The Challenges and Distinguishing Features of Correctional Nursing: Part 3

Tonia FaustThe last two weeks we explored two of the challenges in becoming a correctional nurse and how once mastered, the results are practices that distinguish correctional nursing from other areas of nursing practice. A final cultural challenge for nurses in the land of correctional Oz, a phrase Lorry coined for nurses new to the specialty, is to develop a caring practice, consistent with professional principles. Many correctional nurses lament “how can I be caring when the place where I work exists for the purpose of punishment?” In correctional settings, staff are cautioned against touching an offender, unless it is necessary to perform some task, such as a pat down search. Some places go as far as considering touch, an act for which staff can be disciplined.

Common expressions of caring in nursing such as therapeutic touch or an empathic disclosure of personal information are often prohibited or extremely limited in the correctional setting. These acts earn a nurse derision from other staff, particularly custody staff, and they will be taunted as a “chocolate heart”, “hug-a-thug” or “convict lover.” Correctional officers will not trust nurses who violate the facility’s expectations about maintaining boundaries, to act professionally in other encounters.

Caring however remains a central tenet of correctional nursing and is vital to the therapeutic relationship. Another distinguishing characteristic of the specialty, is that the expression of caring, emphasizes interpersonal communication rather than physical contact and use of self to convey empathy. Correctional nurses express caring when their interactions with patients convey respect, are nonjudgmental, acknowledge the validity of the patient’s subjective experience, are not rushed and are done in the genuine interest of the patient (ANA 2013).

Correctional nurses have described how, it is first, necessary to establish a professional relationship with custody staff before they can negotiate delivery of compassionate nursing care. This means having acting, behaving and speaking in a ways that are consistent with professional practice standards. The most recent version of the Scope and Standards of Practice for Correctional Nursing were published in 2013 and now are identical to those of nursing generally. So a correctional nurse practices as any nurse does; it is only the place and population served that differ.

An example of how a professional relationship with custody staff is established, is in accounting, not just for controlled substances, but for all the sharp instruments as well. This is usually done at the beginning and end of every shift. This means all of the instruments, including those in the dental clinic, those kept in the inpatient and outpatient medical areas, and the lab as well plus every needle on site…it can be an arduous task. This degree of accountability is necessary because sharps can be used as weapons, to do tattooing and to shoot drugs, all dangerous and prohibited activities in a correctional facility. Nurses count sharps because it is necessary for security, not as part of health care delivery. A missing sharp means that the whole facility will be locked down and searched until the item is found. I have experienced an entire facility being locked facility down, for hours on end, because a single insulin syringe could not be accounted for. No other work, even delivery of health care takes place, until the “sharp” is accounted for. Sometimes nurses balk at the requirement for counting or act as though it isn’t as important as patient care. However, failure to account for sharps is not only dangerous, but it undermines the professional relationship with custody staff.

The ANA standards for professional practice are also important because they help to define and protect the role of nurses in the correctional setting. We provide health care in a setting where custody staff, facility commanders and correctional administrators have little or no knowledge of the standards for nursing care, let alone much appreciation for the limits of nursing practice in state law, unlike traditional health care settings. A nurse cannot rely on the correctional facility to have practices and procedures that are compliant with state law or professional practice standards. They may be the only nurse for a small facility and have no other health care professional to provide advice, other than a part time visiting physician. Even in large correctional facilities with many nurses, including nurses in management, practice creep can occur for an individual nurse whose primary interaction during a shift is with correctional officers and inmates who don’t know or appreciate the nurse’s scope of practice. Individual nurses must therefore establish these boundaries on their own, or risk violation of the law and the potential for action on their license.

There are many examples where nurses are asked to perform work that is outside the scope of practice or not consistent with professional standards. A nurse may be asked to approve use of pepper spray or endorse the use of a restraint chair and hood; decisions which are not in the interest of the patient or their health care. For example, another friend of mine, Lynda Bronson, was threatened with insubordination for refusing a direct order from the Warden to forcibly medicate an inmate who was in segregation and screaming obscenities at the officers.

The Warden threatened Lynda three times with insubordination and yet she stood her ground and explained that she did not have a medical order that would allow her to forcibly medicate the inmate. These are tough situations to be in and correctional nurses must be experts in communication, collaboration, and problem solving, with Wardens as well as correctional officers. These skills are necessary to arrive at compromises that solve problems, like screaming obscenities and gravely disordered behavior, while keeping the patient and staff safe.

Well done, this is experienced as practice autonomy, one of the most preferred and distinguishing characteristics of correctional nursing. Nurses who are clear about the standards and boundaries of their practice in correctional settings earn the respect of custody staff and are able to negotiate better outcomes for their patients.

To sum up, correctional nurses provide health care from within the justice system, to a disparate population of prisoners with great disease burden. These features; the location and population served, along with the nurse’s independent negotiation for care, define and characterize correctional nursing.

They say that once a nurse has resolved these cultural challenges, he or she will stay in the Land of Correctional Oz forever. As Tonia Faust, the nurse from the Louisiana State Penitentiary said in The American Nurse “There is a purpose for me here”. Those that don’t survive the transition, leave, usually within the first year.

Do the challenges portrayed over the last three weeks fit the experience you had transitioning into the field of correctional nursing? Are there aspects of your practice in correctional nursing that are different from other nursing fields that have not been highlighted in this series? Please share your thoughts about these questions by responding in the comments section of this post.

If you would like to read more about caring and professional practice in correctional nursing see Chapter 2 on the ethical principles of correctional nursing and chapter that discusses the elements of professional correctional nursing practice in our book, Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

Photo credit: Jaka Vinsek, Cinematographer The American Nurse

The Challenges and Distinguishing Features of Correctional Nursing: Part 2

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

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

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

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

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

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

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

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

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

The racial and ethnic disparities of the criminal justice population are substantial. More than 60 percent are considered racial or ethnic minorities in the general community. One in every three black men and one in every six Latino men will serve time in prison or jail during their lifetime, compared to one in 17 white men. The same racial and ethnic disparities exist among women; one in every 18 black women and one of every 45 Latina women will be incarcerated in their lifetime compared to one of every 111 white women (The Sentencing Project at http://www.sentencingproject.org/template/page.cfm?id=107).

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

Older prisoners also are a small percentage of the total (8%) incarcerated population but their numbers are growing at much faster rates because of mandatory sentencing and increasing numbers of extremely long sentences received. In fact the population of prisoners over the age of 65 increased 63% compared to a 0.7% growth for all other ages between 2007 -2010 (Human Rights Watch (2012) Old Behind Bars at https://www.hrw.org/report/2012/01/27/old-behind-bars/aging-prison-population-united-states).

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

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

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

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

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

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

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

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

 

Photo credit: © Helder Sousa – Fotolia.com

The Challenges and Distinguishing Features of Correctional Nursing: Part 1

00000001What career did you want for yourself when you graduated from nursing school? Did know you wanted to be a correctional nurse? You probably never heard of it, right? This is me back in 1973 and I had never heard of correctional nursing either. Most correctional nurses will tell you that they never planned to be in this field. The reasons they give for trying it out included:

Wanting to try something different.

It was close to home and convenient.

They knew someone else who was a correctional nurse and suggested it.

I made the change because I was bored with hospital-based psychiatric care. The opportunity to develop a health care program for offenders in state prisons came at the perfect time and I took on the challenge and have had a chance to make a difference in the lives of those who could not do so for themselves. I thought I would stay about five years and move on, but it has been 31 years now. The next several posts will explore the challenges of becoming a correctional nursing specialist, the features that distinguish the specialty and explore why nurses stay in the field.

Nurses have advocated for the health and well-being of prisoners practically since the beginning of time. These include Florence Nightingale, who did some of her best work in England’s poor houses in the mid-nineteenth century as well prisoners during the Crimean war, Clara Barton, who cared for prisoners of war in the Civil War, and Dorothea Dix who was responsible for prison reform in the 1800s. The American Nurses Association has considered correctional nursing a specialty since 1985 and publishes standards for the scope of professional practice in correctional nursing.

The Institute of Medicine report The Future of Nursing: Leading Change, Advancing Health (2010) acknowledges correctional nursing when commenting on diversity in the nursing profession, stating that nurses will be present anywhere there are people who have healthcare needs. Those of you who watched the movie, The American Nurse, met Tonia Faust, a correctional nurse, and hospice coordinator at the Louisiana State Penitentiary. Four of the 75 nurses portrayed in the book, The American Nurse, were providing health care in correctional facilities at the time they were interviewed. We don’t really know how many correctional nurses there are because many state boards of nursing don’t include this as an option when indicating your place of employment or area of practice.

My co-contributor, Lorry Schoenly, likens the transition to correctional nursing to the popular tale, The Wizard of Oz when Dorothy Gale, walks out into the Land of Oz, after her prairie home landed on the Wicked Witch of the East, following a tornado ride from Kansas. Our first experiences with correctional officers, handcuffs, sally ports, metal detectors, crossing the yard and pop counts brings to mind Dorothy’s admonition to her little dog “This isn’t Kansas anymore, Toto!” In fact Lorry, published a book by the title, The Wizard of Oz Guide to Correctional Nursing, to help nurses manage the transition to this very different setting.

Well the first cultural challenge for nurses after they have arrived in the Land of Correctional Oz is the realization and understanding that our services are secondary to enforcing the law and protecting the public. This is the primary purpose of incarceration in the United States. The people whose health we are responsible for, are being detained against their free will, as punishment. Even so, the Supreme Court has granted prisoners a constitutional right to health care under the 8th amendment. Failure to do so is considered “cruel and unusual punishment.” The court’s reasoning was that “it is but just, that the public be required to care for the prisoner, who cannot, by reason of the deprivation of his liberty, care for himself.”

This is not just a cultural challenge but one of the distinctive features of correctional nursing practice. The first part of the ANA definition of correctional nursing, is that it takes place at the intersection of an individual and their involvement with the justice system. Legal precedents have been the primary means by which the delivery of health care in the correctional system has been shaped.

The courts have established that inmates have the right to health care during incarceration which includes:

  1. Unimpeded access to care
  2. Care that is ordered must be provided
  3. Entitled to professional clinical judgment

These three rights are referred to as the three legged stool of the Eighth Amendment rights to prisoner health care and they are operative in almost every aspect of a correctional nurse’s daily practice.

Here is an example of the application of these rights to health care from my early experience in correctional nursing. In this instance, three inmates, working in the print shop, drank printing fluid, in an attempt to get high. All three became sick but they did not seek medical attention because the nursing staff would have to report them to security for stealing the printer fluid. One inmate died as a result of the delay in treatment. The courts found a violation of the eighth amendment because the inmates’ access to health care attention was impeded, due to the threat of being reported and subsequently disciplined. In this case, a correctional facility’s requirement for reporting prohibited conduct impeded access to care and resulted in a finding of “cruel and unusual punishment”.   The legal right to health care, its practical interpretation and application in the correctional setting is one of the distinguishing features of correctional nursing.

Do you have some good examples of how legal considerations impact the practice of correctional nursing? If so please share by responding in the comments section of this post.

If you would like to read more about legal considerations in correctional nursing please see Chapter 3 written by Jacqueline Moore in the Essentials of Correctional Nursing; the first and only textbook written so far about the practice of nursing in this specialized field. Order a copy directly from the publisher or from Amazon today!

If you would like to order a copy of The Wizard of Oz Guide to Correctional Nursing go to Lorry’s website, Correctionalnurse.net to order through Amazon.

 

Photo credit: © Africa Studio – Fotolia.com

Knowledge Resources for Medication Management

ReadingThe American Nurses Association statement on the scope of practice for correctional nurses requires that nurses be knowledgeable of the medications administered, including dosages, side effects, contraindications and allergies. Nurses also must be able to teach and coach patients so that they know what medications they are taking, the correct dose and frequency (2013). Many more drugs have been developed to effectively treat a wider variety of conditions in the last several decades and new drug formulations established which reduce treatment time, improve adherence and reduce the burden of side effects. With the proliferation of treatment choices available to prescribers today, the scope of knowledge required of nurses has expanded as well.

The types of health problems presented by our patients during incarceration is very broad therefore correctional nurses must maintain more expansive knowledge about the drugs likely to be prescribed than nurses who specialize their practice to a certain acuity (e.g., critical care) or particular health problem (e.g., kidney dialysis). It is impossible to memorize all this information so what references should a nurse use to aid their knowledge about medications these days? What are the drug references that you use?

A couple years ago another nurse and I were talking about a patient and one of the drugs that had been prescribed. I went in search of the big red text from the American Hospital Formulary Service. He turned to the computer and typed the drug’s name into Wikipedia and before I left the room he had the information we were looking for.  The problem is that anyone can contribute information to Wikipedia and so the accuracy and completeness of drug information on this site has been examined. Drug information on Wikipedia relies most heavily on news articles and commercial websites rather than evidence-based material and the information, especially that which is safety related is not reliably updated (Koppen, Phillips & Papageorgiou 2015).

Nurses in one survey in the U.S. favored using the Physician’s Drug Reference (PDR) or a text written especially for nurses like Lippincott’s Nursing Drug Handbook (Gettig 2007). In another survey nurses reported that, other than the PDR, they relied most on other colleagues in the workplace. The problem with relying on co-workers for information about drugs is that the individual may not be available or authoritative on the subject. Access to information and ease of use were the most important factors in nurses’ choice of drug information resources so that quick and concise answers could be obtained (Ndosi & Newell 2010). As drug information has become more available in electronic format it can be more quickly accessed and is becoming a more reliable reference for busy correctional nurses.

The following is a list of drug references and applications that are available on line and can be obtained for free:

National Library of Medicine has three databases that are useful for nurses in medication management. The first is the Drug Information Portal which provides information on 53,000 drugs from government agencies and scientific journals. The second is Drugs, Herbs and Supplements providing information for patients about the purpose of drugs, correct dosages, side effects and potential interactions with dietary supplements and herbal remedies. Last is a database designed for use in emergencies and developed to help identify unlabeled pills called Pillbox.

Epocrates is one of the most widely used and highly recommended drug references. In addition to drug information the basic package which is free has a dose calculator, drug-drug interaction checker which includes OTC medication and a pill identification program. For an annual fee the program can be upgraded to access medical information, diagnostic information, a medical dictionary and infectious disease guidelines.

Medscape Mobile is a combination medical reference and drug database. In addition to clinical reference for 8,000 drugs, herbals and supplements it includes a robust drug-drug interaction checker and a dosage calculator.

A final resource that should be available at every correctional facility is the telephone number for the poison control center. This is a national hotline number (1 800 222-1212) which connects to the nearest poison control center. Most poison exposures can be treated locally if contact is made with a poison control center because they are staffed 24 hours seven days a week by health care professionals with special training. The facility should also stock a supply of antidotes for various types of poison. A consensus guideline published in the Annals of Emergency Medicine (2009) recommended stocking 12 antidotes available for immediate use in treatment (2009). Since then several poison control centers have lists on-line of recommended antidotes to have on hand.

Availability of antidotes is a decision that should be made by the facility medical director in consultation with the supplying pharmacy. Usually they are stored with other emergency medications. Nurses should be familiar with each antidote stocked at the facility for use in medical emergency care. Here is a link to a list of common drugs and antidotes that nurses should know about.

Are there any knowledge resources for nurses in managing medications that are not described here and should be? Please let us know about them by responding in the comments section of this post. For more about the opportunities and challenges in correctional nursing order a copy of our book, Essentials of Correctional Nursing directly from the publisher or from Amazon today!

References

ANA (2013). Correctional Nursing: Scope and Standards of Practice. Silver Springs: American Nurses Association.

Dart, R.C., Borron, S.W., Caravati, E. M., et.al. (2009) Expert consensus guidelines for stocking of antidotes in hospitals that provide emergency care. Annals of Emergency Medicine 54 (3): 386-394.

Gettig, J.P. (2007). Drug information availability and preferences of health care professionals in Illinois: A pilot survey study. Drug Information Journal 42, 263-272.

Koppen, L., Phillips, J., Papageorgiou, R. (2015) Analysis of reference sources used in drug-related Wikipedia articles. Journal of the Medical Library Association 103 (3), 140- 144.

Ndosi, M. & Newell, R. (2010). Medicine information sources used by nurses at the point of care. Journal of Clinical Nursing 19, 2659-2661.

Photo credit: © Xuejun li – Fotolia.com

Six Challenges Managing Medications that make Correctional Nursing Unique

3d illustration of a corridor

 Medication management is a primary responsibility of nurses working in correctional settings (American Nurses Association (ANA) 2013). The Bureau of Justice Statistics reported that 66% of prisoners and 40% of inmates in jail who had a chronic condition were taking prescription medication. Among inmates with mental illness 27% of those in state prisons, 19% in Federal prisons and 15% in jails reported receiving prescription medication while incarcerated (Bureau of Justice Statistics, 2006). In addition to chronic medical problems and psychiatric disorders, medications are prescribed for inmates who have acute conditions, such as urinary tract infection as well as to provide symptom relief for minor illnesses and discomfort such as headache, constipation or seasonal allergies. As much as 80% of the population at a correctional facility may be taking medication for one or more of these reasons.

Medication management is identified as one of the features of correctional nursing that distinguishes it as a specialized field. Nurses who are new to the correctional setting are often unprepared for the scope and breadth of their role and responsibilities for managing medication delivery and yet they must meet the same standards for delivery of medication as in the community (ANA 2013).These challenges define what is unique about correctional nursing practice with regard to medications.

I started making a list of the challenges correctional nurses deal with in managing medication delivery. When the list became almost a full page long I sat back and thought about what similarities there were between the items and the following groupings came together.

  1. Professional isolation: Health care delivery in correctional facilities is often a very small part of the overall operation. In many cases nurses are expected to deliver services in independently and without advice from other health care providers. Nurses recently commented on CorrectionalNurse.net, Lorry’s other website that double checking dosages of high risk medications is a challenge when there is only one health care person on duty. One solution is to have the inmate confirm that the dose corresponded with what he or she understands it should be. Dispensing, drug packaging, storage inventory and disposal of medications are all subjects governed by state pharmacy laws and regulations. Unless there is a pharmacist on staff, correctional nurses need to be familiar with and ensure their practices comply with these requirements, in addition to the nursing regulations, when managing medication in the correctional setting.
  2. Security: Maintaining security is a primary focus of correctional facilities. This includes accounting for the presence and activities of each inmate throughout the day, ensuring that only authorized persons and products enter and exit the facility, and that contraband does not enter, is not otherwise obtained or manufactured. The most obvious example of a unique responsibility for correctional nurses is counting needles and syringes and accounting for each use. Others are ensuring access to inmates when medication is due (even on lockdown) and protecting patient confidentiality (not having medication lines that serve to identify the mentally ill or those with HIV disease for ridicule or extortion by others). Sometimes a facility will determine that for security reasons, not clinical, that all medication must be floated on water or even worse, crushed, impacting patient adherence, the time it takes to administer medication and in some cases the therapeutic effectiveness of the drug. Nurses need to confer with security on an ongoing basis so that security practices that compromise the therapeutic value of prescribed treatment are not put in place.
  3. Safety: The safety of inmates, staff and the general community is the other primary focus of correctional facilities. For correctional nurses this includes ensuring the safety of themselves and patients as well. A significant aspect of medication delivery is managing inmate behavior. This includes consistent practices for patient identification (two-part identification), checking that inmates don’t cheek or palm medication, providing privacy at the medication window or cart (prevent crowding). Often an officer will be assigned to escort the nurse or mange the medication line. Nurses need to engage the cooperation and assistance of this officer and be alert to their own behavior so that medication administration is conducted in a safe and efficient manner. The patient safety aspects are ensuring the cleanliness and hygiene of the medication delivery area to prevent transmission of infectious disease and monitoring conditions so that side effects from medications that make patients heat or light sensitive are prevented.
  4. Expanded role: Unless a correctional facility is large and has a number of specialized programs the health care program is likely to be staffed pretty simply without the support services nurses are used to in other health care settings such as pharmacy technicians, IV teams, respiratory therapists, inventory clerks and so forth. Nurses in correctional facilities routinely perform these roles instead and if there is assistance the nurse is responsible for their assignments and supervision. Nurses order medication from the pharmacy, arrange for refills and renewals, check for outdated drugs, receive, inventory and store medications and arrange for medication to be returned or properly destroyed. Nurse initiate treatment for patients via nursing standardized protocols that involve providing the patient with medication to treat the illness or manage symptoms. Nurses are the primary health care professional responsible to ensure that patients do receive medication as ordered and are expected to monitor patient adherence and solve problems with medication availability. Correctional nurses also assess the patient’s ability to manage their own medication if the facility has a self-medication or “Keep on Person” (KOP) program and to provide education or other assistance to support the inmates in providing their own care.
  5. Greater volume and scope: Because correctional nurses are responsible for the health needs of the entire population housed at one or more facilities they are generalists in nursing practice not specialists. Medications may be administered by a nurse or other personnel supervised by the nurse so that the inmate is directly observed when taking medication. Inmates may also be provided with a supply of medication by a nurse to take by themselves in a KOP or self- carry program. Nurses may also take medication to administer to patients in restraints, seclusion or housed in a high security setting for disciplinary or protective reasons. Nurses may give some medication under rules that allow for involuntary administration to patients with mental illness. In some correctional facilities nurses may be expected to use PICC lines or other specialized equipment or procedures to administer medication. The volume of medication administered by a nurse in the correctional setting exceeds that in any other setting. One difference is that most patients on pill line would be responsible for taking these medications by themselves or with the assistance of family in their own home.
  6. Timeliness: Medication delivery and administration must take place in coordination with all of the other activities that compete for the time and availability of inmates. In one facility I recently visited medication administration was halted on a unit until the canteen delivery was finished. The nurse was stranded in the corridor for twenty minutes until canteen was over. When the nurse insisted that medications be administered and canteen delivery wait the inmates complained bitterly. This is just one example of the competition for time. These time pressures can affect the therapeutic effectiveness of the drug if given too close or far apart. If inmates go to work or court before nursing staff are on duty inmates may miss important doses. The volume of medication to be given can impact timeliness; if there are too many medications a nurse may feel pressure to short cut or abandon the five rights resulting in increased patient risk.

So what are your thoughts about the uniqueness of medication management in correctional nursing practice? What have I forgotten or you would describe differently? Is there anything discussed here that you disagree with because it is not unique to correctional nursing. Share your thoughts in the comments section of this post.

Are you interested in knowing more about this nursing specialty? If so, see our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

Photo credit: © Yannis Ntousiopoulos – Fotolia.com

References:

American Nurses Association (2013) Correctional Nursing: Scope and standards of professional practice. American Nurses Association. Silver Springs, MD.

James, D.J. & Glaze, L.E. (2006) Mental Health Problems of Prison and Jail Inmates. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mhppji.pdf

Maruschak, L. M., Berzofsky, M., & Unangst J (2015) Medical Problems of State and Federal Prisoners and Jail Inmates, 2011-12. U.S. Department of Justice, Officer of Justice Programs, Bureau of Justice Statistics. Accessed 6.16.2015 at http://www.bjs.gov/content/pub/pdf/mpsfpji1112.pdf

Correctional Nurse Goals for 2015: Expand Your Knowledge

2015 goals on digital tabletHealth care is advancing at the speed of light. We are expected to apply current evidence to our practice and understand the new technologies, medications, and treatments that are being implemented. It can be difficult to merely keep from sliding backward as the treadmill pace ever increases under our feet. That is why my final suggestion for correctional nurse goals for this year is to expand your knowledge about your practice and keep up with the latest developments. Here are a few ideas to get you thinking about ways to improve your foundational correctional nursing knowledge and keep up with changes in nursing practice. Links are provided for easy purchase or subscription.

A Foundational Book Shelf

Every serious correctional nurse should have access to these texts as they are the basis for our specialty practice.

Specialty Periodicals

Journals and magazines provide updates to changing practice and information on movements in the industry.

Ongoing Information Updates

Digital sources keep us posted on day-to-day changes and news of importance to our practice. Although you could go out and regularly check information websites, but I favor sources that collect up the top items and send them to my inbox for scanning. Here are a few of my favorites.

  • Academy Insider – This free weekly email newsletter from the ACHP aggregates correctional health care news and items of interest for those in our field.
  • Medscape for Nurses – Keep up with research and information in the general nursing field with this weekly synopsis sent to your inbox.
  • ANA SmartBrief – Professional news from the American Nursing Association. Keep current on what is going on in our profession.

I’m sure I didn’t include all the possible places for you to gain knowledge and stay on top of changes in our profession and specialty. Share your favorite sources in the comments section of this post.

Photo Credit: © Marek – Fotolia.com

Correctional Nursing Peer Review: Determining Discipline-Specific and Community Standards

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

There are four key components to the ANA definition of nursing peer review according to their published  Guidelines.

  • Practicing Registered Nurses
  • Assess, monitor, and make judgments about
  • Nursing care provided
  • Measured against professional standards of practice

Accepted professional standards of practice for correctional nurses, then, provide the basis for a nursing peer review program. The NCCHC standard C-02 focuses attention on the competence of the individual under review. The ANA places peer review centers on the complementary goals of quality and safety. Thus, a peer review process for correctional nurses that encompasses competent, quality, and safe care provision is recommended.  Three primary sources of community and discipline-specific standards for nursing peer review programs are outlined below.

ANA Correctional Nursing Scope and Standards of Practice

The American Nurses Association Correctional Nursing Scope and Standards of Practice (affiliate link) provide key professional nursing standards focused on the unique nature of the correctional nursing specialty. Therefore, they provide an excellent foundation for a nursing peer review program. The six Standards of Practice, in particular, provide competency statements appropriate for use in peer review. These standards follow the nursing process and include:

  • Assessment
  • Diagnosis
  • Outcomes Identification
  • Planning
  • Implementation: Coordination of care, health teaching and health promotion, consultation, prescriptive authority and treatment (Advanced Practice Nurses)
  • Evaluation

State Boards of Nursing – Nurse Practice Acts

Nursing practice is governed by state legislation. State boards of nursing then provide the guidance for the nursing profession through interpretation of the nurse practice act and by developing administrative rules or regulations that clarify practice act components. Although they vary among the states, nurse practice acts all contain the standards and scope of nursing practice under their jurisdiction. Here are some examples of practice standards common to most Nurse Practice Acts and follow the key elements of the nursing process

  • Nursing Assessment
  • Patient-centered Health Care Plans
  • Independent Nursing Judgments
  • Provision of Care (as ordered or prescribed by authorized health care providers)
  • Evaluation of Interventions
  • Patient Teaching
  • Delegation of Nursing Interventions
  • Patient Advocacy

Links to state nurse practice acts can be found on the National Council of State Boards of Nursing website along with a helpful article describing the standard factors of nurse practice acts.

Accreditation Standards that Address Nursing Clinical Practice

Many NCCHC accreditation standards address organizational structure and process but some address individual professional practice. Most come from Section E: Patient Care and Treatment. Those standards can be incorporated into a nursing peer review program. Here are a few examples of appropriate accreditation standards to consider:

  • Receiving Screening
  • Transfer Screening
  • Initial Health Assessment
  • Mental Health Screening and Evaluation
  • Nonemergency Health Care Requests and Services
  • Nursing Assessment Protocols
  • Discharge Planning
  • Infirmary Care
  • Intoxication and Withdrawal

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

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

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

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

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

What It Is

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

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

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

Practicing Registered Nurses

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

Assess, Monitor, Make Judgments

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

Nursing Care Provided

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

Measured against Professional Standards of Practice

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

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

What it Isn’t

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

Annual Performance Evaluation

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

Nursing Competency Checklists

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

Simulations Such as Man-Down or Disaster Drills

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

Continuous Quality Improvement Projects

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

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

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

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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

 

Minimizing liability in correctional nursing

Overburdened doctor at the hospital in the stressLitigation has been a major catalyst in the reform of the criminal justice system, including the delivery of health care. Correctional nurses can expect to be involved in litigation involving health care during their professional career in this specialty practice area. Being familiar with the legal system particular to correctional health care, regulations and other information about the nurse practice act, as well as the profession’s code of ethics assist nurses in steering through the liability landscape (Moore 2013).

I recently reviewed an article describing a study of nurses practice insurance claims. What really caught my attention was that correctional health was one of the specialty areas included in the analysis. The results were very interesting and are summarized here.

CNA HealthPro and Nurses Service Organization (NSO) analyzed nurses professional liability claims which had been closed between 2006 and 2010 to identify patterns or trends in liability and to make recommendations to both minimize exposure and promote patient safety (Benton & Flynn 2013). This analysis included 516 liability claims and another 1,127 claims for defense against allegations made to regulatory boards. Finally, a survey was conducted of 1,617 nurses who had experienced a liability claim loss between 2006 and 2010 and a random matched sample of nurses who had never had a claim to identify demographic and workplace factors that affect risk exposure. The analysis was limited to registered nurses (RNs) and licensed practical or vocational nurses (LPN/LVN). Please note that a similar analysis was completed in 2012 for advanced registered nurse practitioners (ARNPs) and can be obtained at their website.

Professional liability claims involving nurses in correctional health care are a small proportion of total closed claims and the average indemnity cost in this field was less than the average for all claims. The table below depicts how nurses’ liability in correctional health compares to other practice specialties in terms of closed claim experience.

Nursing specialty % of closed claims Average paid indemnity
Correctional health 3.1 $144,701
Obstetrics 10.3 $382,353
Behavioral health 1.7 $151,944
Adult med/surg 40.1 $143,969
Emergent/urgent care 9.7 $141,832
Community health/hospice 8.9 $138,452
Gerontology 18 $100,294
Overall 100 $161,501

Claims involving scope of practice, assessment and monitoring had the highest average indemnity payments consistent with the significant effects these aspects of practice have on patient safety. Closed claims regarding nursing care or treatment were more prevalent but had a lower average payout. The work profile survey showed that lower indemnity payments were associated with nurses who reported more continuing education, working in an organization that had a policy for disclosing errors and who were comfortable asking managers for help.

The risk control recommendations made as a result of the analysis are similar to those made by Jacqueline Moore in Chapter Three of the Essentials of Correctional Nursing. The recommendations from both these sources are consolidated here:

1. Make sure your individual practice is consistent with the state nurse practice act and the organization’s policies and procedures.

  • Request and review a copy of the nurse practice act from the state regulatory board.
  • Review your organization’s policies and procedures regularly.
  • If the organization’s policy and procedure differ from the state nurse practice act bring this to the attention of your manager. Until clarified follow the directive which is the most restrictive. In other words, the organization can limit your practice in the work setting but cannot assign responsibilities that are broader than the nurse practice act.
  • Know the steps you are to take within your organization if you are given an assignment outside the lawful scope of practice or your personal competence to perform.
  • Do not accept assignments that you are not competent to perform.

2. Ensure communication is professional, accurate, respectful, inclusive, complete, appropriate and timely.

  • Determine the patient’s primary language or communication preferences and arrange translation or other accommodations to ensure the patient understands and agrees with the plan of care.
  • Exchange key information whenever responsibility for the patient is transferred from one caregiver to another or from one setting to another.
  • Do not criticize a provider in the presence of a patient or in documentation in the health record.

3. Maintain clinical competencies relevant to the needs of the population served and standards of practice for correctional nursing.

  • Attend relevant classes, in-service and continuing education. Maintain copies of certificates or other evidence of attendance.
  • Participate in peer review and reflective practice exercises.
  • Subscribe to journals, websites and other means to stay up to date with the literature that pertains to correctional nursing such as this blog post and Correctional Nurse.net.
  • Join professional organizations such as the American Nurses Association, the International Association of Forensic Nurses, the American Correctional Health Services Association, the Academy of Correctional Health Professionals, and the American Corrections Association.

4. Nurses are in the prime position to prevent harm to the patient and are expected to advocate for the patient’s wellbeing.

  • Invoke the chain of command as necessary to focus attention on the patient’s status or when there is a change in condition.
  • Ensure timely attention to patient needs and implementation of the plan of care.
  • Persist in communication and follow-up regarding the patient until a satisfactory resolution is achieved.
  • Address communication issues that deter use of the chain of command including identification of individuals who ignore, bully, retaliate or intimidate when chain of command is accessed.

Kathy Page, a colleague of ours, summed this subject up in a quote from the Essentials of Correctional Nursing “During the years reviewing malpractice cases that took place in correctional settings, most of the litigation was due to nurses not advocating for the patient, resulting in a delay in treatment. This includes nurses being judgmental in their charting (e.g. “malingering, drug seeking”), resulting in lack of access to care. Also, nurses’ failure to follow the provider’s orders for medications and treatments resulted in withholding or lack of care” (page 53).

In publishing the results of this claims analysis, the authors suggest that nurses be inspired to examine their practice to identify the recommendations for change most likely to reduce liability risk using this self-assessment tool developed as part of the full report.

Are these the results you expected? What recommendations do you have to reduce liability for nursing practice in the correctional setting? Please share your thoughts by replying in the comments section of this post.

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

References

Benton, J.H. & Flynn, J. (2013) Identifying and minimizing risk exposures affecting nursing practice to enhance patient safety. Journal of nursing Regulation 3(4):4-9.

Moore, J. (2013) Legal considerations in correctional nursing in Schoenly, L. and Knox, C.M. (eds.) Essentials of Correctional Nursing. New York, NY: Springer Publishing.

 

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