The Circles in Your Practice

On a busy day and in the midst of patient care we are not always aware that much of our nursing practice care is a continuous process. Whether it is completing sick call, medication administration or counseling a patient, we are always “evaluating”. Nursing practice is circular, in that our patients continually respond to our health interventions and as nurses, we observe and act on that response. nursing-process-grid-11-7-16

The American Nurses Association defines correctional nursing as the “protection, promotion and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; advocacy for and delivery of health care to individuals, families, communities and populations under the jurisdiction of the criminal justice system”.

The Nursing Process

The American Nurses Association published the Correctional Nursing: Scope and Standards of Practice in 2013. The goals of the scope and standards are to:

  • inform nurses and others about correctional nursing practice
  • guide nurse’s day-to-day practice and resolve conflicts
  • develop policy and procedure and other governance of professional practice
  • reflect on professional practice and plan improvement.

There are 16 standards of nursing practice with the first six delineating the steps in the nursing process. These six elements of the nursing process are circular as well as inter-related to each other.

  • Assessment is data collection about the patient’s health condition. Nurses use all their skills and senses to identify changes in a patient condition. By observing the patient, interviewing the patient, completing the physical examination, collection history information and reviewing of the patient’s health records an assessment is formulated.
  • Diagnosis is the nurse’s analysis of the data gathered and identification of the patient’s problem which results in the nursing diagnosis. The nurse also validates the diagnosis with the patient.
  • Outcomes Identification focuses the nursing diagnosis on the needs of the patient. The goal of nursing care is for the patient to achieve an improved level of functioning that is realistic to attain. Using the SMART technique, an acronym for setting goals that are specific, measureable, attainable, and realistic and time bound, assists in developing the outcome statement.
  • Planning  for the nursing interventions that will achieve the outcomes identified for the patient is the next step. These plans are specific to each patient and focuses on achievable outcomes. Planning, rather than reacting or practicing by rote, is more effective in reaching the goals of patient care.
  • Implementation are the action steps the nurse follows in carrying out the plan of care. Implementation may be one or more nursing intervention steps, and may take place over hours, weeks or months depending on the patient’s condition. Implementation requires the nurse to delegate care to subordinate personnel and communicate with colleagues to achieve completion of the patient’s plan of care.
  • Evaluation occurs all along during the nursing process. It is both the end and the beginning in the continuous process of care that is delivered to the patient. Documenting the patient’s response to interventions, evaluating their effectiveness and the outcomes achieved leads to modification or revision in the plan for care.  This illustrates how each step is fundamental to the circular process of nursing practice.

The nursing process is an integral part of every patient encounter. Expert nurses move through these steps fluidly without stopping to focus solely on each component. Nurses are attentive to their patient’s response to care provided all along the continuum from illness to wellness.

The Patient Plan & Documentation

The S.O.A.P method of documenting patient care is common in most correctional settings and is used as the main communication method in the patient’s health record. In the literature, two additional elements in SOAP charting are recommended; these are Intervention and Evaluation. These two additional elements of documentation align with the nursing process just discussed and support charting of continuous patient care.

  • S-Subjective: reports what the patient says
  • O-Objective: records what the nurse observes
  • A-Analysis: identifies a nursing diagnosis
  • P-Plan: describes nursing interventions
  • I-Implementation: records how those actions were carried out
  • E-Evaluation: reports the actual patient response and outcome.

This systematic approach to detailing patient care keeps us goal orientated and focused on how the patient is progressing in the treatment plan. With an eye toward always evaluating or “continuing” to evaluate a patient’s response to treatment, the nurse is ready to intervene to prevent an exacerbation of illness or unexpected response to treatment.

When nurses respond to requests for care, complete sick call assessments, administer medications and call patients up to check on how they are doing, it is part of the circular pathway of continually evaluating how our patients are or are not responding to care.

Next weeks’ blog topic will explore a third “circular” area of nursing practice, which is the Continuous Quality Improvement Process. Can you think of more circular processes in your nursing practice or insight into the continual evaluation process in nursing care? We would like to know your thoughts about the nursing process and SOAPIE process. Share in the comment section at the end of this post. We like to hear from you.

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

 

Photo Credit: American Nurses Association NSPS’10_Fig 4. Nursing Process Standards.

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

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

How punishment affects our practice

Close-up Of Brown Gavel And Medical Stethoscope

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Photo credit: © Andrey Popov – Fotolia.com

 

 

References

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

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

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

Six Challenges Managing Medications that make Correctional Nursing Unique

3d illustration of a corridor

 Medication management is a primary responsibility of nurses working in correctional settings (American Nurses Association (ANA) 2013). The Bureau of Justice Statistics reported that 66% of prisoners and 40% of inmates in jail who had a chronic condition were taking prescription medication. Among inmates with mental illness 27% of those in state prisons, 19% in Federal prisons and 15% in jails reported receiving prescription medication while incarcerated (Bureau of Justice Statistics, 2006). In addition to chronic medical problems and psychiatric disorders, medications are prescribed for inmates who have acute conditions, such as urinary tract infection as well as to provide symptom relief for minor illnesses and discomfort such as headache, constipation or seasonal allergies. As much as 80% of the population at a correctional facility may be taking medication for one or more of these reasons.

Medication management is identified as one of the features of correctional nursing that distinguishes it as a specialized field. Nurses who are new to the correctional setting are often unprepared for the scope and breadth of their role and responsibilities for managing medication delivery and yet they must meet the same standards for delivery of medication as in the community (ANA 2013).These challenges define what is unique about correctional nursing practice with regard to medications.

I started making a list of the challenges correctional nurses deal with in managing medication delivery. When the list became almost a full page long I sat back and thought about what similarities there were between the items and the following groupings came together.

  1. Professional isolation: Health care delivery in correctional facilities is often a very small part of the overall operation. In many cases nurses are expected to deliver services in independently and without advice from other health care providers. Nurses recently commented on CorrectionalNurse.net, Lorry’s other website that double checking dosages of high risk medications is a challenge when there is only one health care person on duty. One solution is to have the inmate confirm that the dose corresponded with what he or she understands it should be. Dispensing, drug packaging, storage inventory and disposal of medications are all subjects governed by state pharmacy laws and regulations. Unless there is a pharmacist on staff, correctional nurses need to be familiar with and ensure their practices comply with these requirements, in addition to the nursing regulations, when managing medication in the correctional setting.
  2. Security: Maintaining security is a primary focus of correctional facilities. This includes accounting for the presence and activities of each inmate throughout the day, ensuring that only authorized persons and products enter and exit the facility, and that contraband does not enter, is not otherwise obtained or manufactured. The most obvious example of a unique responsibility for correctional nurses is counting needles and syringes and accounting for each use. Others are ensuring access to inmates when medication is due (even on lockdown) and protecting patient confidentiality (not having medication lines that serve to identify the mentally ill or those with HIV disease for ridicule or extortion by others). Sometimes a facility will determine that for security reasons, not clinical, that all medication must be floated on water or even worse, crushed, impacting patient adherence, the time it takes to administer medication and in some cases the therapeutic effectiveness of the drug. Nurses need to confer with security on an ongoing basis so that security practices that compromise the therapeutic value of prescribed treatment are not put in place.
  3. Safety: The safety of inmates, staff and the general community is the other primary focus of correctional facilities. For correctional nurses this includes ensuring the safety of themselves and patients as well. A significant aspect of medication delivery is managing inmate behavior. This includes consistent practices for patient identification (two-part identification), checking that inmates don’t cheek or palm medication, providing privacy at the medication window or cart (prevent crowding). Often an officer will be assigned to escort the nurse or mange the medication line. Nurses need to engage the cooperation and assistance of this officer and be alert to their own behavior so that medication administration is conducted in a safe and efficient manner. The patient safety aspects are ensuring the cleanliness and hygiene of the medication delivery area to prevent transmission of infectious disease and monitoring conditions so that side effects from medications that make patients heat or light sensitive are prevented.
  4. Expanded role: Unless a correctional facility is large and has a number of specialized programs the health care program is likely to be staffed pretty simply without the support services nurses are used to in other health care settings such as pharmacy technicians, IV teams, respiratory therapists, inventory clerks and so forth. Nurses in correctional facilities routinely perform these roles instead and if there is assistance the nurse is responsible for their assignments and supervision. Nurses order medication from the pharmacy, arrange for refills and renewals, check for outdated drugs, receive, inventory and store medications and arrange for medication to be returned or properly destroyed. Nurse initiate treatment for patients via nursing standardized protocols that involve providing the patient with medication to treat the illness or manage symptoms. Nurses are the primary health care professional responsible to ensure that patients do receive medication as ordered and are expected to monitor patient adherence and solve problems with medication availability. Correctional nurses also assess the patient’s ability to manage their own medication if the facility has a self-medication or “Keep on Person” (KOP) program and to provide education or other assistance to support the inmates in providing their own care.
  5. Greater volume and scope: Because correctional nurses are responsible for the health needs of the entire population housed at one or more facilities they are generalists in nursing practice not specialists. Medications may be administered by a nurse or other personnel supervised by the nurse so that the inmate is directly observed when taking medication. Inmates may also be provided with a supply of medication by a nurse to take by themselves in a KOP or self- carry program. Nurses may also take medication to administer to patients in restraints, seclusion or housed in a high security setting for disciplinary or protective reasons. Nurses may give some medication under rules that allow for involuntary administration to patients with mental illness. In some correctional facilities nurses may be expected to use PICC lines or other specialized equipment or procedures to administer medication. The volume of medication administered by a nurse in the correctional setting exceeds that in any other setting. One difference is that most patients on pill line would be responsible for taking these medications by themselves or with the assistance of family in their own home.
  6. Timeliness: Medication delivery and administration must take place in coordination with all of the other activities that compete for the time and availability of inmates. In one facility I recently visited medication administration was halted on a unit until the canteen delivery was finished. The nurse was stranded in the corridor for twenty minutes until canteen was over. When the nurse insisted that medications be administered and canteen delivery wait the inmates complained bitterly. This is just one example of the competition for time. These time pressures can affect the therapeutic effectiveness of the drug if given too close or far apart. If inmates go to work or court before nursing staff are on duty inmates may miss important doses. The volume of medication to be given can impact timeliness; if there are too many medications a nurse may feel pressure to short cut or abandon the five rights resulting in increased patient risk.

So what are your thoughts about the uniqueness of medication management in correctional nursing practice? What have I forgotten or you would describe differently? Is there anything discussed here that you disagree with because it is not unique to correctional nursing. Share your thoughts in the comments section of this post.

Are you interested in knowing more about this nursing specialty? If so, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

Photo credit: © Yannis Ntousiopoulos – Fotolia.com

References:

American Nurses Association (2013) Correctional Nursing: Scope and standards of professional practice. American Nurses Association. Silver Springs, MD.

James, D.J. & Glaze, L.E. (2006) Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mhppji.pdf

Maruschak, L. M., Berzofsky, M., & Unangst J (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf

Empathy: A Practice not an Emotion

Young man on reception at psychologistEmpathy has been discussed as a basic component of effective nursing practice since the 1960s. It is important because empathy produces insight into an patient’s experience and coping with illness. These insights facilitate the nurse’s diagnostic accuracy, problem solving and care becomes more patient centered. When patients feel understood they become engaged in a helping relationship with the health care professional and are more likely to adhere to treatment recommendations and advice about healthy lifestyle changes (Wiseman 2007).

Concerns about expression of empathy in correctional settings

Correctional nurses sometimes express concern about being empathetic with inmates. A simple definition of empathy is that it involves the ability to see the world through another person’s eyes. In correctional practice this definition is sometimes misinterpreted to mean that you have to think, feel and act like a criminal or a murderer or a sex offender; an impossible and unethical expectation. Another misunderstanding about empathy in correctional nursing is that the nurse is letting their emotions or feelings guide their actions and they are at risk of being manipulated by the inmate. Empathy in nursing practice is not a subjective emotion or feeling but is instead a professional interaction (Dinkins 2011, Mercer & Reynolds 2002).

If empathy isn’t an emotion, what is it?

A more descriptive definition of empathy is that it is the ability to perceive and understand the meanings, feelings and concerns of another person and to communicate that understanding to the other person. Empathy involves perceiving, thinking and communicating about another person’s experience and concerns. You do not have to think or feel like the other person to practice nursing empathically. There are three parts to empathy in nursing practice, sometimes referred to as the Empathy Cycle, these are:

  1. Listening, reasoning and understanding. Essential skills are the ability to listen attentively and the sensitivity to perceive another person’s experience, concerns or perspective on a subject. Understanding is a cognitive process that involves reflection and the suspension of judgment.
  2. Conveying understanding of the other person and your intention to help. Communication must be patient centered, accurate; not judgmental or blaming.
  3. The patient’s awareness that the nurse has communicated understanding and believes it to be genuine and accurate (Mercer & Reynolds 2002, Wiseman 1996, Wiseman 2007).

An example of empathy in correctional nursing practice

Last week I observed a nurse in sick call. She was seeing a 19 year old man for complaints of headache and acne. During her assessment she checked his medication administration record and noted that he had missed several days of thyroid medication. At first she lectured him about the importance of taking it each day. He looked at his feet and mumbled his understanding and agreement. Next she asked why he wasn’t taking it and he replied that he was still bed when it was time for morning meds. They talked some more about why he couldn’t get up and the impact of not taking the medication. Finally she said “Staying in bed in the morning is more important to you right now, isn’t it?” He nodded yes. Her reply was “I understand; let me see if the doctor will change the medication time to noon or the evening. Would that work better for you?” He nodded and indicated verbally that it would help.

The nurse accurately understood that for this young man, the consequences of not taking the prescribed medication were so remote compared to his desire to stay in bed that he would forgo the medication even after having listened to the information she provided. She acknowledged his reality that staying in bed was more important to him and used the information to problem solve a way to increase his medication adherence.

At this same correctional facility where I observed the nurse conducting sick call, the correctional officers are taught in training academy to offer empathy in their interactions with inmates. The curriculum notes that empathy establishes a dynamic that allows the officer to assist the inmate in problem solving, to feel understood and supported. Empathy is described as the “crown jewel” of active listening technique. The fact that correctional officers are taught in training academy how to use empathy really seems to support correctional nurses’ use of empathy in their interactions with patients.

Empathy and the Standards of Professional Practice in Correctional Nursing

Several of the professional practice standards for correctional nurses published by the American Nurses Association describe empathy among the competencies that nurses must demonstrate to meet the standard. The nurse in the example given above demonstrated all of the competencies in her brief interaction with the patient during sick call. These include:

Standard 1 Assessment: The correctional nurse elicits the patient’s values, preferences, expressed needs, and knowledge of the healthcare situation to utilize such information as appropriate within the context of the correctional setting.

Standard 4 Planning: The correctional nurse develops an individualized plan in partnership with the patient considering the patient’s characteristics or situation, including but not limited to values, beliefs, spiritual and health practice preferences, choices, developmental level, coping style, culture and environment, safety of the patient, and available technology.

Standard 5 Implementation: The correctional nurse advocates for health care that is sensitive to the needs of the patient, with particular emphasis on the needs of diverse populations.

Standard 7 Ethics: The correctional nurse maintains a therapeutic and professional nurse-patient relationship within appropriate professional boundaries.

Standard 13 Collaboration: The correctional nurse promotes conflict management and patient engagement (2014).

Reasons for lack of empathy in nursing practice

The primary factor that has been identified as impacting the practice of empathy among health care professionals is a fixation on the tasks and technology of care coupled with time compression. Other reasons identified as impeding empathic practice include:

Difficult patients Anxiety about patients Feeling belittled or insignificant
Unsympathetic colleagues Lack of role models Fear of making a mistake
Individual nurse’s personality Intimidating environment Pressure on task completion

(Ward, Cody, Schaal, & Hojat 2012)

Every one of these factors could be present in the practice environment of a correctional nurse. How many of them factor into your practice environment and to what extent have they impacted your use of empathy in the delivery of patient care? Empathy is not solely a personality trait; it is a skill that can be taught and developed (Wiseman 2007). Taking a moment to reflect on our practice environment may identify opportunities to improve our empathic response in patient interactions. From there it is possible to create a plan of professional development in this area.

Empathy reminders for our practice

Helen Riess, Associate Professor of Psychiatry at Harvard Medical School gave her TEDx Talk audience (2013) the following mnemonic which she uses to help health care providers develop empathic responses in their patient care encounters.

E              Eye contact – this is first indication that we have acknowledged an individual and it begins the interaction

M            Muscles of facial expression – are the road map of human emotion, notice the patient’s facial expression

P             Posture – an open or closed posture indicates receptivity (or lack thereof) to interaction (both yours and the patients). Maintaining an open posture facilitates the patient’s interaction with the health care provider.

A             Affect – is a term for expressed emotion; try to identify label the patient’s emotion, and listen to the patient with that perspective, it will improve your understanding of what the patient is communicating

T              Tone of voice – is an indicator of emotion, vocal chords are located in the brain close to the same area that activates fight or flight response, changes in tone of voice may be an early indicator of emotion

H             Hearing the whole person – more than the words that are said, understand the context of the patient’s experience, and be non-judgmental in order to comprehend

Y             Your response – pay attention to your feelings; we respond to others all the time; know what you are conveying and manage your part of the relationship professionally.

Are the challenges of using empathy in your professional correctional nursing practice similar to those described here? If so what resources have you found helpful in addressing these challenges? Please reply by responding in the comments section of this post.

For more on the nurses professional practice relationship with patients in the correctional setting see Chapter 2 Ethical Principles for Correctional Nursing as well as Chapter 19 Professional Practice in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.

References

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

Dinkins, C. (2011) Ethics: Beyond patient care: Practicing empathy in the workplace. The Online Journal of Issues in Nursing 16(2).

Mercer, S. W. & Reynolds, W.J. (2002) Empathy and quality of care. British Journal of General Practice Quality Supplement 52: S9-S13.

Riess, H. (2013) The power of empathy. TEDxMiddlebury. Accessed 4/25/2015 at https://www.youtube.com/watch?v=baHrcC8B4WM

Ward, J., Cody, J., Schaal, M., & Hojat, M. (2012) The empathy enigma: An empirical study of decline in empathy among undergraduate nursing students. Journal of Professional Nursing 28 (1) 34-40.

Wiseman, T. (1996) A concept analysis of empathy. Journal of Advanced Nursing 23: 1162-1167.

Wiseman, T. (2007) Toward a holistic conceptualization of empathy for nursing practice. Advances in Nursing Science 2(3): E61-E72.

Photo credit: © Africa Studio– Fotolia.com

Inmate satisfaction with health care services during incarceration

 

Customer SatisfactionLast week’s post summarized the results of the most recent survey of inmates’ health published by the Bureau of Justice Statistics (BJS). This survey also reported on inmates’ experience with the delivery of health care in 606 correctional facilities throughout the U.S. and their satisfaction with services provided. So before we look at those results take a minute to reflect on your encounters with inmates seeking or receiving health care and how they might rate their satisfaction. My experience is that many correctional nursing colleagues think that inmate satisfaction with health care is low, that many inmates fail to appreciate their care and take what care they do receive for granted. What is your opinion about how satisfied inmates are with their care?

What Do Inmates Think? 

According to the over 100,000 inmates surveyed, more than half were satisfied or very satisfied with health care received while incarcerated. In jails, 51% of the inmates in the survey reported being satisfied or very satisfied and in prisons it was 56%of those surveyed (Maruschal, Berzofsky, & Unangst 2015). This information certainly bursts the stereotype that inmates don’t value the health care they receive during incarceration! Most inmates do appreciate it. Further evidence is found in another survey done recently in a maximum security prison; the vast majority of prisoners in poor health prior to prison reported that their health had improved during incarceration (Yu et al. 2015).

Identifying Opportunities for Improvement 

Patient satisfaction has long been recognized as a valid tool in quality improvement. Often it is only through a patient’s eyes that we can see opportunities to improve patient outcomes or make the experience more supportive of health attainment. Information about patient satisfaction can provide insight into the perceptions and expectations of patients, one important part of the larger picture of a program’s performance. For example, in the Oregon DOC, one of the questions we used on a patient satisfaction survey was whether follow up appointments after nursing sick call were timely. We expected that inmates would be dissatisfied when wait times were more than a day and found out we were wrong. Even wait times of up to one week were rated as satisfactory.

The results of a patient satisfaction survey conducted in the Connecticut prison system revealed much the same results as that reported in the national survey by the BJS. Forty-three percent of 2,727 inmates surveyed (or 16% of the total population) reported satisfaction with their health care; this was considered “better than expected” by some of the health care staff in the system (Tanguay, Trestman & Weiskopf 2014). There was no difference in satisfaction scores based upon gender (male or female) or the type of facility (maximum security, work camp etc.).

The survey developed in Connecticut consisted of ten questions derived fundamentally from Crossing the Quality Chasm: A New Health System for the 21st Century published by the Institute of Medicine (IOM). There were ten topics that inmates were asked their opinion about. These are listed below:

General satisfaction with care Respect for privacy
Access to care is satisfactory The provider listened
Waiting time in the clinic is short The provider is competent & well trained
The provider introduced themselves The provider explained their findings
Treated in a friendly & courteous manner The patient knows what to do to get better or take care of themselves

The article pointed out that to ensure a good response rate questions were written at the fourth to fifth grade reading level, were limited to ten in number and used only three response categories (yes, no and unsure). Although the survey was anonymous, inmates were reluctant to participate at first but this changed over time as inmates came to understand that the survey was intended for program improvement, was indeed anonymous and therefore participation was “safe”.

Important Findings From the Feedback 

Feedback on inmate satisfaction was discussed with health care and correctional staff at each facility and at a statewide level. Satisfaction with each of the ten measures varied. The results and the ensuing discussion were used to identify areas for focused program improvement. For example access to care was rated as satisfactory by 45% of the inmates surveyed. Areas that made access to care difficult included appointments that were dropped because of facility to facility transfers which required inmates to re-request services. Automation of inmate scheduling was discussed as a way to eliminate this problem with access. Other areas that were selected for improvement included explanations for the patient about what the problem is and their treatment options and productive use of time spent waiting while in the clinic (Tanguay, Trestman, & Weiskopf 2014).

Correctional Nurses’ Role in Quality Improvement

Standard 10 of the Correctional Nursing Scope and Standards of Professional Practice provides guidance for correctional nurses’ contribution to quality. Competencies include participation in the evaluation of clinical care and service delivery, correcting inefficiencies in the process of care delivery, identifying and weakening barriers to quality patient outcomes (American Nurses Association 2013). Satisfaction surveys can provide useful insight into the experiences and expectations of our patients. Some patients may be receiving very good health care and still be unsatisfied but taken in the aggregate inmates tend to rate health care received during incarceration very positively. Consider conducting patient satisfaction surveys at your facility if you haven’t used this feedback method yet; you and other health care staff are likely to be pleasantly surprised.   Satisfaction survey results also provide information that can help focus on the areas of the patient’s experience that greatly impact health outcomes, as the report from Connecticut illustrated.

What Is Your Experience and Advice? 

Have you sought feedback from inmates at your facility about their satisfaction with health care? If so, was your experience with the results similar to that reported by the BJS and for the Connecticut prison system? Do you have copies of the survey questions that were used and if so will you share by responding in the comments section of this post?

For more on the nurses’ role in quality improvement see Chapter 18 Research Participation and Evidence-Based Practice in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.

References

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

Institute of Medicine (IOM) (2001) Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press.

Maruschal, L. M., Berzofsky, M., & Unangst, J. (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Special Report. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Tanguay, S., Trestman, R., & Weiskopf, C. (2014) Patient Health Satisfaction Survey in Connecticut Correctional Facilities. Journal of Correctional Health Care 20 (2); 127-134.

Yu, S-s. V., Sung, H-E., Mellow, J., Koenigsmann, C.J. (2015) Self-Perceived Health Improvement Among Prison Inmates. Journal of Correctional Health Care 21 (1); 59-61. 

Photo credit: © bahrialtay– Fotolia.com

Vital Signs: Essential Tool or Task?

Stethoscope green colorMr. Phillips is a 48 year old inmate with a history of schizophrenia who was admitted to the facility psych unit a week ago because of refusal to eat and potential for self-harm. On morning rounds, the nurse reports that his blood pressure is low (98/51 mmHg), although all of his other vital signs are within normal limits and he does not have any particular complaints. The primary care provider is contacted and asks that his vital signs be monitored closely. The provider is concerned that Mr. Phillips is dehydrated and asks that drinking water be readily available to him. During the remainder of the day he keeps to his cell and does not take any meals. That evening his vital signs are normal except for blood pressure, which is 88/51 mmHg. The night nurse makes a summary chart note at the end of the shift that Mr. Phillips appeared to sleep without complaint or distress. A few hours later he is found lying in bloody feces and barely responsive to verbal stimuli.

Florence Nightingale said “But if you cannot get the habit of observation one way or other, you had better give up the being a nurse, for it is not your calling, however kind and anxious you may be.” In this case example, the provider asked that Mr. Phillips’ vital signs be monitored closely and yet over the next 20 hours nursing staff only take them once. Taking vital signs is an independent nursing intervention (it does not require a provider order) and is considered an essential tool in the collection of information used by nurses to assess and monitor health status.

Monitoring of health status is described by the Institute of Medicine (IOM) as an important aspect of what nurses do in caring for patients. Monitoring or patient surveillance is defined as purposeful and ongoing collection, interpretation and synthesis of data for clinical decision making with the goal of early identification and prevention of potential problems. The practice includes skill in the use of monitoring devices to measure temperature, pulse, blood pressure, respiration, tissue oxygenation and neurological status. It also includes thinking critically about possible reasons for changes in a patient’s vital signs, to think beyond the obvious in constructing a diagnosis, then formulating a plan and intervening to achieve the identified patient outcomes.

In the correctional setting, the nurse is the initial and primary link a patient has to access care for medical and mental illnesses. Utilization of nursing process, including comprehensive assessment is critical to good patient outcomes in the correctional setting. The first practice standard is that correctional nurses collect comprehensive data in a systematic and ongoing process, using appropriate tools and techniques and then synthesizes the data to construct a coherent whole to plan, provide and direct subsequent care (ANA 2013, White & O’Sullivan 2012).

The function of using vital signs to monitor a patient’s physiological status is among the first subjects taught in nursing school along with the development of skill in using various measurement tools and techniques. However the ability to synthesize the information and come to a clinical judgment requires exposure to many clinical situations and the knowledge garnered from experience. It is only from reflection on clinical experiences that the expertise to form a nursing judgment develops (Rathbun & Ruth-Sahd 2009).

The patient safety and quality improvement literature have emphasized development of early warning systems using numerical parameters set for abnormal vital signs to help identify patients whose physiological status is deteriorating during hospitalization (Whittington et al. 2007). Reasons for establishment of these systems are that nurses fail to detect deterioration in patients because they don’t take vital signs as frequently as they should, nurses wait to take vital signs only when they recognize that the patient is deteriorating and they are overly reliant on their experience to alert them when a patient’s condition is deteriorating (Bunkenborg et al. 2012).

All three of these reasons played into the failure to recognize earlier deterioration of the patient in the case example at the start of this post. The next three posts will address best practices for taking vital signs, the interpretation and synthesis of data collected from vital signs and the concept of clinical triggers in patient care. In the meantime take a moment to conduct your own audit and reflect on the use of vital signs in your setting. Here are some questions to get you started:

  1. Are vital signs treated as a tool or a task?
  2. When do you take vital signs and why?
  3. When do you delegate taking vital signs?
  4. What is the significance of the information collected and how is patient care impacted?

For more on the professional practice of nursing in the correctional setting get a copy of our book Essentials of Correctional Nursing. If you order directly from the publisher you can get $15 off and free shipping. Use code AF1209.

References:

American Nurses Association (2013) Correctional Nursing: Scope and Standards of Practice (2nd Ed.) American Nurses Association. Silver Spring, MD.

Bunkenborg, G., Samuelson, K., Åkeson, J., Poulsen, I. (2012) Impact of professionalism in nursing on in-hospital bedside monitoring practice. Journal of Advanced Nursing 1466-1477.

Nightingale, F. (1860) Notes on Nursing: What it is, and what it is not. D. Appleton and Company, New York.

Page, A. (Ed) (2004) Keeping Patients Safe: Transforming the Work Environment of Nurses. Institute of Medicine. The National Academies Press. Washington, D.C.

Rathbun, M. C. & Ruth-Sahd, L. A. (2009) Algorithmic tools for interpreting vital signs. Journal of Nursing Eduction. 48(7): 395-400.

White, K. M. & O’Sullivan, A. (Ed.) (2012) The Essential Guide to Nursing Practice. American Nurses Association. Silver Spring, MD.

Whittington, J., White, R., Haig, K.M., & Slock, M. (2007) Using an automated risk assessment tool to identify patients at risk for clinical deterioration. The Joint Commission Journal on Quality and Patient Safety 33(9): 569-574.

Photo credit: © pakphoto Fotolia.com