Last week’s post on nursing sick call emphasized the importance of receiving and responding in a timely and clinically appropriate manner. Each request must be triaged within 24 hours of receipt. When the request describes a clinical symptom it must be assessed in a face- to- face encounter. Obviously if the symptom is of an emergent nature the assessment must take place immediately. Examples of requests that are potentially life threatening and should be assessed immediately include statements regarding suicide or hopelessness, cardiac or respiratory distress and trauma.
However most requests received via sick call are not of an emergent nature. Patients with non-urgent clinical symptoms need to be evaluated within 48 hours from time the request was received and this timeframe can extend to 72 hours on weekends. Non-urgent health care attention is requested most often for symptoms relating to pain, skin conditions and HEENT problems. Nurses should expect to be very familiar with the assessment, evaluation and treatment of multiple conditions that manifest in these symptoms. Correctional nursing expert, Jessica Lee, as well the National Commission on Correctional Health Care (NCCHC) recommend staff with the most skill and experience in assessment be responsible for sick call.
The face-to- face encounter involves the six components of nursing process defined in the American Nurses Association (ANA) standards for correctional nursing practice (2013). These inter-related components are depicted in the diagram at the top of this post as assessment, diagnosis, outcomes identification, planning, implementation and evaluation. For a description of how the nursing process is used during nursing sick call see Chapter 15 in the Essentials of Correctional Nursing.
What are the pitfalls for nurses in the face-to-face encounter? In thirty years’ experience as a correctional nurse, manager and consultant I have observed thousands of nurses in sick call encounters and reviewed their documentation. Some of these nurses were definitely experts, others were new to the process, and many were competently performing these skills. The following are the problems and pitfalls most often seen with the face-to-face nursing encounter.
Delays: Evaluations that take place long after the request has been submitted place the nurse in a difficult spot. The patient is frustrated because of the delay and may be disrespectful; the condition may have gotten worse and the patient already been seen in an emergency or the condition grown more complex and require a referral when it could have been treated by the nurse if seen earlier. Imagine how you would react if it took three days to receive one dose of aspirin or ibuprofen for a headache. When inmates experience failures in access the response is often to flood the system with requests and soon the nurses can’t keep up. Stay on top of requests so that there are no delays and the volume will be more manageable. There are no defensible reasons for delaying access to care; it is a constitutional requirement.
Incomplete assessment: Nursing assessment involves the collection of both subjective and objective information that is relevant to the patient’s reason for requesting health care attention. The subjective assessment includes asking sufficient questions about the problem to determine additional data to be gathered during the objective exam, diagnostic testing and chart review. Failing to physically examine the patient to adequately verify and amplify subjective information is a common error in nursing sick call. Examples are sick call encounters have incomplete vital signs recorded or dental complaints that do not include an examination of the oral cavity and neck but just a referral to the dental department. This may be because of inexperience, fear or concern about touching inmates or trivializing patient complaints. Nursing assessments should be conducted and documented so that the clinical information contributes to the next provider’s assessment whether it is a provider appointment or the next sick call visit.
Inadequate patient involvement: Involving the patient in each encounter is a sure way to reduce unnecessary requests for health care attention and submission of a grievance both of which take additional time to respond to. This is not to say that a nurse should give the patient what they want. Instead it means to ask for the patient’s input about the outcome they desire and then to provide an explanation of findings, recommended plan and the rationale that takes into account the patient’s input. Involving the patient demonstrates respect and helps build the therapeutic relationship; it also gives useful clues that can help motivate the patient in their own care. If the patient doesn’t understand then another explanation may be useful especially if the patient has low health literacy. The nurse may schedule the patient back for a follow up appointment to go over the information again or to check on the patient’s symptoms. If the patient doesn’t agree with the plan the nurse should reconsider their findings or make a referral for higher level care.
Poor clinical decision making: Making clinical decisions is a skill built by thoughtful reflection on practice while gaining experience. As experience increases diagnostic conclusions are drawn more quickly by patterns recognition rather than the more deliberate process of gathering and analyzing data. The downside to pattern recognition is that the nurse’s conclusions are prone to bias based upon personal experience and cultural socialization. Two common errors in diagnostic reasoning are premature closure (coming to a conclusion before sufficient data is gathered) and confirmation bias (only seeing data that matches our conclusion and ignoring data that doesn’t). See two previous posts about how to build and hone clinical decision making skills.
Inefficient use of resources: Time, space and equipment are the resources nurses use during sick call. Examples of inefficient use of resources include conducting the face-to-face encounter in an area where the nurse cannot properly examine the patient, using a blood pressure cuff that is the wrong size or not calibrated, having to go to another area to get supplies or equipment to complete the examination, not having the chart available or not referring to the chart for data on the patient’s recent health care. See a previous post about safe practices for nurse sick call. Nurses should be able to elicit the health history at the same time observe the patient and gather objective physical assessment data. Like playing the drums the face-to-face encounter takes practice. Nurses develop these skills when they are provided support, coaching and feedback. Face-to-face encounters which are incomplete or inadequate also waste provider resources if an unnecessary referral is made or the information about why the provider appointment is needed is incomplete.
What are the challenges you experience in completing timely, responsive and clinically appropriate face-to-face encounters with patients who have symptom based requests for health care attention? Please provide your thoughts and experience in the comments section of this post.
For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.
American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.
Knox, C & Shelton, S. (2006). Sick Call. In Clinical Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.
LaMarre, M. (2006). Chapter 28: Nursing role and practice in correctional facilities. In M. Puisis (Ed), Clinicsl Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.
National Commission on Correctional Health Care. (2008). Standards for Health Services in Prisons. Chicago: NCCHC.
Photo credit: © dimakp – Fotolia.com