Thanksgiving

Graphic typographic montage illustration of the word Thanksgiving composed of associated terms and defining words in neutral tones. A pair of autumn leaves completes this dramatic, inspirational design.

This week we celebrate Thanksgiving, an American holiday to give thanks for the abundance of the previous year and the fall harvest. Many, but not all of us, get together with family and friends to enjoy a meal and the company of others as fall turns to winter. Some of us will be working, sharing the holiday with our colleagues and patients. No matter what specific plans we each have for the holiday, it is a time of reflection, to identify and give voice to that for which we are thankful.

Lorry, Gayle and I are thankful for you, the readers of the Essentials of Correctional Nursing. Lorry wrote the first post almost five years ago just as we finished editing, our text, The Essentials of Correctional Nursing. We have posted a new blog nearly every week since then. We are grateful to Gayle for joining our blogging adventure this past year and enjoy her take on issues in correctional nursing.

Our purpose in writing the blog is to amplify the material included in the book and to further explore new and recurrent issues in correctional nursing practice. Our most frequently viewed posts address the subjects of delegation, certification in correctional nursing, vital signs, withdrawal, spiritual distress, the ANA Scope and standards of professional practice, and evidence-based practice. As we look back over our files we are thankful for the opportunity the blog has given us to explore subjects in depth.

Day by day, week by week, year by year our readership has grown. We average over 150 hits on the blog every day and have had over 300 hits on some days. Our readership is from all over the world and we have benefited from our contact with correctional nurses from all across the globe. We have more than 200 regular subscribers on email, over 4,000 on Twitter and more than 700 on Facebook. Thank you for your interest and support for the Essentials of Correctional Nursing.

We published The Essentials of Correctional Nursing in 2012, along with eight contributing authors, to reflect the distinguishing features and practices of this specialty in the field of nursing. In doing so we benefited from the support of many colleagues who peer reviewed the manuscript and offered insight about issues in correctional nursing. The text has since been recommended as a resource applicants use to study for certification in correctional nursing. Lorry also has written a series of posts on this blog about how to study for the certification exam and her own journey becoming certified. We are grateful for the growing legion of nurses who are certified in correctional nursing; you are the voice of the profession! If you are not yet certified, perhaps this could be your goal for the new year. It is easier than you think and there are many benefits.

At the end of every year Lorry and I discuss how we are doing with the blog and decide whether to continue and if so, what subjects we are going to tackle in the coming year. This year we decided that with other opportunities and commitments, it is time to move on and no longer will post on the Essentials of Correctional Nursing blog. However we are maintaining the site and the collection of 220 or so posts as a continuing resource for correctional nurses. Next week’s post will be the last and includes a table of contents so that each of our previous posts can be easily accessed from this page!

We continue to support correctional nursing practice through our writing, consulting, and speaking. Here are some helpful links to other correctional nurse resources that we support and endorse:

CorrectionalNurse.Net Blog

Correctional Nursing Today Podcast

CorrectCare Magazine

The Essentials of Correctional Nursing can be ordered directly from the publisher or from Amazon today!  Lorry and I, or any of the contributing authors, are always glad to sign and personalize your copy of the text.

Have a safe and grateful holiday!

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Is Intake Screening Getting the Job Done?

The words Get it Done on a stopwatch or timer to encourage you to complete or finish a task or job

In June I wrote a post about intake screening and how difficult it can be to obtain a full and accurate picture of an inmate’s health status. In spite of the difficulties of the time, place and people involved, a nurse armed with information can still make good decisions about the plan of care for each inmate coming into the facility. One type of information that is useful is knowing the health characteristics of the population served.

The health characteristics of 759 inmates being received into the state correctional system in New York were recently reported in the Journal of Correctional Health Care (July 2015). The data about inmates’ medical conditions was obtained from chart review and information about health behaviors (smoking, etc.) came from individual interviews. There were nearly as many women as men included in the sample (387 men and 372 women). The average age was 35.6 years for women and 33.9 years for men. Eighty percent of the population had less than or equal to a high school education/GED. Given just these findings what are the implications for the nursing plan of care?

One conclusion that can be drawn is that health literacy is likely to be an issue. This means assessing what an individual knows already about a particular health issue and then starting from that point when providing information. Second, this population already has well established behaviors (smoking, sexual practices, use of illegal substances, and other risk taking) but may not yet have experienced the health consequences. Use of motivational interviewing will be a valuable tool to assess a patient’s readiness for change and select behavior change strategies most likely to influence the patient.

The population of men in the New York state prison study was predominately non-Hispanic Black and Hispanic. The majority of women were either non-Hispanic Black or non-Hispanic White. This characteristic will vary from region to region and type of facility. The racial and cultural characteristics of the population being received at the facility are important to know because they are also associated with disease prevalence. For example, Blacks are more likely to experience premature death from cardiovascular disease, while control of hypertension is poorest among Mexican-Americans according to the most recent report from the CDC on health disparities.

Respiratory conditions were the most prevalent chronic disease diagnosed in this population of inmates at admission to prison. Respiratory conditions include asthma, COPD and emphysema and were present among 34% of the newly admitted inmates. A history of smoking and obesity significantly correlated with respiratory diseases.

Cardiovascular conditions, including hypertension, atherosclerosis and heart disease were diagnosed in 17.4% of this population. Obesity was significantly associated with cardiovascular disease and diabetes. Sexually transmitted disease was diagnosed in 16.4% of the population. Women had a higher prevalence of chronic disease than men, particularly greater incidence of diabetes and STDs. It is not clear whether this is because women are more likely to access health care or are more susceptible to certain diseases. Age (40 years of age and older) was also correlated with higher risk for diabetes and cardiovascular disease.

Chronic disease was more prevalent in this inmate population than rates for the same disease in the general community. Rates for respiratory disease among the general community are estimated to be 19% compared to this prison population with a prevalence rate of 34%. Diabetes rates were 2.4% in the community among adults the same average age as the prison population. The rate of diabetes among prisoners was 4.9%. HIV disease was 3.5% among newly admitted prisoners while in the same average age group in the general community the HIV rate was less than half of one percent.

The results of this study done in the New York system are similar to those reported by the CDC a year ago. The CDC study looked at the chronic diseases reported by over 100,000 inmates in 606 state, federal and local correctional facilities in the U.S.

What does all this mean to correctional nurses? It is difficult to elicit a full and accurate history from an inmate during intake screening; especially if we are rushed, there are many screenings still to get done and the setting challenges privacy in sharing of medical information. By knowing that 3 of every 10 inmates screened is likely to have chronic respiratory disease helps me evaluate carefully the answers I am getting about the inmate’s medical history and emphasizes the importance of my skill assessing the respiratory system. The same is true for the other common chronic conditions. This doesn’t mean that the other areas of the health appraisal aren’t important, they are. It means that if diseases like diabetes, STDs, respiratory disease and HIV are not identified at about the same frequency as the rates reported for correctional populations then the screening methods should be examined for possible improvement. We all know that early identification of disease means treatment can be initiated that is less costly and burdensome than the emergence of an urgent or emergent medical crisis.

Are the rates of chronic disease tracked at your facility? If so, how do they compare to the rates reported for the New York state correctional system? How do the rates for chronic disease among inmates at your facility compare to the general community? Are there implications of these findings for correctional nursing that go beyond what has been discussed here? Please share your thoughts by replying in the comments section of this post.

For more about the nursing implications of caring for patients with chronic diseases in the correctional setting and the disease burden of this population see the Essentials of Correctional Nursing, especially the first and sixth chapters. Order a copy directly from the publisher or from Amazon today!

Bai, J.R., Befus, M., Mukherjee, D.V., Lowy, F.D., Larson, E.L. (2015) Prevalence and Predictors of Chronic Health Conditions of Inmates Newly Admitted to Maximum Security Prisons. Journal of Correctional Health Care, 21 (3) 255-264

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The Power of Appearance

fotolia_120043070_xsMeet Jerry, a new registered nurse in on-the-job training who will begin shadowing you next week to learn to how to conduct sick call. She asks you what she should be thinking about in preparation for this role. You respond by saying that how she does in sick call will establish her competence and clinical authority in the eyes of the inmate population and to prepare for an onslaught of sick call requests as everyone seeks to meet and test her skill.

All patients, not just inmates, assess a nurse’s visual appearance to form an opinion about their confidence and professionalism within the first few seconds of an encounter. In correctional nursing, the inmate’s best opportunity to make this assessment will be during a sick call encounter. Since inmates have no choice in who provides their nursing care they are naturally interested whenever someone new joins the nursing staff.

The traditional white uniform was first established by Florence Nightingale in the early 1900’s to distinguish nurses from lay persons who attended the sick at the time and raise nursing to a respectable profession characterized by caring, compassion and clinical competence. Even though the white uniform has given way to more comfortable and durable clothing it still is the strongest association identified by the public between professionalism and nursing.

The correctional facility you work at has no dress code policy for health care staff. The security staff are provided navy blue uniforms with badges and other insignia detailing their name and position within the organization. Health care staff are simply advised to dress in clean and comfortable clothes appropriate for work in the facility.  In considering what advice to give Jerry in preparation for next week you reflect on your past experience at the facility about staff who were able to establish their authority, confidence and nursing competence early in their correctional nursing career. What advice will you give her as a result of this reflection?

Patients want to know that the person caring for them has the credentials to do so. In fact, some state boards of nursing require that registered nurses be identified clearly by name and credential. Nurses who are accountable for their practice introduce themselves to the patient at the beginning of the encounter. Nurses who do not want inmates to know their name or credential will be unable to establish the trust necessary to obtain important information from the patient about their condition and risk poor care outcomes. Jerry has been issued a name tag but keeps it in her pocket and only shows it when asked.

Staff who dress in a more formal, uniform style are considered significantly more skilled and knowledgeable by patients than those dressed like they were ready for the gym, rooting for the local team or sporting funny sayings. While individual self-expression in attire isn’t prohibited by the facility, it took longer and was more challenging for these staff to prove their competence and skill and project authority when it was necessary. Jerry seems to prefer a t-shirt and scrub pants for work attire.

Some of the staff have taken to wearing polo shirts which have embroidered their credential as a certified correctional health professional on the front. Others wear colored scrubs which fit properly and can be layered based upon working temperatures. Staff who wear patterned or cartooned scrub tops have sometimes been coached if it made them appear too informal, approachable or friendly with inmates and their professional authority was challenged. You note that another aspect of projecting professionalism and respect for the patient and others is wearing clothes that are clean, neat and fit properly.

As you talk with Jerry about creating first impressions she laments that it is all a charade-people should judge her on her actions not her appearance. While you agree with her that there is a lot more to a person than just the visual impression created by the first few seconds, it is however, a vital opportunity, not to be squandered. When you ask her if she wants to see the pilot of the plane she just got on, in sweats. She looks at you a second and gulps. You go on to say “That may be the only information you have about the competence of the pilot flying you across country. The pilot’s appearance is important to you to feel safe and trust that the flight will go according to your expectations. Your patient is the same way, dressing professionally helps them have confidence in your ability and trust that you will take care of them appropriately.”

Jerry shows up Monday morning confident that with your ongoing help and advice she will do well learning how to do sick call like a pro. fotolia_119206347_xs

Do you have a different viewpoint about the impact of the nurse’s appearance in establishing professional authority in the nurse patient relationship? If so please share your views by relpying in the comments section of this post. For more on professionalism in correctional nursing see Chapter 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Top Educational and Skill Needs of Correctional Nurses

TRAINING Vector Radial Tag CloudThe most recent issue of CorrectCare, a quarterly publication by the National Commission on Correctional Health Care (NCCHC) included an article by Sue Smith MSN, RN, CCHP-RN reporting the results of a recent survey of nursing leaders about the educational and skill needs of correctional nurses. I have reprinted it here so that you can consider the results in light of your own experience and educational needs. Please take a minute to think about your own answers to each of the five survey questions that were used and compare your opinions to those of others who responded.

Nurse Leader Survey Sheds Light on Nurses’ Top Educational and Skill Needs

by Sue Smith, MSN, RN, CCHP-RN

The Nursing Advisory Council is a stakeholder group that advises the NCCHC multidisciplinary education committee on the continuing education needs of correctional nurses and assists the NCCHC lead nurse planner in assessing continuing education for correctional nurses and evaluating the quality and effectiveness of the continuing education. The council consists of nine nurse members who represent a wide variety of roles and settings, including staff nurses, nurse managers/administrators, nurse educators and advanced practice nurses who work in jails, prisons, governmental agencies and private correctional health care agencies.

In 2015, the Nursing Advisory Council developed a needs assessment survey directed at nursing leaders, including nurse managers and nurse administrators. The survey questions were determined by consensus and consisted of five primary questions:

  1. How much time should be allotted for training a first-time correctional nurse before working independently?
  2. What are the three most important topics for orientation/training of correctional nurses?
  3. What is the single most important piece of knowledge for a correctional nurse to have?
  4. What is the single most important skill for a correctional nurse to have?
  5. What RN/LPN-LVN ratio are you using at your facility? What is the rationale for this ratio?

The survey questions were distributed via SurveyMonkey to nurses who self-identified as nurse managers or nurse administrators at NCCHC educational conferences. The survey was available to the target audience for two weeks. In total, 273 responses were received; a small number of responses were discarded that did not address one or more of the questions. The collected results were analyzed by the lead nurse planner using simple data reduction techniques.

1. How much time should be allotted for training a first-time correctional nurse before the nurse is allowed to work independently? (233 responses)

Less than 2 weeks         18%

2-4 weeks                        14%

5-8 weeks                   49%

9-12 weeks                       8%

3-5 months                      8%

6-12 months                    3%

2. What are the three most important topics for orientation/training of correctional nurses?

     Safety/Security (134)

Inmate manipulation, Safety of self and others

Security issues and procedures, Collaboration with security staff, Contraband

Infection control

     Nursing Practice (129)

Health/physical assessment skills, Emergency response, Sick call procedures, Documentation

Medication issues including administration, verification, pharmacology and competence

Triage/screening, Mental health, including assessment, referrals, suicide prevention, substance abuse

Special needs, Discharge planning

     Professional Practice (52)

Professional boundaries

Neutrality, Firm, fair and consistent

Compassion; patient advocacy; balance of advocacy vs. safety

Emphasis on patient care, Autonomy

     Legal/Constitutional Issues (37)

Access to care, Deliberate indifference, Policies and procedures, Licensure/scope of practice

Standing orders, Patient confidentiality, Standards/guidelines

     Miscellaneous (15)

Time management, Critical thinking, Ethics, Electronic medical records

Unique practice environment, Clinic operations, Limitations and restrictions on care provision

3. What is the single most important piece of knowledge for a correctional nurse to have?

     Professional Nursing Practice Skills (108)

Assessment skill, Professional boundaries

Able to see inmates as patients, quality care, respect, patient advocacy, compassion, nonjudgmental attitude, uses nursing process, appropriate follow-up

Critical thinking skills, previous clinical experience, good judgment, know where to find the answer

Emergency skills including recognition of critical patients, proper CPR, trauma evaluation, emergent care

     Safety/Security (74):  Don’t let guard down, how to get help, staying calm, situational awareness, infection control

     Correctional Nursing Practice (16): Unique practice, understand population served, understand environment and facility culture, how to navigate security/medical issues, role of health care in corrections, concept of firm, fair  and consistent

      Legal Issues (16): Policies and procedures, inmate rights, scope of practice

     Communication/Collaboration (15): Manner, effective communication, with advanced providers and DON/HSA, with security, knowledge of chain of command, SBAR technique, professional communication, who and when to call for help

     Clinical Nursing Knowledge (9): Pathophysiology, medications, current on clinical guidelines, proficiency on treatments

     Mental Health (9): Inmates, staff

     Manipulation (7): Inmate-patient behavior

     Miscellaneous (2): Computer skills, preventive health care

4. What is the single most important skill for a correctional nurse to have?

     Assessment Skills (111)

Physical, mental health, health, rapid

Interviewing skills

     Interpersonal Skills (46): Good listener, nonjudgmental, honest, able to handle manipulation, objectivity, professional behavior, boundary setting, able to get along with others, assertiveness, respect, conflict resolution skills, ethics, flexibility, diligence

     Critical Thinking Skills (33): Accuracy, think and perform under pressure, good judgment, confidence, problem-solving

     Communication (33): Written (including documentation), verbal with staff and inmates, therapeutic.

     Clinical Skills (25)

Evidence-based medicine, clinical knowledge, nursing process, CPR, codes, first responder

Triage/prioritization of care

     Personal Skills/Attributes (21)

Observational skills, including awareness of surroundings

Organizational/time-management skills

Autonomy, Self-motivated learner

5. What is the ratio of RNs to LPNs/LVNs at your facility? (268 responses)

Overall average – 3 (RNs) : 4 (LPN/LVNs)

Most frequently occurring ratio – 1 : 1

27 respondents reported all RN staff.

A few respondents reported use of nursing assistants, medical assistants, medication aides and paramedics in addition to or instead of licensed nurses.

103 (38%) did not give information or a ratio could not be determined from the information given.

6. Which of the following best describes the correctional setting where you work? (236 responses)

 Jail                                                                 45%

Prison facility                                                    19%

State DOC/agency                                            17%

Federal agency                                                   8%

Juvenile detention/confinement facility      6%

Private corporation                                           5%

Other*                                                                 12%

* immigration facility, inpatient acute correctional facility, consultants, tribal jails

Discussion

Total responses were 273. However, not all respondents answered every question and it was necessary to discard a number of unusable responses. Simple arithmetic averages were calculated for questions 1, 5 and 6. Qualitative data received in response to questions 2, 3 and 4 were analyzed and separated into broad categories. The number in parentheses beside each category indicates the number of responses in that category.

There is some overlap in the information requested by questions 2, 3 and 4. This was anticipated by the Nurse Advisory Council, but we felt that there would be enough variation in the responses and/or response rates to ensure that the information gleaned from the survey would be useful. The data analysis does indicate that the weight, or importance, of the topics listed varies between each question. Additionally, there was some variation in the specific topics suggested by respondents.

The information gleaned from this survey is consistent with the results of the general needs assessment survey completed in 2014. The Nurse Advisory Council has been using, and will continue to use, the information collected by these two needs assessment surveys to plan continuing education for correctional nurses who attend NCCHC educational conferences.

Sue Smith, MSN, RN, CCHP-RN, is a correctional nurse educator. She serves as lead nurse planner for NCCHC educational activities and directs the NCCHC Nursing Advisory Council. Contact her at nsuesmith48@yahoo.com.

How similar were your answers to the survey results? Do the results confirm your priorities for correctional nurses’ professional development and continuing education? Please share your comments with others who follow this blog by responding in the comments section of this post.

For more on this subject read Chapters 17 and 19 in the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Medication Reconciliation

Fotolia_85555232_XSAn inmate approaches you at morning med line and asks for his medication. When he gives you his name and identification number you are unable to find a corresponding Medication Administration Record (MAR) and there is no medication with his name on it in the drawer. This is the psych step down unit so he is probably correct to expect to have medication. When asked he tells you that he arrived on the unit last evening from 3E, the acute psych unit. You tell him that there is no medication for him on the cart and that you will contact the pharmacy and will get back to him later that morning. You are thinking that his medication is still in the med cart on 3E and will call the nurse on the unit as soon as you get back to the clinic.

Does this example sound familiar? How many times are you approached to administer a medication and it is not there? It could be because the inmate was just admitted to the facility or just saw the provider and the medication hasn’t been received from the pharmacy. It could be that the inmate was transferred from one unit to another and his or her medication was not transferred to the new location. Maybe the inmate just returned from an off-site procedure and the provider hasn’t reviewed the specialist’s recommendations.

Each admission, provider visit, transfer or change in level of care is an opportunity for omission, duplication, dosing errors, drug-drug interactions and drug-disease interactions to occur and with it the potential for an adverse patient outcome. Almost half of all medication errors in the general health care community occur because medication is not reconciled adequately when there is a handoff in responsibility for the patient’s care and 20% of these result in harm to the patient. Transitions in the responsibility for an inmate’s health care have the same risk. Medication reconciliation prevents mistakes in patient care.

The Institute for Healthcare Improvement and the Joint Commission recommend reconciling medication whenever there is a change in the patient’s setting, condition, provider or level of care required. In corrections medication reconciliation is done when inmates at admission report taking medication prescribed by providers in the community. These medications will need orders to continue or the inmate’s treatment modified by the provider at the correctional facility assuming responsibility for the patient’s care. Medication reconciliation also takes place when an inmate returns to the facility after receiving specialty care in the community, upon admission and discharge from infirmary or another type of inpatient care and whenever their primary care provider changes. There are only three simple steps involved in reconciliation. These are:

  1. Verify the name, dosage, time and route of the medication (s) taken or recommended.
  2. Clarify the appropriateness of the medication and dosing.
  3. Reconcile and document any changes between what is reported or recommended.

The following paragraphs discuss how medication reconciliation is done at several key points in correctional health care.

When Inmates Arrive at a Facility

Intake screening routinely includes an inquiry into what medications an inmate is taking. Sometimes this question is only briefly discussed. However, if an inmate reports recent hospitalization or receipt of health care in an ambulatory care setting it would be a good idea to inquire again about what medications may have been recommended or prescribed. The same is recommended if an inmate reports having a chronic condition. It may be that they are not currently taking medication because they can’t afford it or were unable to obtain the medication for another reason. Inquiry about medications should also include the inmate’s use of over-the-counter or other alternative treatments.

Offenders arriving at a facility from the community, especially jails and juvenile facilities, may have medications on their person and sometimes, family will bring in medications after learning their family member has been detained. It is best practice to verify that the medication received is the same as that on the label. There are several excellent sites for verification of drugs including Drugs.com, Pillbox, and Epocrates.com. Once verified, document the name of the medication, dose, and frequency, date of filling, quantity remaining, physician, pharmacy and prescription number.

Whether it is the inmate’s report or the inmate has brought in their own medication the prescription must next be verified with the pharmacy or community prescriber. Once this is done, notify the institution provider who will determine if the medication should be started urgently so there is no lapse in treatment or if the patient should wait until seen for evaluation.

When Inmates Return From Offsite care

Medication should also be reconciled whenever a patient returns to the facility from a hospitalization or specialty care. The clinical summary or recommendations by the offsite provider should accompany the patient, if not, the nurse should obtain this information right away. Recommendations from off-site specialists or hospital discharge instructions should be reviewed as soon as possible by the nurse and provider in order to continue the patient’s care. When clinical recommendations from off-site care are missed or not followed up on needed treatment is delayed and the patient’s health may deteriorate.

When Inmates Are Followed in Chronic Care Clinic

Chronic care patients are another group that require nursing attentiveness to medication reconciliation including:

  • Evaluating whether the patient is actually taking it as ordered.
  • Following up whenever the medication or the patient is not available and if so, getting scheduled doses to the patient promptly. Also helping the patient to request refills and reorders in time may be necessary so doses are not missed. Also account for the whereabouts of each no show so that medication can be provided as scheduled.
  • Coaching the patient about what to discuss with their provider if they want to make a change or are having side effects. Often patients who want to change or discontinue prescribed treatment will refuse single doses or not pick up their KOP medications. Each of these lapses should be discussed, the patient coached about the next steps to take and the provider notified as well.

When Medications Are Missing

When patients come to the pill cart or widow expecting to receive medication and there is either no medication or MAR asking the patient a few questions as listed below will narrow down where the medication may be located:

  • when was the last dose received (this indicates there is an active prescription and will help determine the urgency for resolution)?
  • If the inmate says that he or she haven’t had any medication yet, ask when they saw the provider who ordered it? (maybe the prescription has not been dispensed yet or it has arrived but hasn’t been unpacked and put away).

Other questions to help narrow down the problem are:

  • if they have been moved recently from another part of the facility (medication and MAR were not transferred).
  • when did they arrive at the facility or were transferred from another (check the transfer sheet, medications and MAR were not transferred).
  • is it a prescription brought in from the community (may be stored elsewhere)?
  • if they have gone by any other names (may be filed elsewhere).

Based upon the answers to these question you may instruct the patient to wait (i.e. “It was just written last night and hasn’t been filled yet, please check back tomorrow.”) or tell the patient that you will look for it and administer it at by at least the next pill call. If you are not able to resolve the problem promptly be sure to assess the patient to determine if the provider should be contacted. Allowing patients to miss medication, even if somebody else is responsible, is equivalent to not providing treatment that is ordered and can be a serious violation of a patient’s constitutional rights in the correctional setting, much less exacerbate their medical condition.

Easing the Burden of Medication Reconciliation

Other recommendations to ease the burden of medication reconciliation from the Institute for Healthcare Improvement are:

  1. Identify responsibilities for medication reconciliation such as standardizing where information about current medications is located, specifying who is responsible for gathering information about medications and when medication reconciliation is to take place, establishing a time frame for resolution of variances and standardizing documentation of medication variance and resolution.
  2. Use standardized forms to ensure that information about medications is elicited and documented.
  3. Establish explicit time frames for when medication is to be reconciled and variances resolved such as within 24 hours of admission, within four hours of identification of variance in high risk medications (antihypertensives, anti seizure, antibiotics, etc.), at every primary care visit.
  4. Educate patients about their medications and their role in reconciliation at every transition in care.

When do you obtain information about the medications a patient takes and how do you verify the patient’s information? Do you provide patients with a list of the medications they take? What is the patient’s role in medication reconciliation at your facility?

If you wish to comment, offer advice about medication reconciliation in correctional health care please do so by responding in the comments section of this post.

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

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Protective Gear for Correctional Nurses

The post last week talked about the problem of nurses being exposed to inappropriate and hostile sexual behaviors by inmates and the kinds of interventions that should be in place to minimize or control antisocial inmate behavior. Nurses were advised not to confront this behavior single handedly but to look to the facility for guidance. But that is just half the solution, the other half, which is the subject of today’s post, is that individuals can take steps on their own to minimize the adverse effects of these unfortunate situations on themselves.

The reality is that bad things do happen in corrections. Even in the best run correctional facilities inmates are injured and sometimes staff are injured as a result of violence and on some of these occasions died as a result of the violence. The nature of the correctional environment is that it always has the potential for immediate violence and direct trauma. Another pervasive aspect of our working environment is that because of the involuntary conditions of incarceration, there is inherent conflict, particularly between staff and inmates. These two features of the work environment combined with operational stressors, such as high workload, contribute to what has been called “Corrections Fatigue”.

It has been suggested that correctional staff prepare themselves to be in this environment the same way that they don other protective gear. An analogy for correctional nurses would be gowning, gloving and putting on a properly fitted mask before going into the isolation room of a patient with active tuberculosis. By wearing protective gear staff minimize their exposure. The same concept applies to the trauma associated with repeated exposure to violence or threatening behavior. What kind of “gear” minimizes our repeated exposure to trauma in the corrections environment?

Resilience is a characteristic that refers to an individual’s ability to cope with adversity; it is the ability to “bounce back” after a stressful experience. Resilience varies from one person to another but we can each tend to and build our resilience. Resilience, then is our protective gear. The following four behaviors have been identified as building resilience in correctional workers.

Build Supportive Relationships at Work – Building and maintaining social support among co-workers has been found to correlate with resilience for the person offering support. By building genuine bonds with co-workers we increase our sense of safety, reduce interpersonal tension and staff conflict. Examples of behaviors that are supportive of relationships at work include:

  • being friendly and respectful,
  • asking how a co-worker is and paying attention to their answer,
  • acknowledging a job well done,
  • looking for ways to assist others when you have time,
  • thanking others for their assistance, and
  • being compassionate with others’ experiences.

Take Care of Yourself – How many times have we as health care providers offered this advice to others? And yet we are known to neglect ourselves, making us vulnerable to burnout, compassion fatigue and now, corrections fatigue. Being healthy is a basic tenet of resilience. Healthy habits and lifestyle behaviors include those that attend not just to your physical needs, but psychological, spiritual and social needs as well. Healthy habits and lifestyle behaviors include:

  • maintaining balance between work and home life
  • mindfully transition to and from work
  • prioritize free time to be with people who are significant in your family and social life
  • engaging in pleasant activity-having fun
  • regulate negative emotions (emotional intelligence)
  • establish a regular and healthy sleep schedule.

Be Confident and Perseverant – These behaviors build competence handling complex or challenging circumstances at work. Confidence and perseverance are a result of:

  • a resolution to complete tasks even when it is difficult,
  • using self-talk to motivate oneself to persevere in the face of adversity,
  • rehearsing and repeating training so that it becomes more automatic and built in,
  • being flexible, open and adaptive to change
  • being ethical and acting with integrity.

Use Logic to Solve Problems – This approach is recommended as a way to keep your cool in the face of the complex or challenging problems we deal with in correctional health care. Thinking logically about situations means considering more than one possible cause and weighing possible responses before choosing the one that is most likely to have the effect you are seeking. This way you maintain control and composure in frustrating or disappointing circumstances. Practical ways to practice logical problem solving and self-control include:

  • divide complex problems into parts and tackle one component at a time,
  • learn how to detach emotionally from challenging situations,
  • view mistakes as learning opportunities,
  • regulate fear and other negative emotions while acting constructively,
  • accept that you cannot always be in control.

These four behaviors, supporting workplace relationships, taking care of yourself, being confident and perseverant, and logical problem solving are your protective gear (resilience) to reduce the effects of violence and other antisocial behaviors, conflict and other operational stressors that are inherent in the correctional setting on your health and well-being.

For more information about promoting wellness among staff who work in correctional settings please see the National Institute of Corrections has collected articles and other resources on this subject. They also sponsored a podcast on the subject in 2014 which can be accessed on the NIC website. Much of this information was adapted for correctional nursing from a series of articles written by Caterina Spinaris PhD., Executive Director of Desert Waters Correctional Outreach which provides training and other materials to support wellness of correctional staff including a monthly newsletter, Correctional Oasis.

I was most surprised to learn from my research for this blog post that when I offered support to co-workers it had a positive effect on me by building resilience. This new idea has me thinking about my work relationships and how I support others to see what I could do better. What resilience building behaviors have caused you to reflect on your own behaviors? Is there more you could do to protect yourself from the negative attributes of your working environment?

If you wish to comment, offer advice or share an experience concerning the subject of staff wellness please do so by responding in the comments section of this post.

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

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Sexual Harassment by Inmates Against Nurses

A nursing colleague recently asked for advice about how to address the problem of inmates masturbating and making verbal threats during nursing encounters. It is a problem nearly all correctional nurses will face at some point in their career. This post is written to ask nurses how they have dealt with inmates who expose themselves or masturbate in front of the nurse while administering medication, evaluating a health care complaint or responding to a man down call.

While nurses put up with some anti-social behavior in almost any setting, nurses really can be challenged with the pervasiveness of this in a correctional setting. Some nurses will confront the behavior, others will ignore it, and some dish it right back all in an effort of controlling the offensive behavior and getting nursing care delivered. However unchecked exhibitionism is a form of violence towards others that is not acceptable even in a correctional facility. In 2006, the Ninth Circuit Court of Appeals agreed with the lower court’s ruling under Title VII of the Civil Rights Act finding for the employee and noted that prison officials in the California Department of Corrections and Rehabilitation may “not ignore sexually hostile conduct and must take corrective action to safeguard the rights of victims, whether they be guards or inmates”. Similar litigation has been successful in Florida.

Nurses should not attempt to confront the problem alone and have good cause to look to their immediate employer as well as prison officials to address the problem of sexually hostile conduct. Another colleague, who is a corrections expert, recommends addressing the problem in an integrated way that includes making expectations for behavior explicit, delineating graduated consequences that include criminal charges and involvement of the local prosecutor. Here is a list of items which if in place at a correctional facility provide the means to address sexual misconduct:

  • There is an inmate handbook including written rules of conduct for inmates that specifically addresses the issue of exhibitionist masturbation and other forms of sexual misconduct.
  • The handbook also delineates the inmate disciplinary process- what specific offenses bring what penalties – including a description of the inmate disciplinary process.
  • The handbook is available in the languages of those who are incarcerated and written at a 5th grade level for those with low literacy skills.
  • Inmates are provided an orientation at intake – that is documented (video or in person) and goes over the rules, including the rules regarding exposure, masturbation and other forms of sexual misconduct.
  • This information is repeated by the housing unit officer, posted on the housing unit or televised in the living areas.
  • There are facility policies and procedures for staff that describe:
    • inmate housing unit management
    • inmate rules of conduct (including exhibitionism, masturbation in public and other forms of sexual misconduct)
    • how rules of conduct will be enforced and
    • the inmate disciplinary process.

          Also there is evidence that staff training about the facility policies and procedures has taken place     and repeated as necessary.

  • There are provisions for management of inmates with mental illness, or suspected of mental illness, related to in-custody behaviors and related discipline, and treatment.
  • There is documentation that inmates who engage in prohibited behavior receive disciplinary notices, participate in a disciplinary process, and if found guilty serve disciplinary sanctions. These sanctions may include but are not limited to disciplinary segregation.
  • For offenses such as exhibitionist masturbation one effective strategy to develop behavior contracts. For example, if the inmate serves X days of disciplinary sanctions without incident they get X days off their sentence.
  • There is a record of disciplinary notices, hearings, sanctions, etc. for these specific offenses.
  • There is a process by which staff notify their supervisors and/or the leadership regarding offensive inmate behavior.
  • The facility has programming and other services that can be withheld from inmates who violate policies/procedures and found guilty of disciplinary infractions.
  • Inmates who engage in this behavior repeatedly are charged via law enforcement and referred for prosecution. At one facility a prosecutor actually speaks to the inmates about how if they engage in this behavior and are administratively and/or criminally charged – how it effects their sentencing at trial, parole consideration, and conditions of release. Most inmates don’t think about the longer term consequences on their own so it helps to point it out.
  • Finally the agency should be aggressive in referring for prosecution – if the prosecutor declines- then the facility should focus on ways to convince the prosecutor to change their position.

Are these measures in place at the correctional facility you work at? You might want to review the inmate handbook at your facility and see if there are explicit guidelines about sexually hostile behavior and the consequences. Have you had experience addressing the problem of inmate masturbation during delivery of health care? If so, what was successful? Please share your experience by responding in the comments section of this post.

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

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Intake Health Screening: Truth or Consequences?

Skinny Fighting LiarLast week I reviewed a letter responding to a complaint from an inmate’s wife that her husband was not receiving proper care for a back injury received when he was apprehended. The response starts like this “During intake screening on February 10, 2016 the inmate denied recent injury or hospitalizations. He also denied any past history of injury. Upon examination there were no signs or symptoms of injury to his back.”

How many times had you had something similar happen- an inmate seems to be healthy and denies any medical or mental health issues at intake, then a few hours, days or weeks later complains about a particular health issue alleging that it either happened just before incarceration or has been long standing? I have seen this happen lots of times. The letter above reminded me once again how inaccurate and unreliable health information obtained at intake can be. Some nurses I work with actually took a retrospective look at the accuracy of health information collected at intake compared to information obtained by asking the same questions a week later.  What were the findings? Well, it was surprising how much more information the inmate was able to provide.

What do you think are some of the reasons that information taken during intake screening differs from that obtained later? These are some of the reasons that nurses give when asked this question:

  1. Inmates are unreliable or untruthful. If you think about your experience with patients in emergency nursing, urgent care and to some extent ambulatory care settings you would probably agree that they didn’t always tell the whole truth either. Inmates really aren’t different in this regard. It is unrealistic to expect patients to tell you the whole truth when you are asking screening questions.
  2. Inmates are affected by drugs or alcohol and not aware of other health problems they may have, like infected teeth or other sources of pain. Jail nurses cite this as a reason more often. This is because the detainee arrives at the facility directly from the community. It’s always wise for the nurse to be mindful that they have not witnessed the inmate or their environment in the minutes, hours or days prior to intake screening and the inmate may not be able tell us that the headache they have, for example, is a subdural hematoma from a fight that happened on the transport bus an hour ago.
  3. Inmates are manipulative and distort the truth for secondary gain. Yes, they do. If I imagine myself in the same situation, I would too. If what I tell the nurse about my health gets me a preferable setting, with more access to visitation or a lower custody housing assignment, or protection from other inmates then I would answer intake screening questions in a way that is likely to result in my desired outcome. It doesn’t matter if the nurse has that kind of decision making power or not; if the inmate believes the nurse can influence these things they will answer accordingly.

Realizing that an inmate may not have answered the health screening questions fully will protect you from coming to clinical judgements and decisions that are based upon incomplete or inaccurate information. Other reasons for inaccurate intake screening information include:

  • An environment that is not conducive to sharing personal health information. This could be because other inmates can overhear the interview or that correctional officers are nearby. At one jail I visited, intake screening took place with a nurse sitting at a computer behind an elevated counter. The inmate was standing below, speaking to the nurse through a Plexiglas screen. Other inmates were standing about five feet away and officers were everywhere. This was equivalent to giving your health history by megaphone at a football game. No thanks!
  • Failure to communicate effectively. This could be because of cultural or language differences or disability. Health information is a complicated subject. If English is not the inmate’s primary language, the accuracy of screening information collected using English is not going to be as accurate as that collected in the inmate’s native language. The same is true of those who are deaf or hard of hearing. Considering cultural practices regarding health care will also yield richer information than when these are disregarded. Lastly, an uninterested and hardened nurse is not going to elicit personal health information very well from a patient in any setting, not just inmates in the correctional setting.
  • Health care is really not a priority at intake. This is true for the inmate as well as the facility. When an inmate arrives at a jail it is usually because they have just been arrested. Again, when I imagine myself in those shoes, I would be more concerned about when or if I could make bail, how to make contact with my family or someone who can help me and the immediate consequences of my arrest. My health care is not very important until I begin to feel bad. Being asked a bunch of questions about my health status and history is really an annoyance, especially if I believe I won’t be in jail very long. Prisons or detention facilities are different, but still at intake, health care is not likely to be as important as other things, such as housing, access to property, contact with family, and safety for most detainees. Later when these other concerns have been addressed, aspects of health care become more important.

So what does a correctional nurse do about this?

  1. Remember that intake screening is for the purpose of safety. It is to make the best determination possible about care or treatment that an inmate will need for the next few days. Establishing medical support for detoxification, arranging for an inmate to continue important medications and addressing trauma are the primary things to get done. It is not the best time to expect a complete history and physical.
  2. Think of every subsequent health care encounter as another opportunity to add meaningful information to the inmate’s health record. What was documented at intake may no longer be as accurate. Inmates are usually not very sophisticated about health care and may not know or remember what is important to tell their health care provider about. You can model this in your interaction with inmates and can also coach them in preparation for their primary care appointment. View each encounter as adding a chapter to a patient’s book rather than a battle over what the inmate gets or not.
  3. Take an objective look at what intake screening is like from the inmate’s perspective. Go out to booking or the intake area and observe the process. What is the experience like? Identify the things that may be barriers to giving information during health screening and see if anything can be changed to improve the process. Not all of the barriers can be eliminated but just knowing what they are gives a good picture of the things that make intake screening vulnerable to inaccuracy. This information can be used to identify inmates or the kinds of situations which might benefit from scheduled follow up.

Are there reasons that you think make intake health screening inaccurate or unreliable that are not mentioned in this post? What advice would you give others to improve the accuracy or reliability of intake health screening?

For more about the art and science of intake health screening refer to Chapter 14 about Health Screening in the Essentials of Correctional Nursing. You can order a copy directly from the publisher or from Amazon today.

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Heart Disease and Women Part 5: Answers to the Cardiac Risk Quiz

Heart disease risk

The last post gave five case examples and readers were asked to identify the cardiac risk factors in each. In addition, readers were asked which of the five had the most cardiovascular risk and which had the least. Finally, readers were asked to identify the counseling recommendations for each patient. The following are the answers to the questions and a discussion of each answer.

Which of the five women is at greatest risk for heart disease?

All five women have risk factors for heart disease however based upon what we know now about each of them, Ms. Joseph is at greatest risk. She has two of the most significant risk factors, smoking and diabetes. Ms. Joseph also has more risk factors than the others and risk accumulates with each additional risk factor. These include that she is over 65, menopausal, sedentary and has little or no social contacts. Because she has diabetic complications we may find other risk factors upon gathering additional data.

Ms. Ott and Ms. Hollister would be the next most at risk. Ms. Ott because of the significant risk factors of continued tobacco use, hyperlipidemia and poor treatment adherence. Ms. Hollister because of the cumulative number of risk factors, including family history of heart disease, menstrual irregularity and now menopause, sedentary lifestyle, being overweight and excessive intake of alcohol.

Which of these women is at the least risk?

Ms. Falwell is in the best cardiovascular health of the group. Her hypertension is well controlled. Her alcohol and drug use and emotions about the separation from her children are the only contributors to her risk of heart disease. She is of normal weight, physically and socially active. Ms. Garcia’s only risk factors are obesity and a sedentary lifestyle. Obesity, though is a significant contributor to heat disease (2-3 x risk increase) and because she is continuing to gain weight, Ms. Garcia cannot be considered at lowest risk.

What are the recommendations you would make in counseling each of these women?

Case example 1. Ms. Falwell’s counseling emphasizes three points: a. continued involvement and attention in managing her hypertension (regular monitoring and medication adherence) b. stress management and developing healthy avenues to address anger and anxiety c. limiting drug and alcohol use (perhaps participating in the facility AA or NA groups or attending classes to increase her knowledge about the effects of drug and alcohol as well as treatment options). Ms. Falwell already has several good lifestyle habits that can be leveraged to increase opportunity to control cardiac risk.

Case example 2. Ms. Joseph’s counseling is focused on achieving good control of her diabetes to prevent further complications as well as the identification and early intervention to address other cardiac risk factors, including obesity, dyslipidemia and hypertension. Most correctional facilities no longer allow smoking so Ms. Garcia has been forced into smoking cessation which will lower her cardiac risk over time but if she is to be released to the community continued smoking cessation would be an important goal for her. I would also recommend a mental health evaluation to rule out depression or another mental health disorder as an explanation for her social isolation and based upon those results try to increase her social interactions. Lastly, a program to increase her physical activity should be developed that is appropriate for her age and physical limitations.

Case example 3. Ms. Ott’s counseling is directed to smoking cessation as a first priority and second, the effectiveness of her treatment for hyperlipidemia. While smoking at the facility is prohibited Ms. Ott continues to crave cigarettes and has violated this disciplinary rule recently. She should be encouraged to participate in one or more smoking cessation programs that are available at the correctional facility and her steps to do this discussed and acknowledged during her health care appointments. Ms. Ott’s medication administration record should be monitored and she should be seen regularly to discuss adherence with the medication she is prescribed. Barriers to adherence should be identified and ways to resolve adherence problems developed with the patient. A change in medication should be considered if her lipid levels cannot be lowered with the currently prescribed medication. Her lipid levels should be monitored closely.

Case example 4. Ms. Garcia’s counseling emphasizes weight loss, proper nutrition and incorporating exercise into her daily life. She has gained weight since admission to prison and is now more than 30% overweight, a tremendous increase in cardiac risk. She already is on a heart healthy, reduced calorie medical diet but eats a lot of canteen food. She should be monitored regularly for symptoms of hypertension, dyslipidemia, and metabolic syndrome perhaps best done in a cardiovascular chronic disease program or nursing driven wellness program, she should receive education about heart disease prevention and encouraged to adopt better eating habits and to begin walking or some other form of aerobic exercise three to five times a week. Finding out what she is most motivated to change and helping her to develop plans to make small change or new behavior is the primary focus of counseling Ms. Garcia.

Case example 5. Ms. Hollister’s family history cannot be changed so her counseling focuses on the alterable risk factors of weight control, exercise, and limited alcohol use. She gave a history of significant alcohol use and should be referred for alcohol and drug counseling, and encouraged to attend AA or NA groups, if she has not already. Helping her to understand her risk of heart disease resulting from alcohol use may provide additional motivation for her to participate in treatment. Education about nutrition choices on the institution menu and canteen, counseling or problem solving to reduce caloric intake along with weight monitoring to lose some or all of the 35 extra pounds would be another counseling goal for Ms. Hollister. She also would benefit from adding aerobic exercise three to five times a week to her schedule. A group wellness or heart healthy program is a convenient way to provide information, educate and encourage adoption of lifestyle changes that increase fitness and reduce weight.

Each of these women would benefit from knowing their cardiac risk profile and participating in an earnest discussion about what can be done to limit or prevent heart disease. Any success you have with these patients not only effects their health during incarceration but far into the future. Even if you are not successful in achieving a single improvement now the information you provide makes it more likely one or more of these women will make a change in the future than if you did nothing. After suicide, heart disease was the leading cause of death among women in jails in the United States from 2000 through 2013. Except for cancer, heart disease caused the most deaths among women in prison in the United States during this same time period (2015).

You might want to identify those women at your facility who have the highest risk for cardiovascular disease and then offer a counseling, diet and activity program developed to reduce their risk. It would be interesting to see what results would be achieved at 4 weeks, 8 weeks and 12 weeks. It would be a great study especially if it was compared to a control group.

What ideas do you have about nurses’ involvement in programs to reduce heart disease and related deaths among women who are incarcerated? Please comment by responding in the comments section of this post.

The following are some excellent online resources about heart disease and women:

To read more about nursing care of women patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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Heart Disease and Women Part 4: Assessing Cardiac Risk Quiz

Portrait of young beautiful woman doctor holding red heart against gray background

We have spent the last several posts examining how women’s’ presentation in an impending cardiac event differs from men. We also looked at the emerging data that differentiates women’s cardiac risk from that of men. In this post we put our knowledge assessing cardiac risk to the test! Review the following paragraphs and identify the cardiac risk factors in each case example.

Case example 1. Ms. Falwell is a 38-year-old black woman who has been incarcerated for 10 months. She is single with three children who are living with her mother. Ms. Falwell has hypertension which has been well controlled with medication (ACE inhibitor). She is of a normal weight and her labs are unremarkable. She has a history of THC use and moderate alcohol intake but has not used tobacco. She is considered well-adjusted to prison life having been active in classes and other programs at the facility and taking part in competitive sports but also has expressed a good deal of anger and anxiety to her counselor and other inmates about the separation from her children and its impact on them.

Case example 2. Ms. Joseph is a 65-year-old white woman who is incarcerated for neglect and abuse of children in her day care. She has been an insulin dependent diabetic since she was in junior high school. She has diabetic retinopathy as well as peripheral neuropathy. Until her incarceration last year, she had been a heavy smoker since adolescence. She is housed in the special needs unit near the infirmary because she uses a wheelchair and needs assistance with all activities of daily living. She has no visitors or contact with her family and does not participate in any programs at the correctional facility.

Case example 3. Ms. Ott is 55 years old, of Malaysian descent and has just been incarcerated for manufacturing and distributing drugs. She has used drugs and tobacco daily for more than 30 years. During her admitting physical she was diagnosed with hyperlipidemia – her HDL was 35 mg/dL and LDL was 145 mg/dL. She has been prescribed a lipid lowering agent but is only partially adherent. Ms. Ott was disciplined recently for having cigarettes in her property so it is likely that she is still smoking even though this is prohibited at the facility.

Case example 4. Ms. Garcia is a 44-year-old Hispanic woman incarcerated the last two years for theft from several businesses where she and her husband were the night janitors. At 5’3” weighing 220 lbs. she is considered obese. Her provider has her on a reduced calorie diet but has gained weight since incarceration because she barters for junk food from the canteen. Her abdominal girth is substantial and the prison jumpsuit she was issued had to be altered to fit. She does not participate in any exercise programming at the facility. She does work two hours a day as the janitor on her living unit.

Case example 5. Ms. Hollister is a black woman 49 years of age and was transferred from jail to prison a few days ago to begin serving a ten-year sentence. During the admission health assessment, she gives a family history of heart disease. Upon further inquiry by the nurse Ms. Hollister’s father had an MI at age 53 and he eventually had a CABG procedure done. Her brother had a fatal MI at the age of 46. She has been receiving hormone replacement therapy for menstrual irregularity and now is in menopause. Ms. Hollister has led a sedentary lifestyle, is 35 lbs. overweight, does not exercise and has a significant history of alcohol use.

Questions:

  • Which of these five women is at greatest risk for heart disease?
  • Which of these woman is at the least risk?
  • What are the recommendations you would make in counseling each of these women?

See how your answers compare with the discussion about each of these questions in the next post. In the meantime, read more about correctional nursing in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

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