Stewardship involves the health care team

The last two posts have been about the challenge we all face in preventing the development of antibiotic resistance and treating those who have antibiotic resistant diseases. In today’s world of antibiotic resistant diseases, we all are guided to be vigilant when the plan of care contains antibiotic therapy. Providers have an important role in antibiotic stewardship and so does the rest of the corrections health team, including the nursing staff, the pharmacy, laboratory and clerical staff to ensure our patients receive the community standard of care with regard to treating infectious disease. This post highlights the U.S. Department of Justice, Bureau of Prisons’ development of guidelines for antibiotic stewardship in correctional health care.

Clinical practice guidelines

In 2013, the Bureau of Prisons (BOP) published Antimicrobial Stewardship Guidance. The BOP is the first correctional health care system to develop and make available to the public a written plan to address prevention and treatment of antibiotic resistant disease. Since then other systems have used it as the basis to develop their own guidelines on the use of antibiotics.  The BOP guidelines provide information about:

  • diagnosing and identifying infections
  • understanding lab values,
  • therapy selections,
  • multi-drug resistant organisms
  • national guidelines for treatment.
  • to communication, competencies and training.

Strategies of the BOP Program

The BOP guidance is based upon four strategies:

  • Education for all staff about appropriate use of antimicrobial agents
  • Formulary management with varying degrees of restriction in the use of antibiotics
  • Prior approval programs for antibiotic medications not on the formulary
  • Converting patients from broad to narrow spectrum antibiotic therapy.

Communication, communication, communication

Communication, is at the heart of success in promoting antibiotic stewardship.  The BOP guidelines stress that patient satisfaction is influenced more by communication, than by whether or not the patient receives an antibiotic. Communication is used to validate the patient’s illness, help them understand the disease as well as the treatment options. Sometimes antibiotics are warranted and sometime they are not and we use communication to help the patient understand the treatment recommended for their illness.  Communication practices recommended by the BOP include:

  • Choosing terminology–using the diagnosis name instead of referring an illness as “just a virus” validates the patient’s symptoms. They will be more willing to participate in the treatment plan when they know you care about what is happening to them. No matter how mild or severe, all illnesses are important to the patient.
  • Offering symptomatic relief—it takes sensitivity when talking about a condition that is a virus or other illness that does not require use of antibiotics. Provide information about symptomatic relief such as over the counter medications, showers, hydration, gargles and warm or cold packs. In addition to talking with the patient provide a handout to reinforce the information.
  • Discuss expectations for the course of illness and possible medication side effects—none of us hears everything the provider tells us at a visit. Our patients benefit from knowing what to report, what improvements looks like and when to report worsening symptoms. Patients should receive information about their illness, treatment or self-care options, what to expect and when to seek medical attention from nursing staff and others at every subsequent patient interaction.

Good communication provides the means to engage patients in the recommended and most appropriate treatment regime.

Nursing competencies and training

Infectious disease is a large group of illness and a challenge in maintaining a current knowledge base. In corrections health, we become more proficient in the most common diseases that our patients have. To assist us we have tools, such as standard protocols for MRSA and skin infections, pneumonia, tuberculosis, sepsis, gynecological infections, urinary infections and sexual transmitted diseases. Just keeping up with the laboratory tests and newly developed antibiotics can be a daily learning experience.

The BOP guidelines list the following infectious disease competencies for correctional nurses:

  • Understanding culture and sensitivity laboratory report results.
  • Understanding common IV antibiotic dosing, frequencies and regimes.
  • Knowing the signs of improving clinical status that facilitate de-escalation.
  • Understanding the timing of medication dosing and blood sample collection.
  • Knowing the signs/symptoms of common allergic reactions to frequently used medications.
  • Awareness of the facility antibiotic therapy guidelines.
  • Knowing the common side effects and adverse events associated with antimicrobials.
  • Understanding the principles of antibiotic stewardship.

The ups and downs of antibiotics

In 1928, Sir Alexander Fleming, discovered a naturally occurring antiseptic enzyme. He was quoted as saying “one sometimes finds what one is not looking for”. From his work, in six years, penicillin was discovered.  From early to modern history antibiotics have played a major part in wellness and prevention of mortality.  Today, we have new challenges from organisms adapting to medications and not curing illness. Everyone in the health care profession is working to curb this and to ensure all of us receive treatment that HEALS.

Are the infectious disease competencies for correctional nurses recommended by the BOP the ones you would recommend? What additions or changes to this list of competencies would you recommend? Please share your ideas by replying in the comments section of this post.

Read more about the identification and management of infectious diseases in the correctional setting in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today! 

Photo Credit:


Antibiotic Stewardship has Four Rights

stewardship photo

The subject of antibiotic stewardship was touched upon in last week’s post about Superbugs. The goal of these programs is to avoid unnecessary and inappropriate use of antibiotics to prevent development of antibiotic resistant disease organisms. In addition to curing illness, appropriate antibiotic use should also reduce side effects of medications and lower health care costs.

Inpatient settings, such as hospitals and long term care, have had programs in place to monitor the use of antibiotics for some time. In 2009, the Centers for Disease Control and Prevention (CDC), launched the “Get Smart for Health Care Campaign  ” to promote the improved use of antibiotics.  The Joint Commission and the Infectious Disease Society of America (IDSA) have also come out with recommendations, guidelines and tool kits for health care settings to begin their own stewardship programs.

Correctional facilities are also patient care settings

A study by the CDC indicates that 30-50% of antibiotics prescribed in hospitals are unnecessary or inappropriate. How does that translate to corrections health? The article states that overprescribing and mis-prescribing is contributing to the development of antibiotic resistant bacteria and challenges from side effects of antibiotic use. Of all the health care settings, corrections health is probably the most cautious in prescribing medications for patients because our patients come from an “medication dependent culture”, whether legal or illegal.  Many corrections health programs have policies, procedures and clinical protocol to guide the assessment, diagnosis and treatment of the most common antibiotic resistant conditions, such as methicillin resistant staph aureus (MRSA), resistant tuberculosis and gonorrhea. Even with these practices in place, are correctional health care programs able to assert that all antibiotic use is appropriate? Probably not.

The fundamental four rights

The goal of antibiotic stewardship has four points to ensure that patients being treated for infectious conditions receive:

  • the right antibiotic
  • at the right dose
  • at the right time and
  • for the right duration

Most correctional health programs already have in place the components of an antibiotic monitoring system. The existing quality improvement (CQI) program or pharmacy and therapeutics (P & T) committee should include monitoring of appropriate antibiotic use among the subjects reviewed. Staff to lead the effort could include the staff or consulting pharmacist, the medical director or other provider, infectious disease specialist or nurse, or one of the staff responsible for medication administration. By using existing resources and interest, it is possible to initiate antibiotic stewardship at your facility, no matter how large or how small.

Common guidelines to ensure antibiotic stewardship

Practical advice for implementation of antibiotic stewardship include these recommendations from the Infectious Disease Society of America, which can be translated into any setting:

  • Pre-authorization or review of orders for targeted antibiotics with consultation provided about alternatives.
  • If pre-authorization or consultation is not available, after two or three days of treatment review the patient’s response to treatment and adjust treatment accordingly.
  • Conduct a continuous quality improvement study or audit of patient response to treatment with antibiotics to identify areas to target for improvement.
  • Timely diagnostic services, especially for respiratory specimens, aids in the determination of whether antibiotics are necessary.
  • Use of standard protocols for specific diagnoses or syndromes to guide the assessment, treatment and evaluation of the patient’s response to treatment.

Corrections health reflects the community.

Correctional health care is consistent with and supportive of health care in the community. With statistics like 23,000 deaths per year in the US from antibiotic resistance, stewardship and oversight of antibiotic use has become the community norm.  The safety of our patients and in essence the community, requires that we attend to the appropriate use of antibiotics in the correctional health care setting as well.

If your facility has an antibiotic oversight or stewardship program, please share your experience with us by replying in the comment section of this article.  Next week will examine the Bureau of Prisons’ antibiotics stewardship program and the role of nursing!



Inmate satisfaction with health care services during incarceration


Customer SatisfactionLast week’s post summarized the results of the most recent survey of inmates’ health published by the Bureau of Justice Statistics (BJS). This survey also reported on inmates’ experience with the delivery of health care in 606 correctional facilities throughout the U.S. and their satisfaction with services provided. So before we look at those results take a minute to reflect on your encounters with inmates seeking or receiving health care and how they might rate their satisfaction. My experience is that many correctional nursing colleagues think that inmate satisfaction with health care is low, that many inmates fail to appreciate their care and take what care they do receive for granted. What is your opinion about how satisfied inmates are with their care?

What Do Inmates Think? 

According to the over 100,000 inmates surveyed, more than half were satisfied or very satisfied with health care received while incarcerated. In jails, 51% of the inmates in the survey reported being satisfied or very satisfied and in prisons it was 56%of those surveyed (Maruschal, Berzofsky, & Unangst 2015). This information certainly bursts the stereotype that inmates don’t value the health care they receive during incarceration! Most inmates do appreciate it. Further evidence is found in another survey done recently in a maximum security prison; the vast majority of prisoners in poor health prior to prison reported that their health had improved during incarceration (Yu et al. 2015).

Identifying Opportunities for Improvement 

Patient satisfaction has long been recognized as a valid tool in quality improvement. Often it is only through a patient’s eyes that we can see opportunities to improve patient outcomes or make the experience more supportive of health attainment. Information about patient satisfaction can provide insight into the perceptions and expectations of patients, one important part of the larger picture of a program’s performance. For example, in the Oregon DOC, one of the questions we used on a patient satisfaction survey was whether follow up appointments after nursing sick call were timely. We expected that inmates would be dissatisfied when wait times were more than a day and found out we were wrong. Even wait times of up to one week were rated as satisfactory.

The results of a patient satisfaction survey conducted in the Connecticut prison system revealed much the same results as that reported in the national survey by the BJS. Forty-three percent of 2,727 inmates surveyed (or 16% of the total population) reported satisfaction with their health care; this was considered “better than expected” by some of the health care staff in the system (Tanguay, Trestman & Weiskopf 2014). There was no difference in satisfaction scores based upon gender (male or female) or the type of facility (maximum security, work camp etc.).

The survey developed in Connecticut consisted of ten questions derived fundamentally from Crossing the Quality Chasm: A New Health System for the 21st Century published by the Institute of Medicine (IOM). There were ten topics that inmates were asked their opinion about. These are listed below:

General satisfaction with care Respect for privacy
Access to care is satisfactory The provider listened
Waiting time in the clinic is short The provider is competent & well trained
The provider introduced themselves The provider explained their findings
Treated in a friendly & courteous manner The patient knows what to do to get better or take care of themselves

The article pointed out that to ensure a good response rate questions were written at the fourth to fifth grade reading level, were limited to ten in number and used only three response categories (yes, no and unsure). Although the survey was anonymous, inmates were reluctant to participate at first but this changed over time as inmates came to understand that the survey was intended for program improvement, was indeed anonymous and therefore participation was “safe”.

Important Findings From the Feedback 

Feedback on inmate satisfaction was discussed with health care and correctional staff at each facility and at a statewide level. Satisfaction with each of the ten measures varied. The results and the ensuing discussion were used to identify areas for focused program improvement. For example access to care was rated as satisfactory by 45% of the inmates surveyed. Areas that made access to care difficult included appointments that were dropped because of facility to facility transfers which required inmates to re-request services. Automation of inmate scheduling was discussed as a way to eliminate this problem with access. Other areas that were selected for improvement included explanations for the patient about what the problem is and their treatment options and productive use of time spent waiting while in the clinic (Tanguay, Trestman, & Weiskopf 2014).

Correctional Nurses’ Role in Quality Improvement

Standard 10 of the Correctional Nursing Scope and Standards of Professional Practice provides guidance for correctional nurses’ contribution to quality. Competencies include participation in the evaluation of clinical care and service delivery, correcting inefficiencies in the process of care delivery, identifying and weakening barriers to quality patient outcomes (American Nurses Association 2013). Satisfaction surveys can provide useful insight into the experiences and expectations of our patients. Some patients may be receiving very good health care and still be unsatisfied but taken in the aggregate inmates tend to rate health care received during incarceration very positively. Consider conducting patient satisfaction surveys at your facility if you haven’t used this feedback method yet; you and other health care staff are likely to be pleasantly surprised.   Satisfaction survey results also provide information that can help focus on the areas of the patient’s experience that greatly impact health outcomes, as the report from Connecticut illustrated.

What Is Your Experience and Advice? 

Have you sought feedback from inmates at your facility about their satisfaction with health care? If so, was your experience with the results similar to that reported by the BJS and for the Connecticut prison system? Do you have copies of the survey questions that were used and if so will you share by responding in the comments section of this post?

For more on the nurses’ role in quality improvement see Chapter 18 Research Participation and Evidence-Based Practice in the Essentials of Correctional Nursing. You can order a copy from Springer Publishing and get $15 off as well as free shipping by using this code – AF1209.


American Nurses Association (2013) Correctional Nursing: Scope & Standards of Practice. Silver Springs, MD:

Institute of Medicine (IOM) (2001) Crossing the quality chasm: A new health system for the 21st century. Washington DC: National Academies Press.

Maruschal, L. M., Berzofsky, M., & Unangst, J. (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-2012. Special Report. U.S. Department of Justice, Office of Justice Programs, Bureau of Justice Statistics.

Tanguay, S., Trestman, R., & Weiskopf, C. (2014) Patient Health Satisfaction Survey in Connecticut Correctional Facilities. Journal of Correctional Health Care 20 (2); 127-134.

Yu, S-s. V., Sung, H-E., Mellow, J., Koenigsmann, C.J. (2015) Self-Perceived Health Improvement Among Prison Inmates. Journal of Correctional Health Care 21 (1); 59-61. 

Photo credit: © bahrialtay–

Factors effecting adherence and more evidenced based strategies

young african nurse explaining medical test resultWe were introduced to your patient, Jessie, in the post last week on medication adherence. She had come to sick call because she was feeling depressed and anxious.  She was only taking about half of her prescribed medications and she didn’t know what the medications are or why they had been prescribed. You have been thinking about how to help Jessie take her medication more regularly.

One of the recommendations from a study by Megan Ehret and her colleagues (2013) is to identify those inmates at risk for non-adherence and intervene early.  This study builds on a literature review by Shelton et al. (2010) which found these variables associated with medication adherence among inmates:

  • Older age
  • Male gender
  • Personal motivation
  • Inmate involvement in care
  • Therapeutic relationship with healthcare providers
  • Positive outcomes of treatment
  • Prior experience with treatment

In Jessie’s case many of these variables are absent so she is at greater risk for non-adherence.  The next step is to explore her reasons for non-adherence. Motivational interviewing (MI) is an evidenced based technique that has been found to improve medication adherence by prompting the patient to consider and adopt behavior that is consistent with their goals (Julius et al. 2009, Velligan et al. 2010, Shelton et al. 2010). Using this technique you help Jessie articulate that she wants relief from feelings of depression and anxiety and yet does not link taking the medication to feeling better.  How can you help Jessie to adopt behavior consistent with her goal?

Your first inclination is to educate Jessie about the medications and why each has been prescribed but recall that education alone is ineffective in improving adherence (Brown & Bussell 2011, Velligan et al. 2010, Julius et al. 2009, Haynes et al. 2008). Instead you look again at her prescriptions and decide to talk with her providers to see if the number of medications and number of doses can be simplified. It is likely that when Jessie was seen by her providers she reported still not feeling well. The MAR is not routinely available to the provider when the patient is seen so the provider asked Jessie if she was taking her meds. She said yes. Patients in general, not just our patients, overestimate their adherence (Velligan et al. 2009, Julius et al. 2009). So over time higher doses have been prescribed and more medication added.  If the number of medications and doses per day are reduced you are sure her adherence will improve (Ehret et al. 2013, Haynes et al. 2008, Brown & Bussell 2011).

Your next step is to find out Jessie’s past experience and preferences when taking medications to determine what kind of schedule or routine works best. She has some cognitive deficits (not knowing her schedule, missed medications and appointments, and disheveled appearance) so you want to embed taking medication into a regular part of her day (Shelton et al. 2010, Velligan et al. 2010). She says that she used stickers on a calendar to remember her children’s appointments and it worked pretty well for her. She thinks that something like a reminder on a calendar or daily diary would help her remember. She also thinks that morning would be the best time to take her meds because she is an early riser and by the end of the day she is too preoccupied with her anxiety to remember.

You schedule her for a return visit in three days. By then you will have talked to the providers and know whether her medication regime can be simplified. She has a calendar so you ask her to bring it to the appointment and you will develop a medication reminder with her. You are also planning to provide some education about the most important medication she is taking but need some time to think about how to link the information to her short term goals and low health literacy. See a prior post on this subject.

Lastly you ask her what has worked in the past to manage feeling anxious. She says that she has had some success with breathing exercises and thinks that she can use this technique to help her now. You suggest adding some visual imagery to the breathing. She agrees with the plan and you are on to your next patient.

Summary: Supporting medication adherence among inmates
  •   Identify patients at risk for non-adherence to intervene early.
  •   Explore the patient’s reasons for non-adherence and motivation for treatment.
  •   Develop multifaceted plan that links medication taking behavior to the patient’s strengths and  motivation (education alone is not enough).
  •   Increase frequency of visits to monitor treatment efficacy and support behavior change.

For more about patient adherence and monitoring treatment efficacy read Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.  

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114

Haynes, R.B., Ackloo, E., Sahota, N. McDonald, H.P. & Yao, X. (2008) Interventions for enhancing medication adherence (Review). Cochrane Database of Systematic Reviews, Issue 2. Art.

Julius, R. J, Novitsky, M.A. & Dubin, W.R. (2009) Medication adherence: a review of the literature and implications for clinical practice. Journal of Psychiatric Practice, 15 (1) 34-44.

Shelton, D., Ehret, M.J., Wakai, S., Kapetanovic, T. & Moran, M. (2010) Psychotropic medication adherence in correctional facilities: a review of the literature. Journal of Psychiatric and Mental Health Nursing, 17, 603-613.

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16 (5) 306-324

Velligan, D.I., Weiden, P.J., Sajatovic, M. et al. (2009) The expert consensus guideline series: adherence problems in patients with serious and persistent mental illness. Journal of Clinical Psychiatry, 70 (suppl 4) 1-48.

Photo credit: © michaeljung

Healthy Workplace = Quality + Patient Safety

Regulation of professional nursing practiceA few weeks ago we summarized features in the new edition of the Correctional Nursing: Scope and Standards of Practice (ANA, 2013).  The scope and standards are described first, as the foundation for professional nursing practice regulation because they define the specialty for nurses as well as the public. The are broad statements about the practice of the profession that transcend geographic location, type of employer and population served. The nurse practice act in the jurisdiction where the nurse is licensed provides the second level of specificity and guidance related to practice.  The employer, organization or institution  provides the third level of specificity by establishing policies, procedures and a work environment that supports professional nursing practice.  The final level in the regulation of professional nursing practice is the individual nurse who is responsible and accountable for their competence and nursing decisions (White & O’Sullivan, 2012).  This description is depicted in the diagram on the left of this post.

There is a strong link between work environments that support professional nursing practice, quality of care and patient safety.  The American Nurses Association (ANA), The Joint Commission (TJC 2012), the International Council of Nurses (ICN 2007) and the American Association of Critical-Care Nurses (AACN) are organizations that have used evidenced-based research to develop resources and establish standards for the workplace that support quality and patient safety. What are the characteristics of work environments that support nursing practice?  The AACN standards align with the core competencies for health care professionals recommended by the Institute of Medicine (IOM). The AACN provides many resources on the web and so their six standards for the healthy workplace were selected to highlight along with examples here:

  1. Nurses are as proficient in communication as they are in clinical care. Examples of practices that improve nurses’ communication skills include nursing grand rounds, assistance to publish articles and present at conferences.
  2. Nurses are relentless in pursuit of true collaboration. Examples of practices that improve nurses’ skills in collaboration include the development of nurse to nurse collaboration such as rapid response teams, development of clinical practice protocols, and participation in CQI activities.
  3. Nurses make policy, direct and evaluate clinical care, and lead organizations. Examples of practices that support nurses’ participation in the development of policy and other aspects of organizational leadership include membership on interdisciplinary committees such as Pharmacy and Therapeutics (P&T), Continuous Quality improvement (CQI), Ethics and Infection Control and other committees responsible for guidance regarding clinical patients care.
  4. Staffing effectively matches patient needs and nurse competencies.  An example of this are systems that acknowledge nurses for clinical expertise in direct patient care by rewarding advancement in clinical education and certification.
  5. Nurses are recognized and recognize others for the value they bring to the organization. Examples of practices that support meaningful recognition include clinical ladders, identification of expert nurses and publication of nurse’s advancement clinically.
  6. Nurse leaders authentically live and engage others in the achievement of a healthy work environment. Examples of practices that support authentic leadership include participation in key decision making forums, access to essential information and the authority to make necessary decisions regarding the professional nursing workforce (AACN, 2005; Vollers, 2009).

One of the distinguishing features of correctional nursing and indeed one of the challenges in the practice of correctional nurses is that prisons, jails and other correctional facilities do not have a health care mission but instead a mission of safety and security. A major role for correctional nurses is to negotiate with the correctional environment to support appropriate patient care delivered in ways that are consistent with the standards for professional practice. In order to support professional practice nurses must be knowledgeable of the state or licensing jurisdiction’s nurse practice act as well as the characteristics of work environments that are linked to quality patient care and patient safety such as the AACN described here.

What successes have you experienced supporting professional nursing practice while negotiating the differences in the mission of the criminal justice system and the delivery of health care?  Please share your experiences by writing in the comments section of this post.

For more on the topic of environments that support professional nursing practice in the correctional setting see Chapters 4, 17 & 19 of the Essentials of Correctional Nursing. The text can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

References and Resources:

American Nurses Association. (2013). Correctional nursing scope and standards of practice. Silver Spring, MD: American Nurses Association.

White, K., O’Sullivan, A. (2012). The Essential Guide to Nursing Practice: Applying ANAs Scope and Standards in Practice and Education. American Nurses Association. Silver Springs, MD.

International Council of Nurses (2007) Positive Practice Environments: Quality Workplaces=Quality Patient Care. Geneva (Switzerland): International Council of Nurses. Accessed 6/10/2010 at

American Association of Critical-Care Nurses. Accessed 6/10/2013 at

The Joint Commission. Improving Patient and Worker Safety (2012).  Accessed 6/10/2013 at

The American Nurses Association.  Accessed 6/10/2013 at

Photo Credit:  American Nurses Association Model for Regulation of Professional Nursing Practice

Assessing Health Literacy in Correctional Health Care

Doctor gives the patient a prescription or referralAmong the characteristics of the incarcerated population described in Chapter 1 of the Essentials of Correctional Nursing the following are also associated with low health literacy:

  • Lower educational attainment than the general community
  • Disproportionate representation of African Americans and Hispanics
  • A growing number of elderly inmates.

Thirty-six percent of all adults in the United States have limited health literacy (Agency for Healthcare Research and Quality, March 2011). Persons who have not completed high school, live in poverty, did not speak English before starting school, are a racial minority or are elderly are also more likely to have limited health literacy.  Difficulty reading and comprehending can be embarrassing and stigmatizing for patients who have compensated for their problem over time with a number of coping strategies.  Often patients considered noncompliant with care are instead not sufficiently health literate to carry out the plan. Finally health care clinicians routinely overestimate the ability of patients to understand medical information (Cornett, 2009).

Limited Health Literacy is Associated with Poor Health

People with low health literacy are more likely to report their health as poor. They make less use of preventive services and have higher rates of hospitalization and use of emergency services. Persons with low literacy are more likely to have chronic conditions (high blood pressure, diabetes, asthma, and HIV) and are less likely to manage the condition effectively.  Patients with limited health literacy are sicker when they access the health care system (AHRQ 2011, Institute of Medicine, 2004).  Interventions to improve comprehension and increase self- management behavior reduced hospitalizations and emergency room visits and increased use of preventive health screening (AHRQ 2011).

What is Health Literacy?

Many times health literacy is assumed to be the same as reading and comprehension skills. Health literacy actually includes in addition to reading and comprehension, the ability to understand numbers and calculations and to act on health information.  Healthy People 2010 defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (United States Department of Health and Human Services, 2000).  Just to get a sense of what is involved in health literacy take the Newest Vital Sign a screening test developed by the Pfizer Clear Health Communication Initiative.  The tool uses a food label to screen for health literacy and it only takes about three minutes to administer. It is a good exercise in understanding what patients need to be able to do to be health literate.

Clues that a Patient May Have Low Health Literacy

Patients are often embarrassed about low literacy and will not readily admit to needing help. Others may not even be aware of deficient in health knowledge and skill. The following behaviors may be a clue that a patient is having trouble understanding health care information or instructions:

  • Making an excuse when asked to read or fill out paperwork such as “I don’t have my glasses.”
  • Checking no on a health history to avoid follow up questions.
  • Missing appointments or making errors in medication dosing.
  • Irritability, nervousness, confusion, or indifference during health care encounters.
  • Identifying medications by color, size or shape rather than name and purpose.
  • Following directions literally.
  • Holding written material closer to read, lack of visual focus on reading material, using a finger to point at the words.

This list isn’t to suggest that when someone displays these behaviors that the nurse should conclude that the patient has low health literacy but instead to adjust approach, consider asking a follow up question or offer to assist in a non-judgmental manner.

What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.

To read more about how to assess and address health literacy order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Cornett, S. (September 1, 2009). Assessing and addressing health literacy. Online Journal of Issues in Nursing, 14 (3)

Berkman ND, et. al. (March 2011). Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality.

National Research Council. (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press.

United States Department of Health and Human Services. (2000) Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington DE: US Government Printing Office. Accessed 2/17/2013 at


Photo Credit: © Alexander Raths

Evidence-Based Practice: Where to Look

Magnifying Glass - FactsFraming a good question points us in the right direction, but how do we find good evidence to answer this question? In my last post, I used the PICOT method to create this search question: Are heel protectors as effective as turning to prevent heel pressure ulcers? In this post we’ll look at our search options to get the answers we need.

Correctional nurses, in particular, can find themselves with more question than answer sources. Jails and prisons are often short on medical library services. In my hospital days, I merely showed up at the library with a list of topics and a medical librarian worked on my request. As with so many other areas of practice, correctional nurses must be creative in seeking out sources of published research for clinical application. Here are a few of my favorite options for finding evidence in our resource-poor environment:

  • The Internet: The world is at our fingertips now that we have search engines and online professional nursing sites to access. Even if your facility does not have open internet access, you are likely to have personal online service to use outside of work. Try the key words of your question in the search bar and see what comes of it. Also consider using these online sites:
  • Libraries: Check out your medical library sources in your geographic area. If your facility provides a clinical experience for nursing students, you may be able to access the school’s medical library. That may also hold true for your local community college if they offer nursing degrees. Even your public library may be a resource if they are linked with the state college library system. You may be able to obtain access to nursing books and periodicals through the library lending services.
  • State Board of Nursing: Some states offer library access through the nursing licensure process. Contact your state board or review their website to see if you have services through your licensing fees.

Seeking out sources of good evidence will allow you access to the information that can transform your nursing practice and help you deliver the quality care you desire. Do you have some advice on where you locate evidence for application to correctional nursing practice? Share your tips in the comments section of this post.

Read more about Evidence-Based Nursing Practice in Chapter 18 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © kbuntu –

Evidence-Based Practice: Asking the Right Questions

A detective circles the body of a slain business man watching the pathologist work. She considers the angle of the body and the trajectory of the bullet based on the wound. Work completed, the pathologist prepares to leave and the detective asks about the time of death. The pathologist responds, “The real question is how did he die? That gunshot wound was not fatal.”

I love a good mystery and often watch or read a detective story as a way to relax after a long day. Nursing can also be detective work as we sift through assessment data and make a judgment about actions to take. If we don’t ask ourselves the right questions, however, we are unlikely to come to the right conclusions.

In a prior post we talked about encouraging evidence based nursing practice in corrections. In order to find good evidence to use in practice, we have to ask the right question at the start. A popular method for developing a good question for locating the right evidence is called PICOT. Each letter provides a component of the question. Strung together, these 5 elements create an effective question to begin the search.

Suppose you are seeing more3 heel pressure ulcers in your infirmary due to a recent increase in paralyzed and elderly patients. Let’s try using the PICOT method to create a research question on this topic. In this case we’ll look into information comparing 2 different methods for preventing heel pressure ulcers. Below is a table showing the PICOT components for this search.

Element Characteristics Search Components
P Patient population or disease Heel Pressure Ulcers
I Intervention or issue of interest Heel Protectors
C Comparison intervention or issue of interest Turning
O Outcome Prevention
T Timeframe (optional) NONE

With these elements identified, the research question would be – Are heel protectors as effective as turning to prevent heel pressure ulcers? Armed with this question, we can begin to search the literature for an answer. In an upcoming post we’ll seek out an answer to this query.

Read more about Evidence-Based Nursing Practice in Chapter 18 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © kbuntu –

Encouraging Evidence-Based Nursing Practice in Corrections

Recent research published in the Journal of Nursing Administration (JONA) confirms that nurses want to practice based on the best evidence but are not consistently putting that desire into action. Many challenges were identified by the national sample of nurses surveyed for the research study. These challenges may be even more acute in the correctional setting where resources can be lacking and technology limited.

Researchers found that evidence-based care is encouraged when there are strong beliefs that EBP improves patient care and outcomes and when there is an organizational culture that supports this care. If health care leadership does not understand EBP or believe that it will make a difference, the processes for this practice will not be created or supported. Knowledge and skills are needed to successfully implement evidence-based practices. This may require educational sessions and mentoring by nurse leaders. Organizational support can also include providing access to best practice databases and literature.

A major consideration in efforts to increase evidence-based nursing practice is time. Nurses rarely have work time allotted to searching and applying research findings. This is a perennial problem in every setting, including corrections. Even if time is available, sources of information may not be. Correctional nurses, in particular, have little access to medical libraries and online resources that are available to many nurses in traditional settings.

Correctional nurse leaders must rise up and provide the leadership and organizational support necessary to make EBP a reality for nurses practicing in jails and prisons. Are you applying evidence in nursing practice in your setting? Share your experiences in the comments section of this post.

Read more about Evidence-Based Nursing Practice in Chapter 18 from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © javier brosch –