JUST – A Dangerous 4-Letter Word

Kelley Johnson, Miss Colorado, delivered a unique monologue about being a nurse at the 2015 Miss America Pageant. In her two and a half minute presentation she explained how she was describing herself as ‘just a nurse’ to her patient Joe, an elderly man with Alzheimer disease. Joe finally shared his perspective that Kelley was not ‘just a nurse’ but a very valuable and effective healer in his life.

Every nurse can relate to Kelley’s presentation of our role in health care. Few nurses have never felt as she did – that we are ‘just a nurse’ and can’t do much in a particular situation. Yet, as her story reveals, JUST is an incorrect and misleading adjective to describe our role to our patients and to society.

I am especially struck by the danger of the word JUST in describing our role as correctional nurses. Our responsibility for our patient’s health and well-being goes beyond the boundaries of a specific nurse-patient relationship. The inmate population of our correctional setting is a patient community that requires the broad application of our nursing role.  Here are three ways correctional nurses go beyond the conventional perspective of being ‘just a nurse’.

Holistic Viewpoint

The increased burden of mental and physical disease in our patient population can strain the resources of correctional officer staff. Their perspective and training is, rightly, focused on public and personal safety. As a nurse, our viewpoint is holistic. We naturally see  any situation as potentially caused by a health or wellness issue. Thus, what may appear to be a behavioral or discipline issue to our correctional colleague, is evaluated as a health need or treatment side effect. More than ‘just a nurse, correctional nurses can contribute knowledge and clinical judgment in a behavioral situation that can lead to a positive resolution.

Healthy Living Perspective

Correctional nurses frequently deliver care in the living areas of a facility. Traveling about the compound, we have opportunity to observe working and living conditions through the lens of healthcare. Cleanliness, containment, and the reduction of disease spread are inherent nursing principles. Nurses ‘see’ things that may go unnoticed by other professionals in the facility. The availability and use of handwashing resources is just one observation a correctional nurse may make while in the course of  daily activities. Others might include inmate hygiene practices, cleanliness of recreational equipment, or the practices of inmate barbers and porters. Correctional nurses can address unhealthy living practices to improve the health of the larger patient community.

Moral Presence

Abuse of power can easily result from situations where one group of people has control over the lives of another group. Although many correctional systems have an organizational culture that discourages and sanctions this abuse of power, just as many do not. Unfortunately, a significant portion of correctional settings are places of disrespect and incivility. Some, in fact, are even mentally or physically abusive of the inmate population. Correctional nurses have the opportunity, even the responsibility, to address issues of human dignity and patient safety in these situations. Our ethical code calls us to make every effort to protect our patients from mental and physical harm.

Falling under the spell of the adjective J-U-S-T in describing correctional nursing practice is dangerous to our understanding of our role and to the health and well-being of our vulnerable and marginalized patient population. Join me in eliminating this 4-letter word from our self-talk and our practice perspective.

Have you ever been called upon to be more than ‘just a nurse’ in your correctional practice? Share your story in the comments section of this post.

Correctional Nursing and the Ethic of Social Justice

Have you ever been asked what you do as a nurse and found yourself launching into a discussion of sick call and medication passes? It is easy to get lost in the weeds on our professional journey. That’s why it can be refreshing to periodically return to the defining qualities of the nursing profession to see the big picture.

The definition of nursing as found in the ANA Scope and Standards of Practice is

  • The protection, promotion, and optimization of health and abilities
  • Prevention of illness and injury
  • Facilitation of healing
  • Alleviation of suffering

We do this through the diagnosis and treatment of human response and we advocate in the care of

  • Individuals
  • Families
  • Groups
  • Communities
  • Populations

As correctional nurses, we fulfill this definition in the criminal justice system. The location of nursing care delivery establishes our unique patient population, environment of care, and ethical dilemmas of practice.

It is invigorating to be reminded that nursing care goes beyond the post duties and task list for the shift. Certainly caring for patients in a one-on-one situation is the majority of many of our job descriptions. However, I was recently struck by the inclusion of communities and populations in the nursing definition. How do we advocate for care and alleviate the suffering of communities and populations as a correctional nurse?

What is Social Justice?

Social justice is a broad term used to describe equity in the distribution of resources and responsibilities among members of society. According to the Canadian Nurses Association social justice in health care involves “working to prevent negative effects of oppressive practices such as discrimination against individuals on the basis of gender, sexual orientation, age or any other social factor that might affect health and well-being. In correctional nursing, social justice would include reducing dehumanizing practices within the criminal justice system and extend toward improving the health and well-being of the homeless, impoverished, and under-educated communities from which our patients and their families enter into the criminal system.

Social Justice in the Criminal Justice System

You would think that a system with justice in its title would be just but there is a lot of social injustice in the criminal justice system. You don’t have to look very far to see oppression in the power structure of many correctional settings. The need to maintain discipline and provide for personal and public safety can lead to severe punishment and even brutality in the organizational culture in some settings. As correctional nurses, we may not ascribe to the incivility but are often required to view or even participate in the culture in order to delivery necessary health care. For example, have you ever had to witness a violent inmate take-down during an emergency man-down that resulted in the use of a severe restraint device? Did you feel there might have been a more humane way to deal with the safety issue but were afraid to speak up or felt you had no voice in the matter? How might a nursing response to restraint practices across the criminal justice system embody advocacy for the alleviation of suffering among our patient community and population?

But This isn’t a Patient Health Care Situation

As nurses in the criminal justice system we can easily get tunnel-vision about our role within the system. Certainly we are helped in this narrow focus by those criminal justice professionals who clearly see nursing as attending to the direct health needs of specific patients. Yet, our definition of nursing practice speaks otherwise. Our patients are the entire community of inmates within our facility and our role, among other things, is to promote their health, prevent their injury, and alleviate their suffering. Correctional nursing, then, is more than serial one-on-one patient care situations.

We Are All in This Together

Correctional nurses, as a group, can be a significant force in the criminal justice system. Our definition and Code of Ethics calls us to consider the human dignity of our patient population and the significant suffering that our patient community bears up under. Working together we have an opportunity to bring about social justice in an institution, a correctional system, and the entire criminal justice system.


How punishment affects our practice

Close-up Of Brown Gavel And Medical Stethoscope

Currently I am working on understanding more about the challenges of providing culturally competent nursing care in correctional settings. The population of patients we serve are not only culturally diverse but also some racial and ethnic groups are disproportionately represented. Many will agree that the prison, jail or detention facility is a culture as well, the culture of incarceration. Culture is described by Madeline Leininger, a well-known nursing theorist as “the learned, shared, and transmitted values, beliefs, norms, and lifeways that guide thinking, decisions, and actions…” (2006).

We all know that correctional settings have their own vocabulary, rules, practices and expectations that prisoners, correctional officers, nurses, and visitors must comply with to survive in the environment. These values, beliefs, norms and ways of being arise from philosophies about punishment in our society. The culture of incarceration and our beliefs about punishment in civil society affect how individual nurses provide “care” in the correctional setting.

Today I came across a tremendous article by Sally Gadow, Professor Emerita at University of Colorado College of Nursing that describes how different philosophies about punishment are manifest in the practice of correctional nurses (2003). Ascribing to a belief about the role of punishment and incarceration in society is necessary for nurses to address the ethical conflict between care and punishment.

It has made me consider how my nursing practice is affected by my beliefs about the role of incarceration and punishment. Here is a summary of the article.

Punishment as an immediate or reflexive consequence of wrong doing: The violation of community values, morays or laws results in an automatic or reflexive consequence for a wrongful act. In this system of beliefs the punishment occurs automatically and enforcement of the law or rule is unquestioned; there is no consideration of the circumstances or characteristics of the situation. Punishment for violation of norms in this system of beliefs require practices that exile the offender, deny freedom and loss of respect for the individual.

Nursing practices that are congruent with this philosophy about punishment include those that assert the authority of the law, morale principle or norm. In other words, nursing care that extends the interest of punishment. An extreme example would be participation in an execution. Other examples are writing infractions, participating in disciplinary hearings, collecting forensic evidence and approving use of force. When nurses comply with the expectations of the correctional system uncritically, they are at risk of providing care that advances the system perhaps at the expense of the individual. The American Nurses Association provides guidance in professional practice standard 11 on Communication stating that correctional nurses must be competent in questioning the rationale of processes and decisions when they do not appear to be in the best interest of the patient (2013).

Punishment as a logical consequence of wrong doing: An emotionally detached and reasoned approach to punishment and it’s meaning in relation to wrongdoing. Punishment still serves to exile the offender, deny freedom and express loss of respect for individuals who violate society norms and laws. Included in this category are the philosophies of “just desserts” which may also be known biblically as “an eye for an eye”. This is a belief that the degree of punishment should be equal to the severity of the violation. An example of this is the death penalty sentence for murder. Another belief is that of “fair play” when the benefits for a group (society) are achieved only when all comply with the rules. When someone fails to respect the rules a debt to society is owed and punishment is necessary to repay the debt. When we say that incarceration is the punishment, not the further denial of health care or programming during incarceration, this is an example of “fair play.” The last belief in this subset is that of “deterrence” which is to establish punishment severe enough to prevent harm or to protect the community. The punishment chosen is not constrained by the concept of fairness or reciprocity. An example of this would be three strikes laws which serve to deter recidivism and to remove repeat offenders from the community.

Correctional nursing practices consistent with this set of beliefs suppress emotion, embodiment and relationships with patients. The practice of nursing is with objective detachment. By being disengaged the nurse avoids being influenced in a negative or positive way by their personal knowledge of the offender. Many nurses adopt this approach to nursing practice believing that the best way to avoid being “conned” or manipulated by a patient is to rely solely on the nurse’s objective data discounting the patient’s report. With-holding analgesia because of a patient’s history of drug abuse is an example. Delays in responding to requests for health care attention because the problem is not significantly urgent would be another example. However there are numerous competencies listed in the ANA Scope and Standards of Practice (2013) that call for nurses to do more than adopt this disengaged approach to correctional nursing practice. The ANA standards for delivery of care in the correctional setting require nurses to elicit the patient’s personal experience and preferences with regard to illness, discomfort or disability and to partner with them to evaluate their care (Standards 1, 5-7) in a manner that preserves and protects the patient’s autonomy, dignity, rights, beliefs, and values.

Engagement as a paradox of punishment: Punishment is not an essential feature of justice but instead the focus is to restore trust and engagement between the offender and society. Detention may be necessary to engage the violator in the actions that are necessary to restore trust. The offender is not objectified and exiled but is made to relate in meaningful ways with the community. Examples of these beliefs in action include strengths based programming, drug and alcohol rehabilitation, probation and community corrections, half way houses and work camps. The meaning of the experience for offenders is the product of their engagement with others rather than an absolute defined by society.

A correctional nurse under this set of beliefs accepts the contradiction between care and punishment and does not need to embrace a particular viewpoint to resolve the conflict. The nurse assumes responsibility for defining their practice in the interest of the patient and does not accept someone else’s interpretation of how their practice should conform to some moral or ethical norm. Nursing actions are designed to assist prisoners to recover their ability to participate in the community and use their relationship with the patient as the crucible for this work. Engagement is characterized as accepting the possible validity of the patient’s perspective and the potential that the nurse’s opinion can be altered by the patient’s perspective. The nurse’s opinions or beliefs can be held firmly (not to be manipulated) but they are not absolute and open to the possibility of revision based upon experience with the patient or their situation. Dignity and respect for the patient is recognized as necessary to the caring relationship. An example is when nurses individualize a patient’s plan of care rather than apply the same intervention for all patients with the same condition. Patients are regarded as individuals rather than inmates. The ANA’s Standard 13 on Collaboration is explicit in that nurses promote engagement and participate in building consensus in the context of care for the patient (2013).

Conclusions: Correctional nurses often talk about the conflict between care and custody. Custody is a manifestation of beliefs about punishment. Nurses in correctional settings are influenced by the correctional culture, affecting their relationship with patients and ultimately their practice. I was surprised at the extent to which beliefs from all three of these descriptions have affected my practice environment. It is a relief to know that it is enough to recognize the care and custody conflict in order to find my way practically in this field. It is not necessary or even recommended that the conflict be resolved in order to provide ethical nursing care.

I suggest that correctional nurses reflect on the ways in which beliefs about punishment are manifest in their nursing practice. Reflection may suggest areas of practice that warrant more review and development. There may be aspects of practice that are unintentionally harmful or conflict with an ethical premise related to the nursing imperative of care. This material has been provided in the interest of stimulating dialogue among correctional nurses not to suggest a particular standard of practice.

For more on the ethical issues in providing nursing care in the correctional setting see Chapter 2 in our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!


Photo credit: © Andrey Popov – Fotolia.com




American Nurses Association (2013) Correctional Nursing: Scope & Standards of Practice. Silver Springs, MD: Nursesbooks.org.

Gadow, S. (2003) Restorative nursing: toward a philosophy of postmodern justice. Nursing Philosophy. 4: 161-167.

Leininger, M. M. & McFarland, M. R. (2006) Culture care diversity and universality: A world wide nursing theory. Boston, MA: Jones and Bartlett.

Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

A reader responds to our recent blog post on the Heavy Burden of Moral Distress. We hope you find this real-life example an encouragement that correctional nurses are speaking up when they have concerns about patient health issues in the criminal justice system.

The topic of moral distress among nurses is an elephant in the conference room of many healthcare organizations but at the core of conversations amongst nurses in the medication room.    A few typical statements made during these informal, ethically charged and expressive gatherings include; “It doesn’t’ do any good to tell anyone, they won’t do anything.” “It’s all about the bottom line.” “They don’t care how much more work they give nurses.” “Nurses who complain too much get fired.” “I need a job to so I can take care of my family.” “This is just the way it is, get used to it.”  Statements like these are made with such frequency today that moral distress could and should be viewed as an epidemic in nursing practice.  The following is a glimpse into the challenges some correctional nurses faced and how their quest and obligation as nurses to do the right thing put them on a path leading directly into the dark, lonely void of moral distress.

My Story

While working at a correctional facility, three nurses expressed their ongoing concerns to supervisors and administration about the well-being of inmates who were:

  • Not getting their prescribed medications for extended periods. This includes medications for chronic conditions, seizures and other serious illnesses,
  • Providers prescribing incompatible medications and refusing to change the order(s),
  • Providers documenting physicals on inmates they had not seen,
  • Stat and other critical orders not getting noted for days,
  • On-call providers not returning calls and,
  • Inmates with serious, potentially life-threatening conditions, being transferred without regard to maintaining some continuity of care.

A few nurses called the allegedly anonymous organization  “ Hot Line,” (nurses are encouraged to use these for reporting purposes) and voiced their concerns but to no avail.  Having exhausted all efforts to report their concerns internally they reached out to their local nursing organizations.  While these organizations provide invaluable services and support in many areas they were unable to provide immediate direction or tangible backing for these situations. They, like the nurses, were uncertain who they should and could turn to for support.

The onset of moral distress began when the first link in the organization’s chain of command broke because of  failed communications and after dismissing the nurses concerns with indifference.  The distress peaked when the nurses were terminated for doing the right thing. Terminated for doing what nurses are required to do, what we have vowed to do – complying with the Nursing Code of Ethics.

Nurses have taken an oath and are required to practice in accordance with the Nursing Code of Ethics which provides:

  1. A succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.
  2. It is the profession’s nonnegotiable ethical standard.
  3. It is an expression of nursing’s own understanding of its commitment to society.

The sections applicable to the events being discussed are 3.4 and 3.5 as noted below:

Nursing Code of Ethics 3.4 “Standards and Review Mechanisms” 

Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review.

Nursing Code of Ethics 3.5, “Acting on Questionable Practice”

When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns.

Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.

Obligated to Speak

Nurses are obligated to bring difficult issues forward for discussion and review. We are duty-bound to report unsafe practices and or circumstances and must do so regardless of personal risk.  However, at the same time there is a responsibility to provide nurses with support and assistance when they do speak out. This is the crossroads where the path of moral distress becomes the loneliest and sometimes most frightening. It is alsothe time when a nurse needs support and encouragement the most. Unfortunately it is at this intersection that most nurses feel alone, abandoned, and with nowhere to turn.  This often becomes a turning point for nurses believing they must choose between speaking out or getting terminated; consequently many nurses make a silent and painfully emotional promise to never speak out again.  This forces nurses to overlook practices that not only put their patients at risk but their nursing license as well.  At this juncture moral distress has become an emotional pathogen.  Were it not for the support and encouragement of our patients and the public, many nurses would leave the profession.

Public Esteem

The public’s long-standing esteem for nurses is well documented in public opinion polls. Nurses rate high with the public in trended national survey questions about trusted professions, prestigious occupations, and “honesty and ethical standards.”  It is disheartening that organizations do not always see their nurses through the public’s eyes.  It is regrettable that even nurses don’t see themselves through the public’s eyes.  If nurses would stand together in our communities of practice perhaps we could begin a dialogue with our local nursing associations and employers to establish the support system illustrated in the Nursing Code of Ethics. Together we could address the circumstances and symptoms associated with moral distress at the onset and transform them into opportunities for change before nurses are forced to make that dreaded silent promise to keep quiet. Speaking out is included in the nonnegotiable ethical standards.

Would you be willing to speak out in a similar situation? Join the conversation with a comment.

Moral Courage: Being Assertive

sassy child with arms foldedSpeaking up in the face of a moral dilemma takes courage. No one likes conflict…well, almost no one….and nurses, it is found, would rather compromise than confront, according to at least one research study. Overcoming a natural inclination to ‘go along to get along’ takes conflict management skill. Like so many other nursing skills, it comes with practice. Being assertive in a moral situation is easier when assertive communication is a natural part of professional practice.

Knowing Me – Knowing You

Assertive communication starts with a good understanding of your own feelings about the situation and a desire to understand the feelings and perspectives of others in the group. Thoughtfully considering the situation, and your best response to it, allows an objective analysis of emotions that reduces the chance for an unhelpful aggressive or angry response.

Whenever you are distressed about a clinical situation, mentally identify your specific emotional response to become familiar with defining your feelings. Also consider the perspective of others in the situation. “Step into their shoes” and try to imagine their emotions and motivations. By evaluating all perspectives you will be prepared to assertively engage in a constructive conversation about the event.


Practicing a planned response to a situation during less significant concerns can help when the stakes are higher. One helpful model for constructing an assertive communication involves four parts:

  • A nonjudgmental explanation of the behavior to be changed
  • An admission of the asserter’s feelings
  • An explanation of the tangible effect of the other person’s behavior on the asserter or someone else
  • Announcement of the desired behavior change solution you want, or an invitation to problem-solve.

Putting these pieces together might creates a communication like this to the Med Line Officer: “When you call Inmate Jones a lousy pervert during pill line I feel upset. It is demeaning and it is important to me that we are civil with each other. Could you avoid this practice?”

By overcoming the desire to compromise and the fear of conflict, you can respond to challenging ethical situations in your correctional nursing practice. Evaluating your own feelings, seeing the perspective of others, and planning an assertive response will develop moral courage to respond when needed.

Have you developed assertive responses to moral situations in your setting? Share your experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: Dealing with Uncertainty


Some ethical issues are obvious and the course of action is clear. A nurse who sees a colleague has documented administering a narcotic when the patient has not received medication requires reporting. However, correctional nurses are often faced with uncertain ethical situations that create decision stress and can lead to immobilization. A nurse who is asked to perform a blood draw for drugs may wonder if the activity will be used for a therapeutic or disciplinary outcome. Moral courage requires skill in dealing with uncertainty in an ethical situation.

Uncertainty of the Moral Situation

An uncertainty about the actual moral situation can hinder the courage to act. Consideration must be given to the actual ethical concern present. Strength for action is developed by clearly articulating the professional values that have been breached. Taking time to thoughtfully consider personal and professional valuing can help pinpoint the real issue embedded in the situation. In addition, confidentially discussing the concern with a spouse, leader, or trusted peer can lead to clarity. Sometimes putting into words the concerns of the situation give voice and vocabulary that strengthen resolve toward action.

Uncertainty of the Outcome of Action

A previous post  discussed the C-O-D-E model for moral courage. The 3rd element of this model is managing danger (D). Our uncertainty about the danger involved in acting or ‘speaking up’ about a potential ethical issue can be very real. Anxiety and a visceral ‘fight or flight’ response can ensue. How can we deal with the uncertainty of the outcome of our action?

Self-soothing. In an emotionally charged situation, free-floating anxiety or even anger can cloud judgment and be immobilizing. Immediate stress-reduction activities can be initiated such as taking a deep breath, slowly counting to 10, or speaking calming words to yourself like “I can do this” or “I have handled many things worse than this”. These are methods of self-soothing that can help to reduce anxiety and encourage clear thinking.

Cognitive Reframing. Worry about the negative outcome of an ethical action can be reframed by actively seeking positive alternative perspectives. Although concerns about job security, peer support, or humiliation may be very real, they can be balanced by positive outcomes of taking action such as personal integrity, strength of character, and satisfaction in doing the right thing in a difficult situation.

Lachman provides a logical progression to guide action in response to fear. Working through this list can help to clarify next-steps in an ethically uncertain situation.

  • Identify the risk you want to take
  • Identify the situational fear you are experiencing
  • Determine the outcome you want and what you have to do to achieve it
  • Identify resources accessible to you
  • Take action

Have you dealt with ethical uncertainty in your correctional nursing practice? Share your situation and how you dealt with it in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: How Do I Find Some?

Little superhero

Tanya was working in a state prison in the nursing pool to make extra money for her college tuition. She was studying to be a nurse practitioner and thought it would be a good experience for her. Although she was learning much from her shifts there, she was also distressed by the treatment of a mentally ill inmate in solitary confinement for striking and injuring one of the officers.  Even in the short time she had been working there she had observed significant mental deterioration. In addition, the officers were rough and rude with this inmate; she assumed due to his injuring one of their own. Tanya was starting to lose sleep over this but she didn’t know what to do about it.

Nurses can experience moral distress over situations they observe in the correctional setting. Moral distress is experienced when painful feelings arise over the awareness of a morally inappropriate activity but feel they cannot respond due to various obstacles. A common obstacle is that of the institution or organizational culture. This is what Tanya is experiencing. Distress can also come from the uncertainty of what action to take and what consequences might ensue. For example, could Tanya be sanctioned, rejected, ridiculed, or fired if action is taken?

Finding moral courage to overcome distress and act in the face of these potential consequences is challenging. As in an emergency situation where all-out effort is needed, nurse ethicist, Vicki Lachman, suggests that we should call a code. That is an acronym for a 4-step process for finding courage to act in the face of a moral dilemma.

Call a C-O-D-E when Moral Courage is Needed

C Courage to be moral Where does my strength come from?
O Obligations to honor What is the right thing to do?
D Dangers to manage What do I need to handle my fear?
E Expression and action What action do I need to take to maintain my integrity?

Courage to be Moral

Taking a moral action requires courage. Where does the strength come from? For many nurses the strength comes from alignment with the ethical standards of our profession. A review of the Code for Nurses can provide strength for action. Look for the particular element of the code that is in violation and ponder the importance of action for your own professional integrity as well as for the good of the patient in the situation.

Obligations to Honor

The Code for Nurses is the ethical standard of nursing practice and establishes a nurse’s patient-centered valuing that is foundational to the profession. This is the primary place to determine our obligation in a moral dilemma. However, correctional nurses work within a security framework with its own value system. It can be important to consider what values drive others involved in the situation. The Institute of Global Ethics, as described by Lachman in another source, reviewed a wide variety of ethical codes and developed a list of the 5 primary values found in all of them: honesty, respect, responsibility, fairness, and compassion. Which of these values might be motivating others in the situation? These can then be considered in working through an action plan for response.

Dangers to Manage

Nurses must acknowledge and manage the fear engendered in taking action in a risky situation. Successfully overcoming fear is, in fact, a definition of courage. Working through the prior steps can help in managing danger as they provide objective reasons for the action and establish the importance for proceeding. This can be powerful and should not be under-estimated.

Also suggested in the process of ‘decatastrophizing’ which in involves working through the ‘what if’s’ of the situation. By objectifying fear, it can be demystified and balanced with the positive outcomes of action. This helps to cognitively reframe the situation and reduce negative thoughts. It also turns thoughts toward planning and action-taking rather than dwelling on fear.

Expression and Action

The final step in the CODE process is to take the practical action that will overcome fear and resolve the issue. Action in a situation such as Tanya’s requires both assertiveness and negotiation skills. It requires an understanding of the organizational reporting structure. It requires the ability to be collaborative rather than confrontational with other disciplines.

Tanya was able to garner the moral courage to respond to her moral distress. Through her actions the inmate was re-evaluated by mental health services and a treatment plan was initiated. She continues to work at the facility and is developing collaborative relationships with her healthcare and custody peers. She has resolved her moral distress and feels good about the outcome.

Have you needed to confront a moral dilemma in your correctional nursing work experience? Share your thoughts and experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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Moral Courage: Do You Have What It Takes?

Courage And RiskA recent news story describes an investigation into 148 female inmate sterilizations in the California Prison System between 2006 and 2010. Inmates report being coerced into tubal ligation surgery following in-custody births. Although the situation is still under investigation, this news story reveals one of many moral situations encountered in correctional health care. One wonders if others in the facilities questioned the actions of the physicians performing these procedures in violation of prison healthcare policy which requires administrative approval of any elective procedure.

Possibly more than any other nursing specialty, correctional nurses confront moral dilemmas in the clinical setting. Clashing worldviews of security and healthcare along with the political and social implications of healthcare delivery to criminals create a quagmire of ethical concerns. Many correctional nurses work in solo practices in small facilities without benefit of a healthcare management structure that supports standard healthcare practices. Even in larger systems, ethical practices may be overruled by a security structure that is not attuned to the patient care implications of custody practices.

Moral courage is the courage to take action on a moral issue by overcoming fear of the consequences. The potential for reprisal, social isolation, and termination can lead to fear in responding to a moral issue such as patient coercion. Self-doubt can also cloud the issue. If no one else in the organization is addressing or responding to unethical or immoral practice, a nurse can question her interpretation of the situation.

Do you have what it takes to respond with courage when confronted with a similar ethical or moral issue? How can correctional nurses strengthen their moral courage?

Back to Your Roots

One way to gain moral courage is through reflection on the defining elements of our professional practice. In addressing concerns nurses can have as whistleblowers, Lachman suggests a need to return to our professional roots. As professionals we must be loyal to the definition of nurses as those who alleviate suffering and advocate on behalf of a patient’s well-being. Therefore, as nurses, we can garner the moral courage to act in the face of unethical colleagues, patient safety violation, or fraud by reflecting on the need to report these behaviors as part of who we are as professionals.

Tempered with Wisdom

Moral courage in nursing practice also requires wisdom. The courageous among us can be rash in responding to what, on first review, is an unethical practice. Yet, a wise nurse considers all the facts and perspectives before sounding the alarm. A wise response is determined based on full information; while misdirected courage can lead to foolhardy actions. Wisdom tempers courage to, instead, seek the right response in any situation.

Practice Makes Perfect

Intentionally practicing moral courage can develop the skill and habit of responding even in the face of fear. Some consider courage to be equivalent to fearlessness; but that is a distortion of the concept. Courage means overcoming fear by acting in the face of adversity. By practicing the skill of overcoming small fears, a nurse can develop moral courage by progression. For example, courageously overcoming fear to respond to rude behavior from a colleague develops the moral courage muscle. Like strength training for our physical muscles, our moral courage muscle must be stressed with ever increasing weight.

What would you do if you saw that providers in your setting were performing elective procedures without appropriate administrative clearance as noted in the opening story? How would you seek out enough information to take the right action? Would you know the mechanism to use to report the situation? Would you have the moral courage to take action? Share your thoughts in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

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An Experience with Moral Distress and its Resolution

ethical issuesSeveral weeks ago I attended a lecture given by a nurse midwife. She reviewed important information about how nurses support the health and wellbeing of patients who are incarcerated during pregnancy. The speaker was very engaging and provided clinically relevant, useful material.  At one point the speaker described the problems resulting from routine use of custody restraints to transport pregnant women.  She noted that the policy of the correctional organization where she provided services was that women were shackled even while in labor.  The speaker being familiar with the experience of women in labor, further commented that risk of escape or assault during this time was not likely.  She also indicated that she found it futile to try and change the correctional system’s practice regarding use of restraint during pregnancy. There are several organizations that recommend against routine use of shackles during labor and delivery. These include the American Corrections Association, the National Commission on Correctional Health Care, the American Congress of Obstetricians and Gynecologists, and the American Civil Liberties Union. No one contributed this information during the presentation. I could have but did not and my failure to act has since haunted me.

This is an example of moral distress, a condition experienced by many correctional nurses. Moral distress occurs when correctional nurses find themselves in situations where nursing values are jeopardized.  In correctional settings where shackles are used routinely in the transport and security of pregnant women nurses are witness to treatment that is not consistent with recommended standards of care and is therefore inhumane. To resolve the distress associated with ethical conflict correctional nurses can use moral reasoning to re-align their actions with professional nursing values. Here is a description of the steps discussed in Chapter 2 Ethical Principles for Correctional Nursing to resolve moral distress and how I used them to address the distress I experienced recently:

1. Assess the Situation: In a presentation made at a national conference an authority on the health care of pregnant women described a correctional system’s routine practice of using shackles during pregnancy, labor and delivery. This practice is not consistent with recommendations of several authoritative organizations. No one in the audience provided information about recommended practices. As a result, participants left the session ill-informed and therefore unable to advocate for change that will reduce risk of injury and prevent re-traumatization of women.

2. Identify Moral Problems: Two moral problems were identified. First, there is a prevailing body of literature that management of women during incarceration should be “trauma-informed” and not include use of custody restraint unless necessary. Therefore routine use of shackles causes harm to the patient and is not consistent with the value of human dignity. Second, the principle of social justice is that in the absence of evidence that that there is imminent risk to the safety of the patient, the infant or the public the criminal justice requirements should not outweigh considerations of human dignity.

3. Set Moral Goals and Plan Moral Actions: My goal is to speak up so that nurses and others in correctional health care and the criminal justice system know that limiting the use of shackles during pregnancy, labor and delivery is recommended.

4. Implement Moral Plan of Action: So far I have had two opportunities to speak up. Because I have identified the problem and set a goal I am also more aware of opportunities to share this information, advocate for and support efforts to change policy and practice.

5. Evaluate Moral Outcomes: The best outcome would bethat no system uses shackles on pregnant women unless there is some evidence of imminent danger to the mother, child or other people. Until then, one outcome is to bring the issue up whenever it is relevant to do so and to generate discussion about steps to implement practices that are more consistent with the recommendations.

Have you experienced moral distress?  I found the discussion of nursing values and ethics in Chapter 2 Ethical Principles for Correctional Nursing very helpful in identifying what bothered me so much about this experience. Even more valuable, though, was developing the action plan because taking thoughtful steps to do something different guarantees that it will not happen to me again. What steps have you found useful in resolving moral distress? Please tell about your experience by responding in the comments section of this post. To read more about how to resolve moral distress order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. Photo Credit: © Marek – Fotolia.com