Correctional Nurse Self Care: Resilience

 

 

Peligro, cuerda rotaLast week’s commentary on the burden of moral distress brought forth the concerns and experiences of several more correctional nurses. Each of these courageous nurses described a turning point where they chose to act rather than stay silent and address the needs of their patients; each also paid a price, including termination, depression, failing health and so forth. I too, had to leave a position I had been in for 17 years because I was “in the way” of achieving the cost savings the organization had promised. This past year I witnessed a colleague being walked off the job because while she was trying to improve nursing practice she didn’t have the full support of the facility health authority. These are tremendous consequences for nursing professionals committed to quality patient care. One nurse commented that it is “easy to blame the nurses that are working with the inmates daily” rather than look up the chain of command to the organization itself and the managers responsible for the delivery of services. These experiences and the accompanying reality are the reason resilience has been identified as an essential quality to nurture as part of the caring practice of the nursing profession (Tusaie & Dyer 2004, Hodges et al. 2005, Warelow & Edward 2007).

Resilience refers to the ability to bounce back or recover from adversity (Garcia-Dia et al. 2013). Others describe resilience as the ability to grow and move forward in the face of misfortune or adversity; to adapt to adversity while retaining some sense of control and moving on in a positive manner (Jackson, Firtko & Edenborough 2007). Resilience has been suggested as a strategy for nurses to manage the emotional and physical demands of caring for patients as well as reduce their vulnerability to workplace adversity (excessive workload, organizational restructuring, lack of autonomy, bullying and violence).

The good news is that resilience is not a personality trait, that we either have or not, but instead consists of behaviors, thoughts and actions that can be developed and fostered to strengthen and adapt to our circumstances. Strategies that help build personal resilience include:

Professional relationships which are supportive and nurturing

A key component in the lives of resilient people is positive social support; having one or more people in the profession who are role models and can be called upon for guidance and support when needed. At least some of these individuals need to be from outside the immediate workplace so that support is unbiased and safe to receive, especially when the workplace is laden with tension. Another feature is that the relationship needs to be nurturing and one that fosters offers encouragement, reassurance, and individual professional growth; such as a mentoring relationship. In thinking about this, my professional network was developed among the members of the Oregon Chapter of the American Correctional Health Services Association. We meet twice a year and each meeting includes training, social time and the opportunity to discuss the workplace challenges we each struggle with. The relationships built through this local organization with other correctional nurses over the years have sustained me during many periods of crisis and change.

Maintain positivity

Positive emotions, including laughter, increase energy, change perceptions and help cope with adversity. Positivity comes from optimism or an ability to visualize potential benefits or positive aspects of an adverse situation. Considering a situation in a broader and longer-term perspective can build optimism. Indeed forcing oneself to think positively develops a greater range of resources and broadens the inventory of possible solutions in the midst of adversity (Jackson, Firtko & Edenborough 2007). The readers’ comments about their experiences with moral distress express an optimistic and positive view that reaching out to each other will create a collective voice to improve conditions in correctional health care. Techniques suggested to support positivity include visualizing what one wants rather than what is feared, identifying what brings joy to one’s life, maintaining hope for a positive outcome and laughter.

Develop emotional insight

Emotional insight is the capacity to identify, express, and recognize emotions; to incorporate emotions into thought; and to regulate both positive and negative emotions. When faced with adversity, emotion is inevitable, however we often are focused on the “who, how, what, when and where” of what is happening; unaware of how emotion is effecting us. When we can identify our emotional response to a situation we can switch our parasympathetic nervous system on and respond in a calm and rational manner and not suffer the effects of a “fight or flight” response. Understanding our emotional needs and reactions provides further insight into how we cope and may yield new ideas about how to improve our response in the future. Specific techniques suggested to develop emotional insight are relaxation exercises, guided imagery, meditation, deep breathing, journaling and reflection. See an earlier post about the use of reflection for professional growth.

Achieve life balance and spirituality

Highly resilient persons express existential beliefs, have a cohesive life narrative and appreciate their own uniqueness. This has also been described as having an anchoring force in life. In nursing, we often use the term achieving a work-life balance which is to engage in activities that are physically, emotionally and spiritually nurturing. This includes being clear about our mission in professional life, the reason for being a correctional nurse, so that we aren’t distracted in challenging times. Activities that support a balanced life include getting enough sleep, eating healthy, regular exercise, and maintaining a spiritual practice. You may want to revisit a recent post introducing self-care for correctional nurses. Another suggestion is to write and then send a letter to yourself recognizing your strengths and expressing gratitude for the work that you do.

Reflective practice

Reflection is a way to develop insight and understanding about situations so that knowledge is developed and can be used in subsequent situations. A concrete experience, such as losing one’s job or experiencing an ethical dilemma is used as a catalyst for thinking and learning. Journaling is especially helpful in adult learning because putting an experience into writing ascribes meaning to the people, places and events involved in the experience. Reflection is an opportunity for self-discovery; many people report better relationships, greater personal strength and self-worth, a deeper spirituality and heightened appreciation for life as a result of the self-growth that takes place after adversity. One of our readers said exactly that… “I have learned so much about myself, and systems change, and leaders vs managers.” I have to agree based upon my own experience; I am a stronger, more skilled professional than I ever was and have more to give others as a result of the self-discovery that took place after leaving, so long ago, a job I loved.

 

No one wants to experience workplace adversity and professional burnout and yet we know from our own experience and those of our readers, it is a reality in correctional nursing. Recognizing and building resilience personally and within our organizations is a strategy that is becoming part of the profession’s uniform. Below are several excellent resources for developing nursing resilience:

  1. Resilient Nurses: How health care providers handle their stressful profession. Written and produced for Public Radio. Consists of two ½ hour interviews with several leading nursing experts. The second segment includes techniques used to handle unusual strain as well as everyday stressors in nursing. It also includes a relaxation audio, a booklet, a CD and a list of resources.
  2. How can nurses build resilience and master stress? A summary of a 16 week series on Activating Resilience in Nursing and Leadership by Cynthia Howard. Links are included to other posts in her series on resilience.
  3. University of Virginia School of Nursing, Compassionate Care Initiative, is dedicated to teaching nurses resilience and compassion in health care. The site includes a link to “nurses thrive!” an online community of nurses dedicated to promoting resiliency. Also includes resources for building resilience through guided practice and exercise.

Do you recognize aspects of your own path to professional resiliency in these descriptions? What has helped you adjust or rebound from adversity? Please share your experiences or advice by responding in the comments section of this post.

References:

Garcia-Dia, , J., DiNapoli, J.M., Garcia-Ona, L., Jakubowski, R. & O’Flaherty, D. (2013) Concept Analysis: Resilience. Archives of Psychiatric Nursing 27; 264-270.

Hodges, H.F., Keeley, A.C., & Grier, E.C. (2005) Professional resilience, practice longevity, and Parse’s theory for baccalaureate education. Journal of Nursing Education 44, 548-554.

Jackson, D. , Firtko, A., & Edenborough, M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing.

McGee, E. M. (2006) The Healing Circle: Resiliency in Nurses. Issues in Mental Health Nursing 27; 43-57.

Sieg, D. (2015) 7 Habits of Highly Resilient Nurses. Reflections on Nursing Leadership 41 (1).

Sullivan, P., Bissett, K., Cooper, M., Dearholt, S., Mammen, K, Parks, J., & Pulia, K. (2012) Grace under fire: Surviving and thriving in nursing by cultivating resilience. American Journal of Nursing, 7 (12).

Tusaie K. & Dyer J. (2004) Resilience: a historical review of the construct. Holistic Nursing Practice 18, 3-10.

Warelow, P. & Edward, K-l. (2007) Caring as a resilient practice in mental health nursing. International Journal of Mental Health Nursing 16, 132-135.

 

For more on moral distress and courage see Chapter 2 Ethical Principles for Correctional Nursing in the Essentials of Correctional Nursing. You can order a copy directly from Springer Publishing and receive $15 off as well as free shipping by using this code- AF1209.

Photo credit: Peligro, cuerda rota@alejandro dans- Fotolio.com

 

Nurses Role in Managing Inmates on Hunger Strike

Prison interior with light shining through a barred window

Hunger strike is a situation every correctional nurse will encounter at least once during their career. It is also one of the unique features of correctional nursing practice and not experienced by nurses in other specialties. Usually the first thoughts that come to mind when the subject of hunger strike comes up are the ethical conflicts; supporting an inmate during their hunger strike (an individual’s right to autonomy) and whether to intervene with life saving measures, such as force feeding (health care professional’s obligation to use their skills and knowledge to benefit the patient). These ethical issues were discussed in this month’s American Journal of Nursing with regard to the hunger strikers at Guantanamo Bay.

In my thirty years’ experience all but one inmate on hunger strike has resumed eating well before their condition became life threatening. It was skillful, concerned nursing care, especially patient advocacy, which eliminated the need to work through the ethical issues that take up so much of the discussion about hunger strikers in correctional settings. The focus of this blog is to describe the practical steps that nurses can take when an inmate informs staff that they are on a hunger strike. These include establishing the patient’s baseline health status, advising and educating the patient, and scheduling ongoing follow-up.

Notification: The highest level officials at a correctional facility will want to be notified when an inmate is on a prolonged fast or hunger strike. They often express concern about preventing the inmate from harms and want to avoid peer pressure or enlisting other inmates in joining the hunger strike. When a nurse is informed that an inmate is on a prolonged fast or hunger strike the first step is to make the proper notifications. These should be spelled out in facility specific policy and usually stipulate the dual responsibility of the facility health authority and chief medical officer to keep the facility command structure informed about the inmate’s health status, any change in condition, and involved in supporting the general plan of care. These leaders are also responsible for ensuring that mental health professionals are actively involved in evaluating and planning for the patient’s care.

Definition: All individuals periodically fast, so it is important to distinguish when fasting is considered a hunger strike or attempt at starvation. Sometimes the inmate will notify staff that they are not eating and the reason why; other times officers notice that an inmate is refusing foods (and maybe fluids as well) and take further steps to inquire about the inmate’s behavior. Correctional systems usually define a hunger striker as an inmate who goes without food and fluid for more than 24 hours or without food (but taking fluid) for more than two consecutive days.

Time is on our side: There is no need to rush into a confrontation with the hunger striker or struggle with the question of whether to force feed for some time. For healthy persons, serious risk does not arise until after 14 days of starvation, or until the patient has a Body Mass Index (BMI) of less than 18.5, or abnormal lab values (↓serum protein and albumin, ↓bicarbonate, abnormal kidney function or electrolytes). Persons with chronic medical or mental health conditions, who are pregnant, elderly or taking certain types of medication (e.g. insulin, diuretics, antacids) risk experiencing complications earlier. Nurses and custody staff should ensure that fluids are available at all times and food is offered according to the regular meal schedule. During this early period it is important for nurses to concentrate on building a therapeutic relationship with the patient; one that demonstrates respect, supports autonomy and self-determination, and preserves dignity.

Baseline Evaluation: When health services is notified or determines that an inmate is on a hunger strike the first step is to establish a baseline against which to monitor changes in the inmate’s health status. This evaluation should be conducted within the first 24 hours of notification if the inmate is at higher risk for complications. High risk includes patients who are elderly, pregnant, on a mental health caseload or have a medical condition that requires ongoing care. Inmates with these characteristics need to be followed and monitored on a more intense and frequent schedule. Inmates who are otherwise healthy still need to have a baseline health evaluation but it can take place anytime within 72 hours to 7 days after notification of hunger strike.

The baseline evaluation should include:

  1. Interview to determine what the inmate is refusing and the reason for refusal. Recommended questions to ask are:
  • What was the last food you ate and when was it?
  • Is this a total fast or are there certain foods you are willing to eat?
  • How much fluid are you taking in?
  • Are you refusing any prescribed medications or other treatments; if so why?
  • Are you protesting something by not eating? If so what can you tell me about your protest?
  • Are you expecting to die as a result of this fast?
  • If not, how long do you intend to continue this fast?

This may not be a quick interview so plan to conduct it when you can give the patient your time and attention to the dialogue. The information that is obtained from this interview is important for the health care team to use in planning how to monitor and care for the patient over the course of the hunger strike. The nature of the encounter is the first step in establishing a relationship between the hunger striker and health care staff that is collaborative which will also be more critical over time.

      2.  Assessment of the patient’s physical and mental condition usually includes:

  • Weight and height
  • Vital signs
  • Level of hydration
  • Mental status evaluation
  • Suicide risk assessment
  • Any finding or condition that should be referred to a higher level of care.

      3.  Patient education about the adverse effects of dehydration, starvation and risk for complications. In particular patients should urged to drink fluids in order to maintain hydration, to take precautions against inadvertent injury because of weakness, dizziness, or confusion and when they are ready to resume eating to proceed cautiously. The nurse should also describe what the health care staff will do to monitor the patient while on hunger strike and attempt to solicit their agreement and cooperation. To supplement the information provided by the nurse during this initial encounter, the California Prison Health Care Service (CPHCS) has developed a one page fact sheet that can be given to inmates at the beginning of a hunger strike.

     4. Disposition or initial plan of care. The nurse will schedule the primary care provider (PCP) to review the patient’s chart or see the patient based upon clinical findings. High risk patients need to be seen promptly or at least have their chart reviewed, including the nurse’s findings from the baseline evaluation. Patients who are not high risk should been seen or at least the chart reviewed within 48 hours but not longer than 72 hours after notification. The nurse also refers or schedules the patient to be seen by behavioral or mental health staff. The urgency of the referral is based upon the patient’s condition. Emergent or immediate referrals would include patients who are suicidal or psychotic. Urgent referrals would be anyone already on a mental health caseload. These appointments should take place within the next 72 hours. Routine referrals should be evaluated by mental health before the end of the first week.

   5. Documentation of the baseline evaluation in the patient’s health record. This should always include a narrative progress note of the date and time health services was informed, most recent fluids and nourishment taken, and who was notified. Documentation also includes the findings of the interview and assessment, what was covered in patient education and their understanding, as well as the disposition. The note should list the specifics of all subsequent appointments that were scheduled. A flow sheet may be initiated for serial recording of health status (weight, vital signs, mental status, suicide assessment, hydration etc.).

Ongoing Monitoring: Once the baseline evaluation is completed nurses continue to monitor the inmate’s condition. On a daily basis the nurse checks to make sure that food and fluids have been available, monitors the patient for changes in mental status, collects information about fluid and food intake, solicits the patient’s description of bothersome signs and symptoms, provides advice to increase comfort and maintain hydration. It is also important that the nurse checks to make sure that provider appointments or referrals are taking place as scheduled, to review and act upon provider recommendations and orders.

Periodically, usually three times a week, the nurse collects supplemental information to include weight, mental status, hydration level, medication and treatment compliance. The provider may also have written orders for routine laboratory testing or labs when vital signs are abnormal. The nurse will schedule provider appointments based upon the results of monitoring or at least once a week. Each of these encounters as well as nursing actions should be documented at least in the progress notes. Use of a flow sheet to monitor changes in signs and symptoms can supplement but should not replace the narrative in the progress note.

Many facilities have adopted the use of a multidisciplinary treatment team to manage the ongoing monitoring and care of inmates while on hunger strike. Participants include medical, nursing, mental health and custody staff. It is helpful to also include the chaplain, food service personnel and anyone else who has a positive relationship with the inmate. These teams meet weekly or more often as necessary to share information, develop or revise the treatment plan and to coordinate interventions. Components of the plan should address housing, mental health needs, medical monitoring, legal advice and preparations for court intervention if necessary. Much of the discussion in developing and revising the plan of care will concern resolving the reason for not eating as well as management of medical and mental health status. Nurses should be prepared to think of this as a negotiation that preserves the patient’s health while finding a solution to the inmate’s issue that is realistic and acceptable while incarcerated.

Nurses maintain daily contact with an inmate on a hunger strike and each of these encounters is an opportunity to strengthen the nurse-patient relationship. It is important to maintain open and non-judgmental communication with the patient. Demonstrating respect for the inmate’s autonomy by providing choices and emphasizing the control they have without fasting will help dissipate the need to continue the strike. Findings ways to preserve the patient’s dignity may also help facilitate the patient’s decision to resume taking food.

Refeeding syndrome is a complication sometimes experienced by patients when they start to take nutrition again and the body doesn’t adjust to changes in glucose metabolism and electrolyte balances. Risk for refeeding syndrome increases the longer a patient has fasted, how much weight they have lost (BMI) and the presence of underlying medical or mental health conditions. Nurses monitor patients at risk of refeeding syndrome on a daily basis which may include vital signs, intake and output, collecting lab specimens, EKG monitoring, observation for fluid overload, provision of electrolyte or vitamin/mineral supplements. Even inmates at low risk still benefit from the advice start by eating and drinking small amounts and to increase portions very slowly over several days to a week.

Additional resources for nursing care of patients while on hunger strike include:

What practical advice would you give nurses about the care of inmates while on hunger strike or prolonged fasting? Add to the advice given here by responding in the comments section of this post.

For more on this subject Lorry Schoenly discusses the ethics involved in the care of patients in the correctional setting, including hunger strike in Chapter 2 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo credit: © doomu – Fotolia.com

Reflective Practice: A Means of Professional Growth

Catherine snapping the Bean in Chicago 10 2008In last week’s post the use of reflection was suggested as a means to improve skill and competency in conflict management.  In this post we will take a closer look at this technique. Reflection is thinking about a situation, experience or event to gain insight that changes how you respond to the next situation.  Reflection is not a casual reminiscence or venting about an event; it is a deliberate assessment to identify problems and areas of improvement. Reflection is an excellent learning tool because it requires nothing more than an experience to analyze.

Take a moment to identify a conflict that you experienced recently. It should be an experience that you would like to have handled better. It could be a coworker’s attitude expressed at a staff meeting, asking for help and getting shrugged off by another nurse, arguing with the treatment team about a plan for a patient, an encounter with the on-call provider or a supervisor; the possibilities are endless. The following are three phases of reflective analysis. You can choose to write about the situation and your answers to the questions below or you can talk it through with a mentor or coach.

1. Describe the conflict situation. Identify and describe your relationship to each of the others in the situation. Your description should identify each of your actions but also what you were thinking and feeling at the time. The description also includes any biases, values, ethics or culture of the work setting that were a factor.  Stop here and wait a couple days before returning to complete the next two steps.

2. Examine your description of the conflict. Select a yardstick or reference against which to evaluate the situation. You could use the conflict management styles discussed in Chapter 17 of the Essentials of Correctional Nursing. You could also use the Corrections Nursing: Scope and Standards of Practice (American Nurses Association, 2007), particularly Standards 10-12 and 15 or another reference on conflict management. How did your actions, thoughts and feelings compare to the standard you selected for comparison?  How did the environment or other aspects of the situation influence you?  What intentions motivated each of your actions?

3. Identify gaps between what happened and what you would like to have happened.  In this phase you are looking for gaps between actual practice and the standard of practice you selected for comparison. Gaps can be in the area of knowledge, skill, attitude or belief. These areas become the focus for further professional development. Typical questions you ask yourself in this phase are:

  • Were my actions the most appropriate and successful ones possible?
  • What were the most important things that got in the way of doing well and why?
  • How could I change to better address conflict in the future?

At the conclusion of a reflective analysis of conflict you decide what you want to do differently in the next conflict experience. This may include changing the way you think or feel about a conflict or gaining knowledge or skill in a particular aspect of conflict management. At the very least reflection provides you with insight about the factors that influenced your feelings, decisions and actions during the conflict experience.

Have you used reflection to evaluate your practice in correctional nursing? Let us know how this technique works for you and any additional tips you have about the use of reflection to improve practice by writing in the comments section of this post.

Read more about reflective practice in Chapter 19 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

Resources:

Asselin, M. E. (2011) Improving practice through reflection. Nursing 2011 April, 44-47

Freshwater, D. (2008). Reflective practice: The state of the art. In D. Freshwater, B. Taylor & G. Sherwood (eds). International textbook of reflective practice in nursing (pp. 1-18). Oxford, United Kingdom: Blackwell Publishing

 

Photo Credit:Catherine Knox 10/22/2008 at NCCHC in Chicago