What are these eight rights anyway?

The picture posted with this column of a nurse on her way to give medications gives rise to many thoughtsNurse Medication Picture and memories. For me, it brings memories of my early years in nursing practice.  We wore white uniforms, white shoes, white nylons and white caps.  . I remember learning how to safely and accurately administer medications through each of the steps from the physician’s order to setting up medications, to administration and documentation. I also remember how much emphasis was placed on giving the right patient the right medications. Like the nurse in the picture, medication rounds were done using a tray holding medication in cups and small cards with the patient information and medication on them.

Years later, the safety of administering medications was outlined in the Five Rights of Medication Administration.  I cannot tell from the literature when these became formalized but when I returned to school in the mid 1980’s, the Five Rights were prominent in nursing practice, risk management and patient safety.

Health Care Advances

As the body of knowledge for nursing practice evolves, we continuously improve our practice to assure our patients receive the highest level of care with an emphasis on patient safety and error reduction. Because of this, three more rights have been added to the body of knowledge for medication administration, making a total of eight rights.

In corrections settings, medication administration is completed by a variety of job classifications. No matter who gives medications to patients, they must be qualified and trained in medication administration and follow the Eight Rights, as described below:

  1. Right Patient: check the name on the medication administration record (MAR), use two identifiers; ask patient to identify themselves, check name &/or picture on ID wrist band or badge.
  2. Right Medication: check the order, select medication, compare to the order, check the MAR, and then check the medication against the MAR before giving to the patient. If it is a new medication does the patient know what it is for and are there any allergies that would contradict giving it.
  3. Right Dose: check the order or the MAR, confirm the appropriateness of the dose, for medications with high risk consequences from dosing errors have someone double check the calculation.
  4. Right Route: check the order and MAR, confirm the route is the correct for that medication and dose, confirm that the patient can receive it by the ordered route.
  5. Right Time: check frequency the medication is to be given on the MAR and the time is correct for this dose, confirm when the last dose was given.
  6. Right Documentation: document administration AFTER giving the medication, document the route, time and other specifics such as site, if injectable, lab value, pain scale or other data as appropriate.
  7. Right Reason: confirm the rationale for the ordered medication; why is it prescribed, does the patient know why they are taking this medication. If they have been taking it for long is its continued use justified?
  8. Right Response: has the drug had its desired effect, does the patient verbalize improvement in symptoms, and does the patient think there is a need for an adjustment in the medication?  Document your monitoring of the patient for intended and unintended effects.

Adapted from Bonsall, L. M. (2011). 8 rights of medication administration. Retrieved June 17, 2016 from http://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration

The Important Three

When you examine the new three rights closely, their importance becomes clear and explains why they are included as best practices:

  • Right Documentation:  We hear from our legal representatives, instructors, managers and peers, that “if it was not documented, it was not done”. No excuses can make up for a patient receiving double dose of medications when it was not documented or a provider changing a medication when they thought a patient was not taking the medication. Besides accurate and timely documentation of medications administered, this right also includes the accurate documentation of the order on the MAR.
  • Right Reason: When taking off orders or preparing to administer a medication, knowing why the patient is taking a medication is the foundation for patient education and evaluating the effects of the treatment. This is especially important when a particular medication, such as gabapentin, may be ordered to address one of several different conditions (seizure, nerve pain, restless leg syndrome etc.). Information in the patient’s chart will often clarify why this medication is being ordered; if not, consult the provider so that you know what the patient can expect from the treatment.
  • Right Response: We cannot effectively teach a patient about a certain medication and the desired effects of treatment if we do not know the drug ourselves.  Knowing about medications is a continual learning process, which grows day by day.  Make a habit of learning about new drugs each day.  This information can be found in the drug reference books kept in the medication room, by talking with providers, consult with the pharmacist, discussing medications at shift or team reports and exchanging information with team members.  See also a previous post that describes all of the online drug references that are available without charge.

Spread the Word about the 8

Even though these additional best practices have been discussed in the literature and have been topics in nursing education for several years, I still hear nurses refer to the Five Rights. They are called rights because they are not a request or desire—but a RIGHT. Each one of the eight rights is fundamental to nursing practice and when used together better promote patient care and enhance safety. By following these steps, nurses promote wellness and identify and prevent harm to our patients. What do the eight rights of medication administration mean to you?  How has understanding the eight rights in your practice, improved your patients care?  Share your experiences and challenges with medication administration in the comment section below.

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

Photo credit:  Yahoo Images

 

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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.

Job, Career, or Calling? It’s Up to You

“It’s not what you look at that matters, it’s what you see” – Henry David Thoreau

Your CallingCorrectional nursing can be a job, a career, or a calling based on your perspective – what do you see?

  • If you see your work life as an endless string of shiftwork passing pills and triaging sick call slips then you may have a job perspective
  • If you see your work life as a stepping stone to an advanced position then you may have a career focus
  • If you see your work life as meaningful to the lives of others and personally fulfilling then you may have a calling focus

Those who research job satisfaction have found that those who see their work as a calling do work they care about. They consider their work to be more than a means to an end, but an opportunity to find meaning and do something important. These researchers also found that those who viewed their work as a calling were healthier, had greater satisfaction with their life and missed less work than those in either the Job or Career categories.

Knowing your work orientation can help you find ways to motivate yourself and craft a better work situation without having to change jobs. Job crafting, in fact, is a primary way correctional nurses can move from a Job perspective to a Calling perspective regarding their work life.

Dimensions of Meaning

Experts have determined five dimensions of meaning that can be found in work.

  • Money: Although correctional nursing salaries can be competitive, it is not the one of the highest paying nursing specialties
  • Status: Correctional nursing practice has made advances of the last decade but nurses working in jails and prisons can still be stigmatized by their patient population and work setting.
  • Making a difference: Correctional nurses can make a significant contribution to the health and well-being of a marginalized and disadvantaged patient group.
  • Following your passions: What motivated you to become a nurse? How would that align with correctional nursing practice?
  • Using your talents: Many passions also end up being talents. What nursing talents do you have that are applied in a correctional nursing position?

What is Job Crafting?

Job crafting is a way to redesign work perspective, relationships, and tasks to improve job satisfaction. Job boundaries can expand or contract over time based on the individual in the position and the aspects that are emphasized or de-emphasized. It starts with determining the areas of a role that are the most meaningful, provide the most satisfaction, and are aligned with gifts and talents. While in many situations other areas of the role cannot be neglected; focusing on extending time and effort toward gaining experience and expertise in areas of fulfillment craft the position.

Ways to Job Craft

Even in the most structured of job descriptions, there is room for modifications to make work life more satisfying and meaningful. Researchers found that successful job crafters took action in three areas: perspective, relationships, and tasks. Here are some suggestions specific to a correctional nursing role.

  • Perspective: It all starts in the mind. Mentally seeing your work as affecting the lives and health of your patients is more helpful than seeing your work as a list of nursing tasks that must be completed by the end of the shift. Thus, correctional nursing is not medication administration, sick call, emergency response, and intake screening but “the protection of health, prevention of illness and injury, and alleviation of suffering” (definition from the Correctional Nursing Scope and Standards of Practice, 2013). Successful job crafters reframe the social purpose of their positions to align with their values and concerns. What parts of the definition of correctional nursing do you highly value? Be mindful of those themes during your day-to-day activities.
  • Relationships: The type and extent of relationship with various workmates can be a way to craft a more positive work experience. Hang around unhappy, stressed, and cynical people and you will find yourself mirroring their moods and emotions. The reverse is also true. Honestly evaluate the perspective of each member of your work team and develop deeper relationship with those who will encourage and facilitate your highly valued role components.
  • Tasks: Evaluate which elements of the correctional nursing role give you the most pleasure and fulfillment. Ponder the specific themes of these elements. For example, if you enjoy sick call, which parts? Is it the assessment, the patient interaction, the teaching component? Find ways to do more of the satisfying component. That might not mean the original job task. For example, if assessment is the satisfying part of the sick call process then intake screening is also a task that would provide opportunity for more assessment. If patient teaching is the driving satisfier than chronic care tasks may be an additional option. Once determined, seek ways to increase satisfying tasks while decreasing or streamlining less-valued tasks to accommodate the change.

Just a Job? Just a Step in the Ladder? Just a Way to Make a Difference?

So, what will it be for you? Is correctional nursing just a job that meets your monthly bills and is available until you find something better? Is your position just a step on the career path to a position of more power and prestige? Or, is correctional nursing a way that you make a difference in the lives of others, creating a meaningful professional life of compassion and service? In the end, it is up to you.

“We don’t see things the way they are, we see things the way we are.” – Anais Nin

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

Photo credit: © Rawpixel.com – Fotolia.com

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!

 

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