Medication management is identified as one of the features of correctional nursing that distinguishes it as a specialized field. Nurses who are new to the correctional setting are often unprepared for the scope and breadth of their role and responsibilities for managing medication delivery and yet they must meet the same standards for delivery of medication as in the community (ANA 2013).These challenges define what is unique about correctional nursing practice with regard to medications.
I started making a list of the challenges correctional nurses deal with in managing medication delivery. When the list became almost a full page long I sat back and thought about what similarities there were between the items and the following groupings came together.
- Professional isolation: Health care delivery in correctional facilities is often a very small part of the overall operation. In many cases nurses are expected to deliver services in independently and without advice from other health care providers. Nurses recently commented on CorrectionalNurse.net, Lorry’s other website that double checking dosages of high risk medications is a challenge when there is only one health care person on duty. One solution is to have the inmate confirm that the dose corresponded with what he or she understands it should be. Dispensing, drug packaging, storage inventory and disposal of medications are all subjects governed by state pharmacy laws and regulations. Unless there is a pharmacist on staff, correctional nurses need to be familiar with and ensure their practices comply with these requirements, in addition to the nursing regulations, when managing medication in the correctional setting.
- Security: Maintaining security is a primary focus of correctional facilities. This includes accounting for the presence and activities of each inmate throughout the day, ensuring that only authorized persons and products enter and exit the facility, and that contraband does not enter, is not otherwise obtained or manufactured. The most obvious example of a unique responsibility for correctional nurses is counting needles and syringes and accounting for each use. Others are ensuring access to inmates when medication is due (even on lockdown) and protecting patient confidentiality (not having medication lines that serve to identify the mentally ill or those with HIV disease for ridicule or extortion by others). Sometimes a facility will determine that for security reasons, not clinical, that all medication must be floated on water or even worse, crushed, impacting patient adherence, the time it takes to administer medication and in some cases the therapeutic effectiveness of the drug. Nurses need to confer with security on an ongoing basis so that security practices that compromise the therapeutic value of prescribed treatment are not put in place.
- Safety: The safety of inmates, staff and the general community is the other primary focus of correctional facilities. For correctional nurses this includes ensuring the safety of themselves and patients as well. A significant aspect of medication delivery is managing inmate behavior. This includes consistent practices for patient identification (two-part identification), checking that inmates don’t cheek or palm medication, providing privacy at the medication window or cart (prevent crowding). Often an officer will be assigned to escort the nurse or mange the medication line. Nurses need to engage the cooperation and assistance of this officer and be alert to their own behavior so that medication administration is conducted in a safe and efficient manner. The patient safety aspects are ensuring the cleanliness and hygiene of the medication delivery area to prevent transmission of infectious disease and monitoring conditions so that side effects from medications that make patients heat or light sensitive are prevented.
- Expanded role: Unless a correctional facility is large and has a number of specialized programs the health care program is likely to be staffed pretty simply without the support services nurses are used to in other health care settings such as pharmacy technicians, IV teams, respiratory therapists, inventory clerks and so forth. Nurses in correctional facilities routinely perform these roles instead and if there is assistance the nurse is responsible for their assignments and supervision. Nurses order medication from the pharmacy, arrange for refills and renewals, check for outdated drugs, receive, inventory and store medications and arrange for medication to be returned or properly destroyed. Nurse initiate treatment for patients via nursing standardized protocols that involve providing the patient with medication to treat the illness or manage symptoms. Nurses are the primary health care professional responsible to ensure that patients do receive medication as ordered and are expected to monitor patient adherence and solve problems with medication availability. Correctional nurses also assess the patient’s ability to manage their own medication if the facility has a self-medication or “Keep on Person” (KOP) program and to provide education or other assistance to support the inmates in providing their own care.
- Greater volume and scope: Because correctional nurses are responsible for the health needs of the entire population housed at one or more facilities they are generalists in nursing practice not specialists. Medications may be administered by a nurse or other personnel supervised by the nurse so that the inmate is directly observed when taking medication. Inmates may also be provided with a supply of medication by a nurse to take by themselves in a KOP or self- carry program. Nurses may also take medication to administer to patients in restraints, seclusion or housed in a high security setting for disciplinary or protective reasons. Nurses may give some medication under rules that allow for involuntary administration to patients with mental illness. In some correctional facilities nurses may be expected to use PICC lines or other specialized equipment or procedures to administer medication. The volume of medication administered by a nurse in the correctional setting exceeds that in any other setting. One difference is that most patients on pill line would be responsible for taking these medications by themselves or with the assistance of family in their own home.
- Timeliness: Medication delivery and administration must take place in coordination with all of the other activities that compete for the time and availability of inmates. In one facility I recently visited medication administration was halted on a unit until the canteen delivery was finished. The nurse was stranded in the corridor for twenty minutes until canteen was over. When the nurse insisted that medications be administered and canteen delivery wait the inmates complained bitterly. This is just one example of the competition for time. These time pressures can affect the therapeutic effectiveness of the drug if given too close or far apart. If inmates go to work or court before nursing staff are on duty inmates may miss important doses. The volume of medication to be given can impact timeliness; if there are too many medications a nurse may feel pressure to short cut or abandon the five rights resulting in increased patient risk.
So what are your thoughts about the uniqueness of medication management in correctional nursing practice? What have I forgotten or you would describe differently? Is there anything discussed here that you disagree with because it is not unique to correctional nursing. Share your thoughts in the comments section of this post.
Photo credit: © Yannis Ntousiopoulos – Fotolia.com
American Nurses Association (2013) Correctional Nursing: Scope and standards of professional practice. American Nurses Association. Silver Springs, MD.
James, D.J. & Glaze, L.E. (2006) Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mhppji.pdf
Maruschak, L. M., Berzofsky, M., & Unangst J (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf