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

 

Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

A reader responds to our recent blog post on the Heavy Burden of Moral Distress. We hope you find this real-life example an encouragement that correctional nurses are speaking up when they have concerns about patient health issues in the criminal justice system.

The topic of moral distress among nurses is an elephant in the conference room of many healthcare organizations but at the core of conversations amongst nurses in the medication room.    A few typical statements made during these informal, ethically charged and expressive gatherings include; “It doesn’t’ do any good to tell anyone, they won’t do anything.” “It’s all about the bottom line.” “They don’t care how much more work they give nurses.” “Nurses who complain too much get fired.” “I need a job to so I can take care of my family.” “This is just the way it is, get used to it.”  Statements like these are made with such frequency today that moral distress could and should be viewed as an epidemic in nursing practice.  The following is a glimpse into the challenges some correctional nurses faced and how their quest and obligation as nurses to do the right thing put them on a path leading directly into the dark, lonely void of moral distress.

My Story

While working at a correctional facility, three nurses expressed their ongoing concerns to supervisors and administration about the well-being of inmates who were:

  • Not getting their prescribed medications for extended periods. This includes medications for chronic conditions, seizures and other serious illnesses,
  • Providers prescribing incompatible medications and refusing to change the order(s),
  • Providers documenting physicals on inmates they had not seen,
  • Stat and other critical orders not getting noted for days,
  • On-call providers not returning calls and,
  • Inmates with serious, potentially life-threatening conditions, being transferred without regard to maintaining some continuity of care.

A few nurses called the allegedly anonymous organization  “ Hot Line,” (nurses are encouraged to use these for reporting purposes) and voiced their concerns but to no avail.  Having exhausted all efforts to report their concerns internally they reached out to their local nursing organizations.  While these organizations provide invaluable services and support in many areas they were unable to provide immediate direction or tangible backing for these situations. They, like the nurses, were uncertain who they should and could turn to for support.

The onset of moral distress began when the first link in the organization’s chain of command broke because of  failed communications and after dismissing the nurses concerns with indifference.  The distress peaked when the nurses were terminated for doing the right thing. Terminated for doing what nurses are required to do, what we have vowed to do – complying with the Nursing Code of Ethics.

Nurses have taken an oath and are required to practice in accordance with the Nursing Code of Ethics which provides:

  1. A succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.
  2. It is the profession’s nonnegotiable ethical standard.
  3. It is an expression of nursing’s own understanding of its commitment to society.

The sections applicable to the events being discussed are 3.4 and 3.5 as noted below:

Nursing Code of Ethics 3.4 “Standards and Review Mechanisms” 

Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review.

Nursing Code of Ethics 3.5, “Acting on Questionable Practice”

When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns.

Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.

Obligated to Speak

Nurses are obligated to bring difficult issues forward for discussion and review. We are duty-bound to report unsafe practices and or circumstances and must do so regardless of personal risk.  However, at the same time there is a responsibility to provide nurses with support and assistance when they do speak out. This is the crossroads where the path of moral distress becomes the loneliest and sometimes most frightening. It is alsothe time when a nurse needs support and encouragement the most. Unfortunately it is at this intersection that most nurses feel alone, abandoned, and with nowhere to turn.  This often becomes a turning point for nurses believing they must choose between speaking out or getting terminated; consequently many nurses make a silent and painfully emotional promise to never speak out again.  This forces nurses to overlook practices that not only put their patients at risk but their nursing license as well.  At this juncture moral distress has become an emotional pathogen.  Were it not for the support and encouragement of our patients and the public, many nurses would leave the profession.

Public Esteem

The public’s long-standing esteem for nurses is well documented in public opinion polls. Nurses rate high with the public in trended national survey questions about trusted professions, prestigious occupations, and “honesty and ethical standards.”  It is disheartening that organizations do not always see their nurses through the public’s eyes.  It is regrettable that even nurses don’t see themselves through the public’s eyes.  If nurses would stand together in our communities of practice perhaps we could begin a dialogue with our local nursing associations and employers to establish the support system illustrated in the Nursing Code of Ethics. Together we could address the circumstances and symptoms associated with moral distress at the onset and transform them into opportunities for change before nurses are forced to make that dreaded silent promise to keep quiet. Speaking out is included in the nonnegotiable ethical standards.

Would you be willing to speak out in a similar situation? Join the conversation with a comment.

Correctional Nurse Self-Care: Preventing Compassion Fatigue

Upset nurse sitting on the floor in hospital wardEven those of us who love correctional nursing know it is a tough specialty. Earlier posts discussed the reasons we need to take care of ourselves, and the issues of secondary traumatization and moral distress. This last post in the Correctional Nurse Self-Care series is about compassion fatigue.

Although some sources consider compassion fatigue and secondary traumatization to be similar concepts, they have different root causes. Secondary trauma comes from absorbing the stress of the traumatic experiences of our patients. It is a taking upon ourselves the weight of another’s past and present life experience and feeling the physical, psychological, and emotional results. Compassion fatigue, on the other hand, is the giving of ourselves to others to the point of depletion repetitively without adequate recovery. The combination of secondary trauma, moral distress, and compassion fatigue can be a deadly cocktail for correctional nurses. Self-care intervention is needed to maintain a healthy equilibrium.

Totally Drained

Compassion fatigue results from the chronic use of empathy in nurse-patient relationships. Correctional nurses battle to stay in the zone of helpfulness while not leaning toward over-involvement or under-involvement with the incarcerated patient population. Maintaining a therapeutic relationship can be draining. We are alternately guarding against being drawn into manipulation on one end of the helpfulness continuum while avoiding becoming jaded to patient needs on the other end.

The key to minimizing compassion fatigue may be in modulating the two elements of empathy and engagement for optimum functioning. Both are necessary for a meaningful nurse-patient relationship, but in balanced and appropriate doses.

Besides the dynamics of the nurse-patient relationship, our environment of care delivery also influences levels of compassion fatigue. The following organizational factors, all prevalent in the correctional health care environment, have been implicated as contributing to compassion fatigue.

  • Bureaucratic constraints
  • Inadequate supervision
  • Lack of available resources
  • Lack of professional colleague support

Preventive Measures

Self-knowledge. As nurses, we know that “an ounce of prevention is worth a pound of cure” for our patients. Unfortunately, we don’t always apply the principle to our own well-being. Going back to the idea of a self-care plan addressed in an earlier post, a first intervention may be gaining knowledge and self-knowledge about your current state of empathy and engagement with your patients. Take stock of where you are on the helpfulness index. If you find yourself over-involved, you may be headed toward compassion fatigue and need to realign. On the other hand, you may have already over-corrected your empathy and engagement and are now under-involved with your patients in order to protect yourself from further compassion fatigue.

Self-care. Basic self-help principles are necessary – even for super nurses! Be sure your schedule includes adequate rest and relaxation. Positive connection with friends and family can help maintain balance. Get some physical exercise. Practice spiritual rituals that are satisfying to you such as prayer, meditation, readings, or service. All of these activities have been found to buffer the effects of compassion fatigue.

Recharge the Battery

Sometimes a serious intervention is necessary. This is especially true if you are going through a season of battery overload and spiking need for emotional reserve. There are times when even the standard self-care activities cannot keep up.

Fellow nurse, Elizabeth Scala, over at Nursing from Within, is running an Art of Nursing program in May that can help recharge your correctional nurse battery.

Art of Nursing

Click here to view more details

How do you manage compassion fatigue? Share your tips with our readers using the comments section of this post.

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Correctional Nurse Self-Care: Are You Carrying the Heavy Burden of Moral Distress?

Kiko con cajaRecently I traded in my clunky 2009 laptop for a new streamlined model. It wasn’t until my first journey with this new laptop that I realized just how heavy my old version was. Now I have a good idea why my shoulders ached after a long day of traversing airports for gate changes while running to make the connection with computer bag in tow.

Moral distress can be like that – a heavy weight on your shoulders that has been slowly building as you work in the criminal justice system. You may not even notice the developing distress until something snaps. Correctional nurses need to monitor moral distress and seek morally satisfying solutions to the ethical dilemmas encountered in day-to-day practice.

What’s in a Name?

The first step in solving moral distress is to identify it. Moral distress has been defined as knowing the right action to take, but being constrained from taking it. In its simplest form, then, moral distress in correctional nursing may be knowing that a patient should be able to make a health decision autonomously but seeing that they are being forced to make that decision against their will.

However, researchers in moral distress among nurses add to this definition in important ways. Nurses are often confronted with an ethical dilemma where the course of action best for the patient is in conflict with what would be best for others; whether it is the organization, other providers, other patients, or society. So, the interior world of the nurse that identifies who they are as a professional is in conflict with the exterior world of the work environment and work team. This is what leads to the distress that can be strongly felt by a nurse.

Moral distress is when:

  1. A nurse is involved in or aware of a situation that calls for a moral action.
  2. Is obstructed from taking that moral action.
  3. Experiences negative feelings because that action was not taken.

I hear of many examples of moral distress among correctional nurses in my various interactions. Intentional bias, poorly staffed medical units, or obstruction from officers or leadership can lead to treatment delays, unrelieved pain, or gaps in care management. Conscientious nurses absorb the stress of longstanding unethical treatment.

The Grimy Build Up of Moral Distress

Absorbing moral stress over time leads to a grubby film that builds up in our nursing souls and affects our emotional, psychological and physical well-being. This has been defined as ‘moral residue’ and is particularly intense when injury to a nurse’s moral integrity is repeated over time. In a correctional setting, a nurse may see the ‘take down’ of mentally ill inmate multiple times over months of practice and have a ‘here we go again’ response to the moral wound caused by seeing this action and feeling unable to do anything about it.

Identifying Moral Distress

Although nurses cannot always name the feeling, most of us know what it is like to be in moral distress. We feel powerless, anxious, and unhappy. Moral residue can lead to typical stress-related symptoms such as nausea, insomnia, and headaches. It can cause us to seek other employment or even leave the profession. When these feelings are present, it is important to seek the source of discontent. It may be the weight of long-standing moral distress.

Seeking a Good Response

Nurses can also feel belittled or unimportant in morally distressing situations. It is easy to experience isolation if we do not feel supported in talking about the morally injuring situations around us. Yet, talking to a supportive colleague is an important action to help identify and clarify moral distress.

Critical care nurses also often find themselves in a morally distressing situation. The American Association of Critical Care Nurses (AACN) developed a 4 step process to help nurses address and reduce moral distress.

STEP ACTION
ASK Ask yourself if what you are feeling is moral distress. Are others exhibiting signs of moral distress, as well?
AFFIRM Affirm your feelings and consider what aspect of your moral integrity is being threatened.
ASSESS Objectively analyze the situation and what the ‘right’ action would be. Consider what is currently being done, who the players are, and your readiness for action.
ACT Create a plan of action considering any pitfalls and strategies to overcome them.

Have you had to deal with moral distress in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

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Correctional Nurse Self-Care: Wear That Secondary Trauma Protective Gear!

Firewoman in fire protection suitHave you ever had a patient that really affected you? I still have memories of caring for a severely burned toddler girl in the early 90’s when I was in a clinical rotation for my graduate nursing program in Burns, Emergency, and Trauma. It was an urban teaching hospital and regional burn center and this little girl was pulled from a burning Philadelphia row house. I was swept in to her intense physical pain (burn pain is the worst) and her abusive family history. It affected my personal life, robbed me of sleep, and almost made me physically ill for a time. This experience taught me I wasn’t cut out to be a burn nurse but was also my first experience with secondary trauma.

Secondary Trauma: Patient Trauma Spill-Over

Secondary trauma (also called vicarious trauma) is the experiencing of the trauma of another through their account or indirect exposure to their trauma. A nurse’s mental or emotional ‘reliving’ of the patient’s traumatic experience can then lead to symptoms or reactions similar to post traumatic stress disorder (PTSD).

Our patient population has high levels of trauma in their lives, past and present. For example, many of our patients, especially women, have history of child abuse, domestic violence, or sexual abuse. Military veterans may enter the system with PTSD from combat duty. Inmates have a heavy burden of current trauma while in the criminal justice system. There can be high levels of assault, coercion, and victimization in inmate cultures.

Depending on the type of nursing care you are delivering, this traumatic stress can spill over onto you and be absorbed into your own system; many times without even realizing it. This is why it is important to guard against secondary trauma and take action when you see signs in your own feelings and behaviors.

Monitor for Warning Signs

Here are some common signs of secondary trauma. Watch for them in yourself and those you work with:

  • Anger and cynicism
  • Avoidance of patients
  • Chronic exhaustion
  • Dropping out of normal social activities
  • Fear
  • Hopelessness
  • Hypervigilance
  • Increased family arguments and agitation
  • Sleeplessness

What to Do About Secondary Trauma – Put on Your Protective Gear

In the first post in this series on correctional nurse self-care, I talked about putting on your oxygen mask first before helping others. We also need to put on our protective gear, just like other professionals. Construction workers have hard hats and football players have extra padding and mouth guards. What protective gear do correctional nurses need to work with traumatized patients day after day? Here are some ideas from the National Center on Family Homelessness:

  • Regularly take your stress temperature – do you see signs of stress in your emotional and interactional responses to daily activities? If so, accelerate your protective activities.
  • Make time for regular decompression. This can include reflection, meditation, or physical activities like yoga.
  • Consider the possibility of a change in work assignment, work shift, or work group for a period of time.
  • Seek out employer-offered programs such as employee assistance or an outside support group for those in helper roles like nursing, social work, counselors, or child assistance workers.
  • Take regular meal breaks.
  • Focus on increasing sleep and nutrition.
  • Find things that make you laugh.
  • Spend time with supportive friends.

Just understanding the possibility of secondary trauma and monitoring for signs of increased stress can make a world of difference in your correctional practice. I didn’t understand secondary trauma back in that burn unit rotation years ago. I might have been able to manage it better if I had. Awareness is a powerful thing!

Have you had to deal with secondary trauma in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

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