Correctional Nursing Peer Review: Making It Practical

Peer Review written in white chalkAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the third in a 4-part series of posts on correctional nursing peer review. Find other posts on this topic here.

Building a nursing peer review program from the ground up can be a daunting task. Here are some practical ideas for how to have a successful nursing peer review process that is efficient and effective.

Create Links to Current Programs

Although nursing peer review is different from continuous quality improvement, nursing competency reviews, or performance evaluations, these programs can be linked to the nursing peer review process in several ways.

  • Trending in CQI studies can help in prioritizing which professional standards to review in any given time period. If studies are showing that withdrawal protocols are not being initiated as expected in a jail setting, assessment and decision-making on intake might be a priority professional standard for nursing peer review.
  • Likewise, if competency evaluation of new orientees shows deficits in differentiating dental urgencies and emergencies, this can become a peer review priority.
  • Because performance evaluations often involve compensation and employment behavior, it is best to have a clear separation between the performance evaluation and the nursing peer review process. However, if trends in clinical issues emerge during the performance evaluation process, these issues might help make determinations of which professional standards will be the focus of upcoming peer reviews.
  • Other clinical data can also inform a nursing peer review program. Information from risk management, medication errors, mortality reviews, and emergency room visit trending may indicate a particular focus for evaluating clinical performance.

Involve Everyone

Involving front-line nurses in the creation of the program and prioritization of the standards used for the review will encourage maximum participation. The challenge of peer review is maintaining a climate of professional development rather than one of evaluation and criticism. It may be tempting for a nurse manager to complete the nursing peer review on all nurse employees. A team effort, instead, can provide professional growth among the staff. Properly managed, nursing peer review can be a supportive and encouraging professional process. Poorly managed nursing peer review can seem punitive and discouraging.

Create Forms

Forms provide structure to any process, especially new ones. If a form is used for peer reviews there is more opportunity for consistency. In addition, a form can operate as a checklist to prompt a reviewer on  elements requiring attention. Staff are more likely to get involved if they have a written format to follow. NCCHC also recommends the use of a standard form in the discussion of the C-02 standard.

Spread Reviews Across the Calendar

Work out a program for peer review throughout the year rather than trying to do it all at once. Make it a monthly or quarterly activity; possibly attached to an existing quality improvement or meeting structure. The important point is to keep nursing peer review as an active and ongoing process rather than a periodic disconnected project.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Correctional Nursing Peer Review: What It Is and What It Isn’t

Frau mit Lupe vor dem GesichtAlthough the concept of nursing peer review is over two decades old, it is just coming of age in the correctional nursing specialty as the newest version of the National Commission on Correctional Health Care Accreditation Standards has expanded the Clinical Performance Enhancement Program (Standard C-02) to include RNs and LPNs. This is the first in a 4-part series on correctional nursing peer review.

Peer review is a familiar program to providers (physician, nurse practitioner, physician assistant) as a means of evaluating the quality of care provision by individual practitioners. Nurses, however, can have difficulty applying this concept to their own clinical practice. The American Nurses Association’s (ANA) Nursing Peer Review Guidelines provides a definition and set of principles for the nursing peer review process that are applicable in the correctional setting.

What It Is

The original ANA definition of nursing peer review stands today as an appropriate description of the process:

“Peer review in nursing is the process by which practicing registered nurses systematically access, monitor, and make judgments about the quality of nursing care provided by peers as measured against professional standards of practice”

Breaking down the components of this definition supplies key concepts for a nursing peer review program in corrections:

Practicing Registered Nurses

Peer review should be performed by nurses who are practicing in a similar context. Thus, it would not be appropriate to have critical care nurses evaluate the nursing care of correctional nurses or for emergency nurses to evaluate the care of neonatal nurses. Nurses practicing in a similar context understand the environment of care, the patient population, and the standard processes for accomplishing care that would not be familiar to a nurse from another context.

Assess, Monitor, Make Judgments

Peer review is an evaluative judgment about the actions of another staff member from the same profession. The primary objective is to determine the quality and safety of care provided by an individual staff member.

Nursing Care Provided

A major component of the definition of nursing peer review is that it is a judgment of actual care provided. This is often done as a chart review but could also be performed as direct observation. However, the evaluation is of actual nursing care provided rather than a nurse’s ability to provide care.

Measured against Professional Standards of Practice

Accepted professional standards of practice are used to determine the quality and safety of care in a peer review. These accepted standards should be known to all members of the peer review process. For correctional nurses, professional standards of practice can come from

  • ANA Correctional Nursing Scope and Standards of Practice
  • State Board of Nursing Practice Act
  • Accreditation Standards that Address Clinical Practice

What it Isn’t

There can be misconceptions about what constitutes nursing peer reviews. Based on the above defining qualities of a nursing peer review, these are not nursing peer review processes:

Annual Performance Evaluation

An annual performance evaluation is a judgment of an employee’s work as it relates to their hired status and job description. Although clinical practice is a part of a nurse’s job performance, it is often not the primary focus of the performance evaluation.

Nursing Competency Checklists

Competency checklists or skills reviews evaluate a nurse’s ability to perform various skills and functions. They do not evaluation actual nursing care provided.

Simulations Such as Man-Down or Disaster Drills

As with competency or skill evaluations, simulations such as man-down or disaster drills evaluate staff ability to perform in an emergency situation but do not evaluate actual nursing care in a real clinical situation.

Continuous Quality Improvement Projects

Continuous quality improvement projects look aggregately at clinical care provided while nursing peer review evaluates a specific clinician’s actual care provision.

Are you developing a Nursing Peer Review program in your setting? Share your experiences in the comments section of this post.

To read more about professional practice issues see Chapter 19 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1402 the price is discounted by $15 off and shipping is free.

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Identifying Prescription Drug Misuse and Abuse

piatto di farmaci e drogaOne of my first mentors in correctional health care described prisons and jails as functioning like a city or town with many of the same characteristics as the surrounding community. I still think that is a good description. So we can expect trends identified in the larger community to eventually transcend the walls of the correctional facility in some way. One of these trends is the growing problem of prescription drug misuse and abuse.

According to a 2010 survey done by the Substance Abuse and Mental Health Services Administration more Americans over age 12 are taking prescription medications for non-medical purposes. These medications include pain relievers, tranquilizers, stimulants, sedatives and psychotherapeutic drugs. More than half of those said that they obtained the drug from a friend or relative for no cost. More than half the teens surveyed in another study obtained prescription drugs for non-medical purposes from the family medicine cabinet (Kirchner et. al., 2014).

The Centers for Disease Control and Prevention (CDC) reports that visits to Emergency Rooms (ER) increased 114% from 2004 to 2011. The majority of this increase is due to misuse or abuse of pharmaceuticals. In 2011 half of the admissions to the ER were related to prescription drug misuse or abuse. Of these admissions, one third involved medications used to treat anxiety or insomnia and another third were opioid analgesics (2014).

Deaths by poisoning or drug overdose have been the leading cause of injury in the United States since 2008. Overdose deaths have increased five-fold since 1980 (Kirchner et. al., 2014). In 2010 among deaths related to overdose with prescription drugs 75 % involved opioid analgesics and 35 % involved benzodiazepines. The number of overdose deaths from opioid analgesics is now greater than those of deaths from heroin and cocaine combined (CDC 2014).

All of this is to say that detainees arriving at our jails and prisons are likely to have recently misused or abused prescription drugs. Thorough, routine and non-judgmental inquiry about recent drug use during reception health screening is essential to identify individuals who will need to be managed medically during withdrawal. These questions should solicit the name of the drug, the usual dose; the route used, frequency, date and time of the last dose. Other questions include previous withdrawal symptoms and whether hospitalization was necessary (Laffan 2013).

The characteristics of people who overdosed with prescription drugs include:

  • Middle age
  • Male
  • White, Native American or Alaska Native
  • Rural community
  • History of chronic pain
  • History of mental health disorder
  • History of substance abuse
  • Have multiple health care providers or inconsistent providers
  • Taking multiple prescriptions (DHHS, 2013).

These are not listed as a definitive means to diagnose prescription drug abuse but instead to point out how many of our inmates have these same characteristics and are at risk of adverse consequences from this behavior.

When inmates are identified who will need assistance with detoxification the nurse’s next step is to contact a provider. Monitoring and management of withdrawal from prescription drug abuse should be initiated by a provider according to protocols established by the facility medical director. Nurses should not be expected to use standing orders to initiate detoxification (NCCHC 2014). For more about drug withdrawal in the correctional setting read Chapter 5 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Resources:

Centers for Disease Control and Prevention. (2014) Prescription Drug Overdose in the United States: Fact Sheet. Accessed at http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.

Kirschner, N., Ginsburg, J., Sulmasy, L. S., (2014) Prescription Drug Abuse: Executive Summary of a Policy Position from the American College of Physicians. Annals of Internal Medicine 160 (3).

Laffan, S. (2013) Alcohol and Drug Withdrawal in Schoenly, L. & Knox, C.M. (ed.) Essentials of Correctional Nursing, pp. 81- 96, (New York: Springer Publishing Company LLC).

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

U.S. Department of Health and Human Services (DHHS), Behavioral Health Coordinating Committee, Prescription Drug Abuse Subcommittee, (2013) Addressing Prescription Drug Abuse in the United States: Current Activities and Future Opportunities. Accessed at http://www.cdc.gov/HomeandRecreationalSafety/overdose/hhs_rx_abuse.html.

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Clinical Communication with Patients who are Deaf or Hard of Hearing

abstract human face 3d illustrationIt is 1 o’clock Saturday morning and the police have just arrived with a middle aged man to book into jail for an assault that took place in the city an hour ago. He has abrasions on his face, neck and hands; he is observant and seems compliant with the officers’ instructions. Custody staff complete booking and he is brought to medical for intake health screening. The officer tells the nurse that the man is deaf. The nurse writes on a notepad “Can you read and write?” The detainee nods his head affirmatively. The nurse puts the intake screening form in front of the detainee and points to each question on the form. The detainee nods his head in a “no” gesture to each of the screening questions. The nurse takes vital signs, examines the abrasions, applies a bactericidal ointment and then observes the detainee while he is changing into the jail uniform. His deafness and abrasions are noted; no other problems are identified by the nurse and the detainee is given a handbook that explains how to access health care when he is released to housing.

Did this nursing encounter meet the standard of care for persons in correctional settings who are deaf or hard of hearing?

The components of receiving screening defined by the American Corrections Association (ACA) and the National Commission on Correctional Health Care (NCCHC) are that a screening form is used to inquire about the status of each detainee’s health and that reception personnel observe the detainee’s condition for signs of illness or injury before making decisions about disposition. NCCHC also states in the discussion of the standard that “Receiving screening is conducted using a form and language fully understood by the inmate, who may not speak English or may have a physical (e.g., speech, hearing, sight) or mental disability” (2014, page 72). The nurse modified how the receiving screening data was collected when the detainee indicated that he could read and write. Literally interpreted the accreditation standards were met. But were best practices used to screen for potential emergency situations, treating illness or continuing prescribed medication?

The Americans with Disabilities Act passed in 1990 establishes specific requirements that apply to persons who are deaf or hard of hearing in correctional settings. These include:

  • Giving primary consideration to providing the aid or service requested by the person with the hearing disability.
  • Communication aids and services may not be denied except when a particular aid or service would result in an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Only the head of the agency or his or her designee can make the determination that a particular aid or service would cause an undue burden or a fundamental change in the nature of the law enforcement services being provided.
  • Not charging for communication aids or services provided.
  • Providing effective, accurate, and impartial interpreters when needed.

In this case the nurse did not inquire about the type of communication aid or service the detainee preferred but instead only asked if the detainee could read and write. Relying on writing or pointing to items is effective communication for brief and relatively simple face-to-face conversations. Having the detainee fill out the health history portion of the intake screening form may be appropriate if he is literate enough in medical terminology. While many who are deaf and hard of hearing indicate the ability to read lips nurses need to be cognizant that only about 30% of what is said can be accurately interpreted (Shuler et. al., 2013). If the detainee indicates he has any medical or mental health problems, is seeing a provider in the community or is taking medication the nurse will have to use a more interactive and accurate communication method. These include:

Sign language interpreters: There are several kinds of sign language, including American Sign Language (ASL) and Signed English. When arranging for an interpreter be sure to ask what form of sign language the detainee uses.

Oral and cued speech interpreters: Some individuals have been trained in lip reading and with assistance from an interpreter can understand spoken words fairly well.

Transcription services: Many people who are deaf or hard of hearing are not trained in either sign language or speech reading. There are several types of devices that allow a person who is deaf or hard of hearing to communicate by typing. These include Computer Assisted Real-time Transcription (CART) and text telephone (TTY or TTD).

Video services: use high speed internet and wireless connections to link a camera or videophone that transmits sign language to an interpreter who conveys the message verbally to the hearing person.

Each state defines the education and training required to be considered a qualified interpreter and may also require certification. Since the ADA requires that interpreters in correctional settings be effective, accurate, and impartial special care should be taken in arranging for interpreters. Using staff who “know sign language” or family members to interpret may not meet these criteria. Further the nurse needs to document in the detainee health record what effort was made to inquire about communication preferences, arrangements made to provide assistance and if an interpreter is used document their name, certification or qualification and contact information.

The detainee in this example was scheduled to be seen by a nurse the following day to review the intake screening information and complete the history portion of the initial health assessment. Correctional staff at booking inquired about the detainee’s communication preferences and had noted in the classification system that he used American Sign Language (ASL). The nurse was aware of this and made arrangements for the presence of a qualified interpreter at the nursing encounter the next day. The ADA does not require that the services of an interpreter be immediately available  at intake for example but that arrangements are made in a reasonable amount of time when they are necessary.

Best practices summary

• Before speaking, get the person’s attention with a wave of the hand or a gentle tap on the shoulder.

• Face the person and do not turn away while speaking.

• Try to converse in a well-lit area.

• Do not cover your mouth or chew gum.

• Minimize background noise and other distractions whenever possible.

• When you are communicating orally, speak slowly and distinctly. Use gestures and facial expressions to reinforce what you are saying.

• Use visual aids when possible, such as pointing to printed information or photos.

• When using an interpreter, look at and speak directly to the deaf person, not to the interpreter.

  • Talk at your normal rate, or slightly slower if you normally speak very fast.
  • Only one person should speak at a time.
  • Use short sentences and simple words (U.S. Department of Justice, Civil Rights Division, Disability Rights January 2006).

It is estimated that up to nine percent of the population has some degree of hearing loss, and this percentage will increase as the population ages. So as correctional nurses, we expect to come into contact with people who are deaf or hard of hearing. In your opinion was the standard of care met in the intake screening and assessment of this detainee’s health status? What are the challenges in providing nursing care for detainees who are deaf or hard of hearing? Please share your opinions and experience by responding in the comments section of this post.

For more on correctional nursing read our book, the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References:

American Corrections Association. (2010). 2010 Standards Supplement. Alexandria, VA.: American Corrections Association.

National Commission on Correctional Health Care. (Prisons and Jails 20014). Standards for Health Services. National Commission on Correctional Health Care.

Shuler, G.K; Mistler, L.A.; Torrey, K.; Depukat, R. (2013). Bridging communication gaps with the deaf. Nursing 2013 43 (11): 24-30.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (January 2006). Communicating with People Who Are Deaf or Hard of Hearing: ADA Guide for Law Enforcement Officers. Accessed June 16, 2014 at http://www.ada.gov/lawenfcomm.htm.

U.S. Department of Justice, Civil Rights Division, Disability Rights. (October 2003). ADA Business BRIEF: Communicating with People Who Are Deaf or Hard of Hearing in Hospital Settings. Accessed June 16, 2014 at http://www.ada.gov/hospcombr.htm.

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Nursing Sick Call Part 3: Use and Misuse of Protocols

Diagram of ideal careProtocols are used by nurses in sick call to evaluate patients’ health care complaints. Protocols describe the steps to be taken in collecting the subjective and objective findings, the factors that lead to a diagnostic conclusion and the resulting actions taken to address the problem. Nursing actions driven by protocol may include treatment that a person would do for themselves if they were living in the community, simple first aid, health education or advice about self-care, and/ or referral to a provider. Protocols also exist for nurses to use in responding to medical emergencies. These protocols are more extensive than those used in sick call. Protocols discussed in this post are limited to those used to address non-urgent health care complaints.

The use of protocols by nurses is not in lieu of provider based care but to facilitate patient access to needed health care. Patient care is enhanced when the protocols involve the patient in self-care and support collaboration between clinicians in the management of a patient’s health status. In the Oregon Department of Corrections, for example, 80% of patient concerns can be addressed during the sick call visit. Every nursing sick call visit should provide information about the patient that is considered useful in the next clinical encounter.

Requirements for the use of protocols: The National Commission on Correctional health Care (NCCHC) provides detailed guidance about the requirements for use of nursing protocols in standard E-11 (2014). The first requirement is that the protocols are developed by the nursing administrator and responsible physician. The physician is responsible for ensuring that the protocols guide clinically necessary medical care and the nurse administrator is responsible for ensuring that nurses are allowed by law to perform the scope of work described in the protocol and that nurses are trained and competent to use the protocols. A note here is that this collaboration should include a discussion of the underlying philosophy and approach to patient care to build understanding of what each profession can contribute to patient access. Protocols are not intended to make nurses into physicians and must be written to remain consistent with the scope of nursing practice while at the same time supporting the patient to access appropriate, timely and responsive health care.

A good place to start is to review the state nurse practice act to determine if there is any guidance regarding practice that is specific to the correctional setting or the use of protocols in any setting. Another important consideration is the differentiation in state law or regulation between the scope of practice for an RN and an LPN. In some states the nurse practice act may prohibit LPNs from performing sick call and in other states there may be limitations or additional supervisory requirements.

Another requirement of the standard is that the program must demonstrate that each nurse has been trained initially in the use of protocols, annually each nurse must demonstrate knowledge and competency in the use of protocol, and training is provided whenever the protocols are revised or new protocol introduced. In addition the protocols are to be reviewed and approved for use each year by the nurse administrator and responsible physician. The annual review and resulting revisions should be based upon the results of:

  • continuous quality improvement studies,
  • clinical performance reviews and competency evaluations,
  • adverse patient events or near misses, and
  • evidence- based practice recommendations from the literature.

Misuse of protocols: The most recent issue of CorrectCare has an article by Tracey Titus, a nurse and the NCCHC accreditation manager that discusses the misuse of nursing assessment protocols. She points out that the correctional environment sometimes lends itself to the misuse of nursing protocols. The following paragraphs are some of the ways that nursing protocols can become misused in correctional healthcare.

1. Protocols do not substitute for primary care encounters: Protocols sometimes go beyond the knowledge and skills of the nursing staff perhaps in the mistaken belief that nursing sick call takes place in order to reduce the workload of physicians, nurse practitioners and physician’s assistants. Nurses do not have the same diagnostic acumen and clinical skills as a primary care provider. Protocols are most appropriate to treat problems that in the community people take care of themselves and to determine the urgency of referrals for problems that need to be seen by a primary care provider. A best practice is to schedule a providers’ clinic at the same time as nursing sick call so that the nurse can confer regarding patients whose problem exceeds the scope of the protocols.

2. Protocols do not substitute for good security practices: At the other extreme sometimes sick call is used to control access to things that can be as effectively managed by good security practices. A couple examples are dispensing and supervising use of dental floss or determining if an inmate should be authorized to receive a second pair of long underwear. This is a waste of nursing time and burdens the efficiency of sick call and sick patients have to wait longer to have their needs addressed. Clinical errors are made when sick call is overcrowded and rushed increasing the risk of adverse patient care events.

3. Protocols cannot cover every problem: In my early experience we wrote protocols for many, many different conditions. A year later when the protocols were reviewed we discovered that the nurses really needed only a few. Furthermore the nurses had no way of remembering the details of so many different protocols. In our re-write we focused only on the most common complaints (e.g. pain, skin conditions, minor trauma and HEENT complaints) and have since only gradually added additional protocols based upon actual utilization data.

4. Unqualified personnel cannot use protocols: Many systems find themselves with legacy staffing patterns and assignments that require health care and other personnel to work outside their lawful scope. Because of a lack of clinical oversight state practice acts may not have been consulted when the assignments were originally made. Do not assume that because certain personnel have been performing sick call that the practice is allowable or has been grandfathered in. Most systems work through this situation by rearranging assignments to better match the qualifications of existing staff.

5. Untrained or incompetent personnel cannot use protocols: There are very few if any other nursing settings that use protocols to manage initial requests for health care attention. Therefore nurses do not bring to corrections experience in this area and must be trained. Some nurses even after initial training are not able to demonstrate sufficient competency. Placing a nurse who is not competent in sick call undermines the nurse’s potential for eventual success and puts patients in harm’s way. Instead an individual performance improvement plan must be developed and coaching, monitoring and supervision provided for a reasonable period of time.

6. Protocols are not standing orders: Standing orders are written orders that specify the same course of treatment for each patient with a certain condition. Historically standing orders have been overused in correctional health care as a way to treat inmates when physician time was inadequate. Protocols differ from standing orders in that the action taken by a nurse to address the patient’s complaint is individualized based upon an assessment of the condition. For example every patient’s headache should not be treated the same way nor should every diabetic be on the same sliding scale for insulin. Standing orders are appropriately used for preventive care, such as immunizations and for diagnostic preparation.

How well do the protocols work at your facility? Are there too many or not enough? What kind of training did you receive in order to conduct nursing sick call? If you could make a change in nursing sick call what would it be? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

 

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Nursing Sick Call Part 2: Pitfalls with the Face- to- Face Encounter

NSPS'10_Fig 4  Nursing Process  StdsLast week’s post on nursing sick call emphasized the importance of receiving and responding in a timely and clinically appropriate manner. Each request must be triaged within 24 hours of receipt. When the request describes a clinical symptom it must be assessed in a face- to- face encounter. Obviously if the symptom is of an emergent nature the assessment must take place immediately. Examples of requests that are potentially life threatening and should be assessed immediately include statements regarding suicide or hopelessness, cardiac or respiratory distress and trauma.

However most requests received via sick call are not of an emergent nature. Patients with non-urgent clinical symptoms need to be evaluated within 48 hours from time the request was received and this timeframe can extend to 72 hours on weekends. Non-urgent health care attention is requested most often for symptoms relating to pain, skin conditions and HEENT problems. Nurses should expect to be very familiar with the assessment, evaluation and treatment of multiple conditions that manifest in these symptoms. Correctional nursing expert, Jessica Lee, as well the National Commission on Correctional Health Care (NCCHC) recommend staff with the most skill and experience in assessment be responsible for sick call.

The face-to- face encounter involves the six components of nursing process defined in the American Nurses Association (ANA) standards for correctional nursing practice (2013). These inter-related components are depicted in the diagram at the top of this post as assessment, diagnosis, outcomes identification, planning, implementation and evaluation. For a description of how the nursing process is used during nursing sick call see Chapter 15 in the Essentials of Correctional Nursing.

What are the pitfalls for nurses in the face-to-face encounter? In thirty years’ experience as a correctional nurse, manager and consultant I have observed thousands of nurses in sick call encounters and reviewed their documentation. Some of these nurses were definitely experts, others were new to the process, and many were competently performing these skills. The following are the problems and pitfalls most often seen with the face-to-face nursing encounter.

Delays: Evaluations that take place long after the request has been submitted place the nurse in a difficult spot. The patient is frustrated because of the delay and may be disrespectful; the condition may have gotten worse and the patient already been seen in an emergency or the condition grown more complex and require a referral when it could have been treated by the nurse if seen earlier. Imagine how you would react if it took three days to receive one dose of aspirin or ibuprofen for a headache. When inmates experience failures in access the response is often to flood the system with requests and soon the nurses can’t keep up. Stay on top of requests so that there are no delays and the volume will be more manageable. There are no defensible reasons for delaying access to care; it is a constitutional requirement.

Incomplete assessment: Nursing assessment involves the collection of both subjective and objective information that is relevant to the patient’s reason for requesting health care attention. The subjective assessment includes asking sufficient questions about the problem to determine additional data to be gathered during the objective exam, diagnostic testing and chart review. Failing to physically examine the patient to adequately verify and amplify subjective information is a common error in nursing sick call. Examples are sick call encounters have incomplete vital signs recorded or dental complaints that do not include an examination of the oral cavity and neck but just a referral to the dental department. This may be because of inexperience, fear or concern about touching inmates or trivializing patient complaints. Nursing assessments should be conducted and documented so that the clinical information contributes to the next provider’s assessment whether it is a provider appointment or the next sick call visit.

Inadequate patient involvement: Involving the patient in each encounter is a sure way to reduce unnecessary requests for health care attention and submission of a grievance both of which take additional time to respond to. This is not to say that a nurse should give the patient what they want. Instead it means to ask for the patient’s input about the outcome they desire and then to provide an explanation of findings, recommended plan and the rationale that takes into account the patient’s input. Involving the patient demonstrates respect and helps build the therapeutic relationship; it also gives useful clues that can help motivate the patient in their own care. If the patient doesn’t understand then another explanation may be useful especially if the patient has low health literacy. The nurse may schedule the patient back for a follow up appointment to go over the information again or to check on the patient’s symptoms. If the patient doesn’t agree with the plan the nurse should reconsider their findings or make a referral for higher level care.

Poor clinical decision making: Making clinical decisions is a skill built by thoughtful reflection on practice while gaining experience. As experience increases diagnostic conclusions are drawn more quickly by patterns recognition rather than the more deliberate process of gathering and analyzing data. The downside to pattern recognition is that the nurse’s conclusions are prone to bias based upon personal experience and cultural socialization. Two common errors in diagnostic reasoning are premature closure (coming to a conclusion before sufficient data is gathered) and confirmation bias (only seeing data that matches our conclusion and ignoring data that doesn’t). See two previous posts about how to build and hone clinical decision making skills.

Inefficient use of resources: Time, space and equipment are the resources nurses use during sick call. Examples of inefficient use of resources include conducting the face-to-face encounter in an area where the nurse cannot properly examine the patient, using a blood pressure cuff that is the wrong size or not calibrated, having to go to another area to get supplies or equipment to complete the examination, not having the chart available or not referring to the chart for data on the patient’s recent health care. See a previous post about safe practices for nurse sick call. Nurses should be able to elicit the health history at the same time observe the patient and gather objective physical assessment data. Like playing the drums the face-to-face encounter takes practice. Nurses develop these skills when they are provided support, coaching and feedback. Face-to-face encounters which are incomplete or inadequate also waste provider resources if an unnecessary referral is made or the information about why the provider appointment is needed is incomplete.

What are the challenges you experience in completing timely, responsive and clinically appropriate face-to-face encounters with patients who have symptom based requests for health care attention? Please provide your thoughts and experience in the comments section of this post.

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References

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

Knox, C & Shelton, S. (2006). Sick Call. In Clinical Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

LaMarre, M. (2006). Chapter 28: Nursing role and practice in correctional facilities. In M. Puisis (Ed), Clinicsl Practice in Correctional Medicine (2nd ed.). Philadelphia: Mosby Elsevier.

National Commission on Correctional Health Care. (2008). Standards for Health Services in Prisons. Chicago: NCCHC.

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Nursing Sick Call Part 1: Receiving and Responding to Requests for Care

PRIGIONIERONursing sick call has been described as the signature practice defining the specialty of correctional nursing. There is no experience quite like sick call in any other area of nursing practice. Nursing sick call is considered the backbone of health care delivery in correctional settings because it is the primary way inmates can access health care during incarceration. In a recent interview Jessica Lee, Vice President for Nursing Support at Corizon commented that sick call is a barometer of the quality of the entire health care program in a correctional facility.

The manner in which inmates make requests for health care attention is the first step in the sick call cycle and the focus of this post. The ability to request health care attention is a fundamental right of persons who are incarcerated. The American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC) both have established standards which require that:

  • requests are received by health care personnel every day,
  • each request is evaluated within 24 hours of receipt and
  • there are no impediments to making requests for health care attention.

Seems pretty simple but compliance requires that correctional officers and nursing staff act in ways that are consistent with these standards in hundreds of encounters and interactions with inmates every day. So access to health care is a high volume, high risk activity in correctional health care. Correctional facilities can protect themselves from adverse patient events and litigation by developing policies, procedures, job descriptions and assignments that meet these standards. In addition it is important to verify that actual practices are consistent with the facilities policies and procedures through supervision and audit of staff performance. The following is a breakdown of the areas that need to be considered to ensure that your facility meets accepted standards for access to care.

Communication: The facility should have one or more ways established for inmates to make requests for health care attention. Inmates must be informed of this process at the time of admission to the facility. Common methods used to request health care attention are by filling out a request slip that is given to a health care provider, signing up on a list, showing up at a particular time, or calling to request an appointment. The next consideration is whether the selected methods are working. Pitfalls to an effective request process include not giving inmates this information at admission, inmates not understanding the process, not having a secure place to put written requests, not picking up written requests every day, forms that are too complicated to fill out, not having sufficient forms, not having access to the sign up list or use of the telephone, lock down or scheduling conflicts, and intimidation of inmates requesting care by other inmates or staff. Nurses should be assigned daily to review and assure that the method(s) used to request care are working. There should be documentation that provides evidence that requests for access to care may be made daily and that there are no impediments. Having the date on each request received, each list of inmate requests, or each walk-in encounter is the kind of documentation that provides this evidence.

Triage: Every request for health care attention must be evaluated within 24 hours of receipt. This evaluation is a form of triage used to determine when and how each request will be handled. Triage is a clinical decision made by licensed health care personnel. Triage requires use of the nursing process to assess the patient, diagnosis the problem, identify the desired outcome, plan and implement intervention(s) to achieve the identified patient outcomes. Simply reading a written sick call slip is not sufficient triage of a request that involves any description of a symptom based complaint. Any inmate submitting a written request for health care attention for a complaint that is symptom based must be evaluated in a face to face encounter within 24 hours of receipt of their request. With other methods for making requests (sign- up, telephone or walk- in) as long as nursing personnel evaluate each request within 24 hours the standards are met. Documentation includes the nurse’s evaluation as well as the date and time the patient was seen. Problems with nursing triage of inmate requests for health care attention include not performing triage seven days a week, not triaging every request received on a daily basis, using inappropriate personnel to perform triage, clinically inadequate triage, trying to talk patients out of needing to be seen, minimizing patient complaints or blaming the patient.

Disposition: The outcome of triage is the disposition or decisions made in response to the patient’s request. Dispositions include treatment, referral, patient education, and advice about self- care. Many times a single request will have more than one disposition decision. In addition to the decision about what is to be done the nurse also decides who will do it and by when. Each of these decisions, including by whom and when, are documented and dated. The nurse should explain the disposition to the patient so that they know what to expect and by when. Every nursing encounter should be considered an opportunity to education that promotes the patient’s engagement in their health care. Pitfalls in the disposition of requests for health care attention include poor clinical decisions, inadequate follow through or handoffs to responsible others, silos between programs and departments that result in disruption of care, and lack of patient understanding or agreement with the plan of care.

Monitoring: When requests for health acre attention are not received and acted upon in a timely, responsive and clinically appropriate manner the efficient operation of the health care program will be in serious jeopardy. Effects of insufficient access are increases in the number of inmate grievances, increases in requests for emergent health care attention and inmates will submit multiple requests for the same problem. Health care programs should track the timeliness, completeness and appropriateness of communication, triage and disposition of health care requests. Other aspects of access to care that should be monitored are the types of requests being made as well as the subject and frequency of multiple requests. This data helps to answer two questions: Is the system to access care working and are the responses clinically appropriate, responsive and timely?

Do the practices in place at your facility meet the standards for access to health care? How does the facility monitor access to health care? What is your role in ensuring that inmates have unimpeded access to health care during incarceration?

For more on nursing sick call and access to care read Chapter 15 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

 

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