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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Contraband: Health or Security Issue? Part III

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

The daily work in corrections health, whether a jail, prison or juvenile facility, easily becomes routine. Concerns for personal safety and facility security can fade as reliance is placed on standard operating procedures, custody colleagues, and our own growing familiarity with the criminal justice system. When this happens our safety can be threatened a couple ways. For correctional nurses, this can happen when someone becomes overfamiliar with a patient or when an inmate has been able to manipulate a staff member to bring drugs into the facility.

A news item reporting that a correctional staff member has assisted an inmate to escape from a facility can lead to a reaction like “How in the world could this happen?” Unfortunately, it does happen; even with good orientation, teamwork and communications.  Inmates have persuasive skills that they learned on the streets and staff member may be going through a difficult, vulnerable life situation. This can be a dangerous combination.

Objects and Relationship Contraband

The book “Games Criminal Play” was helpful to me when I entered the correctional nursing specialty many years ago. Although published in the 1980’s, the principles for dealing with inmate manipulation are timeless and remain helpful today. One key principle is that criminals have a manipulation process so subtle that victims rarely realize what is happening until it is too late. That is why it is important for us to be ever-vigilant in avoiding manipulation traps in our nurse-patient interactions. Here are some actual examples of inappropriate staff activities:

  • Forming a relationship while in the jail leading to the patient moving in with the staff member after release
  • Living with a drug dealer and passing on information to inmates
  • Putting money on an inmates books
  • Not reporting when a family member is in custody

Professionalism and Boundaries

Maintaining professional boundaries with patients is safe practice. Contraband can include not only sharp objects but also information, money and personal relationships. By being a skilled health practitioner, sensitive team member and grounded in yourself, you can deliver good health care while avoiding contraband participation.

To read more about the area of safety for the nurse and patient in correctional settings see Chapter 4 sections on contraband, medical contraband and professional boundaries in the Essentials of Correctional Nursing. You can order a copy directly from the publisher or from Amazon today!

Contraband-Health or Security Issue? Part II

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

The most common examples of contraband we think of are guns, knives (shanks), sharpened toothbrushes, hording medications, and homemade ropes.  When inmates attempt to hide contraband in their body, things can go awry. Here are a few examples:

  • A swallowed balloon of drugs leaks.
  • Eyebrow pencil mistakenly inserted into the urethra instead of the vagina.
  • A swallowed ring lodges in the intestine.
  • Wrapped razor blades cut into the bowel.
  • A wad of money or hidden jewelry causes a vaginal infection.
  • Horded medication traded to another inmate causes an allergic reaction.

Inmates know that bringing in or making unauthorized items is against the rules, so they do not want to tell anyone because they know they will receive discipline. They have read the inmate handbook about the rules inside the facility. Also, they do not want to give up their important possessions because this is the same way they kept valuables when living on the streets.

Patient Awareness

Health staff provide services in chronic disease management, evaluating care requests and medication management and emergency response.  The challenge is to find ways to make patients aware of contraband. This can be done by incorporating information into everyday nursing practice.  Some areas of nursing practice where the topic of the dangers of contraband can be discussed are:

  • At intake or booking, incorporate a statement of awareness that having unauthorized items on your person can have health consequences.
  • During health assessments or nursing sick call evaluations, take the time to mention that contraband is a health issue and we want to prevent any harmful consequences.
  • Posters or videos can be developed to bring awareness of the possible health consequences of some types of contraband.
  • Work with corrections or custody to expand the statements in the inmate handbook to include some health information about the trauma or illness from contraband.

Staff Awareness

Staff also need reminders to be continually aware of the medical implications of contraband. Here are some ways to keep contraband in the forefront of correctional health care activities:

  • Staff meeting or in-service discussing the types of contraband have effects on the health of our patients. Such things as pelvic infections, drug overdoses, perforated bowels, bowel obstructions, rectal bleeding, stomach problems, drug overdoses, trauma or injury can be emergencies from hidden objects.
  • Review contraband situations that have occurred in the facility and complete a Continuous Quality Improvement study to see what could be implemented to target areas for improvement. Use the plan, do, study, act cycle and information from NCCHC to evaluate ways to identify and improve care in this area.
  • Review procedures for sharps and controlled substances in medical. Reinforce the safety aspects of these important procedures.
  • Look at the orientation program to make sure it covers safety from both a custody and health perspective.
  • Work with custody to be a part of their procedures to identify and eliminate risk in the institution. Things that health should be notified about are finding stashes of medications, drugs found in housing areas, and finding things for suicide attempt.
  • Identify the difference when a provider finds a contraband item during a physical examination and when custody asks medical to perform a body cavity search. One is a consented exam and one is asked to do a forensic procedure only performed by personnel trained in this procedure. Body cavity searches are usually completed at the local emergency room by trained staff.  Guidance on the topic may assist in making decisions
  • Use a staff meeting or in-service time to outline the physical assessment skills necessary to identify contraband. Some system are the gastro intestinal system, pelvic area, rectal function, and signs and symptoms of infection.
  • Invite a custody representative to a staff meeting or in-service session to review contraband, what it is and what are examples found in the facility. Sometimes it is a rope, tattoo gun, sharp shank or maybe it is a cute wallet made from gum wrappers.  This increased awareness can change practices and result in discussions about projects or supplies in use by medical.

As a health professional, we have a special relationship with the patients and assist in maintaining their health and overcoming illness. Health staff interview and screen in booking and respond to requests for care and emergencies. We are there as advocates and support. With little in the literature to guide correctional health care in the area of health effects of contraband, we can learn about how to deliver care when things come up.

In the next article will be about a topic that is not easy to discuss. It relates to situations in which custody or health staff contribute to contraband items or comes under the control of an inmates demands.

Share your experiences with contraband in your institutions and share them with us in the comment sections of this post.

For more about correctional nursing practice consult the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

References

Standards for Health Services in Prisons, NCCHC, 2014 edition, Standard P-I-03, Forensic Information, pages 149-150.

Standards for Health Services in Jails, NCCHC, 2014 edition, Standard J-I-03, Forensic Information, pages 149-150.

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Contraband—Health or Security Issue?

This month the Essentials of Correctional Nursing blog welcomes Gayle F. Burrow RN, BSN, MPH, CCHP-RN, Correctional Health Care Consultant from Portland, OR, to the blogging team. Gayle will share insights from her many years of jail nursing experience in a regular monthly rotation with ECN bloggers Catherine Knox and Lorry Schoenly.

Contraband is found frequently in the corrections literature usually with a focus on preventing objects like cell phones, sharp objects and drugs from coming into the institutions at booking or at visiting times. Inmates and their friends and families can be inventive. Drones are becoming a new threat to security. They are dropping packages and weapons into recreation yards. A jail in Ohio has installed body scanners at intake to identify and remove items found in body cavities of those being booked into jail. The officers report, of the four thousand they book annually, they find something every day.

Correctional nurses must understand what constitutes contraband and the damage it can cause. Contraband can consist of weapons, drugs, food, tobacco and even objects that inmates can use to coerce officers into doing their bidding. Contraband can also include medication or medical items that can be harmful if used incorrectly.

Contraband is a Safety Issue

Learning about contraband begins with orientation to the facility and in health orientation. In these sessions new correctional nurses discover:

  • The definition and examples of contraband at this particular facility.
  • Procedures in place to prevent things entering the facility, such as cell phone detectors, body scanners, strip searches, phone detection dogs, housing sweeps, mail inspections and now drone tracking devices.
  • Procedures in place for health staff such as sign out and shift counts for narcotics.
  • The importance of sharps, needles and scissors control and counts.
  • The practices in place during medication rounds to identify and prevent diversion.

Contraband is a Health Issue

Health staff sometimes feel that contraband is a custody responsibility. Nurses often find out about searches or lock down times when heading out on medication rounds or when evaluating a patient in a housing unit. However, contraband can dramatically and quickly affect a person’s health. Health care staff should know about the health effects of contraband and be alert to this unique area of our practice.

In an intake or receiving facility, one common situation is when the arresting officer or custody witnesses someone swallowing baggies of drugs. Sometimes the inmate will become scared and notify the nurse. With a witnessed contraband incident, plans can be made to send the inmate to the hospital for observation and treatment.  It is the unwitnessed situations where harm can occur, such as the collapse of a patient from a leaking baggy or overdose from swallowing drugs. Sharp items can cause stomach or intestinal perforations.

Contraband Risk Reduction

Contraband prevention and identification can become part of everyday patient care practice. Here are some examples of ways to incorporate contraband awareness into clinical practice.

  • Questions included in the booking screening process to identify that contraband is a health issue.
  • Intake evaluation can include discussion of the health problems of hiding objects in body cavities.
  • An evaluation for abdominal pain or even constipation, can include inquiry as to any object swallowed or placed in the rectum.
  • General education during health encounters can elicit information from patients.

Is Contraband a Health or Security Issue?

With the wide variety of contraband brought into a facility, custody has processes in place to locate items with screenings, searches and equipment. Health staff have responsibility for procedures like counts, medication checks, knowing what is on your carts, and locking up sharps and medications. Some items do not cause any health concerns and others can cause death. Since, the safety of the institution is everyone’s responsibility, reviewing the policies and procedures for the facility and health will give guidance.

Next week we will continue to review this complex topic of contraband from a health perspective. It will be interesting to know how your facility handles contraband. Share your experience in the comment section at the end of this article.

To read more about personnel and patient safety in correctional settings in relationship to contraband and other areas, see Chapter 4 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 3: Emerging Risk Factors

Risky Character Showing Dangerous Hazard Or Risk

The emphasis on traditional risk factors alone has been criticized for underestimating heart disease in women, especially those who are not yet manifesting symptoms. Several additional factors have been identified that may improve detection of heart disease in women. Are any of these on your clinical judgement radar when evaluating women and possible heart disease?

Periodontal disease has been linked to increased risk of heart disease for several years now. Specifically, the repeated systemic exposure of the gums to bacteria and bacterial byproducts increase levels of C-reactive protein (CRP) and fibrinogen; both of which are associated with increased likelihood of heart disease. Women with metabolic syndrome and elevated CRP levels had twice the risk of an acute cardiac event as those with metabolic syndrome but low CRP levels. It has been suggested that measuring CRP levels in women with at least intermediate risk of heart disease or metabolic syndrome may identify additional individuals who would benefit from treatment with statins.

Autoimmune disease, such as rheumatoid arthritis and systemic lupus erythematous (SLE), is associated with significantly increased risk of heart disease. Women ages 35-44 years with SLE were found to be 50 times more likely to have an acute myocardial infarction compared to women of the same age without SLE. Systemic autoimmune collagen-vascular disease was listed as a risk factor for heart disease in the Effectiveness-Based Guidelines for Prevention of Cardiovascular Disease in Women, published by the American Heart Association in 2011.

Complications of pregnancy, specifically pre-eclampsia and gestational diabetes, are associated with greater risk of subsequent heart disease. Women with pre-eclampsia, or pregnancy associated hypertension have double the risk of developing cardiovascular disease in the first five to ten years after delivery. They also are significantly greater risk of developing hypertension which is recognized as a traditional risk factor already. Women who experience gestational diabetes are at 1 ½ times greater risk of heart disease compared to those who did not. Women with gestational diabetes have double the risk of developing diabetes mellitus, which is another traditional risk factor for heart disease. Gestational diabetes was also listed as a risk factor for women in the American Heart Association’s 2011 update.

Menstrual irregularities increase the risk of ischemic heart disease in women by 50%. One of these is polycystic ovarian syndrome, a hormone imbalance that prevents normal development and release of eggs. As a result, women experience irregular menstruation (irregular, light or heavy flow) and have difficulty getting pregnant. Polycystic ovarian syndrome is associated with high levels of insulin, which contribute to development of metabolic syndrome and insulin resistance. Another is a type of amenorrhea caused by psychological stress or metabolic insult (caloric reduction or excessive exercise) which results in a hormone imbalance that contributes to risk of heart disease.

Breast cancer treatment is associated with various degrees of injury to the cardiovascular system. Radiation therapy, in particular has an established association with risk of heart disease. With other treatments it is not yet clear if the treatment itself or resulting lifestyle changes increase women’s’ risk of heart disease. Since the rate of breast cancer survival increases more women need providers who are attentive to their cardiovascular risk and prevention.

Sleep apnea is another disease more commonly associated with the male gender and yet there is increasing evidence that women with this disorder present differently and are often misdiagnosed with depression, anxiety, insomnia and fatigue instead. Women with sleep apnea have increased risk of hypertension, coronary artery disease, stroke and atrial fibrillation and have 3 1/2 times greater risk of dying from cardiovascular disease. Treatment with continuous positive pressure reduces the risk to that of women who do not have sleep apnea.

The following table summarizes the traditional as well as the newer risk factors for heart disease in women that we have reviewed the last two weeks.

Risk Factors for Heart Disease in Women
Traditional Risk Factors Emerging Risk Factors
Obesity Periodontal disease
Dyslipidemia Autoimmune disease
Diabetes Complications of pregnancy
Metabolic syndrome Menstrual irregularities
Physical inactivity Breast cancer treatment
Hypertension Sleep apnea
Tobacco use
Psychosocial (depression, loneliness, hostility)
Hormones (postmenopausal and contraceptives)

It can be challenging to convince women to make the lifestyle changes that are necessary to control or limit the risk factors listed above. This is especially so in the absence of symptoms of heart disease and the fact that the benefits of doing so are not immediately apparent. One way that is recommended to assist women to make the necessary lifestyle changes is for health care providers to engage women at a young age and on a regular basis in discussion about their own personal risk of heart disease.

Correctional nurses have the opportunity to make a real difference in the cardiac health of their female patients when completing the initial and periodic health appraisals during incarceration, during every contact with patients who have chronic disease, while caring for women during pregnancy and in any health education programs provided to the population at large. Further correctional nurses are often asked to spear head employee wellness programs which can bring this same information to female employees.

Next week’s post will provide some case examples to practice assessing cardiac risk. In the meantime, what are your thoughts about working with women while they are incarcerated to increase their recognition of cardiac risk and how to prevent heart disease? Please share your thoughts by replying 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!

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

Halm, M. A (2014) Women and Heart Disease. NetCE Course # 33221. Accessed March 2016 at http://www.netce.com/courseoverview.php?courseid=1001

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Heart Disease and Women Part 2: Traditional Cardiac Risk Factors

Heart - Female Organs - Human AnatomyWomen, as well as their healthcare providers, tend to underestimate risk of heart disease in women. The woman in the case example last week presented with six risk factors for heart disease.  Age, gender, family history and ethnic background are the only risk factors that cannot be altered; all of the others can be prevented. By midlife (40 to 50 years of age) almost all women have at least one cardiac risk factor (more than 80%) and the burden of heart disease increases synergistically with the presence of each risk factor. Among women, ages 18-39 years old, followed for an average of 31 years, those with 1 or fewer risk factors had 88% less cardiovascular mortality compared with those who had 2 or more risk factors. This is why the American Heart Association recommends that prevention of cardiovascular risk factors in women begin at an early age. The following paragraphs describe each of the risk factors traditionally associated with heart disease and their impact on women and their health.

Obesity: Incidence of obesity in the U.S. is greater than any other country with 24 states reporting rates of obesity over 30%. The prevalence of heart disease and death are the highest in these states as well. Non-Hispanic black women compared to other racial groups have the highest obesity rates (49.6%). The incidence of obesity among post-menopausal women has been reported as high as 40% and even when women do not gain additional weight, their weight is redistributed to the abdomen which is associated with higher rates of heart disease. Women who are obese have 2-3 times greater risk of an acute cardiac event compared to women who are not overweight.

Dyslipidemia: Elevated serum levels for low density lipoprotein, triglycerides, and total cholesterol as well as low levels of high density lipoprotein are all associated with heart disease in women. Data from the Nurse’s Health Study showed significantly higher risk for myocardial infarction and ischemic heart disease among women who had a higher intake of saturated fat in their diet. All of the major treatment guidelines recommend similar approaches for treatment of men and women and yet women are less likely to be prescribed lipid lowering medication or achieve recommended goals for cholesterol compared to men. This finding supports the role of nurses in informing women about risk factors and helping to advocate for treatment consistent with guideline recommendations.

Diabetes: The number of women diagnosed with diabetes has tripled since 1980 and is now more common in women than men. Women with diabetes experience more serious cardiovascular disease and have a cardiovascular mortality rate twice that of diabetic men. Women with diabetes have 6 times higher risk of cardiovascular death compared with women without diabetes. Diabetes is considered the second most significant risk factor for heart disease.

Metabolic syndrome: This refers to the clustering of obesity, dyslipidemia, diabetes, and hypertension in an individual. Women with metabolic syndrome have significantly increased prevalence of atherosclerotic disease and higher cardiovascular mortality rates than women who do not.

Physical inactivity: Among women 18 years of age and older, only about a third engage in regular physical activity. Women report lower levels of physical activity compared to men which contributes to risk for heart disease. Although the benefits of cardiac rehabilitation programs in reducing cardiovascular risk after a cardiac event are well known, women are referred by their health care provider  at lower rates than men. Those who are referred have low attendance rates compared to men and are significantly less likely to complete cardiac rehabilitation.

Hypertension: Women with hypertension have greater risk of heart disease compared to men with hypertension. Hypertensive women have three to four times the risk of heart disease compared to women with normal blood pressure. Women with hypertension are less often diagnosed than men and when diagnosed and treated, the condition is not as well controlled as in men. Furthermore, hypertension in non-Hispanic black women tends to be more severe, treated less adequately and results in significant cardiac morbidity and mortality. Pregnant women and women older than 65 years of age are also at high risk of developing hypertension.

Tobacco use: Women who smoke are at 25% greater risk of ischemic heart disease than men who smoke. Women who smoke experience significantly higher rates of fatal and non-fatal ischemic heart events compared to women who do not smoke. The largest difference in risk between smokers and non-smokers was among women less than 49 years of age. Women who smoke more than 24 cigarettes a day have a tenfold increase in risk for myocardial infarction compared to non-smokers. Smoking is considered the most preventable cardiac risk factor.

Psychosocial: Depression is a major risk factor for ischemic heart disease and this mental health disorder is twice as common in women compared to men. In addition lack of social relationships, particularly loneliness, in women is associated with greater cardiac morbidity and mortality. Also two studies have found hostility to be a significant predictor of risk for ischemic heart disease in women. Interestingly several studies failed to find a correlation between Type A personality traits and heart disease among women.

Hormones: Postmenopausal women are believed to be more vulnerable to heart disease because of the absence of estrogen. However large clinical trials of postmenopausal women receiving hormone replacement have not shown that it reduces heart disease, suggesting that the relationship between hormones and heart disease is complex and not yet well understood. Women who take oral hormonal contraceptives are at increased risk of heart disease especially in the presence of other cardiovascular risk factors.

The rate of heart disease increases with the number of traditional risk factors present. This is true of both men and women. In Ms. Locke’s case (the example in last week’s post) there were six risk factors for heart disease; which one of these was not preventable? What were the other five risk factors? What nursing interventions should be included in her chronic disease care plan?

The use of traditional risk factors alone has been criticized as underestimating heart disease risk in women, particularly those with subclinical disease. Improving risk estimation and detection of heart disease in women has led to the identification of newer or non-traditional risk factors. Next week we will look at the new or non-traditional risk factors for heart disease in relationship to women’s health.

For more about nursing care of 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!

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

Halm, M. A (2014) Women and Heart Disease. NetCE Course # 33221. Accessed March 2016 at http://www.netce.com/courseoverview.php?courseid=1001

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Heart Disease and Women Part 1: Symptom Presentation

17638Case Example: Ms. Locke, a 45-year-old inmate at your facility seeks medical attention today because of fatigue and shortness of breath. You look at the problem list and note that she was a smoker before incarceration and is being treated for hypertension, hyperlipidemia and diabetes. She is also obese. In your interview and assessment of Ms. Locke, she says that she feels nauseated and has a burning or soreness in her necks and upper arms. She reports experiencing these symptoms intermittently for the last month and being treated for a cold, epigastric distress and anxiety.

Does your differential diagnosis include cardiac disease, particularly ischemia or infarction? She is describing the four most common symptoms experienced by women before an acute cardiac event and there are six risk factors for heart disease in her health history.

The problem: There is still a belief that heart disease is a man’s disease and breast cancer is perceived as a greater threat for women than heart disease. And yet heart disease is the single leading cause of death among women in the United States! While ischemic heart disease is less prevalent among women compared to men; after the age of 45 the risk for women is comparable to men. Since the life expectancy of women is greater than men, as the population ages there is more heart disease among women.

The reason: In a survey of women conducted in 2012 only just over half were aware that cardiovascular disease was the leading cause of death for women and among black and Hispanic women recognition was even lower. In addition, women were not aware of the signs and symptoms of acute myocardial infarction that are more typical for women.

Research also shows that providers minimize the importance of women’s symptoms or disregard their concerns, do not order recommended diagnostic tests for heart disease and are more likely to prescribe treatments for depression or indigestion. Women also have poorer outcomes after diagnosis of ischemic heart disease than men; they are more likely to die the first year after an acute myocardial infarction, more often experience complications after cardiac intervention and have a poorer health related quality of life. While the death rate for younger men (ages 35-44) has decreased with prevention and treatment of heart disease the death rate for young women is increasing. Not knowing prodromal symptoms more typical of women and failure to asses for ischemic heart disease are thought to be the reason for this.

Typical symptom presentation: A meta-analysis of 26 studies concluded that women with acute myocardial infarction were less likely than men to present with chest pain. Women were more like likely to report fatigue, nausea, neck pain, right arm pain, jaw pain, dizziness and syncope than men. Another prospective longitudinal study showed that there were four symptoms that were significantly associated with the likelihood of a woman experiencing a cardiac event: discomfort in the jaw/teeth, unusual fatigue, discomfort in the arms and shortness of breath. Experiencing more than one of these symptoms increased the likelihood of a woman experiencing a cardiac event by four times.

Nursing implications: Here are my suggestions about what nurses should do with this information about the differences between men and women with ischemic heart disease.

  1. Review the nursing protocols at your facility that pertain to cardiac disease, especially those for emergent and urgent conditions. Do they need to be revised to include information that differentiates how ischemic heart disease typically presents in men and women? I looked at a nursing protocol today for angina and among the risk factors was “male gender”. While it is true that ischemic heart disease is more prevalent among men, women are more likely to present with angina when experiencing a worsening cardiac condition. It also doesn’t list age or menopausal status which are extremely relevant risk factors. The symptom description emphasized chest pain or pressure as intense and discounted the importance of other symptoms independent of chest pain. After the immediate problem is addressed does the nursing protocol provide guidelines for referral to a provider for a more comprehensive cardiac assessment?
  2. Educate women about the prevalence of heart disease, the risk factors and the symptoms of cardiac disease. Women tend to attribute their symptoms to non-cardiac reasons and are therefore more likely to be treated for non-cardiac disorders. A more knowledgeable patient helps to reduce delays in treatment for heart disease.
  3. Advocate for patients to receive appropriate diagnostic workups and treatment for heart disease. Unrecognized or “silent” myocardial infarction is more frequent in women and women who experience an MI have a much poorer prognosis than men. Because women are more likely to have their symptoms disregarded or minimized by providers (lack of knowledge by providers about increasing evidence of sex and gender differences in cardiac disease) nurses need to be familiar with diagnostic procedures as well as treatment interventions that are more accurate with women and advocate for these in developing the patient’s plan of care.
  4. You may be saying “Whew, just another reason why I am glad I don’t work in a women’s correctional facility”. But even at male facilities there are women correctional officers, nurses, other officials and visitors who are women. As a nurse you have the opportunity to educate these women about cardiac disease, its prevention and recognition-doing so may change their life. You may also be called to respond to one of these women in a medical emergency and it would be good to be prepared if they present with symptoms more typical of women in a cardiac event.

Next week we will review how sex and gender characteristics of women affect risk factors for heart disease. In the meantime, it would be interesting to know how the emerging information about women and heart disease might change how health care is provided at your correctional facility. Please let us know your thoughts by replying in the comments section of this post.

To read more about nursing care of women and 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!

 

References:

McSweeney, J.C., et al. (2016) Preventing and experiencing ischemic heart disease as a woman: State of the Science. A scientific statement from the American Heart Association. Circulation:133.

McSweeney, J. C., et al. (2014) Predicting coronary heart disease events in women: a longitudinal cohort study. Journal of Cardiovascular Nursing: 29.

Coventry, L.L., Finn, J., Bremmer, A.P. (2011) Sex differences in symptom presentation in acute myocardial infarction: a systemic review and meta-analysis. Heart Lung: 42.

 

Photo by Linda Howard at http://www.picturequotes.com/create?quote=Women-were-always-complications,-bless-their-perverse-little-hearts

JUST – A Dangerous 4-Letter Word

Kelley Johnson, Miss Colorado, delivered a unique monologue about being a nurse at the 2015 Miss America Pageant. In her two and a half minute presentation she explained how she was describing herself as ‘just a nurse’ to her patient Joe, an elderly man with Alzheimer disease. Joe finally shared his perspective that Kelley was not ‘just a nurse’ but a very valuable and effective healer in his life.

Every nurse can relate to Kelley’s presentation of our role in health care. Few nurses have never felt as she did – that we are ‘just a nurse’ and can’t do much in a particular situation. Yet, as her story reveals, JUST is an incorrect and misleading adjective to describe our role to our patients and to society.

I am especially struck by the danger of the word JUST in describing our role as correctional nurses. Our responsibility for our patient’s health and well-being goes beyond the boundaries of a specific nurse-patient relationship. The inmate population of our correctional setting is a patient community that requires the broad application of our nursing role.  Here are three ways correctional nurses go beyond the conventional perspective of being ‘just a nurse’.

Holistic Viewpoint

The increased burden of mental and physical disease in our patient population can strain the resources of correctional officer staff. Their perspective and training is, rightly, focused on public and personal safety. As a nurse, our viewpoint is holistic. We naturally see  any situation as potentially caused by a health or wellness issue. Thus, what may appear to be a behavioral or discipline issue to our correctional colleague, is evaluated as a health need or treatment side effect. More than ‘just a nurse, correctional nurses can contribute knowledge and clinical judgment in a behavioral situation that can lead to a positive resolution.

Healthy Living Perspective

Correctional nurses frequently deliver care in the living areas of a facility. Traveling about the compound, we have opportunity to observe working and living conditions through the lens of healthcare. Cleanliness, containment, and the reduction of disease spread are inherent nursing principles. Nurses ‘see’ things that may go unnoticed by other professionals in the facility. The availability and use of handwashing resources is just one observation a correctional nurse may make while in the course of  daily activities. Others might include inmate hygiene practices, cleanliness of recreational equipment, or the practices of inmate barbers and porters. Correctional nurses can address unhealthy living practices to improve the health of the larger patient community.

Moral Presence

Abuse of power can easily result from situations where one group of people has control over the lives of another group. Although many correctional systems have an organizational culture that discourages and sanctions this abuse of power, just as many do not. Unfortunately, a significant portion of correctional settings are places of disrespect and incivility. Some, in fact, are even mentally or physically abusive of the inmate population. Correctional nurses have the opportunity, even the responsibility, to address issues of human dignity and patient safety in these situations. Our ethical code calls us to make every effort to protect our patients from mental and physical harm.

Falling under the spell of the adjective J-U-S-T in describing correctional nursing practice is dangerous to our understanding of our role and to the health and well-being of our vulnerable and marginalized patient population. Join me in eliminating this 4-letter word from our self-talk and our practice perspective.

Have you ever been called upon to be more than ‘just a nurse’ in your correctional practice? Share your story in the comments section of this post.

Job, Career, or Calling? It’s Up to You

“It’s not what you look at that matters, it’s what you see” – Henry David Thoreau

Your CallingCorrectional nursing can be a job, a career, or a calling based on your perspective – what do you see?

  • If you see your work life as an endless string of shiftwork passing pills and triaging sick call slips then you may have a job perspective
  • If you see your work life as a stepping stone to an advanced position then you may have a career focus
  • If you see your work life as meaningful to the lives of others and personally fulfilling then you may have a calling focus

Those who research job satisfaction have found that those who see their work as a calling do work they care about. They consider their work to be more than a means to an end, but an opportunity to find meaning and do something important. These researchers also found that those who viewed their work as a calling were healthier, had greater satisfaction with their life and missed less work than those in either the Job or Career categories.

Knowing your work orientation can help you find ways to motivate yourself and craft a better work situation without having to change jobs. Job crafting, in fact, is a primary way correctional nurses can move from a Job perspective to a Calling perspective regarding their work life.

Dimensions of Meaning

Experts have determined five dimensions of meaning that can be found in work.

  • Money: Although correctional nursing salaries can be competitive, it is not the one of the highest paying nursing specialties
  • Status: Correctional nursing practice has made advances of the last decade but nurses working in jails and prisons can still be stigmatized by their patient population and work setting.
  • Making a difference: Correctional nurses can make a significant contribution to the health and well-being of a marginalized and disadvantaged patient group.
  • Following your passions: What motivated you to become a nurse? How would that align with correctional nursing practice?
  • Using your talents: Many passions also end up being talents. What nursing talents do you have that are applied in a correctional nursing position?

What is Job Crafting?

Job crafting is a way to redesign work perspective, relationships, and tasks to improve job satisfaction. Job boundaries can expand or contract over time based on the individual in the position and the aspects that are emphasized or de-emphasized. It starts with determining the areas of a role that are the most meaningful, provide the most satisfaction, and are aligned with gifts and talents. While in many situations other areas of the role cannot be neglected; focusing on extending time and effort toward gaining experience and expertise in areas of fulfillment craft the position.

Ways to Job Craft

Even in the most structured of job descriptions, there is room for modifications to make work life more satisfying and meaningful. Researchers found that successful job crafters took action in three areas: perspective, relationships, and tasks. Here are some suggestions specific to a correctional nursing role.

  • Perspective: It all starts in the mind. Mentally seeing your work as affecting the lives and health of your patients is more helpful than seeing your work as a list of nursing tasks that must be completed by the end of the shift. Thus, correctional nursing is not medication administration, sick call, emergency response, and intake screening but “the protection of health, prevention of illness and injury, and alleviation of suffering” (definition from the Correctional Nursing Scope and Standards of Practice, 2013). Successful job crafters reframe the social purpose of their positions to align with their values and concerns. What parts of the definition of correctional nursing do you highly value? Be mindful of those themes during your day-to-day activities.
  • Relationships: The type and extent of relationship with various workmates can be a way to craft a more positive work experience. Hang around unhappy, stressed, and cynical people and you will find yourself mirroring their moods and emotions. The reverse is also true. Honestly evaluate the perspective of each member of your work team and develop deeper relationship with those who will encourage and facilitate your highly valued role components.
  • Tasks: Evaluate which elements of the correctional nursing role give you the most pleasure and fulfillment. Ponder the specific themes of these elements. For example, if you enjoy sick call, which parts? Is it the assessment, the patient interaction, the teaching component? Find ways to do more of the satisfying component. That might not mean the original job task. For example, if assessment is the satisfying part of the sick call process then intake screening is also a task that would provide opportunity for more assessment. If patient teaching is the driving satisfier than chronic care tasks may be an additional option. Once determined, seek ways to increase satisfying tasks while decreasing or streamlining less-valued tasks to accommodate the change.

Just a Job? Just a Step in the Ladder? Just a Way to Make a Difference?

So, what will it be for you? Is correctional nursing just a job that meets your monthly bills and is available until you find something better? Is your position just a step on the career path to a position of more power and prestige? Or, is correctional nursing a way that you make a difference in the lives of others, creating a meaningful professional life of compassion and service? In the end, it is up to you.

“We don’t see things the way they are, we see things the way we are.” – Anais Nin