A nurse is being deposed by the plaintiff’s attorney about the care provided to a patient while in the county jail. The patient suffered a bad outcome and is suing the county, the jail physician and the nurse for inadequate care. The attorney asks why the nurse gave an over-the-counter (OTC) medication to the patient who complained of cold symptoms. The nurse’s response is that the protocol for a common cold allows the nurse to use an OTC decongestant. The attorney asks where the nurse got the protocol. The response is that the nurse obtained the protocols while employed at the state prison. The nurse has continued to use them since taking the sole nursing position at the county jail.
This is an actual case and the starting point for this week’s blog post on avoiding risky practices in the use of nursing protocols and sick call. What problems do you see with the use of nursing protocols in this case? My thoughts in answer to this question are at the end of this post.
Listen to a fascinating interview with Kathy Wild RN, MPA, CCHP, about wise use of nursing protocols at http://correctionalnurse.net/2012/07/19/wise-use/. Kathy views nurse sick call as the signature practice defining the specialty of correctional nursing. The following is a checklist of things to have in place to conduct sick call and use nursing protocols safely.
- Are there written guidelines for sick call at the facility and is the day to day practice of sick call consistent with these guidelines? Guidelines might include a procedure, a checklist, a post order or other written document approved by management that details who, how, what, where and when daily requests for sick call are handled. Is sick call conducted in a manner that is consistent with these directives?
- Are nursing protocols used to assess and treat patients’ health complaints? These may be called care pathways, assessment protocols, standardized procedures, or standing orders. Basically they describe how to evaluate a patient’s health complaint, determine the priority and plan for care and then initiate treatment. The protocols should be developed by nursing staff with involvement and approval of each protocol by the facility physician. The protocols also should have specific directions for contact and referral to providers.
- Is the procedure, practice and are the protocols consistent with the nurse practice act? To obtain the practice act contact the same board that you obtain your license from. Many of the state practice acts are available on-line by simply typing in the search words “nurse practice and the state” (e.g. nurse practice, Oregon). These sites have other helpful resources including how to ask for an opinion, copies of previous opinions and how to determine if an activity is within your scope of practice. Sue Smith, author of the chapter on Sick Call in the Essentials of Correctional Nursing urges nurses to seek advice from the Board about practice in the correctional setting rather than respond after the fact to a complaint.
- Have you received training and clinical supervision in sick call and the protocols? Nursing sick call is a practice that is unique to correctional nursing. Therefore nurses need training to develop the knowledge, skill and expertise to provide effective, timely and clinically appropriate patient care in the correctional setting. Even if you have prior correctional nursing experience you should receive training specific the new facility. All nurses should evaluate their competency in sick call periodically and prepare recommendations for improvement. All nurses should also periodically review the protocols and especially when revised.
- Is the space and equipment sufficient to conduct sick call? Sick call must be carried out in a clinically appropriate manner. The space must provide for privacy so that you can elicit good quality subjective information and thoroughly examine the patient. Without privacy and the proper equipment nurses are unable to make sound clinical decisions about what is wrong and what to do about the patient’s concern. Recommended equipment includes:
|Stethoscope||BP cuff in several sizes|
Calibrated weight scale
|Dressing supplies||Germicidal solution||
Smith, S. (2012) Sick Call. In Schoenly, L. & Knox, C. Ed. Essentials of Correctional Nursing. New York: Springer Publishing. Page 287
References should include copies of written directives and the protocols as well as one or more clinical references, a drug reference and patient education material.
What should I do if the answer to one or more of these questions is no? Bring your concerns to the attention of those responsible for health care delivery at your facility. It is always a good idea to state your concerns as suggestions for improvement and recognize that change may not take place overnight. If you are in a leadership position make plans to improve nursing sick call; there are many references available and mentioned here.
Thoughts on the nurse’s use of protocols in the case example above: The nurse was using protocols developed by and for another organization, not the jail. The medical director at the jail had neither seen these protocols nor approved their use. There were no written guidelines in place at the jail to describe how the nurse was to conduct sick call. The physician was on-site ½ day every two weeks and otherwise available by phone during normal office hours. The nurse in this case was practicing outside the scope of the nurse practice act.
Use the comments section of this post to contribute your thoughts on safe practices for nursing sick call. For more on Nurse Sick Call order Essentials of Correctional Nursing at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4.
Photo Credit: © Hakan Kiziltan