Is Intake Screening Getting the Job Done?

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

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

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

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

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

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

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

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

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

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

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

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

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

Photo credit: © iQoncept-

Heart Disease and Women Part 1: Symptom Presentation

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

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

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

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

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

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

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

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

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

To read more about nursing care of women and patients in correctional settings with cardiovascular disease and other chronic diseases see Chapters 6 and 9 of the Essentials of Correctional Nursing.  Order a copy directly from the publisher or from Amazon today!



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

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

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


Photo by Linda Howard at,-bless-their-perverse-little-hearts

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

Illustration - Woman in jailLast week’s post described the challenge of knowing the impact of the law on the delivery of health care in the correctional setting. Knowledge of the law and prisoners’ rights is one of the distinguishing features of correctional nursing practice. This week’s post describes the second challenge correctional nurses encounter which is the patients themselves. There is no denying that our patients have been charged with or convicted of breaking the law, sometimes violently. For the most part, knowing the nature of their crime is irrelevant to the provision of their health care, but it is also true, that offenders tend to think and behave in ways that get them in trouble with the law. These criminogenic thoughts and behaviors pepper a nurse’s interaction with their patients.

This is otherwise known as “the Con”, which is defined as the purposeful effort to deceive, manipulate or take advantage of another. Convicts gain respect from others when they “con” someone else and the person who gets conned is considered “weak”. Being weak makes one vulnerable to further exploitation.

Correctional nurses describe this as being manipulated. How it often works, is that an offender requests health care attention because of, let’s say, chronic low back pain, for example. In correctional facilities the offender will always be evaluated by a nurse first, who will determine what to do about the request. It may be that with some education, the offender can take care of it themselves, or a nursing intervention may take care for the problem, or finally, the nurse may decide that the offender needs to be seen by another provider and if so will make a referral.

Sometimes the offender will ask for something for which there is no objective evidence they need. The offender’s request for a narcotic analgesic to ease the chronic pain in his back, is likely not to be supported by objective findings. The request could simply be that the offender is seeking drugs; it could also be to sell or used to pay back a loan. The offender probably will also ask for an extra mattress or pillow. This also may be used to repay a debt or it could be just an effort to stand apart from others, as having something “special”.

If there is a medical need, these may be appropriate to give the offender. But if they are not needed and the nurse acquiesces, the offender has successfully “conned” or manipulated the nurse and achieved a secondary gain. The nurse is then considered “weak” and sought out for other such requests. Correctional nurses joking refer to this dynamic when we say “you know you are a correctional nurse when your patients make up reasons to see you and then don’t want to leave until they get what they came for.”

This gives rise to another distinguishing feature of correctional nursing practice which is the emphasis on the assessment of objective signs and symptoms and the accuracy of the resulting clinical judgment. Our patients subjective complaint may be embellished and critical details may be withheld (remember the example last week about the inmates who drank printer fluid). The conditions within which our assessments are done, often are not conducive to the patient giving a full and candid account of what led up to the request for care. Erring on the side of leniency in the absence of objective findings can result in being seen as, easy to con, and as word gets around, the nurse will be bombarded with inappropriate requests thereafter.

Making the wrong decision though, can also result in harm to the patient. An error in clinical judgment can be because the nurse’s skills are poor or undeveloped, or because the nurse lacks of sufficient knowledge. It can also occur, when a nurse has become cynical about their patient’s criminality and views every request as likely to be devious or untrue. This belief will cloud a nurse’s clinical judgement and important clues to the patient’s condition missed.

While they may be manipulative and sometimes untruthful, they have legitimate health care needs as well. So knowledge about the health problems that characterize the population we care for is a critical piece in achieving more accurate clinical judgments.

According to a report issued this year by the Bureau of Justice Statistics, forty percent of the incarcerated or detained adult population are diagnosed with a chronic medical condition compared to a third in the general community. Diabetes is twice as prevalent among the correctional population compared to a matched sample in the general community and hypertension is 1 ½ times more common. In terms of communicable disease, TB infection and STDs among offenders in correctional settings are twice the rates in the general community and hepatitis is six times the community rate (Bureau of Justice Statistics 2015 Medical Problems of State and Federal Prisoners and Jail Inmates 2011-12).

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at

There are age and gender disparities among the incarcerated population as well. The overwhelming majority are men and they are relatively young in age. While women are in a minority, representing only 9% of all incarcerated persons, their population is increasing at much faster rates than men. Incarcerated women have high rates of traumatic history, particularly child abuse and domestic violence; their convictions are usually drug or drug related and most also are responsible for raising children (Bloom, Owen & Covington 2005).

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at

Juveniles are another small but important group, with unique health care needs. They represent less than 1% of all persons incarcerated. Although incarceration rates for youth are declining, we know that incarceration decreases the likelihood of high school graduation and increases the likelihood of subsequent incarceration as an adult (The Hamilton Project 2014 at

What these statistics mean is that correctional nurses provide population-based health care. Nurses must be knowledgeable and vigilant in their clinical judgement, in order to identify and appropriately treat the health conditions that occur more frequently within each of these population subgroups (blacks, Latinos, women, children and the elderly). This focus on the uniqueness of each individual conflicts with one of the major norms of the correctional system; that incarceration is done to deprive a person of their individuality. No one gets special treatment, no one can be singled out and the rules are applied to all, firmly, fairly and consistently.

This norm about uniformity among prisoners, conflicts with the expectation and science of patient-centered care. Yet when individualization is in the best medical interests of the patient, correctional nurses are obligated to speak up. Patient advocacy, therefore is another distinguishing feature of correctional nursing. Often the nurse will have to act alone because they are the only health care provider at the scene.

An example of nursing advocacy for the individual needs of patients is shackling. Shackling is a security measure to prevent escape when prisoners are taken outside the confines of a correctional institution. In some correctional facilities or systems this is a routine practice applied to all, even pregnant women during labor and delivery. The American Medical Association, the American Public Health Association and the American College of Obstetricians and Gynecologists have each decried this as an unsafe and potentially harmful practice. Some states have even passed legislation prohibiting the use of shackles during labor and delivery. And yet we know the practice continues, so it often is the individual nurse who must insist the shackles be removed for the sake of the patient and their care.

In addition to knowledge, vigilance and advocacy for the needs of the population served, correctional nurses must be generalists in their competency to provide all types of nursing care. Like the prisoners themselves, who are not being able to choose their provider, correctional nurses do not get to choose their patients. A friend of mine and author of one of the chapters in our Essentials text, Roseann Harmon, tells a story about one of her first experiences in correctional nursing. She had been hired at the county jail because she had mental health experience. One evening the nurse manager came to her and said “Roseann, we have a woman out in the squad car at intake and she is in active labor. I am going to need your help because we are the only ones close by. Will you go get the OB pack?” Roseann gulped and said, “But I’m the mental health nurse, not an OB nurse.” The manager responded, “Well you are a nurse and so am I. We are the only ones here right now so we have to respond and we will do it together. This woman needs us.” Well, Roseann survived this experience and still tells the story years later, reminding us not to let our general nursing expertise diminish.

The second part of the ANA’s definition of correctional nursing is that the population cared for are prisoners. To summarize our population is characterized by criminality; ethnic, racial and gender disparities and has a high burden of disease. This population has had little in the way of regular health care prior to incarceration and are illiterate about self-care and health generally. Correctional nursing is defined as being responsive to the health care needs of people during their incarceration.

What are the best ways to maintain your knowledge and competencies as a generalist in nursing practices when there are some many changes in the science and best practices of health care? Please share your thoughts and resources that you think help nurses stay current in our field by responding in the comments section of this post.

If you would like to read more about the health care challenges and characteristics of the incarcerated population, see many chapters in our book, Essentials of Correctional Nursing, devoted to the nursing care of women, juveniles, the elderly, the racial and cultural groups as well as those with chronic disease and mental illness. Order a copy directly from the publisher or from Amazon today!


Photo credit: © Helder Sousa –

Health Literacy Tools and Resources

photo“Nurses at a large maximum security prison are teaching patients about sexually transmitted diseases. While the inmates await their chronic care appointment in the clinic holding area, they are given written material printed from the Centers for Disease Control website. During the nurse portion of the chronic care visit, each inmate is asked if they received the material and if they have any questions. If they have no questions, the nurse documents successful patient teaching on the topic in the medical record.”

This example (page 11) from the Essentials of Correctional Nursing invites us to think about the situation and to “Describe flaws in this process and suggest improvements in the teaching method.”  Last week’s post pointed out that at least 36% of the population have limited health literacy. The following are “best practices” to improve health communication. How many would apply to the case example above?

Identify the audience and focus the message: Our ability to understand and act upon communication is effected by the factors listed below:

  • age
  •  gender
  •  race
  •  ethnicity
  •  religion
  •  sexual orientation
  •  economic experience
  •  language
  •  communication ability
  •  occupation
  •  life experiences
  •  attitudes
  •  behavior
  •  social experiences


  •  cultural experiences
  •  beliefs

Communication of health information will be more relevant if it is sensitive to the characteristics of the intended audience. For example, would youth at a detention facility prefer to receive information about basic oral hygiene via a cartoon with rap music or in a film of a dentist in an office setting brushing a large set of false teeth? These options and many more are available for free on Youtube, just type in the search term, oral hygiene. The more the information and it’s delivery can be tailored to the preferences of the audience the more successful the communication will be.

Best Practices for Oral Communication: The problem with verbal information is that patients only retain about half of what they are told and they are uncomfortable asking to have information repeated.  To increase patients’ retention the following are considered “best practices”:

  • speak slowly and keep the message simple
  • limit the amount of advice to no more than 4 points
  • cover the most important point first
  • advice should focus on patient behavior that is the most important to a good outcome
  • organize information logically with the simplest coming before more complicated information
  • give concrete, specific and vivid instructions; avoid abstract or general statements
  • use active rather than passive voice
  • use plain language and a thesaurus to avoid medical terminology or jargon

Best Practices for Print Communication: Patients prefer to have pictures or graphics accompany written information. Pictures also improve comprehension.  Printed material should not replace personal interaction and is most effective when it reinforces verbal information. Patients prefer information presented with simple visuals especially when ill or adjusting to a new diagnosis. The following are “best practices” for print communications:

  • the most important point should appear first
  • use 12 point font, limit sentences or lines to 40-50 characters.
  • use headings and bullets to break up text
  • avoid using all capital letters (this is akin to shouting), italics or fancy script
  • use a lot of white space in the margins, between points and to separate paragraphs or ideas
  • avoid decoration; all print material should be specifically relevant to the point being made
  • pictures are encouraged when the picture
    is linked to the text
    is concrete, not complex
    supports key points
    is without unnecessary detail

Evaluate the Patient’s Understanding of the Message: Don’t assume that the patient understands if they don’t ask any questions.  In fact asking patients to restate what they have been told is among the top patient safety practices recommended by the Agency for Healthcare Research and Quality in their 2001 report.  This technique, referred to as “teach-back”, improves retention and allows the nurse to correct misunderstandings.  The following are tips on how to evaluate patient comprehension:

  • Ask open ended questions. In the example above it would be better if the nurses asked “What questions do you have about sexually transmitted diseases?” rather than “Do you have any questions about STDs”
  • Questions that start with “what” or “how” are more likely to be open ended.
  • Ask the patient to tell you in their own words what they understand. One way to do this is to say “I want to make sure I didn’t leave anything out so would you please tell me in your own words what we have discussed” or “What will you tell your (family member) about your condition?”
  • Present the patient with a problem or scenario to see if the patient can apply the information. The nurse might ask the patient receiving STD education “What should you do if you experience pain and burning upon …”
  • If the patient is unclear about one of the points, re-phrase the information rather than repeat it.

The flaws in the example at the beginning of this post are:

  • the material provided does not appear to have been selected with a specific audience in mind
  • printed material was used in lieu of oral communication
  • there was no evaluation of the patient’s understanding of the information given

Here are some tools and resources to address health literacy:

1. Clear Language and Design evaluate readability, examples, online Thesaurus

2. Plain language thesaurus

3. More on Plain Language

4. Creating easy to understand materials

5. Clear & Simple: Developing Effective Print Materials

6. Health Literacy Tools

7. Gateway to Health Communication and Social Marketing

8. Health Communication, Health Literacy, and e-Health

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 correctional nursing practice 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: Catherine Knox 2/28/2013

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

Cultural Competency

CULTURE. Wordcloud illustration.Inclusion of a patient’s cultural preferences into the plan of care when at the same time the correctional setting demands that we be “firm, fair and consistent” in all our interactions with offenders is a distinguishing feature of correctional nursing. Weiskopf describes this feature as nurses negotiating the boundaries between custody and caring (2005).  Incorporating the patient’s cultural preferences into nursing care has been part of the ANA’s Corrections Nursing: Scope and Standards of Practice since the first edition in 1995 (2007, pg. 74).

Failure to address ethnicity, culture and language has been found to exacerbate health disparities and lower health care quality according to a recent Cochrane Review (Horvath 2011). Cultural and racial minorities are disproportionately represented in the corrections population. The health needs of these groups are discussed at length in the Essentials of Correctional Nursing.  In correctional settings inmates do not get to choose their health care provider and likewise nurses cannot pick their patients, therefore it is inevitable that challenges, misunderstandings and conflict resulting from diverse cultures will occur.

Cultural competence is the ability to effectively provide nursing care to patients from different cultures. Take moment to think about your experiences addressing patients’ cultural preferences when providing nursing care in the correctional setting. What successes would you like to share? Please write us in the comments section of this post?  The paragraphs below describe how to build cultural competency.

Self-Awareness: First we must become aware of how our own views may differ from others.  Mark Fleming, PhD., with the Missouri Department of Corrections, described this as “being willing to take a step on a journey of transformation…” in a recent interview with Lorry Schoenly at  A starting place for this journey is to assess our cultural competence. One great resource was specifically developed for primary health care providers and can be accessed at

Communication: As we experience more diversity, the potential for conflict and misunderstanding increases and the ability to communicate effectively becomes even more important (Pearson, 2007). Effective patient-centered communication is characterized by:

  • an absence of assumptions
  • use of open-ended questions
  • active listening
  • expression of empathy
  • non judgmental words and behavior

What are the tools within the organization that support diversity? How do policies, procedures and clinical protocols support cultural differences and preferences for care?  Are qualified interpreters available for communication with patients?  Have staff been taught how to conduct an effective patient encounter when using an interpreter?  Are patient information materials culturally relevant? Communication tools that support culturally sensitive healthcare delivery can be accessed at

Knowledge: Cultural competence is a dynamic rather than static process so one class in cultural diversity isn’t enough.  Understanding how illness is experienced by different cultural groups enables nurses to better tailor care for individual patients.  We may be able to leverage help from the ethnic and cultural resources at our facility and within the community to deliver health care that is more relevant and effective with particular patients. These resources may also be able to provide meaningful emotional and social support for the patient.    A free online course in culturally competent care specifically developed for nurses is available at and offers 9 CE credits.

Summary:  My favorite tool is a list of 37 concrete things that demonstrate cultural competency in providing primary health care services. The list can be posted in the clinical area as a handy reference. It also can be used to compare against actual practice and then to build an improvement plan. This resource may be obtained at   Read more about the cultural diversity and related health care needs of our patient population in the Essentials of Correctional Nursing.  Order your copy of the book directly from the publisher and use promotional code AF1209 for $15 off and free shipping at


American Nurses Association. (2007). Corrections Nursing: Scope & Standards of Practice. Silver Spring, MD: American Nurses Association.

Horvath, L. (2011) Cultural competence education for health professionals. Cochrane Database of Systematic Reviews, (10)

Pearson, A. (2007). Systematic review on embracing cultural diversity for developing and sustaining a healthy work environment in healthcare. International Journal of Evidence Based Healthcare. (5), 54-91.

Registered Nurses’ Association of Ontario (2007). Embracing Cultural Diversity in Health Care: Developing Cultural Competence. Toronto, Canada

Weiskopf, C. S. (2005). Nurses experience of caring for inmate-patients. Journal of Advanced Nursing, 49, 336-343.

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