Dealing with the Difficult Patient

Stressed manLast week I attended the fall meeting of the Oregon Chapter of the American Correctional Health Services Association. I have belonged to this organization for 30 years and have received a lot of professional support over the years, especially continuing education. These are my notes from an interesting presentation by Daryl Ruthven, M.D., CCHP, Director of Psychiatry for the Oregon Department of Corrections.

Demanding, non-compliant, whining, threatening, somatizing, malingering, drug-seeking, mentally ill, frequent flyer are some of the ways difficult patients are described. Their behavior can be so obstructive that it’s possible to miss important information or data about them and compromise our clinical work. Certain personality types are more likely to take up more time when seen at sick call or in clinic. These include people with antisocial, borderline, narcissistic, histrionic, dependent or organic personality types. The first thing to remember is that the patient’s behavior is consistent with their personality type and not likely to change just because they are seeking health care. Reduce the likelihood of missing important clinical information by remaining non-judgmental about their behavior and objective during assessment and evaluation of their condition.

The Angry Patient: Unless the patient is brain damaged or intoxicated, anger is a response to fear or threat. The patient is afraid of something that either is or is not going to happen as a result of the encounter. Anger sometimes is used as a display to intimidate others. In this situation the patient may need to vent a bit first. Then try to figure out what the patient is scared or anxious about. They may not be aware that their anger is a response to threat and so it may take a bit of dialogue to identify the problem. A good question to ask is “What do you fear will happen?” or “What are you most concerned about?” The encounter should be terminated if the anger is escalating or becomes abusive rather than defusing.

The Demanding Patient: Uses confrontation as a means to force a desired result. Demands are usually accompanied by a direct or indirect threat. Demanding behavior may be a result of fear, sociopathy, or poor assertive skills training or advice. Most patients are as interested in relief of a problematic symptom as they are in a specific outcome. With this in mind, remind the patient of the responsibilities each party has in the patient/provider relationship. The patient’s responsibility is to provide information about the problem and to decide whether to follow the plan of care suggested by the provider. The provider’s responsibility is to listen to the patient, assess the problem and determine the treatment options that are most appropriate to address the problem.

The Splitting Patient: Pits staff against each other to create chaos and in the midst of the confusion achieves a goal. When a nurse (or other provider) feels confused or at odds with other health care providers about a patient’s plan of care it is a good sign that splitting is taking place. The most important action to take with a splitting patient is to bring the team together to agree on a consistent plan to manage the patient’s care. This should include developing a comprehensive treatment plan (including custody and mental health staff) and reviewing it together at regular intervals.

The Threatening Patient: The facility or health care program should have no tolerance for physical threats and train staff in how this kind of behavior is addressed. The specifics of threatening behavior should be documented thoroughly in a report of the incident. Threatening legal action is very common. Suggestions here are to know enough about the law to appreciate how poor health care must be before a finding of “deliberate indifference” and “cruel and unusual punishment” can be made. Staying up to date with the literature and competent clinically along with thorough documentation protects nurses from tort liability. Basically providing and documenting good nursing care provides sufficient protection from legal threats.

Conclusions: Finally, don’t respond unprofessionally to the difficult patient by yelling, use of sarcasm, counter threatening or reacting emotionally. These responses undermine the power of the provider in the relationship with the patient and can destroy the reputation and authority of the clinician.

Difficult patients do have health problems that need to be identified, assessed and treated. These patients also have something that they are scared of or bothering them. Asking “What are you most concerned about?” or “What do you fear will happen?” may help identify this underlying problem so it can be addressed. Set limits that are appropriate to the responsibilities of each in the provider/patient relationship. Discuss the patient’s options calmly and clearly. Seek help from others to manage difficult patients. Take care to prevent becoming jaded, desensitized or overwhelmed by difficult patients by taking regular time off and developing interests and relationships outside of work.

What tips do you have to manage an encounter with a “difficult patient”? Add to the advice given here by responding in the comments section of this post.

There is much more on this subject in the Essentials for Correctional Nursing. Lorry Schoenly discusses working with difficult patients in Chapter 4 Safety for the Nurse and the Patient. Also Roseanne Harmon describes care of patients who have personality disorders in Chapter 12 Mental Health. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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Alcohol Withdrawal: Do You Know the Signs?

AlkoholismusAlcohol withdrawal is the most serious of substance withdrawal situations. Do you know the signs of this condition? Most everyone working in a jail for even a short time is aware of the substantial use of alcohol by those detained for criminal activity or other law violations. Indeed, many of these law violations are a result of alcohol overuse such as DUI, traffic violations, and personal injury due to car crashes. As many as 85% of inmates are substance involved in some way. One study of data from the Arrestee Drug Abuse Monitoring Program (ADAM) estimates 1.2 million arrestees were alcohol dependent in 1997.


Be on the lookout for alcohol withdrawal in all your jail patients. Universal screening for alcohol withdrawal is recommended by the National Commission on Correctional Health Care (NCCHC) in their Alcohol Detoxification Guideline. They recommend that every intake screening include the following:

  • An explanation of why alcohol screening is taking place – to identify those who need treatment for withdrawal
  • Questions about the type, amount, frequency, duration of use, and withdrawal history
  • Immediate medical evaluation for a positive history of heavy and regular alcohol use.

NCCHC guidelines also recommend the use of a standard screening tool such as the Simple Screening Instrument for Substance Abuse (SSI-SA). This list of questions is indeed simple and less cumbersome than many alternatives. An advantage of this tool is that is can be used for either drugs or alcohol. The patient’s answers to 16 yes/no questions are then scored along a continuum of degree of risk for abuse.

Another highly-credible alcohol screening tool is CAGE, discussed in a prior blog post. CAGE is even shorter than the SSI-SA and is specific to alcohol intake. Two positive responses are considered a positive test and indicate further assessment is warranted.

The World Health Organization (WHO) recommends use of AUDIT – the Alcohol Use Disorders Identification Test. This tool was developed and extensively evaluated in a variety of settings, making it a credible screening option.

Whatever tool you use, it is important to consistently screen every incoming patient.

Expect Under-Estimation

There are many reasons your patients may under-estimate their alcohol involvement. First of all, if alcohol use could be a contributor to the activity that resulted in detainment, your patient may not want to emphasize use. Then, trust might be lacking in the nurse-patient relationship that will limit full disclosure. Finally, people generally under-estimate poor habits while over-estimating good behaviors. For all these reasons, some seasoned jail nurses mentally double the estimated drinking reported on intake. Although that might be extreme, expecting under-estimation can help you better predict withdrawal potential.

Assume It Is Present

Alcohol withdrawal should be top-of-mind when screening those entering the criminal justice system. Besides screening tool results, NCCHC guidelines also recommend that immediate medical evaluation be sought for observable symptoms of current alcohol use such as alcohol on the breath, unsteady gait, or confusion.

Withdrawal from alcohol causes increased excitability in the nervous system leading to the following manifestations:

  • Nausea and/or vomiting
  • Tremors, tremulousness, or agitation
  • Confusion
  • Unsteadiness or lack of coordination

Any of these symptoms should indicate a deeper evaluation of alcohol withdrawal potential.

How do you screen for potential alcohol withdrawal in your setting? Share your thoughts in the comments section of this post.

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

Photo Credit: © Jörg Lantelme –

Identifying Prescription Drug Misuse and Abuse

piatto di farmaci e drogaOne of my first mentors in correctional health care described prisons and jails as functioning like a city or town with many of the same characteristics as the surrounding community. I still think that is a good description. So we can expect trends identified in the larger community to eventually transcend the walls of the correctional facility in some way. One of these trends is the growing problem of prescription drug misuse and abuse.

According to a 2010 survey done by the Substance Abuse and Mental Health Services Administration more Americans over age 12 are taking prescription medications for non-medical purposes. These medications include pain relievers, tranquilizers, stimulants, sedatives and psychotherapeutic drugs. More than half of those said that they obtained the drug from a friend or relative for no cost. More than half the teens surveyed in another study obtained prescription drugs for non-medical purposes from the family medicine cabinet (Kirchner et. al., 2014).

The Centers for Disease Control and Prevention (CDC) reports that visits to Emergency Rooms (ER) increased 114% from 2004 to 2011. The majority of this increase is due to misuse or abuse of pharmaceuticals. In 2011 half of the admissions to the ER were related to prescription drug misuse or abuse. Of these admissions, one third involved medications used to treat anxiety or insomnia and another third were opioid analgesics (2014).

Deaths by poisoning or drug overdose have been the leading cause of injury in the United States since 2008. Overdose deaths have increased five-fold since 1980 (Kirchner et. al., 2014). In 2010 among deaths related to overdose with prescription drugs 75 % involved opioid analgesics and 35 % involved benzodiazepines. The number of overdose deaths from opioid analgesics is now greater than those of deaths from heroin and cocaine combined (CDC 2014).

All of this is to say that detainees arriving at our jails and prisons are likely to have recently misused or abused prescription drugs. Thorough, routine and non-judgmental inquiry about recent drug use during reception health screening is essential to identify individuals who will need to be managed medically during withdrawal. These questions should solicit the name of the drug, the usual dose; the route used, frequency, date and time of the last dose. Other questions include previous withdrawal symptoms and whether hospitalization was necessary (Laffan 2013).

The characteristics of people who overdosed with prescription drugs include:

  • Middle age
  • Male
  • White, Native American or Alaska Native
  • Rural community
  • History of chronic pain
  • History of mental health disorder
  • History of substance abuse
  • Have multiple health care providers or inconsistent providers
  • Taking multiple prescriptions (DHHS, 2013).

These are not listed as a definitive means to diagnose prescription drug abuse but instead to point out how many of our inmates have these same characteristics and are at risk of adverse consequences from this behavior.

When inmates are identified who will need assistance with detoxification the nurse’s next step is to contact a provider. Monitoring and management of withdrawal from prescription drug abuse should be initiated by a provider according to protocols established by the facility medical director. Nurses should not be expected to use standing orders to initiate detoxification (NCCHC 2014). For more about drug withdrawal in the correctional setting read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at

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Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

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


American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at

Photo credit: © koya979 –

Happy New Year: Alcohol Withdrawal

Alkoholflasche in PapiertüteIt is New Year’s Eve and the police have just brought a middle aged man into the booking area on an arrest for drinking while driving. The man is in his 50’s, staggering but attempting to follow the booking officer’s directions. This is his first arrest so there is no history or prior information about him. The booking officer asks you to assess the man and decide if he can be accepted at the jail or if the arresting officer should take the man to the hospital for further assessment and possible treatment.

Use of alcohol is widespread among persons brought to jail.  A third of all inmates booked into jail were drinking at the time of arrest. Almost half of all jail inmates report alcohol use that met the definition for dependence or abuse (Karberg & James 2005).  Access to alcohol is disrupted by detention or incarceration and puts individuals who regularly use alcohol at risk of alcohol withdrawal syndrome. Seventy-four percent of deaths from intoxication took place within the first seven days of admission according to the Bureau of Justice Statistics (Noonan 2010). Identifying inmates at risk of alcohol withdrawal and treating these patients proactively is the most important step in preventing alcohol related death in jail. See a post on this topic at The decision to accept this man into the jail or send him to the local hospital for further evaluation is going to depend upon two things:

  • An assessment of the patient’s condition and
  • The facility’s capacity to provide ongoing monitoring and treatment.

At the initial medical clearance any person presenting with the following should be referred to the hospital:

  • Inability to ambulate without assistance
  • Fever greater than 1010 F
  • Serious trauma or other injury
  • Profound confusion or altered sensorium
  • Tremors
  • Seizure activity
  • Autonomic dysfunction (dilated pupils, pulse greater than 120, blood pressure greater than 120, severe diaphoresis and/or flushing).

If the person does not have any of the conditions described above use of a standardized alcohol consumption assessment tool is recommended in addition to the health screening questions asked at intake (Laffan 2013, Department of Veterans Affairs 2009).  Two recommended tools are the CAGE Alcohol Abuse Assessment Tool which was discussed in a previous post and the Alcohol Use Disorders Identification Test (AUDIT-C). The AUDIT-C tool identifies individuals who are hazardous drinkers or have active alcohol use disorders.   It consists of only three questions: 1. How often do you have a drink containing alcohol?

  1. Never
  2. Monthly or less
  3. 2-4 times a month
  4. 2-3 times a week
  5. 4 or more times a week

2. How many drinks of alcohol do you have in a typical day?

  • 1 or 2
  • 3 or 4
  • 5 or 6
  • 7 to 9
  • 10 or more

3. How often do you have six or more drinks on one occasion?

  • Never
  • Less than monthly
  • Monthly
  • Weekly
  • Daily or almost daily

Each answer is scored; an answer of “a” equals zero points and an answer of “e” equals 4 points for a possible total points of 12.  Men who score 4 and women who score 3 or more are considered hazardous drinkers with active alcohol use disorders (Bush et al. 1998, Department of Veterans Affairs 2009). These individuals will likely experience withdrawal symptoms that need to be monitored and treated medically. Inmates who are pregnant, have other chronic medical problems, or give a history of delirium tremens or seizures upon withdrawal are more at risk of morbidity and mortality associated with alcohol withdrawal. A provider should be contacted immediately to initiate and manage the care of these patients during incarceration. The table below describes the symptoms and nursing care required by patients undergoing alcohol withdrawal. Facilities without the capacity to provide 24 hour monitoring and availability of on-call provider consultation should be prepared to refer detainees to the hospital for required monitoring and care. Good clinical oversight, thoughtfully prepared protocols and trained staff are sufficient to manage inmates with minor and moderate withdrawal symptoms.

Condition Symptoms Nursing actions
Minor withdrawal
  •   Nausea
  •   Sleeplessness
  •   Night sweats
  •   Anxiety
  •   Irritability
  •   BP = 140/90
  •   Mild tremor
  •   Disturbance in vision, hearing or sensation.
  •    Symptom monitoring (CIWA –AR) q 4 hours
  •   Encourage fluid intake (8-10 glasses daily)
  •   Medication for anxiety or agitation
  •   Provider ordered medications
Moderate withdrawal
  •   Inability to concentrate
  •   Forgetfulness
  •   Numbness of hands or feet,
  •   Severe agitation or anxiety
  •   Tremors
  •   Disturbance in vision, hearing or sensation
  •  Admit for inpatient care
  •   Vital signs q 4 hours
  •   CIWA-AR q 4 hours
  •   Oral fluids (10-12 glasses daily)
  •   Provider ordered medications
Severe withdrawal
  •   Hallucinations or  delusions
  •   Profound confusion or altered sensorium
  •   Autonomic dysfunction
  •   (dilated pupils, fever, pulse greater than   120, diastolic BP greater than 110, severe diaphoresis or flushing)
  •   Seizure activity
  •  CIWA-AR greater than 15
  •   Emergency transport to the hospital
  •   Notify provider immediately

The Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-AR) is a nationally recognized tool for monitoring alcohol withdrawal (Bayard et al. 2004).  The use of a standardized tool provides a consistent basis for serial evaluations of withdrawal symptom and can serve as the source for protocols that define treatment orders and timeframes for contacting a provider or referring for offsite care (Laffan 2013). On assessment of the inmate in the case example above the nurse found that the patient was at risk of withdrawal symptoms but he did not have any complicating medical conditions and so was cleared for booking. After completing the initial screening exam the nurse put him on the facility’s alcohol withdrawal protocol that included medically supervised housing and a treatment plan concurrent with the suggestions in the table above. What do you do at your facility to recognize and treat alcohol withdrawal? Share your thoughts in the comments section of this post. For more about alcohol withdrawal read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  References Bayard, M., McIntyre, J., Hill, K.R., (2004) Alcohol withdrawal Syndrome. American Family Physician, 69 (6) 1443-1450. Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, F.B., Bradley, K.A. (1998) The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Archives of Internal Medicine 158 (16) 1789-95. Department of Veterans Affairs. (2009) Management of Substance Use Disorder. Accessed 12/230/2013 at Karberg, J.C. & James, D.J. (2005) Substance Dependence, Abuse and Treatment of Jail Inmates, 2002. Bureau of Justice Statistics, Special Report (NCJ 209588). US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC). Noonan, M. (2010) Mortality in Local Jails, 2000-2007. Bureau of Justice Statistics, Special Report, US Department of Justice, Office of Justice Programs. Accessed 12/30/2013 at Photo credit: © artenot

Clinical Judgment in Correctional Nursing Practice

Medicine and LawInmates are entitled under the 8th and 14th amendments to a clinical judgment made by an appropriately credentialed health care provider whenever attention to a health concern is requested. Nurses often are the first health care provider to see an inmate about their health concern and so must have expertise in making clinical judgments. The nurse is the gatekeeper to the rest of the health care program and their clinical judgment includes determining if the inmate will be referred to another health care provider and if so, how soon.  In the correctional setting it can be very challenging to have adequate, thorough and reliable information upon which to make decisions about an inmate’s condition and subsequent care. Finally ineffective clinical judgment can adversely affect the inmate’s health and wellbeing, waste resources and compromise the confidence and trust of inmates and staff in the nurse’s ability to provide effective care. These factors emphasize the importance of nurses’ expertise in clinical judgment as a distinguishing feature of the specialty of correctional nursing practice.

We just returned from the 13th Biennial International Conference on the Nurse’s Role in the Criminal Justice System, in Saskatoon, SK. Correctional nurses from Canada, England, Wales, Norway, Australia and the U.S. shared their research and best practices over two and a half fabulous days of learning. Lorry and I gave a presentation on Clinical Judgment in Correctional Nursing Practice and one of the questions afterwards was “Can you teach nurses good clinical judgment?” An interesting discussion ensued among the participants which is still giving me a lot to think about.

Often a clinical judgment must be made in a situation when the information available to the nurse is ambiguous, the problem or health concern is unclear and there are competing interests at play. Clinical judgment is defined as the best decision that can be reached given the information that is available. Clinical judgment includes:

  • Having a grasp of the situation at hand
  • Developing an understanding of the situation
  • Deciding the course of action that is most appropriate
  • Attending to the patient’s responses
  • Reviewing the outcomes (Tanner, 2006).

Clinical judgment is the outcome of clinical reasoning and critical thinking.  Clinical reasoning is facilitated by past experiences and the use of tools to structure decision making especially for frequently occurring situations. Critical thinking is a broader concept and has been described as purposeful thinking (Paul, 1993), a composite of knowledge, attitudes and skills (Staib, 2003) and results-oriented reasoning (Alfaro-LeFevre, 2004). The National League for Nursing (NLN) defined critical thinking as resulting in both fact and belief based judgments with ethical, diagnostic and therapeutic dimensions (NLNAC, 2000).

Good clinical judgment is the product of the combination of our experience, knowledge, attitudes, and beliefs. It also provides fertile ground for errors in clinical judgment. Our experience can lead to unconscious ‘habits of the mind’ that result in missing an important diagnostic clue or change in situation. Biases, such as selectively attending to data that fit a certain diagnosis and ignoring data to the contrary or coming to a diagnostic conclusion too quickly contribute to poor clinical decisions. Repeated personal experiences and cultural socialization become incorporated into our assumptions, may alter our interpretation of symptoms and cloud our judgment.

So how would you reply to the question “Can you teach nurses good clinical judgment?” What are your thoughts about how to develop nurses’ expertise in making clinical judgments in the correctional setting? Please share your opinions by responding in the comments section of this post.

Read more about clinical judgment in correctional nursing practice in Essentials of Correctional Nursing, Chapter 15: Sick Call. Order your copy directly from the publisher at .

Use promotional code AF1209 for $15 off and free shipping.


  • Alfaro-LeFevre, R. (2004). Critical thinking and clinical judgment: A practical approach (3rd. ed.). Philadelphia: W. B. Saunders.
  • Berkow, S., Virkstis, , K., Stewart, J., Aronson, S., & Donahue, M. (2011). Assessing individual frontline nurse critical thinking. The Journal of Nursing Administration (JONA). 41(4), 168-171.
  • Brunt, B.A., (2005). Critical thinking in nursing: An integrated review. The Journal of Continuing Education in Nursing, 36(2). 60-67.
  • National League for Nursing Accreditation Commission (NLNAC). (2000). Planning for ongoing systematic evaluation and assessment of outcomes. New York: Author.
  • Staib, S. (2003). Teaching and measuring critical thinking. Journal of Nursing Education, 42(11), 498-506.
  • Tanner, C. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6). 20054-211.


Photo credit: © Matthew Benoit

Assessing Health Literacy in Correctional Health Care

Doctor gives the patient a prescription or referralAmong the characteristics of the incarcerated population described in Chapter 1 of the Essentials of Correctional Nursing the following are also associated with low health literacy:

  • Lower educational attainment than the general community
  • Disproportionate representation of African Americans and Hispanics
  • A growing number of elderly inmates.

Thirty-six percent of all adults in the United States have limited health literacy (Agency for Healthcare Research and Quality, March 2011). Persons who have not completed high school, live in poverty, did not speak English before starting school, are a racial minority or are elderly are also more likely to have limited health literacy.  Difficulty reading and comprehending can be embarrassing and stigmatizing for patients who have compensated for their problem over time with a number of coping strategies.  Often patients considered noncompliant with care are instead not sufficiently health literate to carry out the plan. Finally health care clinicians routinely overestimate the ability of patients to understand medical information (Cornett, 2009).

Limited Health Literacy is Associated with Poor Health

People with low health literacy are more likely to report their health as poor. They make less use of preventive services and have higher rates of hospitalization and use of emergency services. Persons with low literacy are more likely to have chronic conditions (high blood pressure, diabetes, asthma, and HIV) and are less likely to manage the condition effectively.  Patients with limited health literacy are sicker when they access the health care system (AHRQ 2011, Institute of Medicine, 2004).  Interventions to improve comprehension and increase self- management behavior reduced hospitalizations and emergency room visits and increased use of preventive health screening (AHRQ 2011).

What is Health Literacy?

Many times health literacy is assumed to be the same as reading and comprehension skills. Health literacy actually includes in addition to reading and comprehension, the ability to understand numbers and calculations and to act on health information.  Healthy People 2010 defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (United States Department of Health and Human Services, 2000).  Just to get a sense of what is involved in health literacy take the Newest Vital Sign a screening test developed by the Pfizer Clear Health Communication Initiative.  The tool uses a food label to screen for health literacy and it only takes about three minutes to administer. It is a good exercise in understanding what patients need to be able to do to be health literate.

Clues that a Patient May Have Low Health Literacy

Patients are often embarrassed about low literacy and will not readily admit to needing help. Others may not even be aware of deficient in health knowledge and skill. The following behaviors may be a clue that a patient is having trouble understanding health care information or instructions:

  • Making an excuse when asked to read or fill out paperwork such as “I don’t have my glasses.”
  • Checking no on a health history to avoid follow up questions.
  • Missing appointments or making errors in medication dosing.
  • Irritability, nervousness, confusion, or indifference during health care encounters.
  • Identifying medications by color, size or shape rather than name and purpose.
  • Following directions literally.
  • Holding written material closer to read, lack of visual focus on reading material, using a finger to point at the words.

This list isn’t to suggest that when someone displays these behaviors that the nurse should conclude that the patient has low health literacy but instead to adjust approach, consider asking a follow up question or offer to assist in a non-judgmental manner.

What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.

To read more about how to assess and address health literacy order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Cornett, S. (September 1, 2009). Assessing and addressing health literacy. Online Journal of Issues in Nursing, 14 (3)

Berkman ND, et. al. (March 2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality.

National Research Council. (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press.

United States Department of Health and Human Services. (2000) Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington DE: US Government Printing Office. Accessed 2/17/2013 at


Photo Credit: © Alexander Raths