Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

A reader responds to our recent blog post on the Heavy Burden of Moral Distress. We hope you find this real-life example an encouragement that correctional nurses are speaking up when they have concerns about patient health issues in the criminal justice system.

The topic of moral distress among nurses is an elephant in the conference room of many healthcare organizations but at the core of conversations amongst nurses in the medication room.    A few typical statements made during these informal, ethically charged and expressive gatherings include; “It doesn’t’ do any good to tell anyone, they won’t do anything.” “It’s all about the bottom line.” “They don’t care how much more work they give nurses.” “Nurses who complain too much get fired.” “I need a job to so I can take care of my family.” “This is just the way it is, get used to it.”  Statements like these are made with such frequency today that moral distress could and should be viewed as an epidemic in nursing practice.  The following is a glimpse into the challenges some correctional nurses faced and how their quest and obligation as nurses to do the right thing put them on a path leading directly into the dark, lonely void of moral distress.

My Story

While working at a correctional facility, three nurses expressed their ongoing concerns to supervisors and administration about the well-being of inmates who were:

  • Not getting their prescribed medications for extended periods. This includes medications for chronic conditions, seizures and other serious illnesses,
  • Providers prescribing incompatible medications and refusing to change the order(s),
  • Providers documenting physicals on inmates they had not seen,
  • Stat and other critical orders not getting noted for days,
  • On-call providers not returning calls and,
  • Inmates with serious, potentially life-threatening conditions, being transferred without regard to maintaining some continuity of care.

A few nurses called the allegedly anonymous organization  “ Hot Line,” (nurses are encouraged to use these for reporting purposes) and voiced their concerns but to no avail.  Having exhausted all efforts to report their concerns internally they reached out to their local nursing organizations.  While these organizations provide invaluable services and support in many areas they were unable to provide immediate direction or tangible backing for these situations. They, like the nurses, were uncertain who they should and could turn to for support.

The onset of moral distress began when the first link in the organization’s chain of command broke because of  failed communications and after dismissing the nurses concerns with indifference.  The distress peaked when the nurses were terminated for doing the right thing. Terminated for doing what nurses are required to do, what we have vowed to do – complying with the Nursing Code of Ethics.

Nurses have taken an oath and are required to practice in accordance with the Nursing Code of Ethics which provides:

  1. A succinct statement of the ethical obligations and duties of every individual who enters the nursing profession.
  2. It is the profession’s nonnegotiable ethical standard.
  3. It is an expression of nursing’s own understanding of its commitment to society.

The sections applicable to the events being discussed are 3.4 and 3.5 as noted below:

Nursing Code of Ethics 3.4 “Standards and Review Mechanisms” 

Nurses must bring forward difficult issues related to patient care and/or institutional constraints upon ethical practice for discussion and review.

Nursing Code of Ethics 3.5, “Acting on Questionable Practice”

When a nurse chooses to engage in the act of responsible reporting about situations that are perceived as unethical, incompetent, illegal, or impaired, the professional organization has a responsibility to provide the nurse with support and assistance and to protect the practice of those nurses who choose to voice their concerns.

Reporting unethical, illegal, incompetent, or impaired practices, even when done appropriately, may present substantial risks to the nurse; nevertheless, such risks do not eliminate the obligation to address serious threats to patient safety.

Obligated to Speak

Nurses are obligated to bring difficult issues forward for discussion and review. We are duty-bound to report unsafe practices and or circumstances and must do so regardless of personal risk.  However, at the same time there is a responsibility to provide nurses with support and assistance when they do speak out. This is the crossroads where the path of moral distress becomes the loneliest and sometimes most frightening. It is alsothe time when a nurse needs support and encouragement the most. Unfortunately it is at this intersection that most nurses feel alone, abandoned, and with nowhere to turn.  This often becomes a turning point for nurses believing they must choose between speaking out or getting terminated; consequently many nurses make a silent and painfully emotional promise to never speak out again.  This forces nurses to overlook practices that not only put their patients at risk but their nursing license as well.  At this juncture moral distress has become an emotional pathogen.  Were it not for the support and encouragement of our patients and the public, many nurses would leave the profession.

Public Esteem

The public’s long-standing esteem for nurses is well documented in public opinion polls. Nurses rate high with the public in trended national survey questions about trusted professions, prestigious occupations, and “honesty and ethical standards.”  It is disheartening that organizations do not always see their nurses through the public’s eyes.  It is regrettable that even nurses don’t see themselves through the public’s eyes.  If nurses would stand together in our communities of practice perhaps we could begin a dialogue with our local nursing associations and employers to establish the support system illustrated in the Nursing Code of Ethics. Together we could address the circumstances and symptoms associated with moral distress at the onset and transform them into opportunities for change before nurses are forced to make that dreaded silent promise to keep quiet. Speaking out is included in the nonnegotiable ethical standards.

Would you be willing to speak out in a similar situation? Join the conversation with a comment.

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

Correctional Nurse Goals for 2015: Expand Your Knowledge

2015 goals on digital tabletHealth care is advancing at the speed of light. We are expected to apply current evidence to our practice and understand the new technologies, medications, and treatments that are being implemented. It can be difficult to merely keep from sliding backward as the treadmill pace ever increases under our feet. That is why my final suggestion for correctional nurse goals for this year is to expand your knowledge about your practice and keep up with the latest developments. Here are a few ideas to get you thinking about ways to improve your foundational correctional nursing knowledge and keep up with changes in nursing practice. Links are provided for easy purchase or subscription.

A Foundational Book Shelf

Every serious correctional nurse should have access to these texts as they are the basis for our specialty practice.

Specialty Periodicals

Journals and magazines provide updates to changing practice and information on movements in the industry.

Ongoing Information Updates

Digital sources keep us posted on day-to-day changes and news of importance to our practice. Although you could go out and regularly check information websites, but I favor sources that collect up the top items and send them to my inbox for scanning. Here are a few of my favorites.

  • Academy Insider – This free weekly email newsletter from the ACHP aggregates correctional health care news and items of interest for those in our field.
  • Medscape for Nurses – Keep up with research and information in the general nursing field with this weekly synopsis sent to your inbox.
  • ANA SmartBrief – Professional news from the American Nursing Association. Keep current on what is going on in our profession.

I’m sure I didn’t include all the possible places for you to gain knowledge and stay on top of changes in our profession and specialty. Share your favorite sources in the comments section of this post.

Photo Credit: © Marek – 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.

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Correctional Nursing Peer Review: What It Is and What It Isn’t

Frau mit Lupe vor dem GesichtAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the first in a 4-part series on correctional nursing peer review.

Peer review is a familiar program to providers (physician, nurse practitioner, physician assistant) as a means of evaluating the quality of care provision by individual practitioners. Nurses, however, can have difficulty applying this concept to their own clinical practice. The American Nurses Association’s (ANA) Nursing Peer Review Guidelines provides a definition and set of principles for the nursing peer review process that are applicable in the correctional setting.

What It Is

The original ANA definition of nursing peer review stands today as an appropriate description of the process:

“Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice”

Breaking down the components of this definition supplies key concepts for a nursing peer review program in corrections:

Practicing Registered Nurses

Peer review should be performed by nurses who are practicing in a similar context. Thus, it would not be appropriate to have critical care nurses evaluate the nursing care of correctional nurses or for emergency nurses to evaluate the care of neonatal nurses. Nurses practicing in a similar context understand the environment of care, the patient population, and the standard processes for accomplishing care that would not be familiar to a nurse from another context.

Assess, Monitor, Make Judgments

Peer review is an evaluative judgment about the actions of another staff member from the same profession. The primary objective is to determine the quality and safety of care provided by an individual staff member.

Nursing Care Provided

A major component of the definition of nursing peer review is that it is a judgment of actual care provided. This is often done as a chart review but could also be performed as direct observation. However, the evaluation is of actual nursing care provided rather than a nurse’s ability to provide care.

Measured against Professional Standards of Practice

Accepted professional standards of practice are used to determine the quality and safety of care in a peer review. These accepted standards should be known to all members of the peer review process. For correctional nurses, professional standards of practice can come from

  • ANA Correctional Nursing Scope and Standards of Practice
  • State Board of Nursing Practice Act
  • Accreditation Standards that Address Clinical Practice

What it Isn’t

There can be misconceptions about what constitutes nursing peer reviews. Based on the above defining qualities of a nursing peer review, these are not nursing peer review processes:

Annual Performance Evaluation

An annual performance evaluation is a judgment of an employee’s work as it relates to their hired status and job description. Although clinical practice is a part of a nurse’s job performance, it is often not the primary focus of the performance evaluation.

Nursing Competency Checklists

Competency checklists or skills reviews evaluate a nurse’s ability to perform various skills and functions. They do not evaluation actual nursing care provided.

Simulations Such as Man-Down or Disaster Drills

As with competency or skill evaluations, simulations such as man-down or disaster drills evaluate staff ability to perform in an emergency situation but do not evaluate actual nursing care in a real clinical situation.

Continuous Quality Improvement Projects

Continuous quality improvement projects look aggregately at clinical care provided while nursing peer review evaluates a specific clinician’s actual care provision.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Correctional Nursing: How to Improve the Practice Environment

Nursing background concept

The first examination of the qualities of professional practice in correctional nursing was done recently in Ontario, Canada. Conclusions from the surveys and interviews of 297 nurses and nurse managers were that the work environment was characterized as understaffed with significant role overload. These nurses also reported limited access to resources, significant autonomy but limited control over practice and experienced significantly higher levels of emotional abuse, conflict and bullying than nurses in other studies. The source of emotional abuse, conflict and bullying most often originated from custody staff followed by other nursing staff (Almost et.al. 2013a). These results support earlier publications about the practice challenges in correctional nursing including limited access to resources and education (Flanagan and Flanagan 2001, Maroney 2005, Smith 2005) , pressure to conform to the values of the custodial subculture (Holmes 2005), and challenges to clinical decision making authority (Smith 2005, Weiskopf 2005).

Reasons to improve the quality of the work environment include the ability to attract and retain nurses, increased productivity, improved organizational performance and better patient outcomes (Almost et.al 2013a, Sherman & Pross 2010, Dall et.al 2009, Needleman et.al 2006). Focusing on improving the professional work environment yields significant results even in the absence of increased staffing (Flynn et.al 2012, Aiken et.al. 2011, Friese et.al. 2008).

The following paragraphs discuss five factors in work environments that can be modified or enhanced to support professional nursing practice.

  1. Control over practice
    • Accurate interpretation and clarification of the state nurse practice act and its guidance in job descriptions, work assignments and policies and procedures (Knox, West, Pinney & Blair 2014, White & O’Sullivan 2012). Workplace directives should also incorporate or reference relevant aspects of the ANA standards of professional practice for correctional nurses (Knox & Schoenly 2014).
    • Work flow should be examined so that barriers to effective practice can be eliminated including system gaps that increase work complexity and work that is not related to patient care (Knox, West, Pinney & Blair 2014, Ebright 2010, Schoenly 2013). An example of the former is locating supplies used for nursing treatments in multiple locations. An example of the later is when nurses are expected to gather and report data on service volume or for quality assurance audits (number of sick call visits, number of clinic appointments, and number of incomplete MARs etc.).
    • Increase nursing participation on committees such as pharmacy and therapeutics, morbidity and mortality review, mental health, utilization review, and medical administration (Aiken et. al. 2011, Flynn et. al. 2012, Almost et.al. 2013a). Staff meetings also should be reviewed to see if meaningful two way dialogue can be increased to involve nurses in identification and early resolution of practice problems.
    • Consider assignment models that emphasize use of nursing process and clinical judgment rather than task completion; where registered nurses provide a greater proportion of direct care themselves while actively supervising care delegated to others (Corrazini et.al 2013a; MacMurdo, Thorpe & Morgan 2013). Staffing takes thoughtful preparation and legacy staffing practices may no longer work as complexity in health care delivery increases (Knox, West, Pinney & Blair 2013, Ebright 2010, MacMurdo, Thorpe & Morgan 2013).
  2. Autonomy in clinical practice
    • Considered one of the hallmarks of correctional nursing it is also an Achilles heel in the absence of appropriate clinical guidelines and support in their use (ANA 2013, Smith 2013, Smith 2005). Protocols should be based upon nursing process and coordination of care rather than reaching a medical diagnoses and rushing to treatment conclusions.
    • Nurses must be appropriately qualified and experienced in assessment and clinical reasoning as well as skilled in surveillance related to the variety of clinical situations encountered in the correctional setting to use protocols.
    • Provide access to information and tools that enhances recognition of clinical patterns and deviations necessary for good clinical judgment (Ebright 2010).
    • Assist nurses to prioritize and coordinate care with daily briefings, debriefings, huddles and work flow tracking to provide real time information about the availability and assignments of other members of the health care team (including primary care and mental health staff).
  3. Positive workplace relationships
    • Establish clear expectations for a respectful workplace in policy, procedure and other written directive. These instructions should define behaviors consistent and inconsistent with professional behavior in the workplace; describe what to do in the presence of unprofessional behavior and how to report these incidents (Almost et.al. 2013a).
    • Joint meetings and interdisciplinary training can be the vehicle to demonstrate support for the goals of both health care and custody (Almost et.al. 2013a, Weiskopf 2005).
    • Nurses may benefit from additional development in the area of conflict resolution because they have such a prominent role negotiating coordination of patient care with custody operations (Schoenly 2013, Weiskopf 2005).
    • Increase communication about patient care between registered nurses and LPN/LVNs (Corrazini et. al. 2013).
  4. Support education and certification
    • Orientation also needs to be tailored to the needs of each individual based upon education, licensure and an assessment of competency (Knox, West, Pinney & Blair 2014; Shelton, Weiskopf & Nicholson 2010). The ANA scope and standards of professional practice should also be incorporated into new employee orientation so that nurses develop institution specific skills consistent with the expectation of the professional discipline (Knox & Schoenly 2014).
    • Mentoring and coaching of new employees should be emphasized in development of expertise in clinical reasoning (Schoenly 2013, Ebright 2010).
    • Use creative, simple approaches to continuing education including self-study, reflective exercises, on-line web based seminars, facilitated case review and discussion, and a journal club (Almost et.al. 2013b, Schoenly 2013). Staff with superior knowledge and skill in a subject area can be asked to assist in developing relevant continuing education material (Knox, West, Pinney & Blair 2014).
    • Certification in correctional nursing is available through both the American Corrections Association and the National Commission on Correctional Health Care. These exams are offered regionally and can be administered at the place of employment if there are enough people taking the exam.
  5. Adequate resources
    • Includes staffing, equipment and supplies as well as access to leadership. Examining the work of first line managers may reveal sources of role overload (scheduling, meetings, payroll data gathering etc.) that impede their availability to line staff and can be reassigned to increase the availability of clinical leadership to line staff(Almost et.al. 2013a).
    • Review legacy staffing practices and work flow to identify opportunities to adjust assignments that result in more appropriate or effective use of existing resources (Knox, West, Pinney & Blair 2013, Ebright 2010).
    • Involve nurses in evaluation of equipment and technology decisions to prevent acquisition of products that complicate rather than improve delivery of patient care (Ebright 2010). For example decisions about how patient specific prescriptions were packaged have impacted timeliness and accuracy of medication administration in some correctional facilities because the packaging was cumbersome and time consuming for nurses to use.

Conclusion: Attention to the work environment of nurses (control over nursing practice, autonomy without isolation, positive working relationships, support for education and specialty certification, and adequate resources) has a profound effect on nursing practice, the ability to recruit and retain nursing personnel and on patient outcomes. More resources about work environments that support professional nursing practice can be found at the sites listed in the resources section below.

What do you think can be done to improve the professional practice work environment for correctional nurses? Are there resources or solutions not discussed here that should be? Please share your opinions 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.

Resources

 

References

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., Neff, D.F. (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care 49(12): 1047-1053.

Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., Rose, D.N., Squires, M., Lee, C., Bookey-Bassett, S. (2013a) Exploring work-life issues in provincial corrections settings. Journal of Forensic Nursing 9:1

Almost, J., Gifford, W.A., Doran, D., Ogilvie, L., Miller, C., Rose, D.N., Squires, M. (2013 b) Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context. Implementation Science 8:71

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org

Corrazzini, 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.

Dall, T.M., Chen, Y.J., Seifert, R.F., Maddox, P.J., Hogan, P.F. (2009). The economic value of professional nursing. Medical Care 47 (1):97-104.

Ebright, P.R. (2010). The complex work of RNs: Implications for a healthy work environment. Online Journal of Issues in Nursing. 15(1).

Flanagan, N. & Flanagan, T. (2001) Correctional nurses’ perceptions of their role, training requirements and prisoner health care needs. The Journal of Correctional Health Care 8:67-85.

Flynn, L., Liang, Y., Dickson, G., Xie, M., Suh, D.C. (2012) Nurse’s practice environments, error interception practices, and inpatient medication errors. The Journal of Nursing Scholarship. 44(2):180-186.

Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J. (2008) Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research. 43(4): 1145-1162.

Holmes, D. (2005) Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care 41(1):3-13.

Knox, C.M., Schoenly, L. (2014) Correctional nursing: A new scope and standards of practice. Correct Care, 28 (1) 12-14.

Knox, C.M., West, K., Pinney, B., Blair, P. (2014) Work environments that support professional nursing practice. Presentation at Spring Conference on Correctional Health Care, National Commission on Correctional Health Care. April 8, 2014. Nashville, TN.

MacMurdo, V., Thorpe, G., & Morgan, R. (2013) Partners in practice: Engaging front-line nursing staff as change agents. Presentation at Custody & Caring, 13th Biennial International Conference on the Nurse’s Role in the criminal Justice System. October 2-4, 2013. Saskatoon, SK.

Maroney, M.K. (2005) Caring and custody: Two faces of the same reality. Journal of Correctional Health Care. 11:157-169.

Needleman, J., Buerhaus, P.I., Stewart, M., Zelevinsky, K. Matke, S. (2006) Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 25(1):204-211.

Shelton, D., Weiskopf, C., Nicholson, M. (2010). Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care. 16 (4). 38-47.

Sherman, R. & Pross, E. (2010) Growing future nurse leaders to build and sustain healthy work environments. Online Journal of Issues in Nursing. 15(1).

Schoenly, L. (2013) Management and Leadership. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2013) Nursing Sick Call. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2005) Stepping through the looking glass: Professional autonomy in correctional nursing. Corrections Today 67(1):54-56.

Weiskopf, C.S. (2005) Nurse’s experience of caring for inmate patients. Journal of Advanced Nursing 49(4):336-343.

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: Nursebooks.org.

Photo credit: © Kheng Guan Toh – Fotolia.com

 

Nursing Sick Call Part 2: Pitfalls with the Face- to- Face Encounter

NSPS'10_Fig 4  Nursing Process  StdsLast week’s post on nursing sick call emphasized the importance of receiving and responding in a timely and clinically appropriate manner. Each request must be triaged within 24 hours of receipt. When the request describes a clinical symptom it must be assessed in a face- to- face encounter. Obviously if the symptom is of an emergent nature the assessment must take place immediately. Examples of requests that are potentially life threatening and should be assessed immediately include statements regarding suicide or hopelessness, cardiac or respiratory distress and trauma.

However most requests received via sick call are not of an emergent nature. Patients with non-urgent clinical symptoms need to be evaluated within 48 hours from time the request was received and this timeframe can extend to 72 hours on weekends. Non-urgent health care attention is requested most often for symptoms relating to pain, skin conditions and HEENT problems. Nurses should expect to be very familiar with the assessment, evaluation and treatment of multiple conditions that manifest in these symptoms. Correctional nursing expert, Jessica Lee, as well the National Commission on Correctional Health Care (NCCHC) recommend staff with the most skill and experience in assessment be responsible for sick call.

The face-to- face encounter involves the six components of nursing process defined in the American Nurses Association (ANA) standards for correctional nursing practice (2013). These inter-related components are depicted in the diagram at the top of this post as assessment, diagnosis, outcomes identification, planning, implementation and evaluation. For a description of how the nursing process is used during nursing sick call see Chapter 15 in the Essentials of Correctional Nursing.

What are the pitfalls for nurses in the face-to-face encounter? In thirty years’ experience as a correctional nurse, manager and consultant I have observed thousands of nurses in sick call encounters and reviewed their documentation. Some of these nurses were definitely experts, others were new to the process, and many were competently performing these skills. The following are the problems and pitfalls most often seen with the face-to-face nursing encounter.

Delays: Evaluations that take place long after the request has been submitted place the nurse in a difficult spot. The patient is frustrated because of the delay and may be disrespectful; the condition may have gotten worse and the patient already been seen in an emergency or the condition grown more complex and require a referral when it could have been treated by the nurse if seen earlier. Imagine how you would react if it took three days to receive one dose of aspirin or ibuprofen for a headache. When inmates experience failures in access the response is often to flood the system with requests and soon the nurses can’t keep up. Stay on top of requests so that there are no delays and the volume will be more manageable. There are no defensible reasons for delaying access to care; it is a constitutional requirement.

Incomplete assessment: Nursing assessment involves the collection of both subjective and objective information that is relevant to the patient’s reason for requesting health care attention. The subjective assessment includes asking sufficient questions about the problem to determine additional data to be gathered during the objective exam, diagnostic testing and chart review. Failing to physically examine the patient to adequately verify and amplify subjective information is a common error in nursing sick call. Examples are sick call encounters have incomplete vital signs recorded or dental complaints that do not include an examination of the oral cavity and neck but just a referral to the dental department. This may be because of inexperience, fear or concern about touching inmates or trivializing patient complaints. Nursing assessments should be conducted and documented so that the clinical information contributes to the next provider’s assessment whether it is a provider appointment or the next sick call visit.

Inadequate patient involvement: Involving the patient in each encounter is a sure way to reduce unnecessary requests for health care attention and submission of a grievance both of which take additional time to respond to. This is not to say that a nurse should give the patient what they want. Instead it means to ask for the patient’s input about the outcome they desire and then to provide an explanation of findings, recommended plan and the rationale that takes into account the patient’s input. Involving the patient demonstrates respect and helps build the therapeutic relationship; it also gives useful clues that can help motivate the patient in their own care. If the patient doesn’t understand then another explanation may be useful especially if the patient has low health literacy. The nurse may schedule the patient back for a follow up appointment to go over the information again or to check on the patient’s symptoms. If the patient doesn’t agree with the plan the nurse should reconsider their findings or make a referral for higher level care.

Poor clinical decision making: Making clinical decisions is a skill built by thoughtful reflection on practice while gaining experience. As experience increases diagnostic conclusions are drawn more quickly by patterns recognition rather than the more deliberate process of gathering and analyzing data. The downside to pattern recognition is that the nurse’s conclusions are prone to bias based upon personal experience and cultural socialization. Two common errors in diagnostic reasoning are premature closure (coming to a conclusion before sufficient data is gathered) and confirmation bias (only seeing data that matches our conclusion and ignoring data that doesn’t). See two previous posts about how to build and hone clinical decision making skills.

Inefficient use of resources: Time, space and equipment are the resources nurses use during sick call. Examples of inefficient use of resources include conducting the face-to-face encounter in an area where the nurse cannot properly examine the patient, using a blood pressure cuff that is the wrong size or not calibrated, having to go to another area to get supplies or equipment to complete the examination, not having the chart available or not referring to the chart for data on the patient’s recent health care. See a previous post about safe practices for nurse sick call. Nurses should be able to elicit the health history at the same time observe the patient and gather objective physical assessment data. Like playing the drums the face-to-face encounter takes practice. Nurses develop these skills when they are provided support, coaching and feedback. Face-to-face encounters which are incomplete or inadequate also waste provider resources if an unnecessary referral is made or the information about why the provider appointment is needed is incomplete.

What are the challenges you experience in completing timely, responsive and clinically appropriate face-to-face encounters with patients who have symptom based requests for health care attention? Please provide your thoughts and experience in the comments section of this post.

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.

References

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

Knox, C & Shelton, S. (2006). Sick Call. In Clinical Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

LaMarre, M. (2006). Chapter 28: Nursing role and practice in correctional facilities. In M. Puisis (Ed), Clinicsl Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

National Commission on Correctional Health Care. (2008). Standards for Health Services in Prisons. Chicago: NCCHC.

Photo credit: © dimakp – 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

Barriers to Effective Delegation

Human Intelligence and CreativityIf delegation is a fundamental aspect of nursing practice why do nurses find it difficult? Part of the reason is that as the resources to provide care shrink and the environment for care becomes more complex the importance of delegation has become more apparent. Nursing care today is delivered in correctional settings by a wide variety of personnel (registered nurses, practical or vocational nurses, unlicensed assistive personnel, etc.) each with different educational preparation and scope of allowable practice. Correctional nurses also work in a very restrictive and challenging environment with a very diverse patient population which has complicated health care needs. The National Council of State Boards of Nursing (NCSBN) identifies delegation as a “complex process of professional practice requiring sophisticated clinical judgment” (2005) and yet many nurses received little formal training in delegation during their education and employers rarely evaluate and develop nurses’ delegation skills as they do other clinical competencies (Weydt, 2010). Well no wonder nurses find delegation challenging!

The American Nurses Association (ANA) recently asked nurses what barriers to delegation they were experiencing as part of the process of updating the Principles for Delegation (2012). Three major barriers were identified and each is discussed below:

Poor partnerships: It is difficult to delegate when the nurse does not know the staff or their capabilities. It is also not practical to assess each of the staffs’ skills in all areas before making a delegation decision. Participating in the orientation of new staff is one way to get to know what skills are evaluated and to become familiar with the capabilities of individual staff.  Nurses should also periodically review staff competency records. Working together is an opportunity to build partnerships with each of the staff.  Good quality partnerships are correlated with improved patient safety (McCoy & Duffy, 2013).

Attitudes: Nurses express concern that delegation results in loss of control over patient outcomes. Another way of saying this is …“If I am held accountable for the patient, why should I delegate?”  This was discussed in last week’s post on the principles of delegation. The staff person accepting delegation is responsible for performing the assignment and accountable for accomplishing it safely and correctly. Therefore the nurse’s accountability is for the patient, not the staff’s performance. This is because the nurse retains authority to direct the patient’s ongoing care. Knowing how to identify and evaluate patient outcomes are critical aspects of accountability and delegation of patient care. These competencies are described in Standard 3 of the ANA’s publication Correctional Nursing:  Scope and Standards of Professional Practice and can be used by nurses as a resource in developing delegation skill (2013).

Sometimes the nurse goes on to say “…especially someone I either don’t know or don’t trust?” Trust comes from concentrating on building good interpersonal relationships while working together.  Delegation is an invitation to participate in the delivery of care and when delivered in a respectful and conscientious manner it promotes communication. When meaningful two-way communication is increased the quality of patient care improves (Corazini et al. 2013).

RN Leadership: The third barrier identified was lack of sufficient registered nurses to support effective delegation. Contributing factors were nurses’ lack of experience with delegation, insufficient ratio of registered nurses in the staff mix, and administrative work that supersedes clinical care.    Many correctional facilities do not have a strong structure to support professional nursing practice with policies, procedures, job descriptions and other directives or guidelines that are consistent with state laws and regulations. Uninformed or ill-advised managers may not fully support a healthy workplace that includes developing the delegation potential of registered nurses. Traditionally, little focus has been placed on developing the leadership responsibilities of nurses to ensure delivery of patient care by delegating and supervising care provided by other members of the nursing staff (Weydt 2010).

The ANA articulates the expectation that correctional registered nurses are competent to delegate care in Standard 15: Resource Utilization (2013).  Nurses can develop delegation skills by, first, becoming familiar with the laws and regulations concerning scope of practice, reviewing job descriptions and other workplace guidance that defines the roles and responsibilities of staff. The next step is to understand how the principles of delegation can be applied to patient care in the correctional setting. The use of a decision tool such the one included in the Joint Statement on Delegation (2006) helps guide nurses through the critical thinking that results in a delegation decision. As experience using structured critical thinking  increases delegation decisions are accomplished with speed and confidence. Using simulation or case review and reflection are also effective ways to build delegation skill (Weydt, 2010). Nurses can do this on their own or with a proctor or mentor at the worksite.

Your thoughts about this subject are important to us. Do these three barriers resonate with your experience as a correctional nurse?  Does your communication contribute to good interpersonal relationships? Are registered nurses sufficiently involved in clinical care to effectively delegate? 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 (2012) Principles for Delegation by Registered Nurses to Unlicensed Assistive Personnel (UAP). Silver Spring, Maryland. Accessed on 1/29/2013 at http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/ANAPrinciples/PrinciplesofDelegation.pdf.aspx 

American Nurses Association (2005) Principles for Delegation. Silver Spring, Maryland. Accessed on 1/29/2013 at http://www.indiananurses.org/education/principles_for_delegation.pdf

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.

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

McCoy, S.F. & Duffy, M. (2013, March 20). Navigating the Complex World of Delegation [Audio podcast]. Retrieved from http://www.nursingworld.org/MainMenuCategories/CertificationandAccreditation/Continuing-Professional-Development/NavigateNursing/Webinars/Nav-deleg.html

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

Weydt, A. (2010). Developing delegation skills. Online Journal of Issues in Nursing 2 (1)

Photo Credit:   © freshidea – Fotolia.com