Is it time for a Change? If so, what’s next?

Occupation Job Careers Expertise Human Resources Concept

A friend of mine just sent an announcement for a position opening with the Washington Department of Corrections and asked if I would distribute it to prospective candidates. I said I would and so here it is-it is for the Director of Nursing a position responsible for standards of nursing practice at each of twelve prisons in the state of Washington. The prospect of recruiting for this position has made me think about who would be interested in a key leadership position like this? You may never have given it a thought and yet have many of the qualifications and expertise that are required.

The New Year is a time when many of us take stock of ourselves and make resolutions for the year ahead. Perhaps it would be a good time to consider your career plans as well? Human resource experts and job coaches recommend having a career map that identifies an individual’s career goal for the next three to five years. They also recommend reviewing and revising the map annually. Career planning gives nurses control over their own professional path and increases job satisfaction (Hall et al. 2004 and Chang et al. 2006). The steps to making a career plan are not complicated and each is described in the next several paragraphs.

  1. Understand yourself. Begin by assessing and listing out your strengths and weaknesses. What are the things you like to do and do well? How do you like to work and what types of work environments do you thrive in? Using myself as an example-I do best in environments where I can predict or anticipate to some extent what the day will be like and I like to work quietly and at a steady pace. The emergency room is not a place for me and I have the experience to know it! I also know that I like to work autonomously and don’t appreciate close supervision. It can be harder to identify weaknesses accurately. A suggestion is to think about this as the areas of practice that you want to develop expertise in. One way to help do this is to use a tool like the American Nurses Association Scope and Standards of Professional Practice for correctional nurses, which lists competencies for each of the standards.Finally describe in writing the kind of nursing practice you want to have three to five years from now. Some authors have suggested that nurses think too narrowly about their career options. As a correctional nurse you already are experienced finding jobs off the beaten path. Answer these questions: What do I want that is different in my career? What would I be responsible for? What kind of hours, days off and commute do I want? What type of boss, co-workers and team do I want? What type of organization and culture do I want to work in? Where do I want to live and what salary and benefits are wanted? Answering these kinds of questions helps to concretize your career goal and make it more specific to your needs and desires.
  2. Know the job market. Now that you have a more specific goal and description of your career goal for the next few years begin looking for organizations and positions that are available. Nearly all job opportunities are on line now so it is possible to research possibilities worldwide from the comfort of your home. The internet is also a source of information about organizations you may be interested in and professional associations provide valuable information about specialty areas of practice. One author suggested using You Tube as a resource to explore non-traditional careers in nursing. Identify organizations and professional associations that are recognized for an area of nursing practice that you are interested in pursuing and use these resources to identify potential mentors, professional contacts and learning opportunities. You should know the job market and professional landscape in the area of practice you are interested in even if you are not actively looking for another position at the moment. You may know someone who would be a good fit for the job or you may come across an opportunity to expand your knowledge or skills that you wouldn’t otherwise know about.
  3. Draw a map of the path to your goal. Start with your career goal and then lay out the steps to get there. The contacts and resources you developed in Step 2 can help you identify those steps. Perhaps you want to be the Chief Nursing Officer at a correctional facility or the whole state prison system as in the one Washington is recruiting for now. The recruitment announcement itself lists the types of experience they are looking for. Talk about your career goal with someone you consider a mentor and ask them to help you identify the steps that will build your knowledge, skills and experience. Many nurses are overly modest about their experience and fear failure when considering change. A mentor can help identify skills and experience you have already that with only modest enhancement would move you toward your goal. There are lots of resources on line about how to map a career, just type Career Map in the search line. Here is one resource and here is an example that University of Colorado Hospital developed for its nurses to show paths to various positions within the organization and the development resources available. A career map is really just a set of strategic steps to move from today toward the goal. Steps should identify ways to develop skills and competencies that were identified in step 1. A career map may include things like identifying a mentor or coach, taking classes, joining an organization, volunteering for certain experiences, applying for a position that provides experience necessary for the next professional position, getting certified in a specialty (like correctional nursing or nursing administration), and building a network of colleagues who know and support your career plan. By building the career map you may identify opportunities to grow in your current position that you were not aware of that will move you incrementally forward. Without a plan, professional growth and development is chaotic and may not contribute to your goal
  4. Focus and target opportunities. Now you have a clear picture of the type of professional practice you want to have in the near future and know the steps you are going to take to get there. You also are familiar with the field of organizations and professional associations and so as opportunities come up that are consistent with your map you are ready to take advantage of them to progress toward that goal. Even if you are perfectly happy today with what you are doing professionally having a career plan ensures that three years from now you are still as happy with your work.

What advice do you have for correctional nurses who are interested in career growth? Please share your advice by responding in the comments section of this post. Also the people in the Washington DOC would love to hear from you if you are interested in the position!

For more about management and leadership positions, as well as professional development in correctional nursing see Chapters 17 and 19 in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today! Happy New Year from both of us! Looking forward to new opportunities for all our blog post readers in the coming year!

References not hyperlinked in the blog post:

Chang P.L., Chou Y.C., Cheng F.C. Designing career development programs through understanding of nurses’ career needs. Journal of Nurses Staff Development 2006; 22 (5):246-253

Hall L.M., Waddell J., Donner G., Wheeler M.M. Outcomes of a career planning and development program for registered nurses. Nursing Economics 2004; 22 (5):231-238

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Why do we stay in correctional nursing?

Model isolated on plain background in studio puzzled

The last several posts have described the challenges and distinguishing features of correctional nursing. Well what are the reasons nurses stay in the field? I thought that I would be in the field about five years before moving on to something new and that was 31 years ago! What is it about correctional nursing that keeps us?

Here are some of the reasons that I am aware of…maybe some of these will resonate with you.

  • We can see our patients every day, for years and years, and so have time and opportunity to establish a strong, therapeutic alliance. This is especially true of prisons where an inmate may spend their lifetime. In jails and detention facilities offenders may not stay very long, but a relationship can be built here also because most of them come back again, again, and again for repeated offenses. The amount of time we can spend with our patients, facilitates teaching and coaching them to manage disease and live healthier lifestyles. They are dealing with loss, grief, in some cases death, and at some point will seek redemption, meaning and purpose in life. A nurse may be the one contact that initiates and supports that change. I remember a prisoner who cried at a ceremony we held at the end of eight weeks of psychoeducational classes. He told us that he had never finished anything before, didn’t think he could finish and now realized he was capable of more. It wasn’t “a con”; he went on to get his GED and learn a trade.
  • Prisons and jails may be considered somber and inhospitable places but for many it is a better environment than how they lived in the “free” community; perhaps homeless, unemployed, sought after by the police or other criminals, high on drugs or alcohol. By contrast, a correctional facility is a highly controlled environment. Advantages here are that disease can easily be detected and treated, and sometimes as in the case of tuberculosis and STDs, the public benefits as well. Lifestyle behaviors that contribute to chronic disease can also be modified during imprisonment. Examples include smoking cessation programs, diabetic education, medication adherence and harm reduction. In some ways it is a perfect place to promote change; the patients are available and easy to interest, their progress can be monitored and outcomes measured. When our patients relapse, as inevitably happens when making lifestyle change, they can re-enroll in the program and do it all again, each time making incremental but positive improvement.
  • A related advantage is that this controlled environment is “safe”; a safe place to work. A light hearted way we express this is when we say that at least in prison we know who the criminals are; they all wear the same uniform. We have custody staff monitoring our every movement and every one going in and out is searched for contraband. The only time I have ever been threatened with a weapon was when I worked in an emergency room at a university hospital and the only time I have been hit, I was working on a med-surg unit in a community hospital. After 31 years of experience I would say that a correctional facility offers a very safe and controlled environment in which to provide health care.
  • Lastly, it is a fascinating field. Here is an example from my experience. One day a nurse is seeing patients who have requested health care attention, for complaints typically seen in an ambulatory care clinic, (low back pain, skin irritation, sore throat, and nasal congestion) and then along comes a patient with mild CNS symptoms and gives a history of GI upset and myalgia. He has escaped from civil warfare in Nicaragua and was picked up in the U.S. recently without immigration papers. Given this description what medical problems would you be considering might be the cause of his symptoms? Ultimately the patient was diagnosed with a severe case of trichinosis that has infected his brain, undoubtedly from eating undercooked infected meat on his desperate travel to America. He recovered fully in the capable care of correctional nurses. The range of clinical problems we see in our day to day practice is a marvel.

Why are you still a correctional nurse? What is it about the field that keeps you coming back to work each day? Is it because it is so different from every other specialty, or is it that you can see how much good you can do and the satisfaction of making a difference? Maybe take a moment and give thanks for the things that make you proud to be a correctional nurse. Let us know about your experiences in the comments field in this post.

If you would like to read more about correctional nursing go to Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

Lorry Schoenly, co-contributor at this site, has published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting. If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing, by Lorry Schoenly go to Correctionalnurse.net and order it through Amazon.

Photo credit: © bruno135_406  – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 3

Tonia FaustThe last two weeks we explored two of the challenges in becoming a correctional nurse and how once mastered, the results are practices that distinguish correctional nursing from other areas of nursing practice. A final cultural challenge for nurses in the land of correctional Oz, a phrase Lorry coined for nurses new to the specialty, is to develop a caring practice, consistent with professional principles. Many correctional nurses lament “how can I be caring when the place where I work exists for the purpose of punishment?” In correctional settings, staff are cautioned against touching an offender, unless it is necessary to perform some task, such as a pat down search. Some places go as far as considering touch, an act for which staff can be disciplined.

Common expressions of caring in nursing such as therapeutic touch or an empathic disclosure of personal information are often prohibited or extremely limited in the correctional setting. These acts earn a nurse derision from other staff, particularly custody staff, and they will be taunted as a “chocolate heart”, “hug-a-thug” or “convict lover.” Correctional officers will not trust nurses who violate the facility’s expectations about maintaining boundaries, to act professionally in other encounters.

Caring however remains a central tenet of correctional nursing and is vital to the therapeutic relationship. Another distinguishing characteristic of the specialty, is that the expression of caring, emphasizes interpersonal communication rather than physical contact and use of self to convey empathy. Correctional nurses express caring when their interactions with patients convey respect, are nonjudgmental, acknowledge the validity of the patient’s subjective experience, are not rushed and are done in the genuine interest of the patient (ANA 2013).

Correctional nurses have described how, it is first, necessary to establish a professional relationship with custody staff before they can negotiate delivery of compassionate nursing care. This means having acting, behaving and speaking in a ways that are consistent with professional practice standards. The most recent version of the Scope and Standards of Practice for Correctional Nursing were published in 2013 and now are identical to those of nursing generally. So a correctional nurse practices as any nurse does; it is only the place and population served that differ.

An example of how a professional relationship with custody staff is established, is in accounting, not just for controlled substances, but for all the sharp instruments as well. This is usually done at the beginning and end of every shift. This means all of the instruments, including those in the dental clinic, those kept in the inpatient and outpatient medical areas, and the lab as well plus every needle on site…it can be an arduous task. This degree of accountability is necessary because sharps can be used as weapons, to do tattooing and to shoot drugs, all dangerous and prohibited activities in a correctional facility. Nurses count sharps because it is necessary for security, not as part of health care delivery. A missing sharp means that the whole facility will be locked down and searched until the item is found. I have experienced an entire facility being locked facility down, for hours on end, because a single insulin syringe could not be accounted for. No other work, even delivery of health care takes place, until the “sharp” is accounted for. Sometimes nurses balk at the requirement for counting or act as though it isn’t as important as patient care. However, failure to account for sharps is not only dangerous, but it undermines the professional relationship with custody staff.

The ANA standards for professional practice are also important because they help to define and protect the role of nurses in the correctional setting. We provide health care in a setting where custody staff, facility commanders and correctional administrators have little or no knowledge of the standards for nursing care, let alone much appreciation for the limits of nursing practice in state law, unlike traditional health care settings. A nurse cannot rely on the correctional facility to have practices and procedures that are compliant with state law or professional practice standards. They may be the only nurse for a small facility and have no other health care professional to provide advice, other than a part time visiting physician. Even in large correctional facilities with many nurses, including nurses in management, practice creep can occur for an individual nurse whose primary interaction during a shift is with correctional officers and inmates who don’t know or appreciate the nurse’s scope of practice. Individual nurses must therefore establish these boundaries on their own, or risk violation of the law and the potential for action on their license.

There are many examples where nurses are asked to perform work that is outside the scope of practice or not consistent with professional standards. A nurse may be asked to approve use of pepper spray or endorse the use of a restraint chair and hood; decisions which are not in the interest of the patient or their health care. For example, another friend of mine, Lynda Bronson, was threatened with insubordination for refusing a direct order from the Warden to forcibly medicate an inmate who was in segregation and screaming obscenities at the officers.

The Warden threatened Lynda three times with insubordination and yet she stood her ground and explained that she did not have a medical order that would allow her to forcibly medicate the inmate. These are tough situations to be in and correctional nurses must be experts in communication, collaboration, and problem solving, with Wardens as well as correctional officers. These skills are necessary to arrive at compromises that solve problems, like screaming obscenities and gravely disordered behavior, while keeping the patient and staff safe.

Well done, this is experienced as practice autonomy, one of the most preferred and distinguishing characteristics of correctional nursing. Nurses who are clear about the standards and boundaries of their practice in correctional settings earn the respect of custody staff and are able to negotiate better outcomes for their patients.

To sum up, correctional nurses provide health care from within the justice system, to a disparate population of prisoners with great disease burden. These features; the location and population served, along with the nurse’s independent negotiation for care, define and characterize correctional nursing.

They say that once a nurse has resolved these cultural challenges, he or she will stay in the Land of Correctional Oz forever. As Tonia Faust, the nurse from the Louisiana State Penitentiary said in The American Nurse “There is a purpose for me here”. Those that don’t survive the transition, leave, usually within the first year.

Do the challenges portrayed over the last three weeks fit the experience you had transitioning into the field of correctional nursing? Are there aspects of your practice in correctional nursing that are different from other nursing fields that have not been highlighted in this series? Please share your thoughts about these questions by responding in the comments section of this post.

If you would like to read more about caring and professional practice in correctional nursing see Chapter 2 on the ethical principles of correctional nursing and chapter that discusses the elements of professional correctional nursing practice in our book, Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

Photo credit: Jaka Vinsek, Cinematographer The American Nurse

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

Illustration - Woman in jailLast week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at www.hamiltonproject.org).

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!

 

Photo credit: © Helder Sousa – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 1

00000001What career did you want for yourself when you graduated from nursing school? Did know you wanted to be a correctional nurse? You probably never heard of it, right? This is me back in 1973 and I had never heard of correctional nursing either. Most correctional nurses will tell you that they never planned to be in this field. The reasons they give for trying it out included:

Wanting to try something different.

It was close to home and convenient.

They knew someone else who was a correctional nurse and suggested it.

I made the change because I was bored with hospital-based psychiatric care. The opportunity to develop a health care program for offenders in state prisons came at the perfect time and I took on the challenge and have had a chance to make a difference in the lives of those who could not do so for themselves. I thought I would stay about five years and move on, but it has been 31 years now. The next several posts will explore the challenges of becoming a correctional nursing specialist, the features that distinguish the specialty and explore why nurses stay in the field.

Nurses have advocated for the health and well-being of prisoners practically since the beginning of time. These include Florence Nightingale, who did some of her best work in England’s poor houses in the mid-nineteenth century as well prisoners during the Crimean war, Clara Barton, who cared for prisoners of war in the Civil War, and Dorothea Dix who was responsible for prison reform in the 1800s. The American Nurses Association has considered correctional nursing a specialty since 1985 and publishes standards for the scope of professional practice in correctional nursing.

The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) acknowledges correctional nursing when commenting on diversity in the nursing profession, stating that nurses will be present anywhere there are people who have healthcare needs. Those of you who watched the movie, The American Nurse, met Tonia Faust, a correctional nurse, and hospice coordinator at the Louisiana State Penitentiary. Four of the 75 nurses portrayed in the book, The American Nurse, were providing health care in correctional facilities at the time they were interviewed. We don’t really know how many correctional nurses there are because many state boards of nursing don’t include this as an option when indicating your place of employment or area of practice.

My co-contributor, Lorry Schoenly, likens the transition to correctional nursing to the popular tale, The Wizard of Oz when Dorothy Gale, walks out into the Land of Oz, after her prairie home landed on the Wicked Witch of the East, following a tornado ride from Kansas. Our first experiences with correctional officers, handcuffs, sally ports, metal detectors, crossing the yard and pop counts brings to mind Dorothy’s admonition to her little dog “This isn’t Kansas anymore, Toto!” In fact Lorry, published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting.

Well the first cultural challenge for nurses after they have arrived in the Land of Correctional Oz is the realization and understanding that our services are secondary to enforcing the law and protecting the public. This is the primary purpose of incarceration in the United States. The people whose health we are responsible for, are being detained against their free will, as punishment. Even so, the Supreme Court has granted prisoners a constitutional right to health care under the 8th amendment. Failure to do so is considered “cruel and unusual punishment.” The court’s reasoning was that “it is but just, that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.”

This is not just a cultural challenge but one of the distinctive features of correctional nursing practice. The first part of the ANA definition of correctional nursing, is that it takes place at the intersection of an individual and their involvement with the justice system. Legal precedents have been the primary means by which the delivery of health care in the correctional system has been shaped.

The courts have established that inmates have the right to health care during incarceration which includes:

  1. Unimpeded access to care
  2. Care that is ordered must be provided
  3. Entitled to professional clinical judgment

These three rights are referred to as the three legged stool of the Eighth Amendment rights to prisoner health care and they are operative in almost every aspect of a correctional nurse’s daily practice.

Here is an example of the application of these rights to health care from my early experience in correctional nursing. In this instance, three inmates, working in the print shop, drank printing fluid, in an attempt to get high. All three became sick but they did not seek medical attention because the nursing staff would have to report them to security for stealing the printer fluid. One inmate died as a result of the delay in treatment. The courts found a violation of the eighth amendment because the inmates’ access to health care attention was impeded, due to the threat of being reported and subsequently disciplined. In this case, a correctional facility’s requirement for reporting prohibited conduct impeded access to care and resulted in a finding of “cruel and unusual punishment”.   The legal right to health care, its practical interpretation and application in the correctional setting is one of the distinguishing features of correctional nursing.

Do you have some good examples of how legal considerations impact the practice of correctional nursing? If so please share by responding in the comments section of this post.

If you would like to read more about legal considerations in correctional nursing please see Chapter 3 written by Jacqueline Moore in the Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

 

Photo credit: © Africa Studio – Fotolia.com

Stay at home ways to build continuing education credits

Man sitting at a computer, learning at home.

I have a friend recently who was lamenting that personal circumstances did not allow her attendance at the National Conference on Correctional Health Care that took place in Dallas Texas this week. She was worried that she would not have enough continuing education hours to satisfy the requirements for recertification as a Certified Correctional Health Professional (CCHP). In addition to professional recertification, many states require evidence of continuing education when nurses renew their license. There are times when life events or circumstances make attending a conference or other educational activity just impossible and then we worry about having enough CEs. This post is written to provide information about some CE resources that can be done at home and are free or inexpensive.

CCHPs and CCHP-RNs recertify once each year. In addition to the renewal fee of $75 the applicant must attest to having obtained 18 hours of continuing education of which 6 hours are specific to correctional health care. CCHPs and CCHP-RNs should maintain a record of the continuing education that they have attested to, in case they are audited. One way to do this is to keep a CE log that includes the following information:

Your name Date Title or subject # of hours

In addition to conference attendance, continuing education credit may be obtained by attending in-service at a correctional facility, writing an article for a journal, or making a presentation at a conference. Another way to obtain CEUs that may be more practical or achievable when life becomes hectic is self-study or independent learning. The following are some self-study options:

The Journal of Correctional Health Care is provided free as one of the benefits to CCHPs and CCHP-RNs. The Journal is published four times each year and contains six to ten scholarly, peer reviewed articles that are specific to correctional health care. If you are not certified an annual subscription costs $125 so this is a tangible return on the investment in certification. You can earn 1 continuing education credit for each article if you complete a corresponding exam. Any article published by the Journal of Correctional Health Care within the previous two years is eligible for continuing education credit. All of this material would meet the requirement of CCHP for 6 hours specific to correctional health care. For more information about this resource go to this link http://www.ncchc.org/journal-of-correctional-health-care.

Medscape is another resource for continuing education credit. This site offers clinicians access to timely clinical information and educational tools to stay current in practice. There is no cost to join and you can access resources that are selected specifically for nurses. For example 0.25 contact hours can be obtained for previewing a slide show and web discussion about motivational interviewing, behavioral action and collaborative care in Strategies for Effective Communication with Patients with Major Depression. There is an easy to use CE Tracker that will keep track of the courses and credits accumulated through the year which can be saved or printed out as necessary. This last year I took two classes, one on the guidelines for prevention of bedsores and the other on prescribing antibiotics and both were easy to access, informative and the exam very simple. For more information about this website go to this link: http://www.medscape.org/

The American Nurses Association is a favorite on-line resource of mine for continuing education. You do have to belong, but an on-line membership only costs $45 a year. Membership benefits include three publications, American Nurse Today, The American Nurse, and the Online Journal of Issues in Nursing. There also is a large library of on-line courses with continuing education credit that can be accessed when it is convenient for you.  I have taken several courses from ANA this year, including a session on the new ethical guidelines for nurses, a course on preventing medication errors and another on the JNC guidelines for managing hypertension. As a member I receive announcements of upcoming Webinars that are offered with continuing education credit and at no charge. This year I took a whole series on building a healthy workplace. Go to this link to find out more about the continuing education resources through the American Nurses Association: http://www.nursingworld.org/JoinANA/E-Membership-Only.

These three resources offer thousands of continuing education hours without ever having to leave your home. Most can be obtained either free or as a benefit of being a CCHP or CCHP-RN. So when time or circumstances make it impossible to access continuing education credits at conferences or on the job, these options may be a help. In my case I’ve chosen to access continued learning through these sites even though I have been able to attend conferences and in-service programs this year.

Do you have resources for continuing education that you would like to share with other correctional nurses? If so, please tell us about them by replying in the comments section of this post.

For more about continuing education in correctional nursing see Chapters 17 Management and Leadership as well as Chapter 19 Professional Practice in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

 

Photo credit: © ponomarenko13 – Fotolia.com

Pender’s Model Could Transform Your Chronic Care Clinic – Honest!

It might be nutty, but I’m really getting into these nursing theorists and how to use their work in the correctional nursing specialty. I recently wrote about Orem’s Self-Care Theory with Nursing Sick Call and Peplau’s Interpersonal Relations with Intake Screening. So, why not try Pender’s Health Promotion Model in a Chronic Care Clinic?  Are you with me on this? Let’s go!

Nola Pender developed the Health Promotion Model (HPM) in the early 1980’s as a framework to describe how nurses can motivate patients toward desired healthful outcomes. The model is based on nursing, human development, and social cognitive theory. Pender sees a nurse’s role as collaborating with the patient to create the most favorable conditions for optimal health and well-being. This is particularly well-positioned for chronic disease management where nurses must motivate patients to make long-term lifestyle changes to improve health.

Assume the Best

A major underpinning of the HPM is the assumption that individuals value growth and seek improvement in their health status. Self-efficacy, a belief in the ability to succeed, is an important part of the model. The nurse, as well as the patient, needs to believe that positive change is possible. Here is where correctional nurses may need some self-reflection. The inmate patient population can seem mired in a sea of poor life choices that they cannot (or will not) overcome. Bringing a negative attitude to the nurse-patient relationship can affect the patient’s willingness to try and the nurse’s desire to motivate the patient to make positive health decisions.

Here are some other propositions that are foundational to this model.

  • Patients commit to actions that they anticipate will provide benefits of high value.
  • The more positive the emotions associated with a behavior, the more likely the behavior will take place.
  • Family, peers, and health care providers are a source of influence in health decision-making.

Past Affects the Present

Of particular importance to correctional nursing may be the connection between past experience and present situation in motivating needed health behavior changes.  Prior related behavior and personal factors affect willingness to take health actions. For example, self-esteem and self-motivation are important factors, as are the patient’s perception of their health status. In addition, race, ethnicity, culture, education, and socioeconomic status influence decisions to improve health.

So, by assuming the patient is able to change and factoring in their past experiences and background, nurses can motivate patients to make the necessary, even difficult, changes to support a healthy outcome. Most definitely, this is a simplistic overview of Pender’s Model but it gives us the basic framework for application in the correctional setting. Here is a diagram of the key elements of the Health Promotion Model borrowed from NursingPlanet.com.

hpm

Applying Pender’s Health Promotion Model to Chronic Care

Could the HPM be helpful in your Chronic Care Clinic (CCC)? Let’s give it a go. Here is a common situation.

Inmate Nagy, age 45, was just diagnosed with Type II Diabetes and is in for his first CCC visit after hearing the news. He has no other chronic diseases and is a Desert Storm veteran with PTSD and brain injury symptoms. He is in a patient education session with the chronic care nurse after his appointment with the provider.

The nurse starts by explaining in simple terms what Type II Diabetes is and the effects and side effects of the new medication prescribed. Inmate Nagy is asked to share back this information to the nurse as he would if he were describing his condition and medication to a family member. Once this is successful, the nurse begins to gather information to help motivate the patient toward changing his eating habits. Based on the principles of the Health Promotion Model, these are the questions asked (modified from this resource):

Prior Behavior

  • What attempts have you made in the past to eat healthy foods?
  • What did you learn from these attempts?

Personal Influences

  • What are the personal benefits of improving your eating habits?
  • What problems (barriers) might you have trying to eat healthier foods?
  • What healthy foods do you enjoy most?

Interpersonal Influences

  • Social Norms – Do any of your family members or friends expect you to eat healthy foods? If so, who, and what do they do?
  • Social Support – Who will encourage you to eat healthy meals?
  • Role Models – Do any of your family members or friends eat healthy meals most of the time? If so, who?

Situational Influences

  • Where can you find healthy foods to eat that you enjoy?

Commitment to a Plan of Action

  • Are you ready to set goals and develop a plan to eat healthier meals?

During this discussion Inmate Nagy identified that he had attempted to eat healthy several times in his early 20’s but was only successful with a lot of effort. He doesn’t like ‘rabbit food’ and prefers a high meat diet. He has noticed in the last few years that he does not feel well on a high starch diet and occasionally tries to avoid chips and ice cream. He does like fruit; especially oranges and grapes. The only vegetable he likes is corn. His younger sister is a ‘health food nut’ and has often tried to get him to eat better.

Armed with this information the nurse asked Inmate Nagy to get in touch with his sister and share his news and ask her for some ideas for health eating. He was also asked to use a provided food list to make at least 3 healthy food substitutions when he is in the dining hall and commissary. An appointment was set for 2 weeks later to review his progress and set new goals.

So, what do you think? Would Pender’s Health Promotion Model transform your Chronic Care Clinic? Share your thoughts in the comments section of this post.

Photo Credit: © flytoskyft11 – Fotolia.com

Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

Peplau’s Theory of Interpersonal Relations – Could This Really Work in Correctional Nursing?

In the last post I applied Orem’s Self-Care Theory to correctional nursing practice. It fit well in a sick call situation but doesn’t give much attention to the emotional/psychological needs of the patient. So, I have been on the search for a practical theory that might help in that sphere. Thus, I happened upon the classic nursing theory of Interpersonal Relations developed by Hildegard Peplau.

What is attractive about Peplau’s theory of nursing practice is that it focuses on the dynamics of the nurse-patient relationship and sees the nurse’s role as a therapeutic force in that relationship. She also emphasizes the importance of communication and interviewing skills in nursing practice and that nurse-patient interactions promote growth for both the patient and the nurse. Correctional nurses must often quickly develop relationship in brief patient encounters in order to determine the health concern and needed interventions so Peplau’s theory holds promise for application in the criminal justice system. Here are the high points.

Progressing Roles

The Theory of Interpersonal Relations provides a number of roles the nurse plays in a patient relationship depending on immediate needs. These roles can change overtime as the patient progresses through various stages in their health or illness. Here are a few of the common nursing roles identified in the theory.

  • Stranger – Start the relationship with an accepting attitude that will build trust
  • Teacher – Provide information related to the patient’s need or interest
  • Resource Person – Provide information that will assist in better understanding a situation or problem
  • Counselor – Assist the patient to integrate the meaning of the current situation along with guidance and encouragement to adapt to new situations
  • Surrogate – Act on the patient’s behalf as an advocate, when needed
  • Leader – Encourage the patient to take on the responsibility for meeting health care needs

Phases of the Nurse-Patient Relationship

Besides various roles, there are also natural phases that a nurse-patient relationship moves through.

  • Orientation: During this phase of the relationship the nurse identifies the health care problem of concern and moves from a stranger to one or more of the other roles depending on what is discovered.
  • Identification: Here the nurse determines the appropriate professional assistance to provide to the patient. The patient, in turn, begins to feel supported and has decreased feelings of helplessness and hopelessness.
  • Exploitation: In this phase assistance is provided and the nurse supports the patient in ‘exploiting’ all the avenues of help.
  • Resolution: In this final phase the patient leaves the relationship in a healthier emotional balance, no longer needing professional nursing services. The relationship ends.

Applying Peplau’s Theory to Correctional Practice

Will Peplau’s theory work in a correctional nursing interaction? Let’s apply it in this intake screening encounter.

A 34 year old husband and father of 2 is booking in to a small county jail on a 30 day sentence for possession and sale of a controlled substance. A nurse is performing the receiving screening and preparing to place a TST when he states, “I just want to get this over with. I figure if I mind my own business I can stay out of trouble and get on with it. They’ll leave me alone, won’t they?” He looks stiff and nervous.

How might Peplau’s Theory of Personal Interaction help in this patient situation? Let’s walk through the phases of the nurse-patient relationship.

Orientation: Using an accepting tone of voice and open body language the nurse responds, “It’s tough going to jail. Tell me about your concerns. Maybe I have some information for you.”

Identification: The patient is slow to respond but finally shares with the nurse that he has never been in jail before and he is anxious about gangs, violence, and sexual assault. He says he has seen a lot of things on television. The nurse determines that she can take on the role of teacher, resource person, and counselor to this patient.

Exploitation: The nurse acknowledges his anxiety, instructs him on how to access health care and some of the other support services available, including chaplain services. She explains that, fortunately, there is little gang activity or sexual assault in this small jail and counsels him on how to report any sexual advances.

Resolution: The patient is visibly more relaxed after this information is shared and proceeds through the rest of the health screening. At the conclusion of the encounter, the nurse makes direct eye contact with the patient and states, “You can do this. It may be one of the toughest things you have ever done, but you can make it through.” The patient nods and seems to be pondering those words as he heads back out to the booking room.

So, what do you think? Would Peplau’s Theory of Interpersonal Relations work in your setting? Share your thoughts in the comments section of this post.

Photo Credit: © raywoo – Fotolia.com

Dorothea Orem Would Make a Great Correctional Nurse!

Dorothea Orem Would Make a Great Correctional Nurse

Dorothea Orem Would Make a Great Correctional Nurse

Just having celebrated National Nurses Week, I am reminded of the many great nurses who helped build the nursing profession we have today. Nursing theorists are in this group of trailblazers. I must admit, I was mostly confused during my first go-round with nursing theories. Some of them are downright undecipherable (in my humble opinion!). However, Orem’s theory stood out as both practical and understandable. I came across her theory again in some reading I was doing for a writing project and was struck by how very applicable this nursing theory is to correctional nursing practice. Indeed, Dorothea Orem would make a great correctional nurse!

Self-Care at the Core

Orem’s theory of nursing targets self-care as the primary goal of nursing. After all, self-care and preservation is a human instinct. We naturally seek out adequate air, water, and food at the most basic of levels. Orem’s theory establishes self-care as initiating and performing actions that maintain life, health, and well-being.

Nursing is Meeting a Need

Nursing care is needed when illness, injury, or disease keeps an individual from meeting care needs independently. The condition may be too severe for self-care, such as a broken ankle. Or, the condition might be beyond the understanding or abilities of the individual, such as a complicated medication regimen for uncontrolled hypertension. Orem’s theory identifies five ways that nurses help patients with their self-care.

  • Acting for and doing for others
  • Guiding others
  • Supporting another
  • Providing an environment promoting personal development
  • Teaching another

Nurses help patients in these five ways through three nursing systems.

  • Wholly Compensatory: The nurse performs all self-care requirements and ‘compensates’ for the patient’s inability to perform these functions themselves. Patients in the infirmary may, at times, need wholly compensatory nursing care, as would patients in a man-down situation
  • Partially Compensatory: The patient is able to provide some self-care but needs nursing assistance in other areas. This is the primary mode for nursing sick call, medication administration, and intake screening.
  • Supportive-Education: Here the nurse supports and educates the patient to be able to maintain and enhance their self-care process. Sometimes this system is active in a nursing sick call situation where the condition does not require treatment as much as patient education. This might also be the system in operation when nurses provide general or group education to the patient population such as at intake or at health fairs.

Applying the Orem Theory to Correctional Practice

Orem’s theory is a practical way to apply nursing theory to correctional nursing practice. Here is an example of use in a common nursing sick call situation.

Inmate Drake, age 32, is 10 days into a 30 day stay in a county jail. He comes to nursing sick call having submitted a slip requesting something for constipation. He states he is usually quite regular but has not had a bowel movement for 5 days.

Nursing System: Partially Compensatory. This patient will likely need some help to regain a regular elimination pattern but should be able to return to self-care with support.

  • After a review of systems and an abdominal assessment, the nurse provides an approved OTC medication for constipation.
  • The nurse also asks about his exercise and eating patterns and provides guidance on how to increase fiber, fluid, and activity while incarcerated.
  • She then instructs him on returning to sick call if these interventions are not successful.

So, this sick call nurse met the patient’s needs through several of Orem’s five nursing activities: doing for the patient, guiding, and teaching him about ways to self-care for bowel hygiene.

Although Orem’s theory is practical and easy to apply, critics of the framework say there isn’t enough attention to the emotional needs of the patient or the impact of the environment on the patient. The emotional and psychological health of incarcerated patients and the unique environment of care behind bars may need further attention than can be provided by applying this theory, but it is a good start.

So, what do you think? Would Dorothea Orem’s theory work in your setting? Share your thoughts in the comments section of this post.

Photo Credit: © bbbar – Fotolia.com

Was Florence Nightingale the First Correctional Nurse?

Florence Nightingale statueHappy Nurse’s Week! This week we celebrate nursing and modern nursing’s founder, Florence Nightingale; who’s birthday is May 12. Since 1974, May 12 has been deemed International Nurse’s Day and the week proceeding May 12 was coined National Nurses Week since 1994.

I must admit that I didn’t know much about Florence Nightingale other than a few ‘facts’ from my Nursing History course a couple decades ago. For example, I know she was the ‘Lady with the Lamp’  and attended the British soldiers in the Crimean War. I also remember that she was a great statistician and a determined woman; willing to risk her upper class status to help the suffering. What my recent search discovered, however, is that Florence Nightingale may, in fact, have been the first correctional nurse. Let me explain.

19th Century Work Houses

Workhouses were developed in England in the 1600’s as relief for the poor. In the 1700’s they became more punitive in order to serve as a deterrent; only accessed in desperation. By the mid-1800’s they had become little more than prisons.  Families were separated into dormitories; meals were provided in communal dining rooms; personal clothing replaced by uniforms. Sound familiar? Dickens wrote Oliver Twist during this time period and portrayed life for an orphan in a workhouse.  Here is a fascinating documentary on British Workhouses.

Workhouse Infirmary Overhaul

Nightingale’s Crimean War service in the 1850’s caught the hearts and minds of the British public through news portrayals. However, long before her war experience she expressed her concern for the health of the poor. As an upper-class lady in mid-19th century England, she had visited the work houses of London and later stated:

 “In days long ago, when I visited in one of the largest London workhouse infirmaries [Marylebone], I became fully convinced of this. How gladly would I have become the matron of a workhouse. But, of a visitor’s visits, the only result is to break the visitor’s heart. She sees how much could be done and cannot do it.” (5 February 1864, in Public Health Care)

Teaming up with philanthropist William Rathbone in the mid-1860’s she began to transform the Liverpool Workhouse Infirmary by adding trained nursing staff and establishing standard health care practices.

Be a Correctional Nurse like Flo

Florence Nightingale transformed the healthcare provided in the British Workhouses and therefore improved public health in 19th Century England. As correctional nurses, our work in providing quality health care in US jails and prisons improves the health of our patients and, therefore, the public health of the nation.

Nightingale’s ideas about nursing were captured in her classic work – Notes on Nursing. She said that nursing “…ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet – all at the least expense of vital power to the patient”

Consider how the living conditions of your patients are affecting their health and illness. What ways can you improve these conditions or help your patient overcome them? Here are some ideas

  • Teaching patients to make good food choices in the dining hall and commissary
  • Advocate for healthy food options in the commissary
  • Encourage all patients to exercise according to ability
  • Provide standard exercise plans that work in-cell (such as boot-camp basic drills) or in the exercise yard
  • Customize standard exercise plans with patients during encounters
  • Encourage good sleep hygiene practices whenever possible

Celebrate Nurse’s Week

Some see Nurses Week as a time for giveaways, nice food, and flowery words about the meaning of our work. Other see the week as an opportunity to complain about how unappreciated they are! I would like to suggest that Nurses Week is an opportunity to reignite our mission as correctional nurses.  Let’s all try to be more like Flo in our correctional nursing practice this week!

So, do you think Florence Nightingale was the first correctional nurse? Share your thoughts about being like Flo in the comments section of this post.

Photo Credit: © Tony Baggett