Thanksgiving

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

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

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

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

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

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

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

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

CorrectionalNurse.Net Blog

Correctional Nursing Today Podcast

CorrectCare Magazine

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

Have a safe and grateful holiday!

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Is Intake Screening Getting the Job Done?

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

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

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

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

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

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

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

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

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

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

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

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

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

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The Power of Appearance

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

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

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

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

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

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

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

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

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

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

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Top Educational and Skill Needs of Correctional Nurses

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

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

by Sue Smith, MSN, RN, CCHP-RN

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

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

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

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

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

Less than 2 weeks         18%

2-4 weeks                        14%

5-8 weeks                   49%

9-12 weeks                       8%

3-5 months                      8%

6-12 months                    3%

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

     Safety/Security (134)

Inmate manipulation, Safety of self and others

Security issues and procedures, Collaboration with security staff, Contraband

Infection control

     Nursing Practice (129)

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

Medication issues including administration, verification, pharmacology and competence

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

Special needs, Discharge planning

     Professional Practice (52)

Professional boundaries

Neutrality, Firm, fair and consistent

Compassion; patient advocacy; balance of advocacy vs. safety

Emphasis on patient care, Autonomy

     Legal/Constitutional Issues (37)

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

Standing orders, Patient confidentiality, Standards/guidelines

     Miscellaneous (15)

Time management, Critical thinking, Ethics, Electronic medical records

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

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

     Professional Nursing Practice Skills (108)

Assessment skill, Professional boundaries

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

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

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

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

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

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

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

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

     Mental Health (9): Inmates, staff

     Manipulation (7): Inmate-patient behavior

     Miscellaneous (2): Computer skills, preventive health care

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

     Assessment Skills (111)

Physical, mental health, health, rapid

Interviewing skills

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

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

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

     Clinical Skills (25)

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

Triage/prioritization of care

     Personal Skills/Attributes (21)

Observational skills, including awareness of surroundings

Organizational/time-management skills

Autonomy, Self-motivated learner

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

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

Most frequently occurring ratio – 1 : 1

27 respondents reported all RN staff.

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

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

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

 Jail                                                                 45%

Prison facility                                                    19%

State DOC/agency                                            17%

Federal agency                                                   8%

Juvenile detention/confinement facility      6%

Private corporation                                           5%

Other*                                                                 12%

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

Discussion

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

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

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

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

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

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

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Superbugs are not only in your garden!

superbugsDo you find bugs in your yard and garden that are eating your plants, roots, grass and eliminating flowers? Have you tried pesticides only to find the bugs come back stronger by becoming pesticide resistant? Our bodies are the same as plant life in the garden.  The ready availability and use of antibiotics to treat illnesses has resulted in emerging infectious diseases that are resistant to known treatment modalities.

News is Full of Superbug Warning

There are more and more articles in the community papers, TV news shows and health care literature about the challenges to cure health conditions that are caused by medication resistant organisms. The most recent story  warned that in the US this new “nightmare superbug” is a strain of e-coli.  They used the words “alarming development and terrifying”.  Other frequently discussed antibiotic resistant infections have been for tuberculosis, gonorrhea, and skin infections. Some parts of the world are trying to get a handle on resistant strains of malaria.

Corrections Health Responses

In recent years, corrections health programs have developed guidelines and procedures for skin infections and tuberculosis.  They vary with the program and include prevention, identification, treatment and follow up care.  The level of isolation or protection and the use of an antibiotic regime is set by the medical directors and pharmacists.  Custody and health staff have become accustomed to being taught about preventing contagious disease and are skilled in using standard precautions, wearing gloves, respecting wounds that are bandaged and reporting concerns to medical.  Having sanitizing gel and gloves available around the facilities is the norm now instead of the exception.

Precautions to Consider

The picture of superbugs really encompasses a world view as changes in how we live and the treatments we receive for illness has contributed to more organisms being resistant to current therapies.  We normally focus on our facilities, however, some of the recommendations to help slow down the emerging resistant diseases encourages us to take a larger world view of public health. The United Kingdom recently published a multi-nation review of how to tackle the problem of drug resistant organisms infections. The report outlines steps that should be taken by each of us individually and as leaders in health care at our facility to curb the tide of emerging “superbugs”.

  • Raise awareness of the threat of inappropriate antibiotic use.
  • Improved hygiene to safeguard against infections.
  • Less unnecessary microbial use in agriculture, aided by improved transparency by retailers and food producers.
  • Better monitoring of drug resistance.
  • Development of both diagnostics to cut unnecessary antibiotic use and improved vaccines and alternatives.

Another recent article about superbugs described a woman in Pennsylvania diagnosed with drug resistant e-coli and noted the specialized diagnostic and therapeutic resources necessary to treat her. The article also described how new the information about emerging drug resistant disease is and the lack of coordinated and widely disseminated research.  So not only do we all need to keep abreast of the infectious disease that are arriving in our facilities, but bring awareness of the need for specialized education and training in infectious disease prevention.

Main Warning

We have heard for years about the dangers of antibiotic resistant diseases and have developed procedures and protocols in monitoring and treatment. The most frequently stated practice change is to have antibiotic stewardship programs to curb the inappropriate use of antibiotics. Many of our patients coming into custody have a history of frequent antibiotic use and want us to give them antibiotics for many of their ailments. We need to provide patients with education about appropriate antibiotic use; we also need to ensure staff are knowledgeable and that the practice guidelines are based upon the most current evidence.  To address resistance in gardening we now treat superbugs with beneficial insects like green lacewings, ladybugs and praying mantis so lets do the same in health care with appropriate antibiotic use and stewardship. That way we may affect the predictions that millions of people may become ill from “superbug infections” by year 2050.

What are you doing to help curb antibiotic use in your place of work? Do you have any special patient teaching tips or resources you would like to share with us? If you do please put your sharing in the comment sections below.  We all can learn from each other.

 

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What are these eight rights anyway?

The picture posted with this column of a nurse on her way to give medications gives rise to many thoughtsNurse Medication Picture and memories. For me, it brings memories of my early years in nursing practice.  We wore white uniforms, white shoes, white nylons and white caps.  . I remember learning how to safely and accurately administer medications through each of the steps from the physician’s order to setting up medications, to administration and documentation. I also remember how much emphasis was placed on giving the right patient the right medications. Like the nurse in the picture, medication rounds were done using a tray holding medication in cups and small cards with the patient information and medication on them.

Years later, the safety of administering medications was outlined in the Five Rights of Medication Administration.  I cannot tell from the literature when these became formalized but when I returned to school in the mid 1980’s, the Five Rights were prominent in nursing practice, risk management and patient safety.

Health Care Advances

As the body of knowledge for nursing practice evolves, we continuously improve our practice to assure our patients receive the highest level of care with an emphasis on patient safety and error reduction. Because of this, three more rights have been added to the body of knowledge for medication administration, making a total of eight rights.

In corrections settings, medication administration is completed by a variety of job classifications. No matter who gives medications to patients, they must be qualified and trained in medication administration and follow the Eight Rights, as described below:

  1. Right Patient: check the name on the medication administration record (MAR), use two identifiers; ask patient to identify themselves, check name &/or picture on ID wrist band or badge.
  2. Right Medication: check the order, select medication, compare to the order, check the MAR, and then check the medication against the MAR before giving to the patient. If it is a new medication does the patient know what it is for and are there any allergies that would contradict giving it.
  3. Right Dose: check the order or the MAR, confirm the appropriateness of the dose, for medications with high risk consequences from dosing errors have someone double check the calculation.
  4. Right Route: check the order and MAR, confirm the route is the correct for that medication and dose, confirm that the patient can receive it by the ordered route.
  5. Right Time: check frequency the medication is to be given on the MAR and the time is correct for this dose, confirm when the last dose was given.
  6. Right Documentation: document administration AFTER giving the medication, document the route, time and other specifics such as site, if injectable, lab value, pain scale or other data as appropriate.
  7. Right Reason: confirm the rationale for the ordered medication; why is it prescribed, does the patient know why they are taking this medication. If they have been taking it for long is its continued use justified?
  8. Right Response: has the drug had its desired effect, does the patient verbalize improvement in symptoms, and does the patient think there is a need for an adjustment in the medication?  Document your monitoring of the patient for intended and unintended effects.

Adapted from Bonsall, L. M. (2011). 8 rights of medication administration. Retrieved June 17, 2016 from http://www.nursingcenter.com/ncblog/may-2011/8-rights-of-medication-administration

The Important Three

When you examine the new three rights closely, their importance becomes clear and explains why they are included as best practices:

  • Right Documentation:  We hear from our legal representatives, instructors, managers and peers, that “if it was not documented, it was not done”. No excuses can make up for a patient receiving double dose of medications when it was not documented or a provider changing a medication when they thought a patient was not taking the medication. Besides accurate and timely documentation of medications administered, this right also includes the accurate documentation of the order on the MAR.
  • Right Reason: When taking off orders or preparing to administer a medication, knowing why the patient is taking a medication is the foundation for patient education and evaluating the effects of the treatment. This is especially important when a particular medication, such as gabapentin, may be ordered to address one of several different conditions (seizure, nerve pain, restless leg syndrome etc.). Information in the patient’s chart will often clarify why this medication is being ordered; if not, consult the provider so that you know what the patient can expect from the treatment.
  • Right Response: We cannot effectively teach a patient about a certain medication and the desired effects of treatment if we do not know the drug ourselves.  Knowing about medications is a continual learning process, which grows day by day.  Make a habit of learning about new drugs each day.  This information can be found in the drug reference books kept in the medication room, by talking with providers, consult with the pharmacist, discussing medications at shift or team reports and exchanging information with team members.  See also a previous post that describes all of the online drug references that are available without charge.

Spread the Word about the 8

Even though these additional best practices have been discussed in the literature and have been topics in nursing education for several years, I still hear nurses refer to the Five Rights. They are called rights because they are not a request or desire—but a RIGHT. Each one of the eight rights is fundamental to nursing practice and when used together better promote patient care and enhance safety. By following these steps, nurses promote wellness and identify and prevent harm to our patients. What do the eight rights of medication administration mean to you?  How has understanding the eight rights in your practice, improved your patients care?  Share your experiences and challenges with medication administration in the comment section below.

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

Photo credit:  Yahoo Images

 

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Medication Reconciliation

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

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

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

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

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

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

When Inmates Arrive at a Facility

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

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

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

When Inmates Return From Offsite care

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

When Inmates Are Followed in Chronic Care Clinic

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

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

When Medications Are Missing

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

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

Other questions to help narrow down the problem are:

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

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

Easing the Burden of Medication Reconciliation

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

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

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

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

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