incarceration in the United States. The people whose health we are responsible for, are being detained against their free will, as punishment. Even so, the Supreme Court has granted prisoners a constitutional right to health care under the 8th amendment. Failure to do so is considered “cruel and unusual punishment.” The court’s reasoning was that “it is but just, that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.”

This is not just a cultural challenge but one of the distinctive features of correctional nursing practice. The first part of the ANA definition of correctional nursing, is that it takes place at the intersection of an individual and their involvement with the justice system. Legal precedents have been the primary means by which the delivery of health care in the correctional system has been shaped.

The courts have established that inmates have the right to health care during incarceration which includes:

  1. Unimpeded access to care
  2. Care that is ordered must be provided
  3. Entitled to professional clinical judgment

These three rights are referred to as the three legged stool of the Eighth Amendment rights to prisoner health care and they are operative in almost every aspect of a correctional nurse’s daily practice.

Here is an example of the application of these rights to health care from my early experience in correctional nursing. In this instance, three inmates, working in the print shop, drank printing fluid, in an attempt to get high. All three became sick but they did not seek medical attention because the nursing staff would have to report them to security for stealing the printer fluid. One inmate died as a result of the delay in treatment. The courts found a violation of the eighth amendment because the inmates’ access to health care attention was impeded, due to the threat of being reported and subsequently disciplined. In this case, a correctional facility’s requirement for reporting prohibited conduct impeded access to care and resulted in a finding of “cruel and unusual punishment”.   The legal right to health care, its practical interpretation and application in the correctional setting is one of the distinguishing features of correctional nursing.

Do you have some good examples of how legal considerations impact the practice of correctional nursing? If so please share by responding in the comments section of this post.

If you would like to read more about legal considerations in correctional nursing please see Chapter 3 written by Jacqueline Moore in the Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.


Photo credit: © Africa Studio – Fotolia.com

Stay at home ways to build continuing education credits

Man sitting at a computer, learning at home.

I have a friend recently who was lamenting that personal circumstances did not allow her attendance at the National Conference on Correctional Health Care that took place in Dallas Texas this week. She was worried that she would not have enough continuing education hours to satisfy the requirements for recertification as a Certified Correctional Health Professional (CCHP). In addition to professional recertification, many states require evidence of continuing education when nurses renew their license. There are times when life events or circumstances make attending a conference or other educational activity just impossible and then we worry about having enough CEs. This post is written to provide information about some CE resources that can be done at home and are free or inexpensive.

CCHPs and CCHP-RNs recertify once each year. In addition to the renewal fee of $75 the applicant must attest to having obtained 18 hours of continuing education of which 6 hours are specific to correctional health care. CCHPs and CCHP-RNs should maintain a record of the continuing education that they have attested to, in case they are audited. One way to do this is to keep a CE log that includes the following information:

Your name Date Title or subject # of hours

In addition to conference attendance, continuing education credit may be obtained by attending in-service at a correctional facility, writing an article for a journal, or making a presentation at a conference. Another way to obtain CEUs that may be more practical or achievable when life becomes hectic is self-study or independent learning. The following are some self-study options:

The Journal of Correctional Health Care is provided free as one of the benefits to CCHPs and CCHP-RNs. The Journal is published four times each year and contains six to ten scholarly, peer reviewed articles that are specific to correctional health care. If you are not certified an annual subscription costs $125 so this is a tangible return on the investment in certification. You can earn 1 continuing education credit for each article if you complete a corresponding exam. Any article published by the Journal of Correctional Health Care within the previous two years is eligible for continuing education credit. All of this material would meet the requirement of CCHP for 6 hours specific to correctional health care. For more information about this resource go to this link http://www.ncchc.org/journal-of-correctional-health-care.

Medscape is another resource for continuing education credit. This site offers clinicians access to timely clinical information and educational tools to stay current in practice. There is no cost to join and you can access resources that are selected specifically for nurses. For example 0.25 contact hours can be obtained for previewing a slide show and web discussion about motivational interviewing, behavioral action and collaborative care in Strategies for Effective Communication with Patients with Major Depression. There is an easy to use CE Tracker that will keep track of the courses and credits accumulated through the year which can be saved or printed out as necessary. This last year I took two classes, one on the guidelines for prevention of bedsores and the other on prescribing antibiotics and both were easy to access, informative and the exam very simple. For more information about this website go to this link: http://www.medscape.org/

The American Nurses Association is a favorite on-line resource of mine for continuing education. You do have to belong, but an on-line membership only costs $45 a year. Membership benefits include three publications, American Nurse Today, The American Nurse, and the Online Journal of Issues in Nursing. There also is a large library of on-line courses with continuing education credit that can be accessed when it is convenient for you.  I have taken several courses from ANA this year, including a session on the new ethical guidelines for nurses, a course on preventing medication errors and another on the JNC guidelines for managing hypertension. As a member I receive announcements of upcoming Webinars that are offered with continuing education credit and at no charge. This year I took a whole series on building a healthy workplace. Go to this link to find out more about the continuing education resources through the American Nurses Association: http://www.nursingworld.org/JoinANA/E-Membership-Only.

These three resources offer thousands of continuing education hours without ever having to leave your home. Most can be obtained either free or as a benefit of being a CCHP or CCHP-RN. So when time or circumstances make it impossible to access continuing education credits at conferences or on the job, these options may be a help. In my case I’ve chosen to access continued learning through these sites even though I have been able to attend conferences and in-service programs this year.

Do you have resources for continuing education that you would like to share with other correctional nurses? If so, please tell us about them by replying in the comments section of this post.

For more about continuing education in correctional nursing see Chapters 17 Management and Leadership as well as Chapter 19 Professional Practice in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!


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Best of the Blog #1: The Five Rights of Delegation

We searched through the stacks of almost 200 blog posts to pull out the most popular ones for this series. If you are new to the Essentials of Correctional Nursing Blog you may have missed some good reads. Enjoy!

This post, written by Catherine Knox, originally aired January 13, 2013.

The post last week included a case example about a licensed practical nurse (LPN) responding to a medical emergency after an altercation between two inmates. The LPN determined that neither inmate required further medical attention. Later in the shift one of the inmates was taken to the emergency room after being found unresponsive in the cell. The inmate subsequently died of the head injury that was sustained in the altercation. This example highlighted the registered nurse’s role in the assignment and supervision of patient care. Correctional nurses use their knowledge of state regulations defining the scope of practice for personnel assisting in the delivery of patient care as well as the employers’ expectations (job description, post orders, policy and procedure) to assign and supervise these personnel.

The American Nurses Association (ANA) describes correctional nurses as responsible for direction of patient care including the assignment and delegation of tasks to others (2007). These responsibilities are unchanged in the draft of the 2013 edition of the Correctional Nursing: Scope and Standards of Practice which was posted at http://www.nursingworld.org/Comment-Correctional-Nursing.html.aspx. Delegation has been described as an essential skill and yet is one of the most difficult responsibilities of a registered nurse. It is a complex process that requires sophisticated clinical judgment about the patient care situation, the competence of staff and the degree of supervision required (Weydt, 2010; NCSBN, 2005).

There are many resources available to help nurses build skill and competency in delegation of patient care tasks. The state board of nursing is an excellent first resource as well as the National Council of State Boards of Nursing (NCSBN) website which can be accessed at https://www.ncsbn.org. A resource suggested in the Essentials of Correctional Nursing is a framework for delegation from the NCSBN referred to as the Five Rights of Delegation (1997). These are discussed in relation to the case example from last week’s post.

1. Right Task: The nurse makes an assessment of the patient or a group of patients and determines that an activity can be delegated to a specific member of the health care team. Knowledge of state practice acts and agency directives are essential when making decisions about what patient care tasks can be delegated. In the case example the registered nurse’s decision to have the LPN respond to the medical emergency was problematic because the LPN was required to assess and make a complex clinical decision about the inmate’s need for medical care.

2. Right Circumstances: The nurse’s assessment of the patient or group of patients also identifies the health care need(s) to be addressed by the delegated task(s) and the goal or outcome to be achieved. The nurse’s decision about which task(s) to delegate matches the staff’s competency and level of supervision available. The registered nurse in the case example did not assess the patient’s needs or identify the outcome to be achieved by the task that was delegated to the LPN. The nurse also made no judgment about what level of supervision or monitoring would be appropriate in the circumstance.

3. Right Person: The registered nurse considers the skills and abilities of individual personnel in making decisions about delegation of tasks. The registered nurse works with each member of the team to improve performance and implements remedies when performance is below standard. In the case example the LPN had considerable experience responding to medical emergencies at the correctional facility and had worked in the emergency department at the local hospital. The registered nurse did not understand that monitoring or supervision of the LPN’s performance was required as part of the state practice act and expected by the employer.

4. Right Communication: The registered nurse communicates specifically what, how and by when delegated tasks are to be accomplished. Communication includes the purpose and goal of the task, limitations and expectations for reporting. In the case example there was no meaningful communication that took place between the RN and LPN. The LPN was not expected to communicate assessment data to the nurse and no limitations on the LPN’s actions were stipulated. The LPN reported the conclusion that both inmates were “okay” but was asked no follow up questions by the RN to amplify the basis for the decision. The LPN did not communicate with the registered nurse when the inmate was later found unresponsive even after the “on call” physician was called.

5. Right Supervision: The registered nurse monitors and evaluates both the patient and the staff’s performance of delegated tasks.  The registered nurse is prepared to intervene on behalf of the patient as necessary and provides staff feedback to increase competency in task performance. In the case example the RN had several opportunities to monitor the patient’s care and to intervene but failed to do so. The nurse was unaware of the responsibility to monitor and supervise the LPN in the performance of the delegated task. The nurse said that the LPN always provided the response to medical emergencies and did not think the RN could alter this “assignment”.

Conclusion of the Case Example: The agency policies, procedures and the description of job duties were consistent with state practice guidelines but were too general. The nurses were not familiar with the nurse practice act and had simply continued practices on the evening shift that had been in place at the time, including staff defining the duties that they were most comfortable performing. The “after action” review resulted in increased staff knowledge of the nurse practice act, coaching of the nurses on delegation of tasks, and increased communication between staff on shift about the goals and process of patient care.

Your thoughts about this subject are important to us. Have you had experience clarifying nursing scope of practice in correctional health care?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.


American Nurses Association. (2007). Corrections Nursing: Scope and Standards of Practice. Silver Spring, MD: Author

National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

Weydt, A. (May 31, 2010). Developing delegation skills. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 2, Manuscript 1 

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