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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Sexual Harassment by Inmates Against Nurses

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

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

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

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

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

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

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

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

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Dealing with the Difficult Patient

Stressed manLast week I attended the fall meeting of the Oregon Chapter of the American Correctional Health Services Association. I have belonged to this organization for 30 years and have received a lot of professional support over the years, especially continuing education. These are my notes from an interesting presentation by Daryl Ruthven, M.D., CCHP, Director of Psychiatry for the Oregon Department of Corrections.

Demanding, non-compliant, whining, threatening, somatizing, malingering, drug-seeking, mentally ill, frequent flyer are some of the ways difficult patients are described. Their behavior can be so obstructive that it’s possible to miss important information or data about them and compromise our clinical work. Certain personality types are more likely to take up more time when seen at sick call or in clinic. These include people with antisocial, borderline, narcissistic, histrionic, dependent or organic personality types. The first thing to remember is that the patient’s behavior is consistent with their personality type and not likely to change just because they are seeking health care. Reduce the likelihood of missing important clinical information by remaining non-judgmental about their behavior and objective during assessment and evaluation of their condition.

The Angry Patient: Unless the patient is brain damaged or intoxicated, anger is a response to fear or threat. The patient is afraid of something that either is or is not going to happen as a result of the encounter. Anger sometimes is used as a display to intimidate others. In this situation the patient may need to vent a bit first. Then try to figure out what the patient is scared or anxious about. They may not be aware that their anger is a response to threat and so it may take a bit of dialogue to identify the problem. A good question to ask is “What do you fear will happen?” or “What are you most concerned about?” The encounter should be terminated if the anger is escalating or becomes abusive rather than defusing.

The Demanding Patient: Uses confrontation as a means to force a desired result. Demands are usually accompanied by a direct or indirect threat. Demanding behavior may be a result of fear, sociopathy, or poor assertive skills training or advice. Most patients are as interested in relief of a problematic symptom as they are in a specific outcome. With this in mind, remind the patient of the responsibilities each party has in the patient/provider relationship. The patient’s responsibility is to provide information about the problem and to decide whether to follow the plan of care suggested by the provider. The provider’s responsibility is to listen to the patient, assess the problem and determine the treatment options that are most appropriate to address the problem.

The Splitting Patient: Pits staff against each other to create chaos and in the midst of the confusion achieves a goal. When a nurse (or other provider) feels confused or at odds with other health care providers about a patient’s plan of care it is a good sign that splitting is taking place. The most important action to take with a splitting patient is to bring the team together to agree on a consistent plan to manage the patient’s care. This should include developing a comprehensive treatment plan (including custody and mental health staff) and reviewing it together at regular intervals.

The Threatening Patient: The facility or health care program should have no tolerance for physical threats and train staff in how this kind of behavior is addressed. The specifics of threatening behavior should be documented thoroughly in a report of the incident. Threatening legal action is very common. Suggestions here are to know enough about the law to appreciate how poor health care must be before a finding of “deliberate indifference” and “cruel and unusual punishment” can be made. Staying up to date with the literature and competent clinically along with thorough documentation protects nurses from tort liability. Basically providing and documenting good nursing care provides sufficient protection from legal threats.

Conclusions: Finally, don’t respond unprofessionally to the difficult patient by yelling, use of sarcasm, counter threatening or reacting emotionally. These responses undermine the power of the provider in the relationship with the patient and can destroy the reputation and authority of the clinician.

Difficult patients do have health problems that need to be identified, assessed and treated. These patients also have something that they are scared of or bothering them. Asking “What are you most concerned about?” or “What do you fear will happen?” may help identify this underlying problem so it can be addressed. Set limits that are appropriate to the responsibilities of each in the provider/patient relationship. Discuss the patient’s options calmly and clearly. Seek help from others to manage difficult patients. Take care to prevent becoming jaded, desensitized or overwhelmed by difficult patients by taking regular time off and developing interests and relationships outside of work.

What tips do you have to manage an encounter with a “difficult patient”? Add to the advice given here by responding in the comments section of this post.

There is much more on this subject in the Essentials for Correctional Nursing. Lorry Schoenly discusses working with difficult patients in Chapter 4 Safety for the Nurse and the Patient. Also Roseanne Harmon describes care of patients who have personality disorders in Chapter 12 Mental Health. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

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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. 


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

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Managing Conflict is Essential to Safe and Effective Correctional Nursing

picket fenceI live in a neighborhood of 36 houses that are built very close to one another. The neighborhood is surrounded by a beautiful landscape. The peacefulness and beauty of the setting was the reason I chose to live here. Last week the moving truck used by a new homeowner blocked the neighbor’s driveway for most of the day.  The neighbor raised such a ruckus that the whole community heard about it and the homeowner’s association had to get involved. The incident made me appreciate how important it is to a “healthy” community that conflict be addressed well by each of the members.

These skills are even more important in health care because they contribute to patient safety and retention of nurses.  Unrecognized or unresolved conflict in the health care setting causes a decrease in nurses’ morale, increases physical and emotional stress, as well as the likelihood that conflict will escalate (Longo, J., 2010; Almost, J., Doran, D., Hall, L., Laschinger, H., 2010; Johansen, M., 2012). “…conflict management skills have been identified as an essential competency for the professional RN to provide safe, quality care to patients…” (Johansen, M., 2012 p. 50).

Conflict is an inherent aspect of correctional nursing practice. Sources of conflicts that are unique to correctional nursing are detailed throughout the Essentials of Correctional Nursing. The American Nurses Association draft of the Correctional Nursing: Scope & Standards of Practice, which has been out for public comments the last month, also discusses conflicts experienced by correctional nurses. Two of the proposed standards explicitly address expectations of correctional nurses to assess and improve their skills in conflict management.

What are the sources of conflict in your day to day nursing practice? How often are these conflicts resolved satisfactorily? Do you wonder what you can do to better address conflict in the practice setting?  The following are some steps to assess and improve conflict management skills.

1. Explore your own emotional triggers and reactions. Nurses who have good self- esteem, perceive themselves as successful, feel they are in control of their life and are optimistic are also more constructive in managing conflict.

2. Identify and review the organization’s written directives related to conflict management. These may be in the code of ethics, rules for professional behavior, bylaws of the governing body or in the collective bargaining agreement. Know what is expected of staff, the methods to identify and resolve conflict as well as avenues for redress when conflict is not satisfactorily resolved.

3. Address conflict quickly, fairly and respectfully. Sometimes people are not aware that their behavior contributes to conflict at the workplace. Communicating in a way that increases understanding and resolves conflict among participants is not an easy task. It should always be done in private. Chapter 17 of the “Essentials” book provides resources and suggests that nurses build their repertoire of conflict management styles, especially those of collaboration.

4. Take care of yourself. Stress can contribute to increased emotions, particularly anger. Nurses who understand how emotions affect their behavior have less risk of burnout associated with conflict in the workplace. Take appropriate breaks; attend to personal needs for nourishment, relaxation and other self-care habits. Reflective journaling has been suggested as way to process negative personal feelings after a conflict. In addition to reliving the negative effects of a conflict situation, reflection can be used to build skills and competencies in conflict management.  We will take a closer look at this technique in a future post on this site.

5. Report abusive or disruptive behaviors through your chain of command. Many nurses opt to ignore or avoid conflict without knowing that if left unattended, it contributes to an escalation in conflict. Avoiding conflict at the worksite only reinforces disruptive, dysfunctional and unprofessional behavior. Knowing your organization’s policies regarding workplace conflict is an important first step.

This post was written from the perspective of the individual registered nurse. Nursing supervisors, managers and executives have an exceedingly important role in creating a workplace that supports the professional practice of nurses and safe environments for patient care. Going back to the example of conflict in my neighborhood, our community works best when individual homeowners address conflict quickly and well.  The same goes for the workplace; it is the everyday acts of individual nurses managing conflict that does the most to keep staff and patients safe.

To read more about conflict management order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.


Almost, J., Doran, D., Hall, L., Laschinger, H. (2010). Antecedents and consequences of intra-group conflict among nurses. Journal of Nursing Management, 18, 981-992.

Dombrowsky, T. (2012). Responding to verbal abuse. Nursing 2012, November, 58-61.

Hocking, B. (2006). Using reflection to resolve conflict. Association of Operating Room Nurses Journal, 84 (2) 249-259.

Johansen, M. (2012). Keeping the peace: conflict management strategies for nurse managers. Nursing Management, February 50-54.

Kupperschmidt, B. (2008). Conflicts at work? Try carefronting. Journal of Christian Nursing, January-March, 10-17.

Longo, J. (2010). Combating disruptive behaviors: strategies to promote a healthy work environment. Online Journal of Issues in Nursing, 15 (1) 3.

Siu, H., Laschinger, H., Finegan, J. (2008). Nursing professional practice environments: setting the stage for constructive conflict resolution and work effectiveness. Journal of Nursing Administration, 38 (5) 250-257.

Thomas, C. (2010). Teaching student nurses and newly registered nurses strategies to deal with violent behaviors in the professional practice environment. The Journal of Continuing Education, 41 (7) 299-308.

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Correctional Nurses: Always on Guard

Personal safety is a growing concern in all nursing specialties. Patient violence can take place in the emergency room, on inpatient psychiatric units and dementia wards. Correctional nurses are no strangers to the need for personal safety. We have visible proof all around us that our patients may turn violent. Officers often escort nurses around the compound and many locked doors must be negotiated to gain access to deliver care. The routine nature of security operations can blunt our continuing vigilance, however. I like to consider personal safety as multi-dimensional with the very basic start being physical safety. Here are some tips in three areas of safety concern for correctional nurses.


Guard Your Body
• Be aware of your surroundings and the location of the nearest security officer.
• Travel in pairs whenever possible. Always tell others in your unit where you are going and when you expect to return.
• Observe all security procedures. Wait for clearance before entering any area, including when responding to an emergency.
• Do not leave sharps and other potential weapons out on surfaces. Keep equipment locked and maintain counts of all potential contraband items.
• Be careful to limit personal conversation or discussion of facility procedures when patients are present.

Guard Your Mind
• Our patient population can be a difficult one to care about. Patients may have cruel or violent histories. To avoid developing a judgmental attitude, do not seek out information about the crimes of your patients. Focus your mind on nursing care provision and the health care issue at hand.
• Our patients can also seek health care for secondary gain such as a privileged status, more comfortable accommodations or items to fuel the underground prison economy. Guard your mind toward manipulative behaviors while maintaining a professional nurse-patient relationship.
• Because inmate patients can try to con you or game the system, it is easy to become jaded or synical. Guard your mind against these attitudes which will decrease your ability to deliver care.

Guard Your Heart
• Regular contact with the inmate population can lead to professional boundary crossing in relationships. Some patients may seek additional ‘favors’ from nursing staff. Be firm, fair and consistent in all patient interaction. Immediately report any such requests to your manager.
• Guard your heart toward flattery or flirtatious comments and actions by inmates. Respond firmly and initiate security procedures with the slightest indication of personal contact. You are guarding yourself from harm and protecting the patient from disciplinary action.
• Agree with your fellow nurses to watch out for each other. Comment on observations of inappropriate conversations or behavior toward patients.

Do you have additional safety tips to add to this post? Use the comments section to expand on these points.

Read more about Safety for the Nurse in Chapter 3 from Essentials of Correctional Nursing. Order your copy directly from the publisher.

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