What’s new and news

Speaker at Business Conference and Presentation.First: What is new with Ebola since the last post? Another nurse from Texas and a doctor in New York are infected. The Centers for Disease Control has held two teleconferences with nurses across the country and issued revised infection control guidelines to prevent transmission of Ebola to health care workers. Also last week the American Jail Association disseminated guidelines developed by two jails in and around Dallas where the first case in the United States originated. I hope you have reviewed and perhaps revised your communicable disease screening and identification procedures as well as the availability and use of personal protective equipment consistent with these new recommendations.

NCCHC Fall Conference: Celebrity Chef Jeff Henderson was the key note speaker at the fall conference took place in Las Vegas last week. Henderson got his GED and learned culinary skills while serving a nine year sentence in Federal prison for drug dealing. Once released he continued to develop his culinary skills, eventually becoming Executive Chef at Café Bellagio and Caesar’s Palace in Las Vegas and writing four self-help books including his autobiography, ‘Cooked’. Now he works with young people to provide alternatives to getting involved in the illegal drug trade and is a motivational speaker. He has appeared on The Oprah Winfrey Show, Good Morning America, The Montel Williams Show, CNBC, NPR’s All Things Considered, People and USA Today.

My favorite of all the stories he told was about buying all the top ramen noodles he could afford from the prison commissary. He wasn’t interested in the noodles which he passed out to everyone on the cell block who wanted some. Instead he wanted the seasoning mix that was included with the noodles. As head chef, he used these to spice up the cheese wiz to make his nachos, now famous in prison lore. Jeff Henderson was a young man in prison when he read his first book, was called “son” for the first time, and had someone acknowledge something that he did well in school. He has a great message about self-help and a convincing perspective for all of us involved in the criminal justice system.

Here is a recipe from Cooked (pages 163-164). When Jeff makes fried chicken he still uses this recipe from Friendly Womack, who was the chief inmate cook at the federal prison outside Las Vegas when Jeff was serving time there.

Friendly’s Famous Buttermilk Fried Chicken

2 tablespoons cayenne pepper                                 2 teaspoons onion powder

3 tablespoons black pepper                                        4 tablespoons kosher salt

2 cups all-purpose flour                                                 1 quart buttermilk

1 chicken cut into eight pieces

  1.  Mix all of the spices together in a bowl. Put half the seasoning mix in another bowl. Add the flour to one bowl, mix well and set aside.
  2. Rub the chicken with the reserved spice mix. Poke all the pieces with a fork a few times and set aside. (Friendly taught me to pierce the chicken pieces with a fork so the buttermilk seeps down into the bird.)
  3. Pour the buttermilk into a stainless steel bowl. Add the remaining spices and the chicken pieces. Cover the bowl with plastic wrap and refrigerate for an hour.
  4. Dip the chicken pieces into the seasoned flour, pat the pieces together and make sure they are heavily coated.
  5. Drop them into a deep fryer or in a deep pan with enough vegetable oil to cover the chicken. Turn the chicken as it browns and remove once done.

News about the doings of contributing authors: Authors who contributed to Essentials of Correctional Nursing were also prominent during the NCCHC Conference. Margaret Collatt and Sue Smith gave a presentation about a project to develop guidelines for correctional nurses in chronic care management. In addition to Margaret and Sue, the group working on this project includes:

Sue Lane, RN, ASN CCHP                              Susan Laffan, RN CCHP-A CCHP-RN

Pat Voermans, MS, RN, ANP, CCHP-RN Patricia Blair, PhD, LLM, JD, MSN, CCHP

Lorry Schoenly, PhD, RN, CCHP-RN          Sabrina McCain, RN, ASN CCHP

Lori Roscoe, PhD, ANP-C, CCHP-RN          Debbie Franzoso, LPN, CCHP

They have two guidelines in development right now. One is on management of hypertension and the other concerns seizure disorders. The presenters encouraged nurses to participate in this process by commenting on the format for the guidelines and the topics that are important to correctional nurses. Watch for more news about this important project.

Mary Muse gave two presentations that serve to inspire the practice of correctional nurses. One was from the ANA Nursing Scope and Standards of Professional Practice on two steps in nursing process: Implementation and Evaluation. She used two case examples which always help to make standards real in their application to our daily practice. She also presented a session on the Transformation of Nursing Leadership reminding us of the challenges and expectations for nurses with the change resulting from the Affordable Care Act and the report from the Institute of Medicine (IOM) on the Future of Nursing.

Margaret and Susan Laffan teamed up to give four presentations throughout the conference. These included sessions on the cardiovascular examination, understanding lab values and critical thinking as part of nursing process. As usual with these two presenters, the sessions were full of practical information, fun and door prizes as well.

Margaret and Susan joined with Sue Medley-Lane for a session on Rejuvenation of Nursing Spirit. For Susan Laffan, rejuvenation comes when she dons her pink fuzzy slippers which you will sometimes see her smoozing around the conference in. These presenters discussed the demands of life that can contribute to a loss of spirit and ways to mitigate the cumulative effect of these experiences. They asked correctional nurses to tell the stories and describe the experiences that have inspired their commitment to the field and will collect these and send the collection back out to participants. If you have a story or experience that has been your inspiration for correctional nursing send it to njjailnurse@aol.com by November 30, 2014. The story must include your name, your state and your email address. It should be no more than 300 words long and the names of any patients in the story should be changed.

If you have some ideas about what you think the guidelines for nursing management of chronic care should include or subjects that should be covered please respond in the comments section of this post. If you have an inspirational story about correctional nursing that you would like to share please send it to Susan Laffan at njjailnurse@aol.com by November 30, 2014.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Ebola: Another Look at Infection Control

EbolaA colleague of mine from Dallas, Texas mentioned on a phone call last week how busy things were in the health care industry with the death of Mr. Duncan from Ebola. Now that Nina Pham, a nurse who cared for him has Ebola, I imagine things have heated up even more. Another nurse in Spain has been infected as well after caring for a patient with Ebola. I’ve also seen one report of a jail in Wisconsin that has a detainee under medical surveillance for Ebola symptoms because she recently arrived from West Africa.

People worry about infectious diseases especially when it is a new and threatening disease, even when the risk of infection seems remote. Nurses are a trusted resource and often the first person staff and inmates seek information from about an infectious disease and what can be done to protect themselves. The next several months will be an opportunity for correctional nurses to shine in providing accurate information and advice about Ebola and infection control more generally.

Health teaching and promotion is one of the American Nurses Association (ANA) practice standards for correctional nurses (2013). The competencies for health teaching and promotion include:

  • Addressing a variety of topics that reduce risk and promote health.
  • Using teaching methods appropriate to the situation and the audience.
  • Seeking feedback and evaluation of the effectiveness of teaching strategies used.
  • Using information technologies to communicate information.

Here are five tips to use in providing health information about Ebola for staff and inmates at your correctional facility.

  1. Give credible information. The Centers for Disease Control (CDC) is going to be your best resource. Here is the link to the CDC web page which includes the latest news and advice for hospitals as well as community settings. Another resource is the local health department for your area. It is not uncommon for people to bring forward concerns or information that is contrary to your information or advice. The best approach here is just to cite your sources and ask that those with opposing information cite theirs so that individuals can make up their own minds after considering the information they have received.
  2. Give concrete suggestions about what to do. People often feel helpless and vulnerable in the face of a disease that they know little about. Suggesting concrete steps that can be taken goes a long way toward reducing the fear and anxiety associated with an unknown risk. You might suggest, for example, looking up one of your references or giving people a resource site to go to. Another suggestion might be for someone to assess their knowledge and skill in hand hygiene or use of personal protective equipment.
  3. Reinforce the information already known about infection control. Ebola is spread by direct contact with infected body fluids. We know that prevention measures are to use standard, contact and droplet precautions when caring for someone with an infectious disease transmitted by direct contact. Emphasize the measures that are already in place at your facility to protect staff and other inmates from transmission by direct contact.
  4. Link new information to past efforts and successes. The concern and anxiety about a new infectious disease can be reduced if staff and inmates can see a link to other successes with infection control practices in everyday life.
  5. Look for allies to help spread the word. If you can demystify the disease, people will feel less victimized by the unknown and uncontrollable and ready to take the steps they need to in protecting themselves. When non-medical personnel at a correctional facility embrace the facts about Ebola and the steps to prevent transmission you have mastered control of the infection. Often getting an organization to this place is jump started when a member of the custody staff becomes a spokesperson about the disease. Invest time in sharing information with interested custody staff and they will help carry the message. The same is true for inmates; often peer educators are more effective than professionals in getting important health information across to others.

Two more thoughts about how as correctional nurses we can prepare for the Ebola virus:

  • Even if the possibility of the disease presenting at your facility may seem remote ask what can be learned from it about the infection control practices you have in place. For example, the nurse in Dallas is hypothesized by CDC to have become infected as a result of a breach in infection control practices. We all know how routine infection control practices are part of the daily routine so ask yourself if there are breakdowns you may not be aware of? It is a good time to audit infection control procedures to ensure that identification and prevention measures are up to date and intact.
  • Keep up with information about the disease and what is recommended in relation to infection control. Our hearts go out to the nurse, Nina Pham; and we want to learn everything we can from her experience so we can protect ourselves. The CDC is investigating the infection control practices she used and it will be important for every nurse to incorporate what we learn into our own practice.

The CDC is sponsoring a teleconference for health care professionals on preparing for Ebola October 14 and the ANA has a resource page about Ebola for nurses. What advice do you have for correctional nurses about how to respond to questions about Ebola virus? Please share your advice by responding in the comments section of this post.

For more on standard, contact and droplet precautions see Chapter 10 Infectious Diseases written by Sue Smith in the Essentials for Correctional Nursing. She also discusses the role of correctional nurses in providing information and education about infectious disease. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo credit: © kentoh – Fotolia.com

Communication is at the Heart of Delegation

tonometer and heartOne of our colleagues, Gayle Burrow, commented last week that “Of the 5 Rights of Delegation the one that is most often missed is communication. Everyone gets busy during the shift and updating each other on the patients’ changes is left for the end of shift.”   This is so true and the result often is an adverse event, compromised patient safety or decreased quality of care.

Detailed and timely communication between registered nurses and delegated personnel has been linked to improved patient outcomes and higher quality measures. Negative patient outcomes (i.e. medication errors, patient falls and failure to rescue) were linked to brief, non-specific or infrequent communication (Corazzini et al. 2013, Bittner & Gravlin 2009).  In a review by the Joint Commission communication issues were the most common cause of deaths related to delays in treatment and the third highest root cause of all sentinel events (O’Keeffe & Saver 2013). Communication is the most influential of the five rights of delegation in shaping quality and patient safety outcomes (Anthony & Vidal 2010).

Characteristics of Information Communicated by Nurses

The type of information we communicate to other nurses and assistive personnel is complex and multifaceted. Some of this information is objective and discrete, like the results of recent blood work. It lends itself easily to written communication that can be easily retrieved from a chart or report. Other information is tacit or contextual and requires description or discussion; it is not so easily documented in a way that is meaningful to others.  The value of a specific bit of information (a change in vital signs for example) decays over time. If information is not conveyed timely it may be too late to intervene proactively or it may be inaccurate because the patient’s condition has changed. When the meaning or importance of information can be interpreted in more than one way miscommunication can occur. For example, a nurse seeing patients during sick call says to an assistant, “Please get a blood sugar on this inmate.”  The assistant, who does not know the patient’s condition the may interpret this request to mean right now or instead may schedule the inmate to return diabetic line which takes place in the next couple hours. Also each time information is handed off from one care provider to another some portion is lost, missing or forgotten. This can result in inadequate surveillance and failure to recognize a patient’s deteriorating condition (Anthony & Preuss 2002, Anthony & Vidal, 2010).

Standards of Professional Performance

The National Council of State Boards of Nursing (NCSBN) define the right communication as that which clearly and concisely describes the delegated task, how the task is to be done, the timing and nature of observations to be made (2005). According to the American Nurses Association (ANA), delegation communication should be respectful, timely and include a rationale that gives the task meaning. Good communicators demonstrate these behaviors:

  • Assesses the effectiveness of their communication
  • Actively works to improve communication skills
  • Desires to improve interpersonal relationship
  • Actions are consistent with words
  • Clear about the role of self and others
  • Candid, without partiality and unbiased (O’Keeffe & Saver 2013).   These behaviors are included in the competencies for the standard on communication in the ANA’s Correctional Nursing: Scope and Standards of Professional Practice (2013).

Strategies, Tools and Techniques to Improve Communication 

Various tools have been developed to support and improve communication in health care delivery. Among these are standardized communication formats such as SBAR and use of checklists which Lorry has written about on correctionalnurse.net. Use of these tools in combination with mindfulness have been shown to improve communication regarding patient care (O’Keeffe & Saver 2013). Mindful communication is characterized by authenticity, awareness, self-reflection and candidness. It involves more than just communicating the facts; it includes the rationale or how the facts pertain to the patient.When nursing personnel experience effective communication, the likelihood of sharing appropriate and timely information in the future increases (Anthony & Vidal 2010).

Clear, concise and complete communication is at the heart of delegation. The outcomes of improved communication are increased staff satisfaction and better clinical outcomes for patients. Some concrete communication suggestions are:

  • Conscientiously appreciate that we need the help of others to deliver safe, high quality nursing care.
  • Use kind words such as “please”, “thank you” and “good job”.
  • Be approachable and make eye contact; be aware of your body language and facial expressions.
  • Teach and don’t blame; give constructive feedback.
  • Speak the truth but speak it gently.
  • Identify checkpoints for communication that can occur throughout the shift.
  • Listen without interruption.
  • Allow time for the other to respond, ask questions or clarify (Ray & Overman 2014).

Do you have an example of an effort to improve communication among health care providers that contributed to better patient care outcomes? Let us know about the techniques or strategies you have used to improve communication when delegating care by responding in the comments section of this post.

For more on nursing delegation read Chapter 17 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1402 for $15 off and free shipping.

References:

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Professional Practice. American Nurses Association. Silver Spring, Maryland: Nursingbooks.org.

Anthony, M.K. & Vidal, K. (2010) Mindful communication: a novel approach to improving delegation and increasing patient safety. Online Journal of Issues in Nursing. 15 (2) 2.

Anthony, M.K. & Preuss, G. (2002) Models of care: the influence of nurse communication on patient safety. Nursing Economic$. 20 (5): 209-215, 248.

Bittner, N.P. & Gravlin, G. (2009) Critical thinking, delegation, and missed care in nursing practice. Journal of Nursing Administration 39 (3): 142146.

Corazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.

National Council of State Boards of Nursing. (2005). Working with others: a position paper. Accessed 2/11/2014 at https://www.ncsbn.org/Working_with_Others.pdf

O’Keeffe, M. & Saver, C. (2013) Communication, Collaboration, and You. American Nurses Association. Silver Spring, Maryland: Nursingbooks.org.

Ray, J.D. & Overman, A.S. (2014). Hard facts about soft skills. The American Journal of Nursing. 114 (2): 64-68.

Photo credit: © Alexander Raths – Fotolia.com

International Perspectives on Nursing Practice within the Criminal Justice Setting

Globe International World FlagsLorry, Pat Voermans and I gave a presentation about the new edition of the ANA Correctional Nursing: Scope and Standards of Professional Practice at the 13th Biennial International Conference on the Nurse’s Role in the Criminal Justice System in Saskatoon, Saskatchewan earlier this month.  Standards for nurses practicing in correctional settings in the United States have been available since 1985 (Schoenly, 2013).  If you are interested in learning more about the new ANA Scope and Standards, an earlier post described these in detail. In the discussion after the presentation we learned a lot about the role of correctional nurses in other countries and the standards that guide their practice.  To bring back some of the international flavor we experienced, here is a description of how correctional nurses in the United Kingdom (UK) are supported in their practice.

The Royal College of Nursing (RCN) has established principles of nursing practice that apply to all settings in the United Kingdom (UK), including criminal justice settings. The Royal College of Nursing is similar to the American Nurses Association in that it is a membership based professional nursing organization that also represents nurses in collective bargaining.  In addition, the organization is committed to making patients, their families, colleagues and the general community aware of what to expect from professional nurses and so the principles have been widely disseminated.  The Principles of Nursing Practice promote these concepts:

  • Dignity
  • Accountability and partnership
  • Managing risk
  • Empowering patients
  • Communication and information governance
  • Evidence-based practice
  • Inter-professional working
  • Leadership in nursing practice

The Criminal Justice Forum is a committee within the Royal College of Nursing that addresses issues regarding nursing practice in criminal justice settings. The Royal College of Nursing has developed additional guidance for correctional nurses in applying the principles listed above to their practice.  In 2012 the group decided to build an online resource that details the application of the eight principles in criminal justice settings.  The website is described as a “one stop shop” for busy nurses in the field to access key information and best practices. The varied roles of nurses in the criminal justice system have been described and each principle has been referenced to a corresponding practice code or regulatory standard. For each standard a list of key websites and publications for nurses working in criminal justice settings is included.

Among the best practice examples of nursing in criminal justice settings are: a program developed to help offenders manage anxiety, guidance on aging and dementia in prison, a toolkit for older offenders,  a nurse led walk-in center for primary care, advice on caring for women with complex needs, and adaptation of a model for transitional care to a prison population. These best practice resources really showcase the incredible influence nurses have in caring for prisoners in the UK.

If you are interested in another country’s perspective on correctional health care and correctional nursing you only need to go to the RCN web site!  Chapters 1 and 19 in the Essentials of Correctional Nursing provide more information about the organizations that are contributing to the specialty of correctional nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

References:

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

Royal College of Nursing. (2009) Health and nursing care in the criminal justice services: RCN guidance for nursing staff. Royal College of Nursing. London Accessed 10/15/2013 at http://www.rcn.org.uk/__data/assets/pdf_file/0010/248725/003307.pdf

Schoenly, L. (2013) Chapter 1: The Context of Correctional Nursing.  In L. Schoenly & C.M. Knox (Eds.), Essentials of Correctional Nursing (pp.4). New York, NY: Springer Publishing

Photo credit: © niroworld-Fotolia.com

Healthy Workplace = Quality + Patient Safety

Regulation of professional nursing practiceA few weeks ago we summarized features in the new edition of the Correctional Nursing: Scope and Standards of Practice (ANA, 2013).  The scope and standards are described first, as the foundation for professional nursing practice regulation because they define the specialty for nurses as well as the public. The are broad statements about the practice of the profession that transcend geographic location, type of employer and population served. The nurse practice act in the jurisdiction where the nurse is licensed provides the second level of specificity and guidance related to practice.  The employer, organization or institution  provides the third level of specificity by establishing policies, procedures and a work environment that supports professional nursing practice.  The final level in the regulation of professional nursing practice is the individual nurse who is responsible and accountable for their competence and nursing decisions (White & O’Sullivan, 2012).  This description is depicted in the diagram on the left of this post.

There is a strong link between work environments that support professional nursing practice, quality of care and patient safety.  The American Nurses Association (ANA), The Joint Commission (TJC 2012), the International Council of Nurses (ICN 2007) and the American Association of Critical-Care Nurses (AACN) are organizations that have used evidenced-based research to develop resources and establish standards for the workplace that support quality and patient safety. What are the characteristics of work environments that support nursing practice?  The AACN standards align with the core competencies for health care professionals recommended by the Institute of Medicine (IOM). The AACN provides many resources on the web and so their six standards for the healthy workplace were selected to highlight along with examples here:

  1. Nurses are as proficient in communication as they are in clinical care. Examples of practices that improve nurses’ communication skills include nursing grand rounds, assistance to publish articles and present at conferences.
  2. Nurses are relentless in pursuit of true collaboration. Examples of practices that improve nurses’ skills in collaboration include the development of nurse to nurse collaboration such as rapid response teams, development of clinical practice protocols, and participation in CQI activities.
  3. Nurses make policy, direct and evaluate clinical care, and lead organizations. Examples of practices that support nurses’ participation in the development of policy and other aspects of organizational leadership include membership on interdisciplinary committees such as Pharmacy and Therapeutics (P&T), Continuous Quality improvement (CQI), Ethics and Infection Control and other committees responsible for guidance regarding clinical patients care.
  4. Staffing effectively matches patient needs and nurse competencies.  An example of this are systems that acknowledge nurses for clinical expertise in direct patient care by rewarding advancement in clinical education and certification.
  5. Nurses are recognized and recognize others for the value they bring to the organization. Examples of practices that support meaningful recognition include clinical ladders, identification of expert nurses and publication of nurse’s advancement clinically.
  6. Nurse leaders authentically live and engage others in the achievement of a healthy work environment. Examples of practices that support authentic leadership include participation in key decision making forums, access to essential information and the authority to make necessary decisions regarding the professional nursing workforce (AACN, 2005; Vollers, et.al. 2009).

One of the distinguishing features of correctional nursing and indeed one of the challenges in the practice of correctional nurses is that prisons, jails and other correctional facilities do not have a health care mission but instead a mission of safety and security. A major role for correctional nurses is to negotiate with the correctional environment to support appropriate patient care delivered in ways that are consistent with the standards for professional practice. In order to support professional practice nurses must be knowledgeable of the state or licensing jurisdiction’s nurse practice act as well as the characteristics of work environments that are linked to quality patient care and patient safety such as the AACN described here.

What successes have you experienced supporting professional nursing practice while negotiating the differences in the mission of the criminal justice system and the delivery of health care?  Please share your experiences by writing in the comments section of this post.

For more on the topic of environments that support professional nursing practice in the correctional setting see Chapters 4, 17 & 19 of the Essentials of Correctional Nursing. The text can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

References and Resources:

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

White, K., O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD.

International Council of Nurses (2007) Positive Practice Environments: Quality Workplaces=Quality Patient Care. Geneva (Switzerland): International Council of Nurses. Accessed 6/10/2010 at http://www.icn.ch/images/stories/documents/publications/ind/indkit2007.pdf

American Association of Critical-Care Nurses. Accessed 6/10/2013 at http://www.aacn.org/wd/hwe/content/resources.content?lastmenu=#articles

The Joint Commission. Improving Patient and Worker Safety (2012).  Accessed 6/10/2013 at http://www.jointcommission.org/improving_Patient_Worker_Safety/

The American Nurses Association.  Accessed 6/10/2013 at http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment

Photo Credit:  American Nurses Association Model for Regulation of Professional Nursing Practice

The New Scope and Standards of Practice for Correctional Nursing

NSPS'10_Fig 4  Nursing Process  StdsOn May 27, 2013 the American Nurses Association (ANA) published the new edition of Correctional Nursing: Scope and Standards of Practice (2013).  These are broad parameters defining our specialty area of practice that transcend geographic location (south, east, west, midwest), type of employer (public/private, jail, prison, detention center), and the various populations served in correctional health care (sentenced, unsentenced, juvenile, female etc.).  The standards define who, what, where, when, why and how of nursing practice (ANA, 2010, p.2). The ANA standards are used 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

Correctional nursing was first acknowledged as a specialty practice by the ANA in 1985. At that time, the first standards for the specialty were published as: Standards of Nursing Practice in Correctional Facilities. Since 1985 the standards for correctional nursing have been revised four times.  This revision was the result of collaboration among seventeen correctional nursing leaders representing various settings and organizations. Input from correctional nurses was sought at various conferences, by survey, and during a public comment period over a period of eighteen months. The input from practicing nurses was incorporated into the description of the scope of correctional nursing practice.

Patricia Voermans MS, RN, APN, CCHP-RN, chairperson of the task force described this edition as “expanding the description of the patient population and addressing the challenges of delivering evidenced based care in the correctional setting.  It also discusses the evolving role of nurses in coordinating care, developing policy and continuing leadership in correctional health care” (April 22, 2013).

Correctional nursing is defined 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, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system” (ANA, 2013).  It is the location of nursing care, with its unique population demographics, environmental constraints and ethical dilemmas that defines our specialty practice (Voermans, Schoenly & Knox, April 22, 2013).

There are sixteen standards of correctional nursing practice in the new edition. The first six standards delineate the steps used in the nursing process. The next ten standards define the professional role of nurses in the correctional setting. This edition emphasizes the importance of communication and collaboration in the delivery of safe and effective patient care. The areas covered by the standards are listed in the table below.

Table 1: Scope & Standards of Practice for Correctional Nurses
     Practice      Professional   Performance
1. Assessment 7. Ethics
2. Diagnosis 8. Education
3. Outcomes Identification 9. Evidence-Based Practice and Research
4. Planning 10. Quality of Practice
5. Implementation 11. Communication
6. Evaluation 12. Leadership
13. Collaboration
14. Professional Practice Evaluation
15. Resource Utilization
16. Environmental Health

Correctional nursing: Scope and standards of practice. (2013). 2nd Edition. Silver Spring, MD: American Nurses Association.

Each standard is further defined by the competencies registered nurses and graduate-level prepared or advanced practice registered nurses (APRN) are expected to demonstrate in meeting the standard. Competency is defined as the integration of knowledge, skills, abilities and judgment needed to achieve an expected level of performance (White & O’Sullivan 2012). The registered nurse is responsible for maintaining professional competence and accountable for each of the decisions made in their nursing practice.

Standard 16 on Environmental Health is a new standard and requires the correctional registered nurse to practice in an environmentally safe and healthy manner. Environmental health is the assessment and control of factors in the environment that can potentially affect health.  Two of the competencies of the correctional registered nurse in this area of practice are:

  • Knowledge of environmental health concepts, with implementation of environmental health strategies.
  • Reducing environmental health risks for workers, patients, and others in the correctional setting.

To experience how the ANA standards are applied in day to day practice they have been interwoven into every chapter of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Copies of Correctional Nursing: Scope and Standards of Practice, 2nd Edition (2013) can be ordered from the ANA at http://nursesbooks.org/Homepage/Hot-off-the-Press/Correctional-Nursing-2nd.aspx. When you receive your copy of the new edition of the ANA standards one suggestion is to assess your competency to practice in conformance with each of the standards.  Select one or more areas that you would like to improve and develop a plan to do so.

We will share more about how to use the standards in correctional nursing practice in future posts.  In the meantime what experiences have you had applying the ANA Correctional Nursing: Scope and standards in your daily practice?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post.

References:

American Nurses Association. (1985). Standards of nursing practice in correctional facilities. Washington, DC: American Nurses Association.

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

Schoenly, L. (2013). Overview of Correctional Nursing. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. New York: Springer.

Voermans, P., Knox, C., Schoenly, L. (April 22, 2013). Correctional Nursing: Applying the New Scope and Standards of Practice. NCCHC Spring Conference 2013, Denver, Co. Accessed May 8, 2013 at http://ncchc.sclivelearningcenter.com/index.aspx?PID=4622&SID=172421

White, K., O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD.

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

Cultural Competency

CULTURE. Wordcloud illustration.Inclusion of a patient’s cultural preferences into the plan of care when at the same time the correctional setting demands that we be “firm, fair and consistent” in all our interactions with offenders is a distinguishing feature of correctional nursing. Weiskopf describes this feature as nurses negotiating the boundaries between custody and caring (2005).  Incorporating the patient’s cultural preferences into nursing care has been part of the ANA’s Corrections Nursing: Scope and Standards of Practice since the first edition in 1995 (2007, pg. 74).

Failure to address ethnicity, culture and language has been found to exacerbate health disparities and lower health care quality according to a recent Cochrane Review (Horvath 2011). Cultural and racial minorities are disproportionately represented in the corrections population. The health needs of these groups are discussed at length in the Essentials of Correctional Nursing.  In correctional settings inmates do not get to choose their health care provider and likewise nurses cannot pick their patients, therefore it is inevitable that challenges, misunderstandings and conflict resulting from diverse cultures will occur.

Cultural competence is the ability to effectively provide nursing care to patients from different cultures. Take moment to think about your experiences addressing patients’ cultural preferences when providing nursing care in the correctional setting. What successes would you like to share? Please write us in the comments section of this post?  The paragraphs below describe how to build cultural competency.

Self-Awareness: First we must become aware of how our own views may differ from others.  Mark Fleming, PhD., with the Missouri Department of Corrections, described this as “being willing to take a step on a journey of transformation…” in a recent interview with Lorry Schoenly at http://correctionalnurse.net/2012/09/07/multicultural-awareness-for-correctional-nurses-podcast/.  A starting place for this journey is to assess our cultural competence. One great resource was specifically developed for primary health care providers and can be accessed at www.nccc.georgetown.edu/features/CCHPA.html.

Communication: As we experience more diversity, the potential for conflict and misunderstanding increases and the ability to communicate effectively becomes even more important (Pearson, 2007). Effective patient-centered communication is characterized by:

  • an absence of assumptions
  • use of open-ended questions
  • active listening
  • expression of empathy
  • non judgmental words and behavior

What are the tools within the organization that support diversity? How do policies, procedures and clinical protocols support cultural differences and preferences for care?  Are qualified interpreters available for communication with patients?  Have staff been taught how to conduct an effective patient encounter when using an interpreter?  Are patient information materials culturally relevant? Communication tools that support culturally sensitive healthcare delivery can be accessed at https://www.thinkculturalhealth.hhs.gov/Content/communication_tools.asp.

Knowledge: Cultural competence is a dynamic rather than static process so one class in cultural diversity isn’t enough.  Understanding how illness is experienced by different cultural groups enables nurses to better tailor care for individual patients.  We may be able to leverage help from the ethnic and cultural resources at our facility and within the community to deliver health care that is more relevant and effective with particular patients. These resources may also be able to provide meaningful emotional and social support for the patient.    A free online course in culturally competent care specifically developed for nurses is available at https://ccnm.thinkculturalhealth.hhs.gov/ and offers 9 CE credits.

Summary:  My favorite tool is a list of 37 concrete things that demonstrate cultural competency in providing primary health care services. The list can be posted in the clinical area as a handy reference. It also can be used to compare against actual practice and then to build an improvement plan. This resource may be obtained at http://nccc.georgetown.edu/documents/checklist_PHC.html.   Read more about the cultural diversity and related health care needs of our patient population in the Essentials of Correctional Nursing.  Order your copy of the book directly from the publisher and use promotional code AF1209 for $15 off and free shipping at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

References:

American Nurses Association. (2007). Corrections Nursing: Scope & Standards of Practice. Silver Spring, MD: American Nurses Association.

Horvath, L. (2011) Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, (10)

Pearson, A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare. (5), 54-91.

Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada

Weiskopf, C. S. (2005). Nurses experience of caring for inmate-patients. Journal of Advanced Nursing, 49, 336-343.

Photo Credit: © Login – Fotolia.com

The Five Rights of Delegation

Question listThe post last week included a case example about a licensed practical nurse (LPN) responding to a medical emergency after an altercation between two inmates. The LPN determined that neither inmate required further medical attention. Later in the shift one of the inmates was taken to the emergency room after being found unresponsive in the cell. The inmate subsequently died of the head injury that was sustained in the altercation. This example highlighted the registered nurse’s role in the assignment and supervision of patient care. Correctional nurses use their knowledge of state regulations defining the scope of practice for personnel assisting in the delivery of patient care as well as the employers’ expectations (job description, post orders, policy and procedure) to assign and supervise these personnel.

The American Nurses Association (ANA) describes correctional nurses as responsible for direction of patient care including the assignment and delegation of tasks to others (2007). These responsibilities are unchanged in the draft of the 2013 edition of the Correctional Nursing: Scope and Standards of Practice which was posted at http://www.nursingworld.org/Comment-Correctional-Nursing.html.aspx. Delegation has been described as an essential skill and yet is one of the most difficult responsibilities of a registered nurse. It is a complex process that requires sophisticated clinical judgment about the patient care situation, the competence of staff and the degree of supervision required (Weydt, 2010; NCSBN, 2005).

There are many resources available to help nurses build skill and competency in delegation of patient care tasks. The state board of nursing is an excellent first resource as well as the National Council of State Boards of Nursing (NCSBN) website which can be accessed at https://www.ncsbn.org. A resource suggested in the Essentials of Correctional Nursing is a framework for delegation from the NCSBN referred to as the Five Rights of Delegation (1997). These are discussed in relation to the case example from last week’s post.

1. Right Task: The nurse makes an assessment of the patient or a group of patients and determines that an activity can be delegated to a specific member of the health care team. Knowledge of state practice acts and agency directives are essential when making decisions about what patient care tasks can be delegated. In the case example the registered nurse’s decision to have the LPN respond to the medical emergency was problematic because the LPN was required to assess and make a complex clinical decision about the inmate’s need for medical care.

2. Right Circumstances: The nurse’s assessment of the patient or group of patients also identifies the health care need(s) to be addressed by the delegated task(s) and the goal or outcome to be achieved. The nurse’s decision about which task(s) to delegate matches the staff’s competency and level of supervision available. The registered nurse in the case example did not assess the patient’s needs or identify the outcome to be achieved by the task that was delegated to the LPN. The nurse also made no judgment about what level of supervision or monitoring would be appropriate in the circumstance.

3. Right Person: The registered nurse considers the skills and abilities of individual personnel in making decisions about delegation of tasks. The registered nurse works with each member of the team to improve performance and implements remedies when performance is below standard. In the case example the LPN had considerable experience responding to medical emergencies at the correctional facility and had worked in the emergency department at the local hospital. The registered nurse did not understand that monitoring or supervision of the LPN’s performance was required as part of the state practice act and expected by the employer.

4. Right Communication: The registered nurse communicates specifically what, how and by when delegated tasks are to be accomplished. Communication includes the purpose and goal of the task, limitations and expectations for reporting. In the case example there was no meaningful communication that took place between the RN and LPN. The LPN was not expected to communicate assessment data to the nurse and no limitations on the LPN’s actions were stipulated. The LPN reported the conclusion that both inmates were “okay” but was asked no follow up questions by the RN to amplify the basis for the decision. The LPN did not communicate with the registered nurse when the inmate was later found unresponsive even after the “on call” physician was called.

5. Right Supervision: The registered nurse monitors and evaluates both the patient and the staff’s performance of delegated tasks.  The registered nurse is prepared to intervene on behalf of the patient as necessary and provides staff feedback to increase competency in task performance. In the case example the RN had several opportunities to monitor the patient’s care and to intervene but failed to do so. The nurse was unaware of the responsibility to monitor and supervise the LPN in the performance of the delegated task. The nurse said that the LPN always provided the response to medical emergencies and did not think the RN could alter this “assignment”.

Conclusion of the Case Example: The agency policies, procedures and the description of job duties were consistent with state practice guidelines but were too general. The nurses were not familiar with the nurse practice act and had simply continued practices on the evening shift that had been in place at the time, including staff defining the duties that they were most comfortable performing. The “after action” review resulted in increased staff knowledge of the nurse practice act, coaching of the nurses on delegation of tasks, and increased communication between staff on shift about the goals and process of patient care.

Your thoughts about this subject are important to us. Have you had experience clarifying nursing scope of practice in correctional health care?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

References:

American Nurses Association. (2007). Corrections Nursing: Scope and Standards of Practice. Silver Spring, MD: Author

National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

Weydt, A. (May 31, 2010). Developing delegation skills. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 2, Manuscript 1 

Photo Credit:   © igor– Fotolia.com

Scope of practice, assignment and delegation of patient care in the correctional setting

Care teamIt is a weeknight shift at a 2000 bed male medium custody correctional facility. The health care staff on duty consists of a registered nurse (RN) who is “in charge” of the shift, three licensed practical nurses (LPN) and a clerk. The ten patients in the infirmary upstairs are cared for by a registered nurse, an LPN and a nursing aide.  A medical emergency is called following an altercation between two inmates and the assigned LPN responds to the housing unit. The LPN determines that the men involved are okay and each is taken to segregation. Later one of the men is found unresponsive in his segregation cell. The LPN calls the on-call physician who orders the inmate transported by emergency vehicle to the local hospital where he dies later of a head injury sustained during the alteration.

Were staff appropriately assigned and supervised on this shift? If the charge nurse asked your opinion about how the shift was managed what comments or advice would you offer? The nursing staff at the facility were so motivated by the experience that the “after action” review included consideration of the state nurse practice act. Nurse staffing and assignment practices at the institution were changed as a result.

Ambiguity in the scope of practice for practical or vocational nurses and unlicensed assistive personnel (UAP) as well as their supervision in patient care are among the most significant challenges of correctional nursing practice. This issue was first identified last spring when nurses discussed the draft revisions to the Corrections Nursing: Scope and Standards of Practice to be published by American Nurses Association in 2014. The problem was discussed more extensively at the National Conference on Correctional Health Care in October 2012. Correctional nurses are not alone in these concerns. The National Council of State Boards of Nursing, Inc. has documented wide variation among state practice acts and among employers in the scope of practice of vocational or practical nurses (2005).

A tragic patient outcome like the one described here can be avoided with attention to scope of practice, clear assignment and delegation and good communication between personnel.  The following are concrete steps that correctional nurses can take to begin to clarify and address concerns about patient safety related to the scope of practice of practical or vocational nurses as well as unlicensed assistive personnel.

1. Recognize that other personnel are necessary to achieve good patient outcomes. Correctional nurses are responsible for managing the health care of individuals who are incarcerated.  To do so nurses assign, direct and supervise others to ensure that appropriate, timely care is delivered as planned. These personnel may include other registered nurses, practical or vocational nurses, and unlicensed assistive personnel. The plan for delivery of care may also include emergency medical technicians and correctional staff. In hospice or palliative care programs inmate caregivers may be included as well. The support of these personnel enables the registered nurse to attend to more patients with complex care needs.  The registered nurse retains accountability for patient outcomes even when specific tasks of care delivery are the responsibility of others.

2. Be familiar with the scope of practice and regulations for registered nurses in the state where you are practicing. Correctional systems are not operated as health care organizations. Registered nurses must ensure that their practice is within the parameters allowed by state regulation because the correctional organization may be uninformed or naïve about the appropriate role or practice limitations of various health care personnel.  Also these regulations change so nurses should review the state practice act annually. Contact information for state boards is obtained at https://www.ncsbn.org/contactbon.htm.

3. Be familiar with the scope of practice and regulations of other personnel relied upon to deliver patient care in the setting.  In some states the nurse practice act also describes the scope of practice for practical or vocational nurses. It may also describe how and under what circumstances patient care can be provided by certified or unlicensed personnel. If not included in the nurse practice act, find and review other relevant information that defines the scope of practice for each of these types of health care providers allowed by state law or regulation.  The registered nurse needs this information to appropriately assign or delegate tasks to others.

4. Review the job description, policies, procedures and other written directives at your facility that delineate the roles and activities to be performed by health care personnel in the delivery of patient care.  This review is done to ensure that written directives of the agency are consistent with the state’s practice regulations and to identify more specifically how the nurse assigns, directs and supervises the delivery of patient care.  Any inconsistencies between the employer’s expectations and state law should be identified and clarified through the nursing chain of command.

Chapter 17 in the Essentials of Correctional Nursing describes the role of nurses in supervising and managing the delivery of patient care in the correctional setting and provides a case example for further discussion. Order your copy directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

General guidelines published by the National Council of State Boards of Nursing (1997) for the types of activities that can be performed by LPN/LVNs or UAPs include those which:

  • frequently reoccur in the daily care of a patient or group of patients
  • do not require the exercise of nursing judgment
  • do not involve complex or multidimensional nursing process
  • the results are predictable or carry minimal risk
  • use a standardized and unchanging procedure.

Do you have concerns about scope of practice and the role of LPN/LVNs or UAP in your work setting? Share your thoughts in the comments section of this post.

References:

National Council of State Boards of Nursing. (2005) Practical Nurse Scope of Practice White Paper. Retrieved December 26, 2012 from  https://www.ncsbn.org/Final_11_05_Practical_Nurse_Scope_Practice_White_Paper.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

Photo Credit: © Kurhan Fotolia.com

Reflective Practice: A Means of Professional Growth

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

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

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

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

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

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

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

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

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

Resources:

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

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

 

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