Where to Go from Here

Welcome to the Essentials of Correctional Nursing Blog! This resource has over 200 posts discussing every dimension of correctional nursing practice and compliments the content found in the book – Essentials of Correctional Nursing.

Although the authors are no longer adding posts to the blog, those created from 2012-2016 remain relevant for your practice. Here are a few categories to help you navigate the archives.

  • Assessment – Intake Assessment, Emergency Assessment, Clinical Judgement and more
  • Certification – Options, Preparation, Taking the Exam
  • Dental – Triage, Assessment, Medical Conditions
  • Juveniles – Physical Development, Psycho-social Development
  • Medication – Managing Medication Line, Reconciliation, Contraband, Safety, and much more.
  • Mental Health – Assessment and Clinical Judgement
  • Sick Call – Assessment, Protocols, Practices
  • Withdrawal – Alcohol, Stimulants, Depressants
  • Women’s Health – Pregnancy, Heart Disease, Eating Disorders, and more.

Use the search bar on the left sidebar for more specific blog searching.

If you are a regular blog reader, thank you for your support and participation. If you are a new visitor, we hope you find the information you need.

 

Thanksgiving

Graphic typographic montage illustration of the word Thanksgiving composed of associated terms and defining words in neutral tones. A pair of autumn leaves completes this dramatic, inspirational design.

This week we celebrate Thanksgiving, an American holiday to give thanks for the abundance of the previous year and the fall harvest. Many, but not all of us, get together with family and friends to enjoy a meal and the company of others as fall turns to winter. Some of us will be working, sharing the holiday with our colleagues and patients. No matter what specific plans we each have for the holiday, it is a time of reflection, to identify and give voice to that for which we are thankful.

Lorry, Gayle and I are thankful for you, the readers of the Essentials of Correctional Nursing. Lorry wrote the first post almost five years ago just as we finished editing, our text, The Essentials of Correctional Nursing. We have posted a new blog nearly every week since then. We are grateful to Gayle for joining our blogging adventure this past year and enjoy her take on issues in correctional nursing.

Our purpose in writing the blog is to amplify the material included in the book and to further explore new and recurrent issues in correctional nursing practice. Our most frequently viewed posts address the subjects of delegation, certification in correctional nursing, vital signs, withdrawal, spiritual distress, the ANA Scope and standards of professional practice, and evidence-based practice. As we look back over our files we are thankful for the opportunity the blog has given us to explore subjects in depth.

Day by day, week by week, year by year our readership has grown. We average over 150 hits on the blog every day and have had over 300 hits on some days. Our readership is from all over the world and we have benefited from our contact with correctional nurses from all across the globe. We have more than 200 regular subscribers on email, over 4,000 on Twitter and more than 700 on Facebook. Thank you for your interest and support for the Essentials of Correctional Nursing.

We published The Essentials of Correctional Nursing in 2012, along with eight contributing authors, to reflect the distinguishing features and practices of this specialty in the field of nursing. In doing so we benefited from the support of many colleagues who peer reviewed the manuscript and offered insight about issues in correctional nursing. The text has since been recommended as a resource applicants use to study for certification in correctional nursing. Lorry also has written a series of posts on this blog about how to study for the certification exam and her own journey becoming certified. We are grateful for the growing legion of nurses who are certified in correctional nursing; you are the voice of the profession! If you are not yet certified, perhaps this could be your goal for the new year. It is easier than you think and there are many benefits.

At the end of every year Lorry and I discuss how we are doing with the blog and decide whether to continue and if so, what subjects we are going to tackle in the coming year. This year we decided that with other opportunities and commitments, it is time to move on and no longer will post on the Essentials of Correctional Nursing blog. However we are maintaining the site and the collection of 220 or so posts as a continuing resource for correctional nurses. Next week’s post will be the last and includes a table of contents so that each of our previous posts can be easily accessed from this page!

We continue to support correctional nursing practice through our writing, consulting, and speaking. Here are some helpful links to other correctional nurse resources that we support and endorse:

CorrectionalNurse.Net Blog

Correctional Nursing Today Podcast

CorrectCare Magazine

The Essentials of Correctional Nursing can be ordered directly from the publisher or from Amazon today!  Lorry and I, or any of the contributing authors, are always glad to sign and personalize your copy of the text.

Have a safe and grateful holiday!

Photo credit: © gdarts- Fotolia.com

More Circles in Your Practice

cqi-circle-fotolia

Last week’s post reflected on how the nursing process and SOAPIE documentation are circular processes in correctional nursing practice.  This week, a third circular process that is part of every correctional nurse’s tool bag is considered. This is Continuous Quality Improvement (CQI), known to most correctional health care professionals in both positive and negative ways.

The goal of CQI is to improve quality of care and build efficiency into processes and procedures. An article I read recently described the feelings of many family practice providers about CQI as “the mere mention of the words quality improvement can evoke dread in the minds of many physicians” and I would add nurses also.  Often CQI is mistakenly thought of as more work ;focusing on problems and not solutions. However, if you look at CQI as what you do every day to make things better, it takes on a new light. For example when your washing machine stops working, you evaluate the problem, look at what went wrong and fix it. If the machine still does not work, you examine and try again. Out of all this you put in place practices or changes that will prevent the washer from having the same problem again. That is CQI. No matter if you work in a small jail or a large prison system – it only takes ONE person to improve the effectiveness of health care delivery.

What is CQI Anyway?
The National Commission on Correctional Health Care (NCCHC) describes CQI as a pathway to improve health care by identifying problems, implementing and monitoring corrective action and studying its effectiveness. In short, it is a method of continuously examining effectiveness and improving the outcome of care or procedures to deliver service.

There are volumes written about CQI and it can seem very complex but if you think of CQI as a simple process that is done all the time, you will be able to find areas of health care delivery or patient care that can be improved and take steps to find and implement solutions.

A Little History
Even before health care began looking at ways to improve systems, industry had in place methods to look at products that did not work correctly. W. Edwards Deming, PhD., a statistician who revolutionized management theories in Japan and the US, developed the following principles of quality improvement:
• A strong focus on customers—in our case, patients.
• Continuous improvement of all processes.
• Involvement of the entire organization in the pursuit of quality
• Use of data and team knowledge to improve decision making.
In the 1980’s, the Joint Commission set standards for hospital systems to establish a formal program to monitor the delivery of care. The effort to improve the health care provided to patients spread to all health care institutions, hospitals, clinics, care homes and correctional facilities. When the National Commission on Correctional Health Care (NCCHC) developed standards for jails, prisons and juvenile facilities, in the early 1980”s, quality improvement was an essential standard.

Components of CQI
The CQI model requires that you identify the problem area, and your aim or what you want to improve or change. Some common methods for identifying areas for improvement are routine chart reviews by members of the care team, targeted audits to see if forms are completed, referrals made, and labs reviewed. Others might be staff concerns such as equipment not on the emergency cart, missing charts, emergency send outs, or patients not coming to clinic. NCCHC suggests that the areas to study be those that are high-risk, high volume or problem prone aspects of health care. Some program processes to look at are intake, continuity of care through incarceration, emergency care as well as adverse patient events.

Once you have identified the problem area and goal for improvement you bring about the desired changes using the CQI circular model of going through the steps 1. plan 2. do 3. study/check 4. act. Each step is very simple as you can see in the following description:
Plan: Analyze the process, determine what changes would most improve the process, and establish a plan for making the improvement.
Do: Put the changes into motion on a small scale or trial basis.
Check/Study: Check to see whether the change is working.
Act: If the change is working, implement it on a large scale. If the change is not working, refine it or reject it and begin the cycle again.

If you have experience in a quality improvement, you have heard about outcome studies and process studies. If you are new to quality improvement, these two types of studies help to focus quality improvement efforts. An Outcome Study looks at the outcome of a patient’s condition after an intervention has occurred. Examples include: are infections healed with antibiotics, is the A1C in the normal zone, and are chest pain emergency visits reduced when nitroglycerine is kept on person. A Process Study: focuses on procedural or policy oriented issues, such as timeliness of intake screening, physician review of diagnostic results, health assessments completed before day 7 or 14, and TB skin tests read on time.

Documentation and communication of CQI results are extremely important. Each CQI study should be written up and shared with others along with the changes in practice, procedures or training. Most important is to CELEBRATE the successes with staff and be PROUD of the CQI work the team accomplishes.thumbs-up-picture

In summary, the key points of Quality Improvement are:
• It is focused on making processes better.
• The first step is finding key problem areas.
• Identify and prioritize potential change projects. Then use the PDSA cycle to study and implement the change

On reflection of nursing practice, the American Nurses Association, Standards of Correctional Nursing Practice, Standard 10, Quality of Practice, talks about the contributions to quality practice is a responsibility for all of us. One of the competencies is to participate in quality improvement activities with the purpose of improving nursing practice, healthcare delivery and the corrections system.

CQI is a continuous and ongoing part of correctional nursing practice, like the use of the nursing process and SOAPIE documentation discussed in the last week’s post. At the center of each of these processes is the NURSE and the important, skilled and thoughtful care nurses deliver.

Have you participated in CQI projects that improved patient care? We learn from each other so please share with us your successes and examples in the comment section below.

Read more about the practice of nursing in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo Credit: © canbedone- Fotolia.com & © naruedom- Fotolia.com

The Circles in Your Practice

On a busy day and in the midst of patient care we are not always aware that much of our nursing practice care is a continuous process. Whether it is completing sick call, medication administration or counseling a patient, we are always “evaluating”. Nursing practice is circular, in that our patients continually respond to our health interventions and as nurses, we observe and act on that response. nursing-process-grid-11-7-16

The American Nurses Association defines correctional nursing as the “protection, promotion and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; advocacy for and delivery of health care to individuals, families, communities and populations under the jurisdiction of the criminal justice system”.

The Nursing Process

The American Nurses Association published the Correctional Nursing: Scope and Standards of Practice in 2013. The goals of the scope and standards are to:

  • inform nurses and others about correctional nursing practice
  • guide nurse’s day-to-day practice and resolve conflicts
  • develop policy and procedure and other governance of professional practice
  • reflect on professional practice and plan improvement.

There are 16 standards of nursing practice with the first six delineating the steps in the nursing process. These six elements of the nursing process are circular as well as inter-related to each other.

  • Assessment is data collection about the patient’s health condition. Nurses use all their skills and senses to identify changes in a patient condition. By observing the patient, interviewing the patient, completing the physical examination, collection history information and reviewing of the patient’s health records an assessment is formulated.
  • Diagnosis is the nurse’s analysis of the data gathered and identification of the patient’s problem which results in the nursing diagnosis. The nurse also validates the diagnosis with the patient.
  • Outcomes Identification focuses the nursing diagnosis on the needs of the patient. The goal of nursing care is for the patient to achieve an improved level of functioning that is realistic to attain. Using the SMART technique, an acronym for setting goals that are specific, measureable, attainable, and realistic and time bound, assists in developing the outcome statement.
  • Planning  for the nursing interventions that will achieve the outcomes identified for the patient is the next step. These plans are specific to each patient and focuses on achievable outcomes. Planning, rather than reacting or practicing by rote, is more effective in reaching the goals of patient care.
  • Implementation are the action steps the nurse follows in carrying out the plan of care. Implementation may be one or more nursing intervention steps, and may take place over hours, weeks or months depending on the patient’s condition. Implementation requires the nurse to delegate care to subordinate personnel and communicate with colleagues to achieve completion of the patient’s plan of care.
  • Evaluation occurs all along during the nursing process. It is both the end and the beginning in the continuous process of care that is delivered to the patient. Documenting the patient’s response to interventions, evaluating their effectiveness and the outcomes achieved leads to modification or revision in the plan for care.  This illustrates how each step is fundamental to the circular process of nursing practice.

The nursing process is an integral part of every patient encounter. Expert nurses move through these steps fluidly without stopping to focus solely on each component. Nurses are attentive to their patient’s response to care provided all along the continuum from illness to wellness.

The Patient Plan & Documentation

The S.O.A.P method of documenting patient care is common in most correctional settings and is used as the main communication method in the patient’s health record. In the literature, two additional elements in SOAP charting are recommended; these are Intervention and Evaluation. These two additional elements of documentation align with the nursing process just discussed and support charting of continuous patient care.

  • S-Subjective: reports what the patient says
  • O-Objective: records what the nurse observes
  • A-Analysis: identifies a nursing diagnosis
  • P-Plan: describes nursing interventions
  • I-Implementation: records how those actions were carried out
  • E-Evaluation: reports the actual patient response and outcome.

This systematic approach to detailing patient care keeps us goal orientated and focused on how the patient is progressing in the treatment plan. With an eye toward always evaluating or “continuing” to evaluate a patient’s response to treatment, the nurse is ready to intervene to prevent an exacerbation of illness or unexpected response to treatment.

When nurses respond to requests for care, complete sick call assessments, administer medications and call patients up to check on how they are doing, it is part of the circular pathway of continually evaluating how our patients are or are not responding to care.

Next weeks’ blog topic will explore a third “circular” area of nursing practice, which is the Continuous Quality Improvement Process. Can you think of more circular processes in your nursing practice or insight into the continual evaluation process in nursing care? We would like to know your thoughts about the nursing process and SOAPIE process. Share in the comment section at the end of this post. We like to hear from you.

Read more about the practice of nursing in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

 

Photo Credit: American Nurses Association NSPS’10_Fig 4. Nursing Process Standards.

Remembering Meaningful Milestones

ncchc-40th-celebrationThe National Commission on Correctional Health Care (NCCHC) held its national conference in Las Vegas last week (October 24th through the 26th).  For the over 1600 attendees, it was a recognition of the profession of correctional health care and the path from the beginning to present day.

40 Years of Educational Offerings

For 40 years, NCCHC has been offering educational opportunities during four educational sessions each year. Edward Harrison CCHP, former NCCHC president was at this conference to bestow some awards and meet friends. His words reflect some of the highlights accomplished along the way.

  • Correctional health care providers were caregivers for AIDS patients before the disease had a name and before many in community health care settings overcame their fear of the disease.
  • Although decades ago telemedicine was widely promoted throughout the country, it advanced in correctional health settings more so than in many community environments.
  • Treating sexually transmitted and other infectious diseases in the community often relies on the interventions provided patients in the correctional system .
  • Correctional systems picked up the slack when community mental health programs lost their funding.
  • Health care for all, regardless of one’s ability to pay, was the established practice in corrections 30 years before the Patient Protection and Affordable Care Act.

During the conference the foundation of correctional health and the early leaders were recognized.  To add to our recognitions, nothing is more noteworthy than our next celebrated milestone.

Estelle vs Gamble- 40 Years Ago

The 40 year milestone of this court case, which is considered the basis for correctional healthcare, forces us to reflect on the advancement of quality care that today is provided across the country to all our detainees. This court case forced everyone to look at care in the jails and prisons across the country and build health care delivery systems that were comprised of qualified health professionals, identified illness, treated disease and prevented harm and suffering.

Estelle vs Gamble is a case brought forward by a prisoner in Texas in 1976. Even though the state “lost” the case, the decisions by the courts provided the foundation for care of all prisoners and the basis of deliberate indifference. During initial orientation, each new employee in correctional health care hears about Estelle vs Gamble and learns that detainees have:

  • The right to access health care in all settings.
  • The right to a professional medical opinion
  • The right to the care that is ordered.

The first standard in the NCCHC’s Accreditation Standards is “Access to Care”. The discussion states that “this standard intends to ensure that inmates have access to care to meet their serious health needs and is the principle on which all National Commission on Correctional Health Care standards are based. It is also the basic principle established by the U.S. Supreme Court in the 1976 landmark case Estelle v. Gamble.” (A-01, 2014 standards, page 3)

Remembering the foundations of correctional health, will provide us with a vision that expands the quality of health care and integrates us into the communities in which we practice.

Certified Correctional Health Professional (CCHP) for 25 Years

The third celebration was to honor the 25 years that the special certification for correctional health professional has been in place. Before 1991, a group of correctional health leaders, worked to develop a test that would reflect the unique challenges and foundation upon which correctional health is practiced across the country. Other health care specialties already had in place specific  certifications, such as ICU nurses, emergency nurses, IV nurses and some mental health specialties. These certifications recognize the knowledge base and competencies required in a specific field or specialty area of practice.

The first CCHP exam was in 1991 and was a take home exam with multiple choice and essay questions. At the conference, we honored 17 CCHP’s who completed the test in 1991 and are still certified today.

As the years have progressed, the test has expanded to a proctored exam at various conferences and sites.  Also other exams for specialties within correctional health have been developed. After you obtain your CCHP certification you may add to your credentials by taking a specialty exam. These include the CCHP-RN, CCHP-Physician, CCHP-Mental Health and CCHP-Advanced.  Achieving professional certification is the surest way to demonstrate that you have the qualifications and expertise to meet the challenges of delivering correctional health care in any setting.

As we go through our daily work, it is good to take time to reflect on how we achieved this proud and important professional career, and all the people who came before us and showed the dedication and leadership to improve care and show us the way.

Do have a reflection on the history of correctional health care that you would like to share? Please reply in the comments sections of this post.

Read more about legal foundations of correctional health care and the professional organizations that support correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo Credit: NCCHC,org, education and conferences link

FLU-Give it a Shot!

flu-shot-photoOctober is a busy month for health professionals. We celebrate Breast Cancer Awareness Month, Mental Health Awareness Week, Dental Hygiene Month, Chiropractic Health Month, Pharmacist Month, Domestic Violence Awareness Month, Health Literacy Month and Patient Centered Care Awareness Month.

There are more awareness areas to be celebrated.  However, one is missing from the list.  It is special to October as it is the month that flu season begins and we all should be planning flu clinics and getting our own flu vaccines.

Recently the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization and Practices (ACIP) adopted recommendations for the 2016-2017 flu season. This year two changes are noteworthy. The first is that the live, attenuated influenza vaccine (LAIV) has been found to be ineffective and will be unavailable this year. The second is that they have eliminated the egg allergy limitations of the past.

2016-2017 Changes

  • Flu Mist is Out-With no significant effectiveness found with the live virus vaccine, this year children’s immunization recommendations are for intermuscular doses only. Basically, children under 9 years of age will require one injection, children 6months to 8 years old will require two doses of the vaccine, unless they have received intermuscular injections in the past. Everyone 9 years of age and older, require only one dose of the 2016-2017 flu vaccine.
  • Egg Allergy Recommendations-These recommendations have changed a lot from prior years and the ACIP has listed the changes on their website. In summary, patients should still be observed for 15 minutes after the vaccine just in case there is a reaction. If a person has a history of a severe allergy to eggs, a medical provider should monitor their vaccinations. 

Nurses Responsibilities in Herd Immunity: Since corrections health is community health in many ways, nurses have a very important role during flu season and that begins with getting vaccinated. In the world of patient safety, a term called “Herd Immunity” is referred to as a means of stopping the spread of diseases. It also be called community immunity and describes protection from a contagious disease with community wide vaccination. The goal is prevention and containment of the disease. The concept is for the chain of infection to be interrupted by those vaccinated thus stopping the spread of disease to a susceptible host.

18 States have Mandates: In taking a leadership role in disease prevention, 18 states no longer allow health professionals to make a personal choice in obtaining an influenza vaccine. These laws are based on the hospital or facility type at this time. Since corrections facilities have a very fragile and vulnerable population, the same mandate should apply to personnel who work in these facilities as well.  Use this link to research the vaccination laws being published by the CDC.

Prevention is the Key: As nurses, we incorporate prevention into all our patient care activities and treatments. Key prevention tips include:

  • Wash your hands frequently and effectively.
  • Avoid close contact with those who show signs and symptoms of illness.
  • Stay home from work when you are sick.
  • Cover your mouth and nose when coughing or sneezing.
  • Avoid touching your eyes, nose or mouth.
  • Practice good health habits to stay healthy yourself.
  • Obtain flu vaccines for yourself and your family.

Outbreaks: In our corrections facilities, we do not have the luxury of isolating people in their homes or controlling their activities. However, there are processes we can plan for before an outbreak occurs or put in place if an outbreak occurs in your facility.

  • Educate the population about flu season and what they can do to reduce their risk.
  • Work with the local health department or pharmacist for a supply of flu vaccine. The supply this year is supposed to be adequate.
  • Monitor for outbreaks and track them. Work with custody to group ill inmates together, reduce movement, and limit visiting and other things to reduce transmission.
  • If ill patients have to go to court, institute droplet precautions by issuing a mask. Use a gown and gloves if necessary. Sometimes I have seen video court used with ill inmates or court delayed.
  • Administer antiviral treatment for those most vulnerable such as the elderly, chronically ill, immune compromised, pregnant or have acute medical conditions.
  • Consider vaccines for the entire population. Whether a jail or prison, every flu vaccine you administer, reduces the spread of disease in the community when they are released or have visitors.
  • Remember custody in your vaccination program. They want to stay healthy and not spread disease just like health staff.

Remember that vaccination is a community effort. Nurses’ commitment to vaccination best practices is critical to staying healthy and saving patient lives this influenza season. GIVE IT A SHOT

What is the influenza immunization policy in your institution? What practices are part of your plan to reduce the spread of disease? What happens when your facility has a flu outbreak? We enjoy hearing about your experience so please reply in the comment section.

Read more about the identification and management of infectious diseases in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today! 

Photo Credit: http://www.U.S.fotolia.com/ https://www.fotolia.com/id/120105499

Is Intake Screening Getting the Job Done?

The words Get it Done on a stopwatch or timer to encourage you to complete or finish a task or job

In June I wrote a post about intake screening and how difficult it can be to obtain a full and accurate picture of an inmate’s health status. In spite of the difficulties of the time, place and people involved, a nurse armed with information can still make good decisions about the plan of care for each inmate coming into the facility. One type of information that is useful is knowing the health characteristics of the population served.

The health characteristics of 759 inmates being received into the state correctional system in New York were recently reported in the Journal of Correctional Health Care (July 2015). The data about inmates’ medical conditions was obtained from chart review and information about health behaviors (smoking, etc.) came from individual interviews. There were nearly as many women as men included in the sample (387 men and 372 women). The average age was 35.6 years for women and 33.9 years for men. Eighty percent of the population had less than or equal to a high school education/GED. Given just these findings what are the implications for the nursing plan of care?

One conclusion that can be drawn is that health literacy is likely to be an issue. This means assessing what an individual knows already about a particular health issue and then starting from that point when providing information. Second, this population already has well established behaviors (smoking, sexual practices, use of illegal substances, and other risk taking) but may not yet have experienced the health consequences. Use of motivational interviewing will be a valuable tool to assess a patient’s readiness for change and select behavior change strategies most likely to influence the patient.

The population of men in the New York state prison study was predominately non-Hispanic Black and Hispanic. The majority of women were either non-Hispanic Black or non-Hispanic White. This characteristic will vary from region to region and type of facility. The racial and cultural characteristics of the population being received at the facility are important to know because they are also associated with disease prevalence. For example, Blacks are more likely to experience premature death from cardiovascular disease, while control of hypertension is poorest among Mexican-Americans according to the most recent report from the CDC on health disparities.

Respiratory conditions were the most prevalent chronic disease diagnosed in this population of inmates at admission to prison. Respiratory conditions include asthma, COPD and emphysema and were present among 34% of the newly admitted inmates. A history of smoking and obesity significantly correlated with respiratory diseases.

Cardiovascular conditions, including hypertension, atherosclerosis and heart disease were diagnosed in 17.4% of this population. Obesity was significantly associated with cardiovascular disease and diabetes. Sexually transmitted disease was diagnosed in 16.4% of the population. Women had a higher prevalence of chronic disease than men, particularly greater incidence of diabetes and STDs. It is not clear whether this is because women are more likely to access health care or are more susceptible to certain diseases. Age (40 years of age and older) was also correlated with higher risk for diabetes and cardiovascular disease.

Chronic disease was more prevalent in this inmate population than rates for the same disease in the general community. Rates for respiratory disease among the general community are estimated to be 19% compared to this prison population with a prevalence rate of 34%. Diabetes rates were 2.4% in the community among adults the same average age as the prison population. The rate of diabetes among prisoners was 4.9%. HIV disease was 3.5% among newly admitted prisoners while in the same average age group in the general community the HIV rate was less than half of one percent.

The results of this study done in the New York system are similar to those reported by the CDC a year ago. The CDC study looked at the chronic diseases reported by over 100,000 inmates in 606 state, federal and local correctional facilities in the U.S.

What does all this mean to correctional nurses? It is difficult to elicit a full and accurate history from an inmate during intake screening; especially if we are rushed, there are many screenings still to get done and the setting challenges privacy in sharing of medical information. By knowing that 3 of every 10 inmates screened is likely to have chronic respiratory disease helps me evaluate carefully the answers I am getting about the inmate’s medical history and emphasizes the importance of my skill assessing the respiratory system. The same is true for the other common chronic conditions. This doesn’t mean that the other areas of the health appraisal aren’t important, they are. It means that if diseases like diabetes, STDs, respiratory disease and HIV are not identified at about the same frequency as the rates reported for correctional populations then the screening methods should be examined for possible improvement. We all know that early identification of disease means treatment can be initiated that is less costly and burdensome than the emergence of an urgent or emergent medical crisis.

Are the rates of chronic disease tracked at your facility? If so, how do they compare to the rates reported for the New York state correctional system? How do the rates for chronic disease among inmates at your facility compare to the general community? Are there implications of these findings for correctional nursing that go beyond what has been discussed here? Please share your thoughts by replying in the comments section of this post.

For more about the nursing implications of caring for patients with chronic diseases in the correctional setting and the disease burden of this population see the Essentials of Correctional Nursing, especially the first and sixth chapters. Order a copy directly from the publisher or from Amazon today!

Bai, J.R., Befus, M., Mukherjee, D.V., Lowy, F.D., Larson, E.L. (2015) Prevalence and Predictors of Chronic Health Conditions of Inmates Newly Admitted to Maximum Security Prisons. Journal of Correctional Health Care, 21 (3) 255-264

Photo credit: © iQoncept- Fotolia.com

The Power of Appearance

fotolia_120043070_xsMeet Jerry, a new registered nurse in on-the-job training who will begin shadowing you next week to learn to how to conduct sick call. She asks you what she should be thinking about in preparation for this role. You respond by saying that how she does in sick call will establish her competence and clinical authority in the eyes of the inmate population and to prepare for an onslaught of sick call requests as everyone seeks to meet and test her skill.

All patients, not just inmates, assess a nurse’s visual appearance to form an opinion about their confidence and professionalism within the first few seconds of an encounter. In correctional nursing, the inmate’s best opportunity to make this assessment will be during a sick call encounter. Since inmates have no choice in who provides their nursing care they are naturally interested whenever someone new joins the nursing staff.

The traditional white uniform was first established by Florence Nightingale in the early 1900’s to distinguish nurses from lay persons who attended the sick at the time and raise nursing to a respectable profession characterized by caring, compassion and clinical competence. Even though the white uniform has given way to more comfortable and durable clothing it still is the strongest association identified by the public between professionalism and nursing.

The correctional facility you work at has no dress code policy for health care staff. The security staff are provided navy blue uniforms with badges and other insignia detailing their name and position within the organization. Health care staff are simply advised to dress in clean and comfortable clothes appropriate for work in the facility.  In considering what advice to give Jerry in preparation for next week you reflect on your past experience at the facility about staff who were able to establish their authority, confidence and nursing competence early in their correctional nursing career. What advice will you give her as a result of this reflection?

Patients want to know that the person caring for them has the credentials to do so. In fact, some state boards of nursing require that registered nurses be identified clearly by name and credential. Nurses who are accountable for their practice introduce themselves to the patient at the beginning of the encounter. Nurses who do not want inmates to know their name or credential will be unable to establish the trust necessary to obtain important information from the patient about their condition and risk poor care outcomes. Jerry has been issued a name tag but keeps it in her pocket and only shows it when asked.

Staff who dress in a more formal, uniform style are considered significantly more skilled and knowledgeable by patients than those dressed like they were ready for the gym, rooting for the local team or sporting funny sayings. While individual self-expression in attire isn’t prohibited by the facility, it took longer and was more challenging for these staff to prove their competence and skill and project authority when it was necessary. Jerry seems to prefer a t-shirt and scrub pants for work attire.

Some of the staff have taken to wearing polo shirts which have embroidered their credential as a certified correctional health professional on the front. Others wear colored scrubs which fit properly and can be layered based upon working temperatures. Staff who wear patterned or cartooned scrub tops have sometimes been coached if it made them appear too informal, approachable or friendly with inmates and their professional authority was challenged. You note that another aspect of projecting professionalism and respect for the patient and others is wearing clothes that are clean, neat and fit properly.

As you talk with Jerry about creating first impressions she laments that it is all a charade-people should judge her on her actions not her appearance. While you agree with her that there is a lot more to a person than just the visual impression created by the first few seconds, it is however, a vital opportunity, not to be squandered. When you ask her if she wants to see the pilot of the plane she just got on, in sweats. She looks at you a second and gulps. You go on to say “That may be the only information you have about the competence of the pilot flying you across country. The pilot’s appearance is important to you to feel safe and trust that the flight will go according to your expectations. Your patient is the same way, dressing professionally helps them have confidence in your ability and trust that you will take care of them appropriately.”

Jerry shows up Monday morning confident that with your ongoing help and advice she will do well learning how to do sick call like a pro. fotolia_119206347_xs

Do you have a different viewpoint about the impact of the nurse’s appearance in establishing professional authority in the nurse patient relationship? If so please share your views by relpying in the comments section of this post. For more on professionalism in correctional nursing see Chapter 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

Photo credit: © one- Fotolia.com

Emergency Triage and the ESI

Emergency Concept Vector Illustration

This spring, a correctional facility I visit regularly, implemented a new triage system as part of the facility’s emergency response plan. It’s called the Emergency Severity Index (ESI) and has been recommended by the American College of Emergency Physicians (ACEP) and the Emergency Nurses Association (ENA) since 2010. Since then, more and more hospital emergency departments have been implementing use of the ESI. In the Essentials of Correctional Nursing we recommended that correctional facilities use the same triage categories as those used by emergency service providers in the local community. If the ESI is being used in your community maybe it’s time to consider incorporating it into your facility’s emergency response system.

What is the Emergency Severity Index or ESI?

The ESI guides nurses’ in the evaluation of patient acuity and the resources that will be needed to treat the patient. Acuity is defined as the stability of a patient’s vital functions and the potential threat to life, limb or organ. Resources are defined as the number of resources to stabilize and initiate treatment. The result is a triage decision that stratifies patients’ need for emergency treatment into five levels of urgency. It was developed by a group of emergency nurses, physicians, managers, educators and researchers in collaboration with the Agency for Healthcare Research and Quality (AHRQ) who continue to update the tool and related training material.

How does it work?

The ESI is an algorithm that incorporates only four questions and the answers lead to a triage conclusion. The four questions are:

  • Does the patient require immediate life-saving intervention? If so the patient is triaged as ESI level 1. No further triage is necessary and life saving measures are initiated immediately. Life saving measures are those which secure an airway, maintain breathing, support circulation or address a major change in level of consciousness. If the answer is no then go to the next question.
  • Can the patient wait to be seen medically? Three criteria are used to make this determination.
    1. Is it a condition that could deteriorate quickly or for which treatment is time-critical?
    2. Is the patient confused, lethargic or disoriented?
    3. Is the patient in severe pain or distress?

A yes answer to any of the above means that the patient cannot wait and so is triaged as ESI level 2. No further triage evaluation is necessary and the nurse’s focus shifts to ensuring prompt initiation of treatment. If the patient does not need to be seen urgently then proceed to the next question.

  • How many different resources are needed to address the patient’s chief complaint? The nurse uses their experience to predict how many different kinds of interventions will be necessary to diagnose and treat the patient. Resources are those beyond basic first aid, point of care testing and medications. Diagnostic tests, procedures, consults, and inpatient admission are considered resources.

If more than two different resources will be needed (i.e. lab and an EKG) the patient is triaged ESI level 3. If one resource will be needed (i.e. x rays) the patient is triaged ESI level 4. If no resources will be needed (i.e. injury dressed, ice applied and medication administered) the patient is triaged ESI level 5. These level determinations may be altered by the presence of abnormal vital signs, which is considered next.

  • Does the patient have abnormal vital signs? Any patient with an elevated heart rate, increased respirations or a low oxygen saturation rate should be reconsidered for ESI level 2 and seen urgently.

What are the advantages of using the ESI?

The ESI has been found to be more accurate than other triage systems because it is simple and reduces subjectivity. One benefit is that it identifies patients in need of immediate attention more rapidly than other methods. The ESI can help prioritize clinical staff attention and resources and it facilitates communication about patient acuity more effectively. It also has been used as the foundation for facility policy and procedure. The jail referred to at the beginning of this post has since drafted policy and procedure setting timeframes for response to each of the ESI levels. By keeping track of emergencies by ESI level the data can be used to determine if practices could be improved with targeted training or enhanced resources. Finally, the AHRQ maintains a website on the ESI that includes an implementation handbook that can be downloaded for free. There are also DVDs that include lectures and case studies that can be used to support training in use of the ESI. There is no charge for these materials but they must be requested from the site.

How easy and reliable is it?

The ESI has been found to be an easy, reliable and valid measure of patient acuity and resource need in multiple hospital settings and comparison groups. If you want to try it out, use your experience to determine the ESI rating for the patients in these four examples which come from the training material provided at the AHRQ site:

  1. A 58-year-old male complains of left lower-quadrant abdominal pain for 3 days. He denies nausea, vomiting, or diarrhea. No change in appetite. past medical history HTN. Vital signs: T 100°F, RR 18, HR 80, BP 140/72, SpO2 98%. Pain 5/10.
  2. An 18-year-old female is brought to medical because her cell mate found her lethargic and “not acting right”. The patient has a history of depression. On exam, you notice multiple superficial lacerations to both wrists. Her respiratory rate is 10, and her SpO2 on room air is 86 percent.
  3. A 72-year-old male fell and hit his head in the cell. He is awake, alert, and oriented and remembers the fall. He has a past medical history of atrial fibrillation and is on multiple medications, including warfarin. His vital signs are within normal limits.
  4. “I have had a cold for a few days, and today I started wheezing. I need a breathing treatment,” reports a 39-year-old female with a history of asthma. T 98°F, RR 22, HR 88, BP 130/80, SpO2 99%, No meds, no allergies.

Answers: 

  1. ESI level 3: Two or more resources. Abdominal pain in a 58-year-old male will require two or more resources. At a minimum, he will need labs and an abdominal CT.
  2. ESI level 1: Requires immediate lifesaving intervention. The patient’s respiratory rate, oxygen saturation, and inability to protect her own airway indicate the need for immediate endotracheal intubation.
  3. ESI level 2: High risk. Patients taking warfarin who fall are at high risk of internal bleeding. Although the patients’ vital signs are within normal limits and he shows no signs of a head injury, he needs a prompt evaluation and a head CT.
  4. ESI level 4: One resource. This patient only needs a nebulizer treatment for her wheezing. No labs or x-ray should be necessary because the patient does not have a fever.

How did you do? Was it easy to use? There are hundreds of case examples included in the ESI training materials which is a great resource for correctional nurses. There also is a chapter devoted to evaluating competency in the use of the ESI tool.

This blog post is dedicated to bringing down to earth, practical resources and advice for nurses who practice in correctional settings. The ESI is described here because it is increasingly being used by emergency departments in the United States and may be used in your community. If so, you may want to consider using it at your facility as well. If you use the ESI at your facility, please share your experience by replying in the comments section of this post.

For more on this subject read Chapters 16 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Top Educational and Skill Needs of Correctional Nurses

TRAINING Vector Radial Tag CloudThe most recent issue of CorrectCare, a quarterly publication by the National Commission on Correctional Health Care (NCCHC) included an article by Sue Smith MSN, RN, CCHP-RN reporting the results of a recent survey of nursing leaders about the educational and skill needs of correctional nurses. I have reprinted it here so that you can consider the results in light of your own experience and educational needs. Please take a minute to think about your own answers to each of the five survey questions that were used and compare your opinions to those of others who responded.

Nurse Leader Survey Sheds Light on Nurses’ Top Educational and Skill Needs

by Sue Smith, MSN, RN, CCHP-RN

The Nursing Advisory Council is a stakeholder group that advises the NCCHC multidisciplinary education committee on the continuing education needs of correctional nurses and assists the NCCHC lead nurse planner in assessing continuing education for correctional nurses and evaluating the quality and effectiveness of the continuing education. The council consists of nine nurse members who represent a wide variety of roles and settings, including staff nurses, nurse managers/administrators, nurse educators and advanced practice nurses who work in jails, prisons, governmental agencies and private correctional health care agencies.

In 2015, the Nursing Advisory Council developed a needs assessment survey directed at nursing leaders, including nurse managers and nurse administrators. The survey questions were determined by consensus and consisted of five primary questions:

  1. How much time should be allotted for training a first-time correctional nurse before working independently?
  2. What are the three most important topics for orientation/training of correctional nurses?
  3. What is the single most important piece of knowledge for a correctional nurse to have?
  4. What is the single most important skill for a correctional nurse to have?
  5. What RN/LPN-LVN ratio are you using at your facility? What is the rationale for this ratio?

The survey questions were distributed via SurveyMonkey to nurses who self-identified as nurse managers or nurse administrators at NCCHC educational conferences. The survey was available to the target audience for two weeks. In total, 273 responses were received; a small number of responses were discarded that did not address one or more of the questions. The collected results were analyzed by the lead nurse planner using simple data reduction techniques.

1. How much time should be allotted for training a first-time correctional nurse before the nurse is allowed to work independently? (233 responses)

Less than 2 weeks         18%

2-4 weeks                        14%

5-8 weeks                   49%

9-12 weeks                       8%

3-5 months                      8%

6-12 months                    3%

2. What are the three most important topics for orientation/training of correctional nurses?

     Safety/Security (134)

Inmate manipulation, Safety of self and others

Security issues and procedures, Collaboration with security staff, Contraband

Infection control

     Nursing Practice (129)

Health/physical assessment skills, Emergency response, Sick call procedures, Documentation

Medication issues including administration, verification, pharmacology and competence

Triage/screening, Mental health, including assessment, referrals, suicide prevention, substance abuse

Special needs, Discharge planning

     Professional Practice (52)

Professional boundaries

Neutrality, Firm, fair and consistent

Compassion; patient advocacy; balance of advocacy vs. safety

Emphasis on patient care, Autonomy

     Legal/Constitutional Issues (37)

Access to care, Deliberate indifference, Policies and procedures, Licensure/scope of practice

Standing orders, Patient confidentiality, Standards/guidelines

     Miscellaneous (15)

Time management, Critical thinking, Ethics, Electronic medical records

Unique practice environment, Clinic operations, Limitations and restrictions on care provision

3. What is the single most important piece of knowledge for a correctional nurse to have?

     Professional Nursing Practice Skills (108)

Assessment skill, Professional boundaries

Able to see inmates as patients, quality care, respect, patient advocacy, compassion, nonjudgmental attitude, uses nursing process, appropriate follow-up

Critical thinking skills, previous clinical experience, good judgment, know where to find the answer

Emergency skills including recognition of critical patients, proper CPR, trauma evaluation, emergent care

     Safety/Security (74):  Don’t let guard down, how to get help, staying calm, situational awareness, infection control

     Correctional Nursing Practice (16): Unique practice, understand population served, understand environment and facility culture, how to navigate security/medical issues, role of health care in corrections, concept of firm, fair  and consistent

      Legal Issues (16): Policies and procedures, inmate rights, scope of practice

     Communication/Collaboration (15): Manner, effective communication, with advanced providers and DON/HSA, with security, knowledge of chain of command, SBAR technique, professional communication, who and when to call for help

     Clinical Nursing Knowledge (9): Pathophysiology, medications, current on clinical guidelines, proficiency on treatments

     Mental Health (9): Inmates, staff

     Manipulation (7): Inmate-patient behavior

     Miscellaneous (2): Computer skills, preventive health care

4. What is the single most important skill for a correctional nurse to have?

     Assessment Skills (111)

Physical, mental health, health, rapid

Interviewing skills

     Interpersonal Skills (46): Good listener, nonjudgmental, honest, able to handle manipulation, objectivity, professional behavior, boundary setting, able to get along with others, assertiveness, respect, conflict resolution skills, ethics, flexibility, diligence

     Critical Thinking Skills (33): Accuracy, think and perform under pressure, good judgment, confidence, problem-solving

     Communication (33): Written (including documentation), verbal with staff and inmates, therapeutic.

     Clinical Skills (25)

Evidence-based medicine, clinical knowledge, nursing process, CPR, codes, first responder

Triage/prioritization of care

     Personal Skills/Attributes (21)

Observational skills, including awareness of surroundings

Organizational/time-management skills

Autonomy, Self-motivated learner

5. What is the ratio of RNs to LPNs/LVNs at your facility? (268 responses)

Overall average – 3 (RNs) : 4 (LPN/LVNs)

Most frequently occurring ratio – 1 : 1

27 respondents reported all RN staff.

A few respondents reported use of nursing assistants, medical assistants, medication aides and paramedics in addition to or instead of licensed nurses.

103 (38%) did not give information or a ratio could not be determined from the information given.

6. Which of the following best describes the correctional setting where you work? (236 responses)

 Jail                                                                 45%

Prison facility                                                    19%

State DOC/agency                                            17%

Federal agency                                                   8%

Juvenile detention/confinement facility      6%

Private corporation                                           5%

Other*                                                                 12%

* immigration facility, inpatient acute correctional facility, consultants, tribal jails

Discussion

Total responses were 273. However, not all respondents answered every question and it was necessary to discard a number of unusable responses. Simple arithmetic averages were calculated for questions 1, 5 and 6. Qualitative data received in response to questions 2, 3 and 4 were analyzed and separated into broad categories. The number in parentheses beside each category indicates the number of responses in that category.

There is some overlap in the information requested by questions 2, 3 and 4. This was anticipated by the Nurse Advisory Council, but we felt that there would be enough variation in the responses and/or response rates to ensure that the information gleaned from the survey would be useful. The data analysis does indicate that the weight, or importance, of the topics listed varies between each question. Additionally, there was some variation in the specific topics suggested by respondents.

The information gleaned from this survey is consistent with the results of the general needs assessment survey completed in 2014. The Nurse Advisory Council has been using, and will continue to use, the information collected by these two needs assessment surveys to plan continuing education for correctional nurses who attend NCCHC educational conferences.

Sue Smith, MSN, RN, CCHP-RN, is a correctional nurse educator. She serves as lead nurse planner for NCCHC educational activities and directs the NCCHC Nursing Advisory Council. Contact her at nsuesmith48@yahoo.com.

How similar were your answers to the survey results? Do the results confirm your priorities for correctional nurses’ professional development and continuing education? Please share your comments with others who follow this blog by responding in the comments section of this post.

For more on this subject read Chapters 17 and 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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