Correctional Nurse Self Care: Resilience

 

 

Peligro, cuerda rotaLast week’s commentary on the burden of moral distress brought forth the concerns and experiences of several more correctional nurses. Each of these courageous nurses described a turning point where they chose to act rather than stay silent and address the needs of their patients; each also paid a price, including termination, depression, failing health and so forth. I too, had to leave a position I had been in for 17 years because I was “in the way” of achieving the cost savings the organization had promised. This past year I witnessed a colleague being walked off the job because while she was trying to improve nursing practice she didn’t have the full support of the facility health authority. These are tremendous consequences for nursing professionals committed to quality patient care. One nurse commented that it is “easy to blame the nurses that are working with the inmates daily” rather than look up the chain of command to the organization itself and the managers responsible for the delivery of services. These experiences and the accompanying reality are the reason resilience has been identified as an essential quality to nurture as part of the caring practice of the nursing profession (Tusaie & Dyer 2004, Hodges et al. 2005, Warelow & Edward 2007).

Resilience refers to the ability to bounce back or recover from adversity (Garcia-Dia et al. 2013). Others describe resilience as the ability to grow and move forward in the face of misfortune or adversity; to adapt to adversity while retaining some sense of control and moving on in a positive manner (Jackson, Firtko & Edenborough 2007). Resilience has been suggested as a strategy for nurses to manage the emotional and physical demands of caring for patients as well as reduce their vulnerability to workplace adversity (excessive workload, organizational restructuring, lack of autonomy, bullying and violence).

The good news is that resilience is not a personality trait, that we either have or not, but instead consists of behaviors, thoughts and actions that can be developed and fostered to strengthen and adapt to our circumstances. Strategies that help build personal resilience include:

Professional relationships which are supportive and nurturing

A key component in the lives of resilient people is positive social support; having one or more people in the profession who are role models and can be called upon for guidance and support when needed. At least some of these individuals need to be from outside the immediate workplace so that support is unbiased and safe to receive, especially when the workplace is laden with tension. Another feature is that the relationship needs to be nurturing and one that fosters offers encouragement, reassurance, and individual professional growth; such as a mentoring relationship. In thinking about this, my professional network was developed among the members of the Oregon Chapter of the American Correctional Health Services Association. We meet twice a year and each meeting includes training, social time and the opportunity to discuss the workplace challenges we each struggle with. The relationships built through this local organization with other correctional nurses over the years have sustained me during many periods of crisis and change.

Maintain positivity

Positive emotions, including laughter, increase energy, change perceptions and help cope with adversity. Positivity comes from optimism or an ability to visualize potential benefits or positive aspects of an adverse situation. Considering a situation in a broader and longer-term perspective can build optimism. Indeed forcing oneself to think positively develops a greater range of resources and broadens the inventory of possible solutions in the midst of adversity (Jackson, Firtko & Edenborough 2007). The readers’ comments about their experiences with moral distress express an optimistic and positive view that reaching out to each other will create a collective voice to improve conditions in correctional health care. Techniques suggested to support positivity include visualizing what one wants rather than what is feared, identifying what brings joy to one’s life, maintaining hope for a positive outcome and laughter.

Develop emotional insight

Emotional insight is the capacity to identify, express, and recognize emotions; to incorporate emotions into thought; and to regulate both positive and negative emotions. When faced with adversity, emotion is inevitable, however we often are focused on the “who, how, what, when and where” of what is happening; unaware of how emotion is effecting us. When we can identify our emotional response to a situation we can switch our parasympathetic nervous system on and respond in a calm and rational manner and not suffer the effects of a “fight or flight” response. Understanding our emotional needs and reactions provides further insight into how we cope and may yield new ideas about how to improve our response in the future. Specific techniques suggested to develop emotional insight are relaxation exercises, guided imagery, meditation, deep breathing, journaling and reflection. See an earlier post about the use of reflection for professional growth.

Achieve life balance and spirituality

Highly resilient persons express existential beliefs, have a cohesive life narrative and appreciate their own uniqueness. This has also been described as having an anchoring force in life. In nursing, we often use the term achieving a work-life balance which is to engage in activities that are physically, emotionally and spiritually nurturing. This includes being clear about our mission in professional life, the reason for being a correctional nurse, so that we aren’t distracted in challenging times. Activities that support a balanced life include getting enough sleep, eating healthy, regular exercise, and maintaining a spiritual practice. You may want to revisit a recent post introducing self-care for correctional nurses. Another suggestion is to write and then send a letter to yourself recognizing your strengths and expressing gratitude for the work that you do.

Reflective practice

Reflection is a way to develop insight and understanding about situations so that knowledge is developed and can be used in subsequent situations. A concrete experience, such as losing one’s job or experiencing an ethical dilemma is used as a catalyst for thinking and learning. Journaling is especially helpful in adult learning because putting an experience into writing ascribes meaning to the people, places and events involved in the experience. Reflection is an opportunity for self-discovery; many people report better relationships, greater personal strength and self-worth, a deeper spirituality and heightened appreciation for life as a result of the self-growth that takes place after adversity. One of our readers said exactly that… “I have learned so much about myself, and systems change, and leaders vs managers.” I have to agree based upon my own experience; I am a stronger, more skilled professional than I ever was and have more to give others as a result of the self-discovery that took place after leaving, so long ago, a job I loved.

 

No one wants to experience workplace adversity and professional burnout and yet we know from our own experience and those of our readers, it is a reality in correctional nursing. Recognizing and building resilience personally and within our organizations is a strategy that is becoming part of the profession’s uniform. Below are several excellent resources for developing nursing resilience:

  1. Resilient Nurses: How health care providers handle their stressful profession. Written and produced for Public Radio. Consists of two ½ hour interviews with several leading nursing experts. The second segment includes techniques used to handle unusual strain as well as everyday stressors in nursing. It also includes a relaxation audio, a booklet, a CD and a list of resources.
  2. How can nurses build resilience and master stress? A summary of a 16 week series on Activating Resilience in Nursing and Leadership by Cynthia Howard. Links are included to other posts in her series on resilience.
  3. University of Virginia School of Nursing, Compassionate Care Initiative, is dedicated to teaching nurses resilience and compassion in health care. The site includes a link to “nurses thrive!” an online community of nurses dedicated to promoting resiliency. Also includes resources for building resilience through guided practice and exercise.

Do you recognize aspects of your own path to professional resiliency in these descriptions? What has helped you adjust or rebound from adversity? Please share your experiences or advice by responding in the comments section of this post.

References:

Garcia-Dia, , J., DiNapoli, J.M., Garcia-Ona, L., Jakubowski, R. & O’Flaherty, D. (2013) Concept Analysis: Resilience. Archives of Psychiatric Nursing 27; 264-270.

Hodges, H.F., Keeley, A.C., & Grier, E.C. (2005) Professional resilience, practice longevity, and Parse’s theory for baccalaureate education. Journal of Nursing Education 44, 548-554.

Jackson, D. , Firtko, A., & Edenborough, M. (2007) Personal resilience as a strategy for surviving and thriving in the face of workplace adversity: A literature review. Journal of Advanced Nursing.

McGee, E. M. (2006) The Healing Circle: Resiliency in Nurses. Issues in Mental Health Nursing 27; 43-57.

Sieg, D. (2015) 7 Habits of Highly Resilient Nurses. Reflections on Nursing Leadership 41 (1).

Sullivan, P., Bissett, K., Cooper, M., Dearholt, S., Mammen, K, Parks, J., & Pulia, K. (2012) Grace under fire: Surviving and thriving in nursing by cultivating resilience. American Journal of Nursing, 7 (12).

Tusaie K. & Dyer J. (2004) Resilience: a historical review of the construct. Holistic Nursing Practice 18, 3-10.

Warelow, P. & Edward, K-l. (2007) Caring as a resilient practice in mental health nursing. International Journal of Mental Health Nursing 16, 132-135.

 

For more on moral distress and courage see Chapter 2 Ethical Principles for Correctional Nursing in the Essentials of Correctional Nursing. You can order a copy directly from Springer Publishing and receive $15 off as well as free shipping by using this code- AF1209.

Photo credit: Peligro, cuerda rota@alejandro dans- Fotolio.com

 

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

 

An Experience with Moral Distress and its Resolution

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

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

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

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

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

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

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

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

Silence Kills: Communicating for Patient Safety

covering mouth dog

What do you do if you see a fellow nurse not washing her hands after a dressing change or not checking the MAR (Medication Administration Record) before administering routine medication to a patient? Speaking up about breaches in safety rules or other concerning issues can be a struggle of conscience. Staff nurses like to avoid conflict. This can be particularly true in a correctional setting where a punitive culture may pervade (See an earlier post on this topic). Nurses must be able to speak up on critical issues of patient safety. The HealthGrades Quality Study of 2004 estimates that each year one in twenty patients will receive a wrong medication, over 3 million will obtain an infection from unwashed hands and nearly 200,000 will die of a mistake while hospitalized. How many of these poor outcomes and deaths might have been avoided if someone had spoken up about what they observed?

Maxwell et al. surveyed healthcare staff from a variety of professions and settings to determine the primary areas of concerning behaviors. Results indicate that many of us are witnessing team members cutting corners, breaking rules and being disrespectful but few are addressing these concerns. Surprisingly, the majority of those surveyed did not believe it was their responsibility to address these patient safety issues. The following seven areas of concern emerged as key issues we need to actively address.

  • Broken Rules – Examples include standard safety rules such as checking doses or wearing gloves when drawing blood.                                              
  • Mistakes – Involve Incorrect judgments, poor assessments, or not getting help when needed.
  • Lack of Support– Can include reluctance to help, impatient, refuse to answer questions, or a teammate who complains when asked to help out.
  • Incompetence– Both doctors and nurses expressed concern about the competence of a few of their team members.
  • Poor Teamwork-Gossiping and cliques are mentioned in this category.
  • Disrespect– Examples include condescending, insulting, or rude comments. A small percentage of respondents also reported verbally abusive conduct such as yell, shout, swear, or name call.
  • Micromanagement-This category includes abuse of authority such as pulling rank, threatening, bullying or forcing a point of view on others.

How many of these concerns have you experienced in your correctional nursing practice? Although intervening in the face of any of the above situations is difficult, correctional nurses are called to protect their patient’s safety in every possible area. We must find ways to overcome our discomfort to advocate for our patients.

Are you challenged to speak up when you see mistakes, incompetence, or disrespect? Share your experiences in the comments section of this post.

Read more about Patient Safety in Chapter 4 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © javier brosch – Fotolia.com

Reflective Practice: A Means of Professional Growth

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

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

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

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

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

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

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

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

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

Resources:

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

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

 

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

Managing Conflict is Essential to Safe and Effective Correctional Nursing

picket fenceI live in a neighborhood of 36 houses that are built very close to one another. The neighborhood is surrounded by a beautiful landscape. The peacefulness and beauty of the setting was the reason I chose to live here. Last week the moving truck used by a new homeowner blocked the neighbor’s driveway for most of the day.  The neighbor raised such a ruckus that the whole community heard about it and the homeowner’s association had to get involved. The incident made me appreciate how important it is to a “healthy” community that conflict be addressed well by each of the members.

These skills are even more important in health care because they contribute to patient safety and retention of nurses.  Unrecognized or unresolved conflict in the health care setting causes a decrease in nurses’ morale, increases physical and emotional stress, as well as the likelihood that conflict will escalate (Longo, J., 2010; Almost, J., Doran, D., Hall, L., Laschinger, H., 2010; Johansen, M., 2012). “…conflict management skills have been identified as an essential competency for the professional RN to provide safe, quality care to patients…” (Johansen, M., 2012 p. 50).

Conflict is an inherent aspect of correctional nursing practice. Sources of conflicts that are unique to correctional nursing are detailed throughout the Essentials of Correctional Nursing. The American Nurses Association draft of the Correctional Nursing: Scope & Standards of Practice, which has been out for public comments the last month, also discusses conflicts experienced by correctional nurses. Two of the proposed standards explicitly address expectations of correctional nurses to assess and improve their skills in conflict management.

What are the sources of conflict in your day to day nursing practice? How often are these conflicts resolved satisfactorily? Do you wonder what you can do to better address conflict in the practice setting?  The following are some steps to assess and improve conflict management skills.

1. Explore your own emotional triggers and reactions. Nurses who have good self- esteem, perceive themselves as successful, feel they are in control of their life and are optimistic are also more constructive in managing conflict.

2. Identify and review the organization’s written directives related to conflict management. These may be in the code of ethics, rules for professional behavior, bylaws of the governing body or in the collective bargaining agreement. Know what is expected of staff, the methods to identify and resolve conflict as well as avenues for redress when conflict is not satisfactorily resolved.

3. Address conflict quickly, fairly and respectfully. Sometimes people are not aware that their behavior contributes to conflict at the workplace. Communicating in a way that increases understanding and resolves conflict among participants is not an easy task. It should always be done in private. Chapter 17 of the “Essentials” book provides resources and suggests that nurses build their repertoire of conflict management styles, especially those of collaboration.

4. Take care of yourself. Stress can contribute to increased emotions, particularly anger. Nurses who understand how emotions affect their behavior have less risk of burnout associated with conflict in the workplace. Take appropriate breaks; attend to personal needs for nourishment, relaxation and other self-care habits. Reflective journaling has been suggested as way to process negative personal feelings after a conflict. In addition to reliving the negative effects of a conflict situation, reflection can be used to build skills and competencies in conflict management.  We will take a closer look at this technique in a future post on this site.

5. Report abusive or disruptive behaviors through your chain of command. Many nurses opt to ignore or avoid conflict without knowing that if left unattended, it contributes to an escalation in conflict. Avoiding conflict at the worksite only reinforces disruptive, dysfunctional and unprofessional behavior. Knowing your organization’s policies regarding workplace conflict is an important first step.

This post was written from the perspective of the individual registered nurse. Nursing supervisors, managers and executives have an exceedingly important role in creating a workplace that supports the professional practice of nurses and safe environments for patient care. Going back to the example of conflict in my neighborhood, our community works best when individual homeowners address conflict quickly and well.  The same goes for the workplace; it is the everyday acts of individual nurses managing conflict that does the most to keep staff and patients safe.

To read more about conflict management order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

References:

Almost, J., Doran, D., Hall, L., Laschinger, H. (2010). Antecedents and consequences of intra-group conflict among nurses. Journal of Nursing Management, 18, 981-992.

Dombrowsky, T. (2012). Responding to verbal abuse. Nursing 2012, November, 58-61.

Hocking, B. (2006). Using reflection to resolve conflict. Association of Operating Room Nurses Journal, 84 (2) 249-259.

Johansen, M. (2012). Keeping the peace: conflict management strategies for nurse managers. Nursing Management, February 50-54.

Kupperschmidt, B. (2008). Conflicts at work? Try carefronting. Journal of Christian Nursing, January-March, 10-17.

Longo, J. (2010). Combating disruptive behaviors: strategies to promote a healthy work environment. Online Journal of Issues in Nursing, 15 (1) 3.

Siu, H., Laschinger, H., Finegan, J. (2008). Nursing professional practice environments: setting the stage for constructive conflict resolution and work effectiveness. Journal of Nursing Administration, 38 (5) 250-257.

Thomas, C. (2010). Teaching student nurses and newly registered nurses strategies to deal with violent behaviors in the professional practice environment. The Journal of Continuing Education, 41 (7) 299-308.

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