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!

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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

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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!

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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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Medication Reconciliation

Fotolia_85555232_XSAn inmate approaches you at morning med line and asks for his medication. When he gives you his name and identification number you are unable to find a corresponding Medication Administration Record (MAR) and there is no medication with his name on it in the drawer. This is the psych step down unit so he is probably correct to expect to have medication. When asked he tells you that he arrived on the unit last evening from 3E, the acute psych unit. You tell him that there is no medication for him on the cart and that you will contact the pharmacy and will get back to him later that morning. You are thinking that his medication is still in the med cart on 3E and will call the nurse on the unit as soon as you get back to the clinic.

Does this example sound familiar? How many times are you approached to administer a medication and it is not there? It could be because the inmate was just admitted to the facility or just saw the provider and the medication hasn’t been received from the pharmacy. It could be that the inmate was transferred from one unit to another and his or her medication was not transferred to the new location. Maybe the inmate just returned from an off-site procedure and the provider hasn’t reviewed the specialist’s recommendations.

Each admission, provider visit, transfer or change in level of care is an opportunity for omission, duplication, dosing errors, drug-drug interactions and drug-disease interactions to occur and with it the potential for an adverse patient outcome. Almost half of all medication errors in the general health care community occur because medication is not reconciled adequately when there is a handoff in responsibility for the patient’s care and 20% of these result in harm to the patient. Transitions in the responsibility for an inmate’s health care have the same risk. Medication reconciliation prevents mistakes in patient care.

The Institute for Healthcare Improvement and the Joint Commission recommend reconciling medication whenever there is a change in the patient’s setting, condition, provider or level of care required. In corrections medication reconciliation is done when inmates at admission report taking medication prescribed by providers in the community. These medications will need orders to continue or the inmate’s treatment modified by the provider at the correctional facility assuming responsibility for the patient’s care. Medication reconciliation also takes place when an inmate returns to the facility after receiving specialty care in the community, upon admission and discharge from infirmary or another type of inpatient care and whenever their primary care provider changes. There are only three simple steps involved in reconciliation. These are:

  1. Verify the name, dosage, time and route of the medication (s) taken or recommended.
  2. Clarify the appropriateness of the medication and dosing.
  3. Reconcile and document any changes between what is reported or recommended.

The following paragraphs discuss how medication reconciliation is done at several key points in correctional health care.

When Inmates Arrive at a Facility

Intake screening routinely includes an inquiry into what medications an inmate is taking. Sometimes this question is only briefly discussed. However, if an inmate reports recent hospitalization or receipt of health care in an ambulatory care setting it would be a good idea to inquire again about what medications may have been recommended or prescribed. The same is recommended if an inmate reports having a chronic condition. It may be that they are not currently taking medication because they can’t afford it or were unable to obtain the medication for another reason. Inquiry about medications should also include the inmate’s use of over-the-counter or other alternative treatments.

Offenders arriving at a facility from the community, especially jails and juvenile facilities, may have medications on their person and sometimes, family will bring in medications after learning their family member has been detained. It is best practice to verify that the medication received is the same as that on the label. There are several excellent sites for verification of drugs including Drugs.com, Pillbox, and Epocrates.com. Once verified, document the name of the medication, dose, and frequency, date of filling, quantity remaining, physician, pharmacy and prescription number.

Whether it is the inmate’s report or the inmate has brought in their own medication the prescription must next be verified with the pharmacy or community prescriber. Once this is done, notify the institution provider who will determine if the medication should be started urgently so there is no lapse in treatment or if the patient should wait until seen for evaluation.

When Inmates Return From Offsite care

Medication should also be reconciled whenever a patient returns to the facility from a hospitalization or specialty care. The clinical summary or recommendations by the offsite provider should accompany the patient, if not, the nurse should obtain this information right away. Recommendations from off-site specialists or hospital discharge instructions should be reviewed as soon as possible by the nurse and provider in order to continue the patient’s care. When clinical recommendations from off-site care are missed or not followed up on needed treatment is delayed and the patient’s health may deteriorate.

When Inmates Are Followed in Chronic Care Clinic

Chronic care patients are another group that require nursing attentiveness to medication reconciliation including:

  • Evaluating whether the patient is actually taking it as ordered.
  • Following up whenever the medication or the patient is not available and if so, getting scheduled doses to the patient promptly. Also helping the patient to request refills and reorders in time may be necessary so doses are not missed. Also account for the whereabouts of each no show so that medication can be provided as scheduled.
  • Coaching the patient about what to discuss with their provider if they want to make a change or are having side effects. Often patients who want to change or discontinue prescribed treatment will refuse single doses or not pick up their KOP medications. Each of these lapses should be discussed, the patient coached about the next steps to take and the provider notified as well.

When Medications Are Missing

When patients come to the pill cart or widow expecting to receive medication and there is either no medication or MAR asking the patient a few questions as listed below will narrow down where the medication may be located:

  • when was the last dose received (this indicates there is an active prescription and will help determine the urgency for resolution)?
  • If the inmate says that he or she haven’t had any medication yet, ask when they saw the provider who ordered it? (maybe the prescription has not been dispensed yet or it has arrived but hasn’t been unpacked and put away).

Other questions to help narrow down the problem are:

  • if they have been moved recently from another part of the facility (medication and MAR were not transferred).
  • when did they arrive at the facility or were transferred from another (check the transfer sheet, medications and MAR were not transferred).
  • is it a prescription brought in from the community (may be stored elsewhere)?
  • if they have gone by any other names (may be filed elsewhere).

Based upon the answers to these question you may instruct the patient to wait (i.e. “It was just written last night and hasn’t been filled yet, please check back tomorrow.”) or tell the patient that you will look for it and administer it at by at least the next pill call. If you are not able to resolve the problem promptly be sure to assess the patient to determine if the provider should be contacted. Allowing patients to miss medication, even if somebody else is responsible, is equivalent to not providing treatment that is ordered and can be a serious violation of a patient’s constitutional rights in the correctional setting, much less exacerbate their medical condition.

Easing the Burden of Medication Reconciliation

Other recommendations to ease the burden of medication reconciliation from the Institute for Healthcare Improvement are:

  1. Identify responsibilities for medication reconciliation such as standardizing where information about current medications is located, specifying who is responsible for gathering information about medications and when medication reconciliation is to take place, establishing a time frame for resolution of variances and standardizing documentation of medication variance and resolution.
  2. Use standardized forms to ensure that information about medications is elicited and documented.
  3. Establish explicit time frames for when medication is to be reconciled and variances resolved such as within 24 hours of admission, within four hours of identification of variance in high risk medications (antihypertensives, anti seizure, antibiotics, etc.), at every primary care visit.
  4. Educate patients about their medications and their role in reconciliation at every transition in care.

When do you obtain information about the medications a patient takes and how do you verify the patient’s information? Do you provide patients with a list of the medications they take? What is the patient’s role in medication reconciliation at your facility?

If you wish to comment, offer advice about medication reconciliation in correctional health care please do so by responding in the comments section of this post.

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

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Protective Gear for Correctional Nurses

The post last week talked about the problem of nurses being exposed to inappropriate and hostile sexual behaviors by inmates and the kinds of interventions that should be in place to minimize or control antisocial inmate behavior. Nurses were advised not to confront this behavior single handedly but to look to the facility for guidance. But that is just half the solution, the other half, which is the subject of today’s post, is that individuals can take steps on their own to minimize the adverse effects of these unfortunate situations on themselves.

The reality is that bad things do happen in corrections. Even in the best run correctional facilities inmates are injured and sometimes staff are injured as a result of violence and on some of these occasions died as a result of the violence. The nature of the correctional environment is that it always has the potential for immediate violence and direct trauma. Another pervasive aspect of our working environment is that because of the involuntary conditions of incarceration, there is inherent conflict, particularly between staff and inmates. These two features of the work environment combined with operational stressors, such as high workload, contribute to what has been called “Corrections Fatigue”.

It has been suggested that correctional staff prepare themselves to be in this environment the same way that they don other protective gear. An analogy for correctional nurses would be gowning, gloving and putting on a properly fitted mask before going into the isolation room of a patient with active tuberculosis. By wearing protective gear staff minimize their exposure. The same concept applies to the trauma associated with repeated exposure to violence or threatening behavior. What kind of “gear” minimizes our repeated exposure to trauma in the corrections environment?

Resilience is a characteristic that refers to an individual’s ability to cope with adversity; it is the ability to “bounce back” after a stressful experience. Resilience varies from one person to another but we can each tend to and build our resilience. Resilience, then is our protective gear. The following four behaviors have been identified as building resilience in correctional workers.

Build Supportive Relationships at Work – Building and maintaining social support among co-workers has been found to correlate with resilience for the person offering support. By building genuine bonds with co-workers we increase our sense of safety, reduce interpersonal tension and staff conflict. Examples of behaviors that are supportive of relationships at work include:

  • being friendly and respectful,
  • asking how a co-worker is and paying attention to their answer,
  • acknowledging a job well done,
  • looking for ways to assist others when you have time,
  • thanking others for their assistance, and
  • being compassionate with others’ experiences.

Take Care of Yourself – How many times have we as health care providers offered this advice to others? And yet we are known to neglect ourselves, making us vulnerable to burnout, compassion fatigue and now, corrections fatigue. Being healthy is a basic tenet of resilience. Healthy habits and lifestyle behaviors include those that attend not just to your physical needs, but psychological, spiritual and social needs as well. Healthy habits and lifestyle behaviors include:

  • maintaining balance between work and home life
  • mindfully transition to and from work
  • prioritize free time to be with people who are significant in your family and social life
  • engaging in pleasant activity-having fun
  • regulate negative emotions (emotional intelligence)
  • establish a regular and healthy sleep schedule.

Be Confident and Perseverant – These behaviors build competence handling complex or challenging circumstances at work. Confidence and perseverance are a result of:

  • a resolution to complete tasks even when it is difficult,
  • using self-talk to motivate oneself to persevere in the face of adversity,
  • rehearsing and repeating training so that it becomes more automatic and built in,
  • being flexible, open and adaptive to change
  • being ethical and acting with integrity.

Use Logic to Solve Problems – This approach is recommended as a way to keep your cool in the face of the complex or challenging problems we deal with in correctional health care. Thinking logically about situations means considering more than one possible cause and weighing possible responses before choosing the one that is most likely to have the effect you are seeking. This way you maintain control and composure in frustrating or disappointing circumstances. Practical ways to practice logical problem solving and self-control include:

  • divide complex problems into parts and tackle one component at a time,
  • learn how to detach emotionally from challenging situations,
  • view mistakes as learning opportunities,
  • regulate fear and other negative emotions while acting constructively,
  • accept that you cannot always be in control.

These four behaviors, supporting workplace relationships, taking care of yourself, being confident and perseverant, and logical problem solving are your protective gear (resilience) to reduce the effects of violence and other antisocial behaviors, conflict and other operational stressors that are inherent in the correctional setting on your health and well-being.

For more information about promoting wellness among staff who work in correctional settings please see the National Institute of Corrections has collected articles and other resources on this subject. They also sponsored a podcast on the subject in 2014 which can be accessed on the NIC website. Much of this information was adapted for correctional nursing from a series of articles written by Caterina Spinaris PhD., Executive Director of Desert Waters Correctional Outreach which provides training and other materials to support wellness of correctional staff including a monthly newsletter, Correctional Oasis.

I was most surprised to learn from my research for this blog post that when I offered support to co-workers it had a positive effect on me by building resilience. This new idea has me thinking about my work relationships and how I support others to see what I could do better. What resilience building behaviors have caused you to reflect on your own behaviors? Is there more you could do to protect yourself from the negative attributes of your working environment?

If you wish to comment, offer advice or share an experience concerning the subject of staff wellness please do so by responding in the comments section of this post.

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

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