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.

Correctional Nursing and the Ethic of Social Justice

Have you ever been asked what you do as a nurse and found yourself launching into a discussion of sick call and medication passes? It is easy to get lost in the weeds on our professional journey. That’s why it can be refreshing to periodically return to the defining qualities of the nursing profession to see the big picture.

The definition of nursing as found in the ANA Scope and Standards of Practice is

  • The protection, promotion, and optimization of health and abilities
  • Prevention of illness and injury
  • Facilitation of healing
  • Alleviation of suffering

We do this through the diagnosis and treatment of human response and we advocate in the care of

  • Individuals
  • Families
  • Groups
  • Communities
  • Populations

As correctional nurses, we fulfill this definition in the criminal justice system. The location of nursing care delivery establishes our unique patient population, environment of care, and ethical dilemmas of practice.

It is invigorating to be reminded that nursing care goes beyond the post duties and task list for the shift. Certainly caring for patients in a one-on-one situation is the majority of many of our job descriptions. However, I was recently struck by the inclusion of communities and populations in the nursing definition. How do we advocate for care and alleviate the suffering of communities and populations as a correctional nurse?

What is Social Justice?

Social justice is a broad term used to describe equity in the distribution of resources and responsibilities among members of society. According to the Canadian Nurses Association social justice in health care involves “working to prevent negative effects of oppressive practices such as discrimination against individuals on the basis of gender, sexual orientation, age or any other social factor that might affect health and well-being. In correctional nursing, social justice would include reducing dehumanizing practices within the criminal justice system and extend toward improving the health and well-being of the homeless, impoverished, and under-educated communities from which our patients and their families enter into the criminal system.

Social Justice in the Criminal Justice System

You would think that a system with justice in its title would be just but there is a lot of social injustice in the criminal justice system. You don’t have to look very far to see oppression in the power structure of many correctional settings. The need to maintain discipline and provide for personal and public safety can lead to severe punishment and even brutality in the organizational culture in some settings. As correctional nurses, we may not ascribe to the incivility but are often required to view or even participate in the culture in order to delivery necessary health care. For example, have you ever had to witness a violent inmate take-down during an emergency man-down that resulted in the use of a severe restraint device? Did you feel there might have been a more humane way to deal with the safety issue but were afraid to speak up or felt you had no voice in the matter? How might a nursing response to restraint practices across the criminal justice system embody advocacy for the alleviation of suffering among our patient community and population?

But This isn’t a Patient Health Care Situation

As nurses in the criminal justice system we can easily get tunnel-vision about our role within the system. Certainly we are helped in this narrow focus by those criminal justice professionals who clearly see nursing as attending to the direct health needs of specific patients. Yet, our definition of nursing practice speaks otherwise. Our patients are the entire community of inmates within our facility and our role, among other things, is to promote their health, prevent their injury, and alleviate their suffering. Correctional nursing, then, is more than serial one-on-one patient care situations.

We Are All in This Together

Correctional nurses, as a group, can be a significant force in the criminal justice system. Our definition and Code of Ethics calls us to consider the human dignity of our patient population and the significant suffering that our patient community bears up under. Working together we have an opportunity to bring about social justice in an institution, a correctional system, and the entire criminal justice system.


Commentary on the Heavy Burden of Moral Distress in Correctional Nursing

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

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

My Story

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

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

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

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

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

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

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

Nursing Code of Ethics 3.4 “Standards and Review Mechanisms” 

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

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

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

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

Obligated to Speak

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

Public Esteem

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

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

Correctional Nurse Self-Care: Are You Carrying the Heavy Burden of Moral Distress?

Kiko con cajaRecently I traded in my clunky 2009 laptop for a new streamlined model. It wasn’t until my first journey with this new laptop that I realized just how heavy my old version was. Now I have a good idea why my shoulders ached after a long day of traversing airports for gate changes while running to make the connection with computer bag in tow.

Moral distress can be like that – a heavy weight on your shoulders that has been slowly building as you work in the criminal justice system. You may not even notice the developing distress until something snaps. Correctional nurses need to monitor moral distress and seek morally satisfying solutions to the ethical dilemmas encountered in day-to-day practice.

What’s in a Name?

The first step in solving moral distress is to identify it. Moral distress has been defined as knowing the right action to take, but being constrained from taking it. In its simplest form, then, moral distress in correctional nursing may be knowing that a patient should be able to make a health decision autonomously but seeing that they are being forced to make that decision against their will.

However, researchers in moral distress among nurses add to this definition in important ways. Nurses are often confronted with an ethical dilemma where the course of action best for the patient is in conflict with what would be best for others; whether it is the organization, other providers, other patients, or society. So, the interior world of the nurse that identifies who they are as a professional is in conflict with the exterior world of the work environment and work team. This is what leads to the distress that can be strongly felt by a nurse.

Moral distress is when:

  1. A nurse is involved in or aware of a situation that calls for a moral action.
  2. Is obstructed from taking that moral action.
  3. Experiences negative feelings because that action was not taken.

I hear of many examples of moral distress among correctional nurses in my various interactions. Intentional bias, poorly staffed medical units, or obstruction from officers or leadership can lead to treatment delays, unrelieved pain, or gaps in care management. Conscientious nurses absorb the stress of longstanding unethical treatment.

The Grimy Build Up of Moral Distress

Absorbing moral stress over time leads to a grubby film that builds up in our nursing souls and affects our emotional, psychological and physical well-being. This has been defined as ‘moral residue’ and is particularly intense when injury to a nurse’s moral integrity is repeated over time. In a correctional setting, a nurse may see the ‘take down’ of mentally ill inmate multiple times over months of practice and have a ‘here we go again’ response to the moral wound caused by seeing this action and feeling unable to do anything about it.

Identifying Moral Distress

Although nurses cannot always name the feeling, most of us know what it is like to be in moral distress. We feel powerless, anxious, and unhappy. Moral residue can lead to typical stress-related symptoms such as nausea, insomnia, and headaches. It can cause us to seek other employment or even leave the profession. When these feelings are present, it is important to seek the source of discontent. It may be the weight of long-standing moral distress.

Seeking a Good Response

Nurses can also feel belittled or unimportant in morally distressing situations. It is easy to experience isolation if we do not feel supported in talking about the morally injuring situations around us. Yet, talking to a supportive colleague is an important action to help identify and clarify moral distress.

Critical care nurses also often find themselves in a morally distressing situation. The American Association of Critical Care Nurses (AACN) developed a 4 step process to help nurses address and reduce moral distress.

ASK Ask yourself if what you are feeling is moral distress. Are others exhibiting signs of moral distress, as well?
AFFIRM Affirm your feelings and consider what aspect of your moral integrity is being threatened.
ASSESS Objectively analyze the situation and what the ‘right’ action would be. Consider what is currently being done, who the players are, and your readiness for action.
ACT Create a plan of action considering any pitfalls and strategies to overcome them.

Have you had to deal with moral distress in your correctional nursing practice? Share your experience with our readers using the comments section of this post.

Photo Credit: © KostaKostov – Fotolia.com

Nurses Role in Managing Inmates on Hunger Strike

Prison interior with light shining through a barred window

Hunger strike is a situation every correctional nurse will encounter at least once during their career. It is also one of the unique features of correctional nursing practice and not experienced by nurses in other specialties. Usually the first thoughts that come to mind when the subject of hunger strike comes up are the ethical conflicts; supporting an inmate during their hunger strike (an individual’s right to autonomy) and whether to intervene with life saving measures, such as force feeding (health care professional’s obligation to use their skills and knowledge to benefit the patient). These ethical issues were discussed in this month’s American Journal of Nursing with regard to the hunger strikers at Guantanamo Bay.

In my thirty years’ experience all but one inmate on hunger strike has resumed eating well before their condition became life threatening. It was skillful, concerned nursing care, especially patient advocacy, which eliminated the need to work through the ethical issues that take up so much of the discussion about hunger strikers in correctional settings. The focus of this blog is to describe the practical steps that nurses can take when an inmate informs staff that they are on a hunger strike. These include establishing the patient’s baseline health status, advising and educating the patient, and scheduling ongoing follow-up.

Notification: The highest level officials at a correctional facility will want to be notified when an inmate is on a prolonged fast or hunger strike. They often express concern about preventing the inmate from harms and want to avoid peer pressure or enlisting other inmates in joining the hunger strike. When a nurse is informed that an inmate is on a prolonged fast or hunger strike the first step is to make the proper notifications. These should be spelled out in facility specific policy and usually stipulate the dual responsibility of the facility health authority and chief medical officer to keep the facility command structure informed about the inmate’s health status, any change in condition, and involved in supporting the general plan of care. These leaders are also responsible for ensuring that mental health professionals are actively involved in evaluating and planning for the patient’s care.

Definition: All individuals periodically fast, so it is important to distinguish when fasting is considered a hunger strike or attempt at starvation. Sometimes the inmate will notify staff that they are not eating and the reason why; other times officers notice that an inmate is refusing foods (and maybe fluids as well) and take further steps to inquire about the inmate’s behavior. Correctional systems usually define a hunger striker as an inmate who goes without food and fluid for more than 24 hours or without food (but taking fluid) for more than two consecutive days.

Time is on our side: There is no need to rush into a confrontation with the hunger striker or struggle with the question of whether to force feed for some time. For healthy persons, serious risk does not arise until after 14 days of starvation, or until the patient has a Body Mass Index (BMI) of less than 18.5, or abnormal lab values (↓serum protein and albumin, ↓bicarbonate, abnormal kidney function or electrolytes). Persons with chronic medical or mental health conditions, who are pregnant, elderly or taking certain types of medication (e.g. insulin, diuretics, antacids) risk experiencing complications earlier. Nurses and custody staff should ensure that fluids are available at all times and food is offered according to the regular meal schedule. During this early period it is important for nurses to concentrate on building a therapeutic relationship with the patient; one that demonstrates respect, supports autonomy and self-determination, and preserves dignity.

Baseline Evaluation: When health services is notified or determines that an inmate is on a hunger strike the first step is to establish a baseline against which to monitor changes in the inmate’s health status. This evaluation should be conducted within the first 24 hours of notification if the inmate is at higher risk for complications. High risk includes patients who are elderly, pregnant, on a mental health caseload or have a medical condition that requires ongoing care. Inmates with these characteristics need to be followed and monitored on a more intense and frequent schedule. Inmates who are otherwise healthy still need to have a baseline health evaluation but it can take place anytime within 72 hours to 7 days after notification of hunger strike.

The baseline evaluation should include:

  1. Interview to determine what the inmate is refusing and the reason for refusal. Recommended questions to ask are:
  • What was the last food you ate and when was it?
  • Is this a total fast or are there certain foods you are willing to eat?
  • How much fluid are you taking in?
  • Are you refusing any prescribed medications or other treatments; if so why?
  • Are you protesting something by not eating? If so what can you tell me about your protest?
  • Are you expecting to die as a result of this fast?
  • If not, how long do you intend to continue this fast?

This may not be a quick interview so plan to conduct it when you can give the patient your time and attention to the dialogue. The information that is obtained from this interview is important for the health care team to use in planning how to monitor and care for the patient over the course of the hunger strike. The nature of the encounter is the first step in establishing a relationship between the hunger striker and health care staff that is collaborative which will also be more critical over time.

      2.  Assessment of the patient’s physical and mental condition usually includes:

  • Weight and height
  • Vital signs
  • Level of hydration
  • Mental status evaluation
  • Suicide risk assessment
  • Any finding or condition that should be referred to a higher level of care.

      3.  Patient education about the adverse effects of dehydration, starvation and risk for complications. In particular patients should urged to drink fluids in order to maintain hydration, to take precautions against inadvertent injury because of weakness, dizziness, or confusion and when they are ready to resume eating to proceed cautiously. The nurse should also describe what the health care staff will do to monitor the patient while on hunger strike and attempt to solicit their agreement and cooperation. To supplement the information provided by the nurse during this initial encounter, the California Prison Health Care Service (CPHCS) has developed a one page fact sheet that can be given to inmates at the beginning of a hunger strike.

     4. Disposition or initial plan of care. The nurse will schedule the primary care provider (PCP) to review the patient’s chart or see the patient based upon clinical findings. High risk patients need to be seen promptly or at least have their chart reviewed, including the nurse’s findings from the baseline evaluation. Patients who are not high risk should been seen or at least the chart reviewed within 48 hours but not longer than 72 hours after notification. The nurse also refers or schedules the patient to be seen by behavioral or mental health staff. The urgency of the referral is based upon the patient’s condition. Emergent or immediate referrals would include patients who are suicidal or psychotic. Urgent referrals would be anyone already on a mental health caseload. These appointments should take place within the next 72 hours. Routine referrals should be evaluated by mental health before the end of the first week.

   5. Documentation of the baseline evaluation in the patient’s health record. This should always include a narrative progress note of the date and time health services was informed, most recent fluids and nourishment taken, and who was notified. Documentation also includes the findings of the interview and assessment, what was covered in patient education and their understanding, as well as the disposition. The note should list the specifics of all subsequent appointments that were scheduled. A flow sheet may be initiated for serial recording of health status (weight, vital signs, mental status, suicide assessment, hydration etc.).

Ongoing Monitoring: Once the baseline evaluation is completed nurses continue to monitor the inmate’s condition. On a daily basis the nurse checks to make sure that food and fluids have been available, monitors the patient for changes in mental status, collects information about fluid and food intake, solicits the patient’s description of bothersome signs and symptoms, provides advice to increase comfort and maintain hydration. It is also important that the nurse checks to make sure that provider appointments or referrals are taking place as scheduled, to review and act upon provider recommendations and orders.

Periodically, usually three times a week, the nurse collects supplemental information to include weight, mental status, hydration level, medication and treatment compliance. The provider may also have written orders for routine laboratory testing or labs when vital signs are abnormal. The nurse will schedule provider appointments based upon the results of monitoring or at least once a week. Each of these encounters as well as nursing actions should be documented at least in the progress notes. Use of a flow sheet to monitor changes in signs and symptoms can supplement but should not replace the narrative in the progress note.

Many facilities have adopted the use of a multidisciplinary treatment team to manage the ongoing monitoring and care of inmates while on hunger strike. Participants include medical, nursing, mental health and custody staff. It is helpful to also include the chaplain, food service personnel and anyone else who has a positive relationship with the inmate. These teams meet weekly or more often as necessary to share information, develop or revise the treatment plan and to coordinate interventions. Components of the plan should address housing, mental health needs, medical monitoring, legal advice and preparations for court intervention if necessary. Much of the discussion in developing and revising the plan of care will concern resolving the reason for not eating as well as management of medical and mental health status. Nurses should be prepared to think of this as a negotiation that preserves the patient’s health while finding a solution to the inmate’s issue that is realistic and acceptable while incarcerated.

Nurses maintain daily contact with an inmate on a hunger strike and each of these encounters is an opportunity to strengthen the nurse-patient relationship. It is important to maintain open and non-judgmental communication with the patient. Demonstrating respect for the inmate’s autonomy by providing choices and emphasizing the control they have without fasting will help dissipate the need to continue the strike. Findings ways to preserve the patient’s dignity may also help facilitate the patient’s decision to resume taking food.

Refeeding syndrome is a complication sometimes experienced by patients when they start to take nutrition again and the body doesn’t adjust to changes in glucose metabolism and electrolyte balances. Risk for refeeding syndrome increases the longer a patient has fasted, how much weight they have lost (BMI) and the presence of underlying medical or mental health conditions. Nurses monitor patients at risk of refeeding syndrome on a daily basis which may include vital signs, intake and output, collecting lab specimens, EKG monitoring, observation for fluid overload, provision of electrolyte or vitamin/mineral supplements. Even inmates at low risk still benefit from the advice start by eating and drinking small amounts and to increase portions very slowly over several days to a week.

Additional resources for nursing care of patients while on hunger strike include:

What practical advice would you give nurses about the care of inmates while on hunger strike or prolonged fasting? Add to the advice given here by responding in the comments section of this post.

For more on this subject Lorry Schoenly discusses the ethics involved in the care of patients in the correctional setting, including hunger strike in Chapter 2 of the Essentials for Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo credit: © doomu – Fotolia.com

Moral Courage: Being Assertive

sassy child with arms foldedSpeaking up in the face of a moral dilemma takes courage. No one likes conflict…well, almost no one….and nurses, it is found, would rather compromise than confront, according to at least one research study. Overcoming a natural inclination to ‘go along to get along’ takes conflict management skill. Like so many other nursing skills, it comes with practice. Being assertive in a moral situation is easier when assertive communication is a natural part of professional practice.

Knowing Me – Knowing You

Assertive communication starts with a good understanding of your own feelings about the situation and a desire to understand the feelings and perspectives of others in the group. Thoughtfully considering the situation, and your best response to it, allows an objective analysis of emotions that reduces the chance for an unhelpful aggressive or angry response.

Whenever you are distressed about a clinical situation, mentally identify your specific emotional response to become familiar with defining your feelings. Also consider the perspective of others in the situation. “Step into their shoes” and try to imagine their emotions and motivations. By evaluating all perspectives you will be prepared to assertively engage in a constructive conversation about the event.


Practicing a planned response to a situation during less significant concerns can help when the stakes are higher. One helpful model for constructing an assertive communication involves four parts:

  • A nonjudgmental explanation of the behavior to be changed
  • An admission of the asserter’s feelings
  • An explanation of the tangible effect of the other person’s behavior on the asserter or someone else
  • Announcement of the desired behavior change solution you want, or an invitation to problem-solve.

Putting these pieces together might creates a communication like this to the Med Line Officer: “When you call Inmate Jones a lousy pervert during pill line I feel upset. It is demeaning and it is important to me that we are civil with each other. Could you avoid this practice?”

By overcoming the desire to compromise and the fear of conflict, you can respond to challenging ethical situations in your correctional nursing practice. Evaluating your own feelings, seeing the perspective of others, and planning an assertive response will develop moral courage to respond when needed.

Have you developed assertive responses to moral situations in your setting? Share your experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © ericro – Fotolia.com

Moral Courage: Dealing with Uncertainty


Some ethical issues are obvious and the course of action is clear. A nurse who sees a colleague has documented administering a narcotic when the patient has not received medication requires reporting. However, correctional nurses are often faced with uncertain ethical situations that create decision stress and can lead to immobilization. A nurse who is asked to perform a blood draw for drugs may wonder if the activity will be used for a therapeutic or disciplinary outcome. Moral courage requires skill in dealing with uncertainty in an ethical situation.

Uncertainty of the Moral Situation

An uncertainty about the actual moral situation can hinder the courage to act. Consideration must be given to the actual ethical concern present. Strength for action is developed by clearly articulating the professional values that have been breached. Taking time to thoughtfully consider personal and professional valuing can help pinpoint the real issue embedded in the situation. In addition, confidentially discussing the concern with a spouse, leader, or trusted peer can lead to clarity. Sometimes putting into words the concerns of the situation give voice and vocabulary that strengthen resolve toward action.

Uncertainty of the Outcome of Action

A previous post  discussed the C-O-D-E model for moral courage. The 3rd element of this model is managing danger (D). Our uncertainty about the danger involved in acting or ‘speaking up’ about a potential ethical issue can be very real. Anxiety and a visceral ‘fight or flight’ response can ensue. How can we deal with the uncertainty of the outcome of our action?

Self-soothing. In an emotionally charged situation, free-floating anxiety or even anger can cloud judgment and be immobilizing. Immediate stress-reduction activities can be initiated such as taking a deep breath, slowly counting to 10, or speaking calming words to yourself like “I can do this” or “I have handled many things worse than this”. These are methods of self-soothing that can help to reduce anxiety and encourage clear thinking.

Cognitive Reframing. Worry about the negative outcome of an ethical action can be reframed by actively seeking positive alternative perspectives. Although concerns about job security, peer support, or humiliation may be very real, they can be balanced by positive outcomes of taking action such as personal integrity, strength of character, and satisfaction in doing the right thing in a difficult situation.

Lachman provides a logical progression to guide action in response to fear. Working through this list can help to clarify next-steps in an ethically uncertain situation.

  • Identify the risk you want to take
  • Identify the situational fear you are experiencing
  • Determine the outcome you want and what you have to do to achieve it
  • Identify resources accessible to you
  • Take action

Have you dealt with ethical uncertainty in your correctional nursing practice? Share your situation and how you dealt with it in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © adrenalinapura – Fotolia.com

Moral Courage: How Do I Find Some?

Little superhero

Tanya was working in a state prison in the nursing pool to make extra money for her college tuition. She was studying to be a nurse practitioner and thought it would be a good experience for her. Although she was learning much from her shifts there, she was also distressed by the treatment of a mentally ill inmate in solitary confinement for striking and injuring one of the officers.  Even in the short time she had been working there she had observed significant mental deterioration. In addition, the officers were rough and rude with this inmate; she assumed due to his injuring one of their own. Tanya was starting to lose sleep over this but she didn’t know what to do about it.

Nurses can experience moral distress over situations they observe in the correctional setting. Moral distress is experienced when painful feelings arise over the awareness of a morally inappropriate activity but feel they cannot respond due to various obstacles. A common obstacle is that of the institution or organizational culture. This is what Tanya is experiencing. Distress can also come from the uncertainty of what action to take and what consequences might ensue. For example, could Tanya be sanctioned, rejected, ridiculed, or fired if action is taken?

Finding moral courage to overcome distress and act in the face of these potential consequences is challenging. As in an emergency situation where all-out effort is needed, nurse ethicist, Vicki Lachman, suggests that we should call a code. That is an acronym for a 4-step process for finding courage to act in the face of a moral dilemma.

Call a C-O-D-E when Moral Courage is Needed

C Courage to be moral Where does my strength come from?
O Obligations to honor What is the right thing to do?
D Dangers to manage What do I need to handle my fear?
E Expression and action What action do I need to take to maintain my integrity?

Courage to be Moral

Taking a moral action requires courage. Where does the strength come from? For many nurses the strength comes from alignment with the ethical standards of our profession. A review of the Code for Nurses can provide strength for action. Look for the particular element of the code that is in violation and ponder the importance of action for your own professional integrity as well as for the good of the patient in the situation.

Obligations to Honor

The Code for Nurses is the ethical standard of nursing practice and establishes a nurse’s patient-centered valuing that is foundational to the profession. This is the primary place to determine our obligation in a moral dilemma. However, correctional nurses work within a security framework with its own value system. It can be important to consider what values drive others involved in the situation. The Institute of Global Ethics, as described by Lachman in another source, reviewed a wide variety of ethical codes and developed a list of the 5 primary values found in all of them: honesty, respect, responsibility, fairness, and compassion. Which of these values might be motivating others in the situation? These can then be considered in working through an action plan for response.

Dangers to Manage

Nurses must acknowledge and manage the fear engendered in taking action in a risky situation. Successfully overcoming fear is, in fact, a definition of courage. Working through the prior steps can help in managing danger as they provide objective reasons for the action and establish the importance for proceeding. This can be powerful and should not be under-estimated.

Also suggested in the process of ‘decatastrophizing’ which in involves working through the ‘what if’s’ of the situation. By objectifying fear, it can be demystified and balanced with the positive outcomes of action. This helps to cognitively reframe the situation and reduce negative thoughts. It also turns thoughts toward planning and action-taking rather than dwelling on fear.

Expression and Action

The final step in the CODE process is to take the practical action that will overcome fear and resolve the issue. Action in a situation such as Tanya’s requires both assertiveness and negotiation skills. It requires an understanding of the organizational reporting structure. It requires the ability to be collaborative rather than confrontational with other disciplines.

Tanya was able to garner the moral courage to respond to her moral distress. Through her actions the inmate was re-evaluated by mental health services and a treatment plan was initiated. She continues to work at the facility and is developing collaborative relationships with her healthcare and custody peers. She has resolved her moral distress and feels good about the outcome.

Have you needed to confront a moral dilemma in your correctional nursing work experience? Share your thoughts and experiences in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © olly – Fotolia.com

Moral Courage: Do You Have What It Takes?

Courage And RiskA recent news story describes an investigation into 148 female inmate sterilizations in the California Prison System between 2006 and 2010. Inmates report being coerced into tubal ligation surgery following in-custody births. Although the situation is still under investigation, this news story reveals one of many moral situations encountered in correctional health care. One wonders if others in the facilities questioned the actions of the physicians performing these procedures in violation of prison healthcare policy which requires administrative approval of any elective procedure.

Possibly more than any other nursing specialty, correctional nurses confront moral dilemmas in the clinical setting. Clashing worldviews of security and healthcare along with the political and social implications of healthcare delivery to criminals create a quagmire of ethical concerns. Many correctional nurses work in solo practices in small facilities without benefit of a healthcare management structure that supports standard healthcare practices. Even in larger systems, ethical practices may be overruled by a security structure that is not attuned to the patient care implications of custody practices.

Moral courage is the courage to take action on a moral issue by overcoming fear of the consequences. The potential for reprisal, social isolation, and termination can lead to fear in responding to a moral issue such as patient coercion. Self-doubt can also cloud the issue. If no one else in the organization is addressing or responding to unethical or immoral practice, a nurse can question her interpretation of the situation.

Do you have what it takes to respond with courage when confronted with a similar ethical or moral issue? How can correctional nurses strengthen their moral courage?

Back to Your Roots

One way to gain moral courage is through reflection on the defining elements of our professional practice. In addressing concerns nurses can have as whistleblowers, Lachman suggests a need to return to our professional roots. As professionals we must be loyal to the definition of nurses as those who alleviate suffering and advocate on behalf of a patient’s well-being. Therefore, as nurses, we can garner the moral courage to act in the face of unethical colleagues, patient safety violation, or fraud by reflecting on the need to report these behaviors as part of who we are as professionals.

Tempered with Wisdom

Moral courage in nursing practice also requires wisdom. The courageous among us can be rash in responding to what, on first review, is an unethical practice. Yet, a wise nurse considers all the facts and perspectives before sounding the alarm. A wise response is determined based on full information; while misdirected courage can lead to foolhardy actions. Wisdom tempers courage to, instead, seek the right response in any situation.

Practice Makes Perfect

Intentionally practicing moral courage can develop the skill and habit of responding even in the face of fear. Some consider courage to be equivalent to fearlessness; but that is a distortion of the concept. Courage means overcoming fear by acting in the face of adversity. By practicing the skill of overcoming small fears, a nurse can develop moral courage by progression. For example, courageously overcoming fear to respond to rude behavior from a colleague develops the moral courage muscle. Like strength training for our physical muscles, our moral courage muscle must be stressed with ever increasing weight.

What would you do if you saw that providers in your setting were performing elective procedures without appropriate administrative clearance as noted in the opening story? How would you seek out enough information to take the right action? Would you know the mechanism to use to report the situation? Would you have the moral courage to take action? Share your thoughts in the comments section of this post.

Read more about ethical practice in corrections in Chapter 2: Ethical Principles of Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © freshidea – Fotolia.com

An Experience with Moral Distress and its Resolution

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

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

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

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

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

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

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

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