An overview of medication management in correctional settings

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The roles and responsibilities of correctional nurses for medication management are broader in scope than other practice settings. In health care settings many other professional and support personnel contribute to delivery of patient care.  However in correctional facilities nurses are relied upon to deliver care without the availability of these other types of personnel. The result is that correctional nurses often work in professional isolation and may feel like they are in a foreign country (Muse, 2012). I think traveling in a foreign country is a good analogy for correctional nursing. Doing this well involves preparation by learning something about the sights to see, building skill using a little of the language, familiarizing yourself with the rules, particularly which side of the road people drive on and finding out how to avoid being robbed or harmed in some way. The thrill of correctional nursing, like the thrill of foreign travel, comes when you realize how much you are enjoying it, especially the independence of professional nursing practice in this field. This post is the first part of a guidebook for your journey managing medication in correctional settings.

State law, rule and regulation

State law serves as the basis for nearly all of the practices and procedures involved in medication management. Most nurses are familiar with the nurse practice act in their state. If not, this is the place to start by reviewing it for definitions and references to medication. The nurse practice act will be especially helpful in describing the training and supervision requirements if non-licensed personnel, such as nursing assistants, administer medication at the correctional facility.

The pharmacy practice act is the most important resource to review. These laws will define how to obtain, store, dispense and account for medication which are often the responsibility of nurses when there is no pharmacist on site.  Even if there is a pharmacist at the facility, being familiar with the law that governs their practice is helpful in understanding the recommendations pharmacists make about drug storage, packaging of medications and accountability.

The medical practice act provides important information about how a physician’s order for medication is lawfully carried out. The medical practice act also has information about how medical assistants and paramedics work as well as the requirements for training and supervision which need to be followed if these personnel are involved in medication management.

This is not interesting reading but it does provide information that nurses can use in determining the responsibilities of personnel for medication management. It also provides definitions and terminology to accurately communicate with the pharmacy that provides medication to the facility and with providers about implementation of orders. Finally it provides nurses a basis to knowledgably resist inappropriate requests from custody and other personnel not familiar with health care laws to carry out tasks that are inconsistent with state law.

Accreditation standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are organizations which accredit correctional facilities for providing services and programs consistent with national standards. The standards are also used by most correctional facilities in developing policy and practices even if accreditation is not sought. Both organizations have standards related to medication management which are summarized in Figure 1. This list is a handy description of all the moving parts and pieces of medication management in correctional settings and nurses are involved in all of these components. This list can be used to review how medication management is handled at a facility and identify areas that may need attention.

Figure 1:   Standards for medication management in correctional facilities
NCCHC ACA
Applicable standards C-05, D-01, D-02 4-4378, 4-4379
1. Facility operates in compliance with state and federal laws regarding medications. Similar
2. There is a formulary and method to obtain non-formulary medication. Similar
3. Policy and procedures address how to procure, receive and account, dispense, distribute, store, administer and dispose medication. Similar
4. Medications are under control of appropriate staff and accounted for. Secure storage and perpetual inventory of controlled substances, syringes and needles.
5. Medication is only prescribed as clinically indicated after provider evaluation. Similar
6. Providers are notified of medication needing renewal prior to expiration. Similar
7. Staff are properly trained to administer or distribute medication. Similar
8. Inmates do not prepare, dispense, or administer medications. Self-carry medication programs are allowed.
9. There are no outdated, discontinued, or recalled medications at the facility.
10. If there is no on-site pharmacist, a consulting pharmacist is available for advice and makes inspections of the facility’s medication program at least quarterly.

Nursing standards

The American Nurses Association (ANA) has recognized correctional nursing as a specialized field of practice since 1995. The ANA publishes a reference that describes the scope and sets standards for the practice of correctional nurses. With regard to medication management the role and responsibility of correctional nurses is as follows:

  1. To be knowledgeable of medications administered, including dosages, side effects, contraindications and food and drug allergies.
  2. Practices with regard to medication management in the correctional setting meet the same standards as in the community. To do so nurses must be knowledgeable about state practice acts (as suggested earlier in this chapter).
  3. Ensure that patients know what medications they are taking, the correct dosage and potential side effects.
  4. If patients are expected to take medications without supervision the nurse evaluates the patient’s competence to self-manage and takes steps to protect those who are not competent to do so.
  5. Work with custody staff so that patients receive medication in a timely and safe manner (ANA, 2013).

This overview makes me reflect on my first experience with medication management in correctional nursing. I was being oriented to administer medications on the evening shift at a maximum custody men’s prison. A technician rolled a grocery cart filled with stock bottles of all kinds of medication out to me. The cart was full. In giving me the cart he said “You roll this along the tier and stop at every cell. Ask the inmates what meds they want. When you give them the medication then you record it on one of these index cards that has the medication listed at the top.” I remember being shocked and asked the technician why they did it that way. He shrugged his shoulders and went on with his tasks. While this experience is pretty extreme you might use it to review against the ANA nursing standards of practice, the accreditation standards and state law that were reviewed in this post and identify the inconsistencies. Being knowledgeable about the standards and requirements for medication management prevents erosion of professional practice and ultimately protects patients from harm.

Going back to the travel analogy, knowing state law, the national standards for correctional facilities as well as the standards of practice for correctional nurses is like having a guidebook to review the sights to see in place you have selected to travel to. These become a reference point to plan so you can make the most of your time as well as an expectation for what will take place while on your journey.

Is medication management a troublesome area where you practice correctional nursing? Have you looked at the problem through the lens of applicable state law, corrections standards and the nursing practice standards? If so, what have you identified as the problem areas? Please comment by responding in the comments section of this post.

For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

 

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Muse, M. (2012). Professional role and responsibility. In C. Schoenly L. & Knox, Essentials of Correctional Nursing (pp. 364-377). New York: Springer.

National Commission on Correctional Health Care. (2014). Standards for Health Services. Chicago: National Commission on Correctional Health Care.

American Correctional Association. Performance Based Standards for Correctional Health Care. Retrieved August 19, 2015 from http://www.aca.org/standards/healthcare/

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Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

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.

References:

American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at http://www.ada.gov/lawenfcomm.htm.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at http://www.ada.gov/hospcombr.htm.

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Nursing Sick Call Part 1: Receiving and Responding to Requests for Care

PRIGIONIERONursing sick call has been described as the signature practice defining the specialty of correctional nursing. There is no experience quite like sick call in any other area of nursing practice. Nursing sick call is considered the backbone of health care delivery in correctional settings because it is the primary way inmates can access health care during incarceration. In a recent interview Jessica Lee, Vice President for Nursing Support at Corizon commented that sick call is a barometer of the quality of the entire health care program in a correctional facility.

The manner in which inmates make requests for health care attention is the first step in the sick call cycle and the focus of this post. The ability to request health care attention is a fundamental right of persons who are incarcerated. The American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC) both have established standards which require that:

  • requests are received by health care personnel every day,
  • each request is evaluated within 24 hours of receipt and
  • there are no impediments to making requests for health care attention.

Seems pretty simple but compliance requires that correctional officers and nursing staff act in ways that are consistent with these standards in hundreds of encounters and interactions with inmates every day. So access to health care is a high volume, high risk activity in correctional health care. Correctional facilities can protect themselves from adverse patient events and litigation by developing policies, procedures, job descriptions and assignments that meet these standards. In addition it is important to verify that actual practices are consistent with the facilities policies and procedures through supervision and audit of staff performance. The following is a breakdown of the areas that need to be considered to ensure that your facility meets accepted standards for access to care.

Communication: The facility should have one or more ways established for inmates to make requests for health care attention. Inmates must be informed of this process at the time of admission to the facility. Common methods used to request health care attention are by filling out a request slip that is given to a health care provider, signing up on a list, showing up at a particular time, or calling to request an appointment. The next consideration is whether the selected methods are working. Pitfalls to an effective request process include not giving inmates this information at admission, inmates not understanding the process, not having a secure place to put written requests, not picking up written requests every day, forms that are too complicated to fill out, not having sufficient forms, not having access to the sign up list or use of the telephone, lock down or scheduling conflicts, and intimidation of inmates requesting care by other inmates or staff. Nurses should be assigned daily to review and assure that the method(s) used to request care are working. There should be documentation that provides evidence that requests for access to care may be made daily and that there are no impediments. Having the date on each request received, each list of inmate requests, or each walk-in encounter is the kind of documentation that provides this evidence.

Triage: Every request for health care attention must be evaluated within 24 hours of receipt. This evaluation is a form of triage used to determine when and how each request will be handled. Triage is a clinical decision made by licensed health care personnel. Triage requires use of the nursing process to assess the patient, diagnosis the problem, identify the desired outcome, plan and implement intervention(s) to achieve the identified patient outcomes. Simply reading a written sick call slip is not sufficient triage of a request that involves any description of a symptom based complaint. Any inmate submitting a written request for health care attention for a complaint that is symptom based must be evaluated in a face to face encounter within 24 hours of receipt of their request. With other methods for making requests (sign- up, telephone or walk- in) as long as nursing personnel evaluate each request within 24 hours the standards are met. Documentation includes the nurse’s evaluation as well as the date and time the patient was seen. Problems with nursing triage of inmate requests for health care attention include not performing triage seven days a week, not triaging every request received on a daily basis, using inappropriate personnel to perform triage, clinically inadequate triage, trying to talk patients out of needing to be seen, minimizing patient complaints or blaming the patient.

Disposition: The outcome of triage is the disposition or decisions made in response to the patient’s request. Dispositions include treatment, referral, patient education, and advice about self- care. Many times a single request will have more than one disposition decision. In addition to the decision about what is to be done the nurse also decides who will do it and by when. Each of these decisions, including by whom and when, are documented and dated. The nurse should explain the disposition to the patient so that they know what to expect and by when. Every nursing encounter should be considered an opportunity to education that promotes the patient’s engagement in their health care. Pitfalls in the disposition of requests for health care attention include poor clinical decisions, inadequate follow through or handoffs to responsible others, silos between programs and departments that result in disruption of care, and lack of patient understanding or agreement with the plan of care.

Monitoring: When requests for health acre attention are not received and acted upon in a timely, responsive and clinically appropriate manner the efficient operation of the health care program will be in serious jeopardy. Effects of insufficient access are increases in the number of inmate grievances, increases in requests for emergent health care attention and inmates will submit multiple requests for the same problem. Health care programs should track the timeliness, completeness and appropriateness of communication, triage and disposition of health care requests. Other aspects of access to care that should be monitored are the types of requests being made as well as the subject and frequency of multiple requests. This data helps to answer two questions: Is the system to access care working and are the responses clinically appropriate, responsive and timely?

Do the practices in place at your facility meet the standards for access to health care? How does the facility monitor access to health care? What is your role in ensuring that inmates have unimpeded access to health care during incarceration?

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

 

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An Experience with Moral Distress and its Resolution

ethical issuesSeveral weeks ago I attended a lecture given by a nurse midwife. She reviewed important information about how nurses support the health and wellbeing of patients who are incarcerated during pregnancy. The speaker was very engaging and provided clinically relevant, useful material.  At one point the speaker described the problems resulting from routine use of custody restraints to transport pregnant women.  She noted that the policy of the correctional organization where she provided services was that women were shackled even while in labor.  The speaker being familiar with the experience of women in labor, further commented that risk of escape or assault during this time was not likely.  She also indicated that she found it futile to try and change the correctional system’s practice regarding use of restraint during pregnancy. There are several organizations that recommend against routine use of shackles during labor and delivery. These include the American Corrections Association, the National Commission on Correctional Health Care, the American Congress of Obstetricians and Gynecologists, and the American Civil Liberties Union. No one contributed this information during the presentation. I could have but did not and my failure to act has since haunted me.

This is an example of moral distress, a condition experienced by many correctional nurses. Moral distress occurs when correctional nurses find themselves in situations where nursing values are jeopardized.  In correctional settings where shackles are used routinely in the transport and security of pregnant women nurses are witness to treatment that is not consistent with recommended standards of care and is therefore inhumane. To resolve the distress associated with ethical conflict correctional nurses can use moral reasoning to re-align their actions with professional nursing values. Here is a description of the steps discussed in Chapter 2 Ethical Principles for Correctional Nursing to resolve moral distress and how I used them to address the distress I experienced recently:

1. Assess the Situation: In a presentation made at a national conference an authority on the health care of pregnant women described a correctional system’s routine practice of using shackles during pregnancy, labor and delivery. This practice is not consistent with recommendations of several authoritative organizations. No one in the audience provided information about recommended practices. As a result, participants left the session ill-informed and therefore unable to advocate for change that will reduce risk of injury and prevent re-traumatization of women.

2. Identify Moral Problems: Two moral problems were identified. First, there is a prevailing body of literature that management of women during incarceration should be “trauma-informed” and not include use of custody restraint unless necessary. Therefore routine use of shackles causes harm to the patient and is not consistent with the value of human dignity. Second, the principle of social justice is that in the absence of evidence that that there is imminent risk to the safety of the patient, the infant or the public the criminal justice requirements should not outweigh considerations of human dignity.

3. Set Moral Goals and Plan Moral Actions: My goal is to speak up so that nurses and others in correctional health care and the criminal justice system know that limiting the use of shackles during pregnancy, labor and delivery is recommended.

4. Implement Moral Plan of Action: So far I have had two opportunities to speak up. Because I have identified the problem and set a goal I am also more aware of opportunities to share this information, advocate for and support efforts to change policy and practice.

5. Evaluate Moral Outcomes: The best outcome would bethat no system uses shackles on pregnant women unless there is some evidence of imminent danger to the mother, child or other people. Until then, one outcome is to bring the issue up whenever it is relevant to do so and to generate discussion about steps to implement practices that are more consistent with the recommendations.

Have you experienced moral distress?  I found the discussion of nursing values and ethics in Chapter 2 Ethical Principles for Correctional Nursing very helpful in identifying what bothered me so much about this experience. Even more valuable, though, was developing the action plan because taking thoughtful steps to do something different guarantees that it will not happen to me again. What steps have you found useful in resolving moral distress? Please tell about your experience by responding in the comments section of this post. To read more about how to resolve moral distress order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. Photo Credit: © Marek – Fotolia.com

Certification Journey: Determining What to Study

In an earlier blog post I discussed certification options for correctional nurses. Both Catherine and I are CCHP-RN certified through the National Commission on Correctional Health Care. We are pursuing CCN/M certification through the American Corrections Association (ACA) and will be sitting for the exam at the 2013 Winter Conference (Be sure to let us know if you will be there so we can meet!).

Now that I have completed the CCN/M certification registration and set an exam date, it is time to decide what to study. Every certification exam has an outline of content, sometimes called a test blueprint, that is used to determine the subject areas for evaluation. This blueprint also determines the amount of questions that will address the various subjects. A test blueprint is a good starting point for determining what to study for an exam. Many certification bodies publish their test blueprint in a public document. The CCN/M test blueprint is a private document provided only to accepted test applicants, once they have registered. However, a Certification Handbook with some preliminary information is available online.

The following general list of exam components was located on the ACA website:

  • Health Care in Corrections
  • Legal Issues in Corrections
  • Mental Health
  • Nursing Practice and Standards
  • Managing Security and Environment
  • General and Offender Management
  • Conflict Management
  • Human Resource Management

This general list is a good place to start. In addition, the ACA provides study materials in the online bookstore. However, we are testing out the ability to use our book, Essentials of Correctional Nursing, to serve as a study book for the certification exam, so I will only be using that text for my study materials.

Now I have one more thing to do to have everything I need to create a study plan. I need to prioritize the exam content so I spend the most time studying the material least familiar to me. Looking at the list above, here is my priority list with the top items requiring the most study time:

  • General and Offender Management
  • Legal Issues in Corrections
  • Mental Health
  • Human Resource Management
  • Managing Security and Environment
  • Health Care in Corrections
  • Nursing Practice and Standards
  • Conflict Management

Now I have everything I need to create a study plan:

  • Prioritized exam content
  • Selected study materials
  • Deadline for study completion

In my next certification journey post, I’ll tell you how I set up my study plan.

Preparing for the CCHP-RN or CCN/M Certification Exams? Order your copy of Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209  for $15 off and free shipping.

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