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

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