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: http://www.U.S.fotolia.com/#100153097/healing

 

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!

 

Photo credit:www.U.S.fotolia.com/#86136484/antibiotics

Superbugs are not only in your garden!

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

News is Full of Superbug Warning

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

Corrections Health Responses

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

Precautions to Consider

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

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

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

Main Warning

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

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

 

Photo Credit: Fotolia.com/photo #114516907

 

 

 

What are these eight rights anyway?

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

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

Health Care Advances

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

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

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

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

The Important Three

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

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

Spread the Word about the 8

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

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

Photo credit:  Yahoo Images

 

.

 

Medication Reconciliation

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

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

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

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

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

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

When Inmates Arrive at a Facility

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

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

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

When Inmates Return From Offsite care

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

When Inmates Are Followed in Chronic Care Clinic

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

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

When Medications Are Missing

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

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

Other questions to help narrow down the problem are:

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

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

Easing the Burden of Medication Reconciliation

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

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

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

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

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

Photo credit: © sato00 – Fotolia.com

Protective Gear for Correctional Nurses

The post last week talked about the problem of nurses being exposed to inappropriate and hostile sexual behaviors by inmates and the kinds of interventions that should be in place to minimize or control antisocial inmate behavior. Nurses were advised not to confront this behavior single handedly but to look to the facility for guidance. But that is just half the solution, the other half, which is the subject of today’s post, is that individuals can take steps on their own to minimize the adverse effects of these unfortunate situations on themselves.

The reality is that bad things do happen in corrections. Even in the best run correctional facilities inmates are injured and sometimes staff are injured as a result of violence and on some of these occasions died as a result of the violence. The nature of the correctional environment is that it always has the potential for immediate violence and direct trauma. Another pervasive aspect of our working environment is that because of the involuntary conditions of incarceration, there is inherent conflict, particularly between staff and inmates. These two features of the work environment combined with operational stressors, such as high workload, contribute to what has been called “Corrections Fatigue”.

It has been suggested that correctional staff prepare themselves to be in this environment the same way that they don other protective gear. An analogy for correctional nurses would be gowning, gloving and putting on a properly fitted mask before going into the isolation room of a patient with active tuberculosis. By wearing protective gear staff minimize their exposure. The same concept applies to the trauma associated with repeated exposure to violence or threatening behavior. What kind of “gear” minimizes our repeated exposure to trauma in the corrections environment?

Resilience is a characteristic that refers to an individual’s ability to cope with adversity; it is the ability to “bounce back” after a stressful experience. Resilience varies from one person to another but we can each tend to and build our resilience. Resilience, then is our protective gear. The following four behaviors have been identified as building resilience in correctional workers.

Build Supportive Relationships at Work – Building and maintaining social support among co-workers has been found to correlate with resilience for the person offering support. By building genuine bonds with co-workers we increase our sense of safety, reduce interpersonal tension and staff conflict. Examples of behaviors that are supportive of relationships at work include:

  • being friendly and respectful,
  • asking how a co-worker is and paying attention to their answer,
  • acknowledging a job well done,
  • looking for ways to assist others when you have time,
  • thanking others for their assistance, and
  • being compassionate with others’ experiences.

Take Care of Yourself – How many times have we as health care providers offered this advice to others? And yet we are known to neglect ourselves, making us vulnerable to burnout, compassion fatigue and now, corrections fatigue. Being healthy is a basic tenet of resilience. Healthy habits and lifestyle behaviors include those that attend not just to your physical needs, but psychological, spiritual and social needs as well. Healthy habits and lifestyle behaviors include:

  • maintaining balance between work and home life
  • mindfully transition to and from work
  • prioritize free time to be with people who are significant in your family and social life
  • engaging in pleasant activity-having fun
  • regulate negative emotions (emotional intelligence)
  • establish a regular and healthy sleep schedule.

Be Confident and Perseverant – These behaviors build competence handling complex or challenging circumstances at work. Confidence and perseverance are a result of:

  • a resolution to complete tasks even when it is difficult,
  • using self-talk to motivate oneself to persevere in the face of adversity,
  • rehearsing and repeating training so that it becomes more automatic and built in,
  • being flexible, open and adaptive to change
  • being ethical and acting with integrity.

Use Logic to Solve Problems – This approach is recommended as a way to keep your cool in the face of the complex or challenging problems we deal with in correctional health care. Thinking logically about situations means considering more than one possible cause and weighing possible responses before choosing the one that is most likely to have the effect you are seeking. This way you maintain control and composure in frustrating or disappointing circumstances. Practical ways to practice logical problem solving and self-control include:

  • divide complex problems into parts and tackle one component at a time,
  • learn how to detach emotionally from challenging situations,
  • view mistakes as learning opportunities,
  • regulate fear and other negative emotions while acting constructively,
  • accept that you cannot always be in control.

These four behaviors, supporting workplace relationships, taking care of yourself, being confident and perseverant, and logical problem solving are your protective gear (resilience) to reduce the effects of violence and other antisocial behaviors, conflict and other operational stressors that are inherent in the correctional setting on your health and well-being.

For more information about promoting wellness among staff who work in correctional settings please see the National Institute of Corrections has collected articles and other resources on this subject. They also sponsored a podcast on the subject in 2014 which can be accessed on the NIC website. Much of this information was adapted for correctional nursing from a series of articles written by Caterina Spinaris PhD., Executive Director of Desert Waters Correctional Outreach which provides training and other materials to support wellness of correctional staff including a monthly newsletter, Correctional Oasis.

I was most surprised to learn from my research for this blog post that when I offered support to co-workers it had a positive effect on me by building resilience. This new idea has me thinking about my work relationships and how I support others to see what I could do better. What resilience building behaviors have caused you to reflect on your own behaviors? Is there more you could do to protect yourself from the negative attributes of your working environment?

If you wish to comment, offer advice or share an experience concerning the subject of staff wellness please do so by responding in the comments section of this post.

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

Photo credit: © designer491 – Fotolia.com

Sexual Harassment by Inmates Against Nurses

A nursing colleague recently asked for advice about how to address the problem of inmates masturbating and making verbal threats during nursing encounters. It is a problem nearly all correctional nurses will face at some point in their career. This post is written to ask nurses how they have dealt with inmates who expose themselves or masturbate in front of the nurse while administering medication, evaluating a health care complaint or responding to a man down call.

While nurses put up with some anti-social behavior in almost any setting, nurses really can be challenged with the pervasiveness of this in a correctional setting. Some nurses will confront the behavior, others will ignore it, and some dish it right back all in an effort of controlling the offensive behavior and getting nursing care delivered. However unchecked exhibitionism is a form of violence towards others that is not acceptable even in a correctional facility. In 2006, the Ninth Circuit Court of Appeals agreed with the lower court’s ruling under Title VII of the Civil Rights Act finding for the employee and noted that prison officials in the California Department of Corrections and Rehabilitation may “not ignore sexually hostile conduct and must take corrective action to safeguard the rights of victims, whether they be guards or inmates”. Similar litigation has been successful in Florida.

Nurses should not attempt to confront the problem alone and have good cause to look to their immediate employer as well as prison officials to address the problem of sexually hostile conduct. Another colleague, who is a corrections expert, recommends addressing the problem in an integrated way that includes making expectations for behavior explicit, delineating graduated consequences that include criminal charges and involvement of the local prosecutor. Here is a list of items which if in place at a correctional facility provide the means to address sexual misconduct:

  • There is an inmate handbook including written rules of conduct for inmates that specifically addresses the issue of exhibitionist masturbation and other forms of sexual misconduct.
  • The handbook also delineates the inmate disciplinary process- what specific offenses bring what penalties – including a description of the inmate disciplinary process.
  • The handbook is available in the languages of those who are incarcerated and written at a 5th grade level for those with low literacy skills.
  • Inmates are provided an orientation at intake – that is documented (video or in person) and goes over the rules, including the rules regarding exposure, masturbation and other forms of sexual misconduct.
  • This information is repeated by the housing unit officer, posted on the housing unit or televised in the living areas.
  • There are facility policies and procedures for staff that describe:
    • inmate housing unit management
    • inmate rules of conduct (including exhibitionism, masturbation in public and other forms of sexual misconduct)
    • how rules of conduct will be enforced and
    • the inmate disciplinary process.

          Also there is evidence that staff training about the facility policies and procedures has taken place     and repeated as necessary.

  • There are provisions for management of inmates with mental illness, or suspected of mental illness, related to in-custody behaviors and related discipline, and treatment.
  • There is documentation that inmates who engage in prohibited behavior receive disciplinary notices, participate in a disciplinary process, and if found guilty serve disciplinary sanctions. These sanctions may include but are not limited to disciplinary segregation.
  • For offenses such as exhibitionist masturbation one effective strategy to develop behavior contracts. For example, if the inmate serves X days of disciplinary sanctions without incident they get X days off their sentence.
  • There is a record of disciplinary notices, hearings, sanctions, etc. for these specific offenses.
  • There is a process by which staff notify their supervisors and/or the leadership regarding offensive inmate behavior.
  • The facility has programming and other services that can be withheld from inmates who violate policies/procedures and found guilty of disciplinary infractions.
  • Inmates who engage in this behavior repeatedly are charged via law enforcement and referred for prosecution. At one facility a prosecutor actually speaks to the inmates about how if they engage in this behavior and are administratively and/or criminally charged – how it effects their sentencing at trial, parole consideration, and conditions of release. Most inmates don’t think about the longer term consequences on their own so it helps to point it out.
  • Finally the agency should be aggressive in referring for prosecution – if the prosecutor declines- then the facility should focus on ways to convince the prosecutor to change their position.

Are these measures in place at the correctional facility you work at? You might want to review the inmate handbook at your facility and see if there are explicit guidelines about sexually hostile behavior and the consequences. Have you had experience addressing the problem of inmate masturbation during delivery of health care? If so, what was successful? Please share your experience by responding in the comments section of this post.

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

Photo credit: © Maridav – Fotolia.com