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! 

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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!

 

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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.

 

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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!

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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!

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Patient Safety – What’s Holding You Back?

Patient safety is a core concept to professional nursing practice. Indeed, we have an ethical responsibility to keep our patients from harm and to always seek their good. I discuss this in an earlier post. Wouldn’t it be nice if we could just say – OK, patient safety is a great model – Let’s do it! Unfortunately, changing a mindset is difficult in any setting; maybe even more so in an entrenched correctional culture.

There are many reasons it can be challenging to embark on a serious journey toward a patient safety culture in a correctional setting. Here are the three frequent barriers to advancing a patient safety model that I found while working with health care leaders in jails and prisons. Would these be barriers in your facility?

Organizational Culture

An organization’s culture is the collection of norms of behaviors that are approved, allowed, or ignored. Culture determines what behaviors are rewarded and what behaviors are punished. Many work cultures in the criminal justice system are built on incivility and disrespect. These cultures are more likely to reward conforming and ‘by the book’ behaviors that rely on administrative controls rather than innovation and initiative. Leaders in this type of environment do not want to hear the ‘bad news’ of a possible safety issue and may marginalize those who try to make them aware of concerns that need addressed to avoid harm.

On the other hand, a patient safety culture builds on a culture of respect and is non-punitive in nature; valuing accountability, honesty, and mutual respect. This has been described as “allowing the boss to hear bad news”. A patient safety culture, then, requires open communication based on trust and positive regard, not always present in our hierarchical and para-military settings.

Broken Systems

Another common barrier to implementing a patient safety mindset is broken or absent systems. Health care, in and of itself, is a complex system of interactions of care providers, patients, diagnostics, equipment and environment. Correctional health care is all of that with an overlay of the criminal justice system and security structure. Not only is health care a complex system but also one that is constantly adapting to changing context and outcomes.

We are in a high-stakes profession where broken systems can mean loss – injury and death – as this case in a prior post illustrates.  Human error is inevitable. We must admit that and embrace it to move forward in designing our health care processes and systems to limit and avoid human error potential.

Nobody Cares

There are many more barriers to a patient safety perspective in corrections but I will close with just one more – Nobody Cares. Granted, there is good reason for developing an uncaring attitude toward our work and our patients. After all, it only takes being manipulated or duped by a patient to be on guard against that happening again. No one wants to be on the other end of deception or exploitation.

Even as healers, we can absorb a pervading “us against them” mentality in many of our settings. If cynicism does not harden our souls, maybe compassion fatigue or secondary traumatization from working with patients in such distressing life situations can zap energy and leave us focusing on merely performing tasks without really considering the people we care for. Layered upon this can be the challenges of dealing with uncivil or bullying peers. All of this can lead to a ‘why bother’ attitude toward our role in patient care and patient safety.

Yet, only clinicians thoughtfully considering their practice and environment will actually see and respond to potentially harmful situations. Only engaged practitioners will reflect on a patient situation to improve the care they provide.

Does this paint a hopeless picture regarding patient safety? I hope not! No matter what your position, you have an opportunity to make a difference and move the organization forward toward patient safety.

Great things are done by a series of small things brought together. – Vincent Van Gogh

What is a small step you could take toward a patient safety culture in your setting? Share your thoughts in the comments section of this post.

Correctional Nursing: How to Improve the Practice Environment

Nursing background concept

The first examination of the qualities of professional practice in correctional nursing was done recently in Ontario, Canada. Conclusions from the surveys and interviews of 297 nurses and nurse managers were that the work environment was characterized as understaffed with significant role overload. These nurses also reported limited access to resources, significant autonomy but limited control over practice and experienced significantly higher levels of emotional abuse, conflict and bullying than nurses in other studies. The source of emotional abuse, conflict and bullying most often originated from custody staff followed by other nursing staff (Almost et.al. 2013a). These results support earlier publications about the practice challenges in correctional nursing including limited access to resources and education (Flanagan and Flanagan 2001, Maroney 2005, Smith 2005) , pressure to conform to the values of the custodial subculture (Holmes 2005), and challenges to clinical decision making authority (Smith 2005, Weiskopf 2005).

Reasons to improve the quality of the work environment include the ability to attract and retain nurses, increased productivity, improved organizational performance and better patient outcomes (Almost et.al 2013a, Sherman & Pross 2010, Dall et.al 2009, Needleman et.al 2006). Focusing on improving the professional work environment yields significant results even in the absence of increased staffing (Flynn et.al 2012, Aiken et.al. 2011, Friese et.al. 2008).

The following paragraphs discuss five factors in work environments that can be modified or enhanced to support professional nursing practice.

  1. Control over practice
    • Accurate interpretation and clarification of the state nurse practice act and its guidance in job descriptions, work assignments and policies and procedures (Knox, West, Pinney & Blair 2014, White & O’Sullivan 2012). Workplace directives should also incorporate or reference relevant aspects of the ANA standards of professional practice for correctional nurses (Knox & Schoenly 2014).
    • Work flow should be examined so that barriers to effective practice can be eliminated including system gaps that increase work complexity and work that is not related to patient care (Knox, West, Pinney & Blair 2014, Ebright 2010, Schoenly 2013). An example of the former is locating supplies used for nursing treatments in multiple locations. An example of the later is when nurses are expected to gather and report data on service volume or for quality assurance audits (number of sick call visits, number of clinic appointments, and number of incomplete MARs etc.).
    • Increase nursing participation on committees such as pharmacy and therapeutics, morbidity and mortality review, mental health, utilization review, and medical administration (Aiken et. al. 2011, Flynn et. al. 2012, Almost et.al. 2013a). Staff meetings also should be reviewed to see if meaningful two way dialogue can be increased to involve nurses in identification and early resolution of practice problems.
    • Consider assignment models that emphasize use of nursing process and clinical judgment rather than task completion; where registered nurses provide a greater proportion of direct care themselves while actively supervising care delegated to others (Corrazini et.al 2013a; MacMurdo, Thorpe & Morgan 2013). Staffing takes thoughtful preparation and legacy staffing practices may no longer work as complexity in health care delivery increases (Knox, West, Pinney & Blair 2013, Ebright 2010, MacMurdo, Thorpe & Morgan 2013).
  2. Autonomy in clinical practice
    • Considered one of the hallmarks of correctional nursing it is also an Achilles heel in the absence of appropriate clinical guidelines and support in their use (ANA 2013, Smith 2013, Smith 2005). Protocols should be based upon nursing process and coordination of care rather than reaching a medical diagnoses and rushing to treatment conclusions.
    • Nurses must be appropriately qualified and experienced in assessment and clinical reasoning as well as skilled in surveillance related to the variety of clinical situations encountered in the correctional setting to use protocols.
    • Provide access to information and tools that enhances recognition of clinical patterns and deviations necessary for good clinical judgment (Ebright 2010).
    • Assist nurses to prioritize and coordinate care with daily briefings, debriefings, huddles and work flow tracking to provide real time information about the availability and assignments of other members of the health care team (including primary care and mental health staff).
  3. Positive workplace relationships
    • Establish clear expectations for a respectful workplace in policy, procedure and other written directive. These instructions should define behaviors consistent and inconsistent with professional behavior in the workplace; describe what to do in the presence of unprofessional behavior and how to report these incidents (Almost et.al. 2013a).
    • Joint meetings and interdisciplinary training can be the vehicle to demonstrate support for the goals of both health care and custody (Almost et.al. 2013a, Weiskopf 2005).
    • Nurses may benefit from additional development in the area of conflict resolution because they have such a prominent role negotiating coordination of patient care with custody operations (Schoenly 2013, Weiskopf 2005).
    • Increase communication about patient care between registered nurses and LPN/LVNs (Corrazini et. al. 2013).
  4. Support education and certification
    • Orientation also needs to be tailored to the needs of each individual based upon education, licensure and an assessment of competency (Knox, West, Pinney & Blair 2014; Shelton, Weiskopf & Nicholson 2010). The ANA scope and standards of professional practice should also be incorporated into new employee orientation so that nurses develop institution specific skills consistent with the expectation of the professional discipline (Knox & Schoenly 2014).
    • Mentoring and coaching of new employees should be emphasized in development of expertise in clinical reasoning (Schoenly 2013, Ebright 2010).
    • Use creative, simple approaches to continuing education including self-study, reflective exercises, on-line web based seminars, facilitated case review and discussion, and a journal club (Almost et.al. 2013b, Schoenly 2013). Staff with superior knowledge and skill in a subject area can be asked to assist in developing relevant continuing education material (Knox, West, Pinney & Blair 2014).
    • Certification in correctional nursing is available through both the American Corrections Association and the National Commission on Correctional Health Care. These exams are offered regionally and can be administered at the place of employment if there are enough people taking the exam.
  5. Adequate resources
    • Includes staffing, equipment and supplies as well as access to leadership. Examining the work of first line managers may reveal sources of role overload (scheduling, meetings, payroll data gathering etc.) that impede their availability to line staff and can be reassigned to increase the availability of clinical leadership to line staff(Almost et.al. 2013a).
    • Review legacy staffing practices and work flow to identify opportunities to adjust assignments that result in more appropriate or effective use of existing resources (Knox, West, Pinney & Blair 2013, Ebright 2010).
    • Involve nurses in evaluation of equipment and technology decisions to prevent acquisition of products that complicate rather than improve delivery of patient care (Ebright 2010). For example decisions about how patient specific prescriptions were packaged have impacted timeliness and accuracy of medication administration in some correctional facilities because the packaging was cumbersome and time consuming for nurses to use.

Conclusion: Attention to the work environment of nurses (control over nursing practice, autonomy without isolation, positive working relationships, support for education and specialty certification, and adequate resources) has a profound effect on nursing practice, the ability to recruit and retain nursing personnel and on patient outcomes. More resources about work environments that support professional nursing practice can be found at the sites listed in the resources section below.

What do you think can be done to improve the professional practice work environment for correctional nurses? Are there resources or solutions not discussed here that should be? Please share your opinions 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.

Resources

 

References

Aiken, L.H., Cimiotti, J.P., Sloane, D.M., Smith, H.L., Flynn, L., Neff, D.F. (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care 49(12): 1047-1053.

Almost, J., Doran, D., Ogilvie, L., Miller, C., Kennedy, S., Timmings, C., Rose, D.N., Squires, M., Lee, C., Bookey-Bassett, S. (2013a) Exploring work-life issues in provincial corrections settings. Journal of Forensic Nursing 9:1

Almost, J., Gifford, W.A., Doran, D., Ogilvie, L., Miller, C., Rose, D.N., Squires, M. (2013 b) Correctional nursing: a study protocol to develop an educational intervention to optimize nursing practice in a unique context. Implementation Science 8:71

American Nurses Association. (2013) Correctional Nursing: Scope and Standards of Practice. Silver Spring, MD: Nursebooks.org

Corrazzini, K.N.; Anderson, R.A.; Mueller, C.; Hunt-McKinney, S.; Day, L.; Porter, K. (2013). Understanding RN and LPN Patterns of Practice in Nursing Homes. Journal of Nursing Regulation. 4(1); 14-18.

Dall, T.M., Chen, Y.J., Seifert, R.F., Maddox, P.J., Hogan, P.F. (2009). The economic value of professional nursing. Medical Care 47 (1):97-104.

Ebright, P.R. (2010). The complex work of RNs: Implications for a healthy work environment. Online Journal of Issues in Nursing. 15(1).

Flanagan, N. & Flanagan, T. (2001) Correctional nurses’ perceptions of their role, training requirements and prisoner health care needs. The Journal of Correctional Health Care 8:67-85.

Flynn, L., Liang, Y., Dickson, G., Xie, M., Suh, D.C. (2012) Nurse’s practice environments, error interception practices, and inpatient medication errors. The Journal of Nursing Scholarship. 44(2):180-186.

Friese, C.R., Lake, E.T., Aiken, L.H., Silber, J.H., Sochalski, J. (2008) Hospital nurse practice environments and outcomes for surgical oncology patients. Health Services Research. 43(4): 1145-1162.

Holmes, D. (2005) Governing the captives: Forensic psychiatric nursing in corrections. Perspectives in Psychiatric Care 41(1):3-13.

Knox, C.M., Schoenly, L. (2014) Correctional nursing: A new scope and standards of practice. Correct Care, 28 (1) 12-14.

Knox, C.M., West, K., Pinney, B., Blair, P. (2014) Work environments that support professional nursing practice. Presentation at Spring Conference on Correctional Health Care, National Commission on Correctional Health Care. April 8, 2014. Nashville, TN.

MacMurdo, V., Thorpe, G., & Morgan, R. (2013) Partners in practice: Engaging front-line nursing staff as change agents. Presentation at Custody & Caring, 13th Biennial International Conference on the Nurse’s Role in the criminal Justice System. October 2-4, 2013. Saskatoon, SK.

Maroney, M.K. (2005) Caring and custody: Two faces of the same reality. Journal of Correctional Health Care. 11:157-169.

Needleman, J., Buerhaus, P.I., Stewart, M., Zelevinsky, K. Matke, S. (2006) Nurse staffing in hospitals: Is there a business case for quality? Health Affairs. 25(1):204-211.

Shelton, D., Weiskopf, C., Nicholson, M. (2010). Correctional Nursing Competency Development in the Connecticut Correctional Managed Health Care Program. Journal of Correctional Health Care. 16 (4). 38-47.

Sherman, R. & Pross, E. (2010) Growing future nurse leaders to build and sustain healthy work environments. Online Journal of Issues in Nursing. 15(1).

Schoenly, L. (2013) Management and Leadership. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2013) Nursing Sick Call. In Schoenly, L., & Knox, C. (Ed.) Essentials of Correctional Nursing. New York: Springer.

Smith, S. (2005) Stepping through the looking glass: Professional autonomy in correctional nursing. Corrections Today 67(1):54-56.

Weiskopf, C.S. (2005) Nurse’s experience of caring for inmate patients. Journal of Advanced Nursing 49(4):336-343.

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

Photo credit: © Kheng Guan Toh – Fotolia.com

 

Preventing diversion of prescription drugs in prison and jail

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Last week’s post described the epidemic of prescription drug abuse in the United States and the impact on the nation’s jails and prisons. This week we return to the same subject but focus on the problem of prescription drug diversion during incarceration. There are many more medications available and appropriate to be used in treatment today than when I started in nursing 40 years ago. Just to illustrate there were an average of 13 prescriptions written in 2011 for every person in the United States. At one of the jails I am familiar with an average of 24 prescriptions per inmate are filled each month.

Most correctional facilities allow some medications to be taken by inmates on their own as directed by the provider. This is usually called a “self-carry” or “keep on person” program. Virtually all facilities also require that certain medication be administered to inmates. These medications usually have potential for misuse (narcotics) or are medication regimes that require close monitoring (TB prophylaxis). The volume of medications handled daily in correctional facilities is substantial.

Nearly 85% of incarcerated adults in the United States have a substance use disorder and four out of five crimes committed by youth involve substance abuse (National Center on Addiction and Substance Abuse 2010, 2004). Some misuse of prescription drugs takes place simply because access to illegal drugs is so greatly limited during incarceration. Incarceration also brings other discomforts such as insomnia, pain, anxiety and boredom. Inmates may request medication from health care staff; they may also simply take or trade for someone else’s medication in an effort to alleviate problems like these. As correctional health care professionals we all have experience with patients who feign an illness or symptom to get a prescription for a preferred medication. Prescription medication has a value in prison or jail that is greater than in the general community (Phillips 2014).

Diversion and misuse of prescription medication is as much a clinical problem as a custodial one. If patients are bullied or coerced into giving up needed medication their condition may deteriorate. The provider may prescribe higher doses or additional intervention to treat a condition that appears unimproved when instead the patient was not treated effectively in the first place. In addition inmates who take someone else’s medication are not monitored clinically and expose themselves to potential for adverse reaction or other injury.

Methods to prevent or mitigate diversion

  1. Formulary controls: Often the first reaction to counter diversion is to ban prescription of the drug in the first place. The problem with this approach is that once a particular drug is banned another becomes the drug of choice for misuse. Secondly there are appropriate clinical indications for these medications and not allowing their use is to deny medically necessary care. It is possible to designate a particular drug as a non-formulary item that requires additional rationale and review before it can be issued. An example of this is that many facilities have made bupropion a non-formulary anti-depressant and thus limited its use (Phillips 2012). It is also possible to designate a certain housing location with greater supervision and control for patients receiving drugs at high risk for diversion. For example some facilities require patients to be admitted to the infirmary in order to receive treatment with an opiate analgesic.
  2. Choice of preparation: Another action is to administer the drug in a way that limits the possibility of diversion. Choices include ordering the drug in a liquid, aerosol or injectable preparation or that the tablet be “crushed and floated” (Bicknell et.al. 2011). Challenges are that these methods are either more expensive or time consuming to administer. A policy to “crush and float” an entire class of drugs (i.e. psychotropics) is not advised since the effectiveness and safety of some medications may be altered. Nurses expose themselves to liability if they “crush and float” medications against manufacturer advice (Phillips 2012).
  3. Increased multidisciplinary communication: Communication between providers, nurses and custody staff about prescription drug abuse generally and the importance of each method used to minimize diversion will reinforce the roles of each (Phillips 2014). Both correctional officers and nurses have responsibilities to ensure that inmates take medications as prescribed. These include maintaining orderliness during medication administration, monitoring ingestion, observing individual inmates for intended and unintended effects of medication. Correctional officers should be invited to provide information about behavior that suggests coercion by others or diversion. Providers and nurses may ask correctional officers about their observations of an inmate’s behavior to help with diagnosis or clinical monitoring. Random cell searches by correctional staff and periodic review of adherence by nursing staff are very helpful in identifying inmates who are diverting medication. Recently a facility changed their procedure for medication administration to include checking an inmate’s hands as well as their mouth before leaving the medication area. This change was made after discussion with an inmate who was found trading medication. The provider asked the inmate how he managed to get the medication and he gladly demonstrated his sleight of hand. It was an educational experience for all the staff and improved the methods used to control diversion at the facility.
  4. Caring for patients: Proactive identification and preventive treatment of inmates withdrawing from use of illicit drugs is an important first step in reducing diversion. This includes programming and targeted education to build alternative coping skills and recovery (Phillips 2012).Indications that a patient may be “at risk” of diverting prescribed medication include:
  • Requesting a particular drug by name before describing symptoms
  • Objective data about the patient’s condition is inconsistent with the description of symptoms
  • Refusal or non-adherence with other drugs prescribed for the condition
  • Claiming allergies or side effects to other possible drugs without being able to provide specific detail
  • Not remembering or being able to pronounce drugs other than the preferred drug
  • Threatening or other signs of excessive distress when the requested drug is not prescribed (Phillips 2012, 2014).

The nurse should be observant for these behaviors when seeing patients in sick call, nurse clinics or during medication administration, document the findings in the inmate’s health record and inform the patient’s prescribing provider. This information is more helpful to the treating provider when it is descriptive rather than judgmental. Nurses should also discuss with patients the potential for victimization when taking medication, the adverse outcomes of prescription drug abuse as well as steps to protect the inmate. This discussion is most effective if it is specific to the patient, the drug and their behavior rather than more general information.

Medications with high diversion value in the correctional setting

Click on this link to a table Common Prescription Medications- Use and Misuse which lists the prescription medications that are commonly misused or abused by inmates. The table also lists the purpose each drug is usually prescribed for as well as the reason for its misuse. During administration or when working with patients to self-administer these drugs nurses should be hyper-vigilant for possible diversion. Please remember though that any prescription medication can be misused if there is a belief that the drug will produce some desired effect.

Conclusion:

What have you learned about diversion of prescribed medications at your correctional facility that has not been discussed here? Are there methods to prevent diversion not discussed here that should be? Please share your opinions and experience by responding in the comments section of this post.

Anthony Tamburello, MD, FAPA, Statewide Associate Director of Psychiatry,  Rutgers University Correctional Health Care in New Jersey provided much of this information in a continuing education presentation for nurses and was willing to share it for use in this post. Also correctional physicians in the United Kingdom have published Safer Prescribing in Prisons: Guidance for Clinicians a thoughtful and well organized on-line resource. 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.

Resources:

Bicknell, M., Brew, I., Cooke, C., Duncall, H., Palmer, J., Robinson, J. (2011) Safer Prescribing in Prisons: Guidance for Clinicians. Royal College of General Practitioners, Secure Environments Group. Accessed at http://www.rpharms.com/news-story-downloads/prescribinginprison.pdf.

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.

Phillips, A. (2014) Prescribing in prison: complexities and considerations. Nursing Standard 28 (21): 46-50.

Phillips, D. (2012) Wellbutrin®: Misuse and abuse by incarcerated individuals. Journal of Addiction Nursing, 23: 65-69.

Tamburello, A. (n.d.) Prescription Medication Abuse. Presentation for University Correctional Health Care. Rutgers, The State University of New Jersey. Personal correspondence dated 6/17/2014.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Behind bars II: Substance abuse and America’s prison population. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-prison-system-2010.

The National Center on Addiction and Substance Abuse at Columbia University. (2010). Criminal neglect: Substance abuse, juvenile justice and the children left behind. New York, NY: The National Center on Addiction and Substance Abuse at Columbia University. Retrieved from http://www.casacolumbia.org/addiction-research/reports/substance-abuse-juvenile-justive-children-left-behind.

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.

Photo credit: © torsius – Fotolia.com

 

Best wishes for a safe and error-free holiday season

In correctional settings the Christmas and New Year holidays bring special challenges. Prisons, jails and detention facilities operate 24/7 every day of the year and holidays can be stressful and busy. Inmates are particularly aware of their isolation from family, friendship and goodwill that characterize the holiday season. To prevent suicide, self-harm and victimization correctional staff must be extra vigilant and attentive to the population during this time. In addition to the challenges of the work environment staff also are preparing for and participating in their own holiday activities.  Staff fatigue coupled with the heightened tensions and emotion that accompany the holiday season makes this a time of “high risk” for error. The last thing anyone wants right now is to be involved in an accident, injury or adverse patient care event. Here are some ways to thrive this holiday season.

Get sufficient sleep 

Each hour of sleep less than eight increases an individual nurse’s risk of error by seven percent.  So if you only got six hours of sleep your risk of error during the next work shift is 14 percent higher than if you slept eight hours.  If there is one other nurse working the shift and you both had six hours of sleep the collective chance of patient care error is increased nearly 30 percent.

Getting enough sleep is independent of shift duration.  For example if you get off at 2:30 pm but it takes 30 minutes to get home. Then you go to the gym, have dinner, help the kids with homework and watch television until 11:30 pm.  The next day you arise at 5:00 am for work. This is less than eight hours of sleep. In this example you should alter your routine so that you can be asleep by 9:00 pm to get the recommended eight hours of sleep.

If you get less than six to six and a half hours of sleep you are probably not “fit for duty” from a patient safety standpoint. It is common to think that you can catch up on your days off but every shift you work until then you have greater chance of making an error. The chance of error increases for every hour less than eight hours of sleep in a 24 hour period.

Avoid overwork

The risk of error in patient care doubles when nurses work twelve or more consecutive hours. Errors also increase when nurses work more than 40 hours in a week or more than three twelve hour shifts without a day off.

Once I encountered a nurse who volunteered to work a third consecutive overtime shift at a maximum custody facility. This meant that the nurse was volunteering to work twenty four hours then come back 16 hours later and work another eight hour shift. I was shocked that there was no prohibition against working these hours in the collective bargaining agreement or in the regulations governing nursing practice in the state.  It was basically up to the nurse to determine that he/she was “fit for duty” when volunteering to work extra shifts. The managers came to rely on these individuals, known as the “overtime dogs” to pick up whatever shifts needed coverage because they seldom turned down an opportunity for the extra pay.

The Veterans Administration is the only organization which has put limits on the hours that nurses can work in the interest of patient safety. Unions have generally limited mandatory overtime assignments but have been silent regarding voluntary overtime. Nurses are expected to make their own decision about their ability to work extended hours.

The data show that nurses’ motor skills are preserved when working extended hours but cognition and executive functions, such as assessment and clinical vigilance decline.  Extended work hours result in decreasing situational awareness, an important component of personal safety and emergency response in the correctional setting.  Finally nurses working extended hours are less accurate under time pressure such as in an emergency response or during medication administration.  Your ability to perform essential nursing functions decreases the longer you work beyond your regular shift.

Take breaks and leave on time

The work demands of the shift usually determine when and if breaks will take place. Taking regular breaks helps to mitigate the adverse effects nurses’ fatigue has on patient care and shorter more frequent breaks are most effective.  However 20 percent of hospital nurses report not taking breaks. Even more nurses said that they took breaks but were ready to be interrupted if patient care required; which is essentially not taking a break.  Self-scheduling breaks has not been found to be effective. Nurses wait until they are too fatigued or chose to remain patient centered and subject to break interruption. Does this sound true for your setting?

Usual reasons for not leaving on time are to document or to make arrangements for continuity of patient care.  Hospital nurses report that they leave on time only one out of five shifts.  How true is this for you?  Not leaving on time extends the work shift and impinges on the family and social obligations you have. These are especially important during the holiday season and can lead to loss of sleep that is associated with increased patient care error. Managing documentation and delegating responsibilities during the shift are critical to finishing your work on time and this is most important during the holidays when your family and social lives make additional demands.

Say “No” positively

During the holidays you may feel pressured to commit to working shifts and doing work you would otherwise decline. Remember you are not responsible for solving time pressures for others but instead for managing your own time and energy. Does this commitment leave you enough reserves for the other priorities that are important to you? If not, be firm but polite and say “No”. Suggested ways to say no in a positive way are:

  • I would love to but I have other priories right now.
  • I can’t do it this time but would like to be considered for another time.
  • Thanks for giving me the opportunity but no, I can’t this time.

Your time and energy are limited and precious commodities; using them to honor your priorities is a sign of self-respect.  Merry Christmas and Happy New Year.

For more about staffing, fatigue and patient safety read Chapters 4 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping. 

References:

Rogers, A. E. (2013) Navigating Shiftwork: 5 tips for managing fatigue. American Nurses Association Navigate Nursing Webinar 12/17/2013.

Sherman, R.O. (2013) Nurse Leader Insight: Reduce your stress by learning to say no. Emerging RN Leader. Accessed 12/19/2013 at http://www.emergingrnleader.com/nurse-leader-insight-reduce-stress-learning-say/?utm_source=rss&utm_medium=rss&utm_campaign=nurse-leader-insight-reduce-stress-learning-say.

Photo credit: © artenot -Fotolia.com

Caring for Women in Prison: Sexually Transmitted Infections

Sexually transmitted disease concept.Sexually transmitted infections (STI) are higher among the incarcerated population than the general public and female inmates have higher rates of chlamydia and gonorrhea than their male counterparts. Early detection and treatment of these conditions reduces transmission in the community and reduces the likelihood of subsequent illness and disability.

Fix It Early

Chronic inflammation from sexually transmitted infections leads to chronic pelvic pain, ectopic pregnancies, and infertility. Correctional nurses have opportunity to reduce these outcomes through assessing, treating, and educating patients about chlamydia and gonorrhea. This can start with routine screening for both conditions upon entry into the correctional setting. Treatment, then, should be guided by national standards. The CDC 2010 STI Treatment Guidelines have some recent revisions, but remain the current national standard.

Longstanding STIs lead to chronic inflammation. Pelvic inflammatory disease (PID) should be considered and receive follow-up evaluation when female patients come to sick call with a fever, nausea, vomiting and severe abdominal pain – even when the flu is making the round in the housing unit.  According to CDC STI Guidelines, the following findings are definitive for PID:

  • Oral temperature >101° F (>38.3° C);
  • Abnormal cervical or vaginal mucopurulent discharge;
  • Presence of abundant numbers of WBC on saline microscopy of vaginal fluid;
  • Elevated erythrocyte sedimentation rate;
  • Elevated C-reactive protein; and
  • Laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.

Treating for Two

Most women with STI’s are sexually active and fertile; making pregnancy a concern when assessing for and treating infection. It is important to know the pregnancy status of any patient diagnosed with an STI in order to arrange for appropriate treatment.  The CDC recommends that all pregnant women be screened for chlamydia and gonorrhea.

Ectopic pregnancy should also be considered when a women of reproductive age experiences significant pelvic pain. This pain may or may not be accompanied by bleeding. With high rates of STIs and PID, sexually active female inmates are at high risk for this condition. Disregarding pelvic pain in this patient population can be deadly, as this unfortunate situation in one jail illustrates.

Let’s Not Talk About It

We really don’t like talking about STI’s as this research on chlamydia confirms. However, it is an important topic and we should make the effort, especially as many women are uninformed or have misconceptions about how to prevent and treat the condition. The Centers for Disease Control and Prevention have patient education resources in English and Spanish that can help in your efforts to educate yourself and your patients about STI’s.

How do you manage sexually transmitted infection in your setting? Share your thoughts in the comments section of this post.

To read more about the unique aspects of women’s health care in the correctional setting see Chapter 9 in the Essentials of Correctional Nursing. The text can be ordered directly from the publisher and if you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Photo Credit: © creative soul – Fotolia.com