Nursing Sick Call Part 3: Use and Misuse of Protocols

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Photo credit:© Dmitry– Fotolia.com

Medication Adherence

Знак вопроса из медицинских таблетJessie has put in a sick call request because she is depressed and anxious.  You see her later in the day; she is worried about her children, who are under the care of their aunt while Jessie is incarcerated. She is unable to sleep, tearful and was sanctioned recently for not following orders. She is having difficulty getting along with her cellmate and prefers to stay in the corner of the dayroom.  You note in her record that Jessie has diagnoses of schizoaffective disorder, asthma and hypertension.  She takes several different medications and misses taking them about half of the time.  Jessie uses sick call frequently and has declared several medical emergencies for chest pain and shortness of breath; later diagnosed as anxiety. Jesse missed a recent mental health appointment and claimed she was not notified. She unsure about her work and program assignments and her appearance at the sick call is disheveled.

This is a classic example of a patient seen in the correctional setting; one who has a chronic mental health condition, comorbid chronic health problems and a likely history of substance abuse, who is only partially compliant with treatment. How many times have you wondered what else you might do to better support her and other patients like this to adhere to the plan of treatment?

The first step is to congratulate yourself that you identified non-adherence to treatment as a primary reason for the symptoms she is experiencing. What would Jessie’s clinical condition be like today if she were taking medication as prescribed, keeping her appointments with mental health providers and engaged in work and other program assignments? When you ask Jesse why she is not taking her medication her answer is vague. She professes to have a good relationship with the psychiatric nurse practitioner but cannot tell you what medications she is prescribed or why.

According to the World Health Organization (Sabaté 2003) approximately 50% of patients with chronic illnesses do not take medications as prescribed. Failure to take medications as prescribed is associated with poor patient outcomes, relapse, increased mortality and increased hospitalization (O’Malley 2013). Adherence is defined as the extent to which a person’s behavior corresponds with the recommendations for treatment to which the patient agreed. Adherence is complex, involving the patient’s knowledge, beliefs and attitudes, and their relationship with health care providers. Adherence also changes over time and may vary from day to day. The nature of the treatment itself, health care provider behavior and the system that provides the patient care impact adherence.

One of the most important factors affecting adherence among inmates is the patient’s experience of symptom relief (Mills et al. 2011, Ehret et al. 2013). In Jessie’s case, the anxiety and depression she is experiencing probably is because she is missing half of her medications. Several studies report good adherence rates among prisoners because of directly observed therapy (Gray et al. 2008, Westergaard et al. 2013, Saberi et al. 2012). However, even with directly observed therapy, inmates miss taking their medication because the request for refill was not made timely, the inmate was asleep or not present at the time medication was administered, the inmate forgot or was experiencing unwanted side effects (Mills et al. 2011, Ehret et al. 2013).

Viewing the patient as solely accountable for adherence is considered an uninformed and destructive model. Experts suggest instead that helping patients’ increase adherence would have a greater effect on health outcomes than any other specific medical treatment (Brown & Russell 2011, Sabaté 2003).  In an expert guideline series on adherence two first-line interventions were recommended:

1. Symptom and side effect monitoring

2. Medication monitoring and environmental supports

Listed below are specific actions that can be taken which are consistent with these two interventions. They provide guidance about how to assist our patient, Jessie.  Monitoring and support of patients to improve adherence are independent functions and within the scope of practice for registered nurses.

Symptom and side effect monitoring

Medication monitoring and environmental supports

  • Monitor closely for symptom response using a daily checklist or chart
  • Institute directly observed therapy
  • Increase frequency of contact
  • Provide reminders to take medication
  • Address side effects promptly
  • Provide reminders to get medication refills
  • Consider how distressing the side effect is for the patient
  • Target support to address barriers
  • Provide information about how to manage side effects
  • Increase visit frequency to monitor for relapse
  • Simplify the medication regime
  • Involve family or other social support
  • Consider the patient’s preference for dosing regime

(Velligan et al. 2010)

Poor adherence is due to multiple factors and requires several concurrent strategies to effect change. The goal of our interventions is not adherence, per se, but to achieve the best possible outcome for the patient. Involving the patient in the identification of the outcome she wants to achieve will provide clarity and motivation for the patient. Tailoring the medication experience, as much as possible, to the patient’s goals will improve their adherence.

The next post will describe the various factors affecting adherence among our patients and provide more strategies which have evidence to support their use to improve adherence. Until then, we invite you to tell us about the most challenging aspects of supporting patient adherence to prescribed medication in your setting?  Please share your opinions by responding in the comments section of this post.

Read more about monitoring and supporting patient compliance with prescribed medication in Chapters 6 and 12 in the Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

References: 

Brown, M. T. & Bussell, J.K. (2011) Medication adherence: WHO cares? Mayo Clinic Proceedings 86 (4) 304-314.

Ehret, M.J., Barta, W., Maruca, A., et al. (2013) Medication adherence among female inmates with bipolar disorder: results from a randomized controlled trail. Psychological Services, 10 (1), 106-114

Gray, R., Bressington, D., Lathlean, J. & Mills, A. (2008) Relationship between adherence, symptoms, treatment attitudes, satisfaction, and side effects in prisoners taking antipsychotic medication. The Journal of Forensic Psychiatry & Psychology, 19 (3), 335-351

Mills, A., Lathlean, J., Forrester, A., Van Veenhuyzen, W., & Gray, R. (2011) Prisoners’ experiences of antipsychotic medication: influences on adherence. The Journal of Forensic Psychiatry & Psychology, 22 (1) 110-125

O’Malley, P. A. (2013) Medication adherence and patient outcomes. Part 1: Why patients fail to take prescribed medications. Clinical Nurse Specialist, 227-228

Sabaté, E., ed. (2003) Adherence to Long-Term Therapies: Evidence for Action. Geneva, Switzerland: World Health Organization. Accessed 11/20/2013 at http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf

Saberi, P., Caswell, N.H., Jamison, R., Estes, M. & Tulsky, J.P. (2012) Directly observed versus self-administered antiretroviral therapies: preference of HIV-positive jailed inmates in San Francisco. Journal of Urban Health 89 (5) 794-801

Velligan, D.I., Weiden, P.J. & Sajatovic, M., et al. (2010) Strategies for addressing adherence problems in patients with serious and persistent mental illness: recommendations from the Expert Consensus Guidelines. Journal of Psychiatric Practice 16 (5) 306-324

Westergaard, R.P.; Spaulding, A. C., Flanigan, T.P. (2013) HIV among persons incarcerated in the USA: a review of evolving concepts in testing, treatment and linkage to community care. Current Opinion in Infectious Disease 26 (1) 10-16

Photo credit:© Sylverarts -Fotolia.com

Developing Expertise in Clinical Judgment

feedbackLast week we left you with the question “Can you teach nurses good clinical judgment?”  We received several thoughtful responses over the week. One of these was the question ” If good clinical judgment is the product of the individual’s combined experience, knowledge, attitudes, and beliefs what are the best practices to teach nurses this essential skill?”

Take a moment to consider your nursing in-service and continuing education experiences recently. Many times these important clinical training sessions are filled with information about assessment, interventions, coordination of care and facility policy. The experience often consists of primarily one way communication from the instructor to the student. Application of the material is measured by the nurse’s ability to perform the clinical skill according to facility policy, procedure and protocol.

To develop or improve clinical judgment nurses must be engaged to actively think and apply the information. The educational experience should involve opportunities for participants to think about the material and use it through interactive dialog and probing questions.  One technique we have had good success with is the use of case examples with questions designed to support nurses’ critical thinking.  Questions that support critical thinking ask the nurse to describe what they were thinking and feeling about a clinical situation and how those assumptions contributed to a conclusion about what was going on with the patient.  The nurse’s reasoning process is the focus of learning and development not their skill performing a procedure or accuracy in drawing the “right” conclusion.

Mind mapping is another tool that can help develop clinical judgment. It is a creative method nurses can use to display information and show how it connects together. Developing an algorhythm or decision tree that guides a nurse through a response to a problem, such as chest pain for example, is another option. The key point here is that the individual nurse develops the map or decision tree to show how they are organizing information and reflecting on the situation.

Reflective practice is another activity that encourages development of clinical judgment. Reflection on an actual clinical experience can yield a wealth of wisdom for the nurses involved. By guiding the discussion toward analysis and synthesis of information, the experience can expand both individual and group learning. Another example of reflection is to ask nurses in orientation and mentoring to keep a journal of their patient experiences and then review these entries periodically to guide discussion into deeper meanings of assessments or a better understanding of the variation and nature of the correctional healthcare setting. For more information see a previous post about reflective practice.

A final approach to development of clinical judgment is simulation. Simulation can be used to mimic common man-down situations or other presentations of important clinical events to encourage staff to think about the factors that they were aware of and that influenced the various decisions made. Simulation allows nurses to gain practice experience in a safe clinical environment.

A common thread throughout all these activities is the emphasis on thought processes, inquiry and reasoning. This can take some guidance, as nurses are more likely to focus on the “how” and “what” to do rather than the why. Redirecting questions to engage staff in truly thinking about their thinking and the reasoning behind their decisions can be difficult to sort out, but the hard work pays dividends.

SO, the good news is that correctional nursing clinical judgment CAN be taught and developed. It involves the nursing process and critical thinking. Finally, it is influenced by both the nurse’s background and the patient’s typical pattern of responses. Read more about developing nurses’ clinical judgment in Essentials of Correctional Nursing, Chapter 19: Professional Practice. Order your copy directly from the publisher at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4 .

Use promotional code AF1209 for $15 off and free shipping.

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Healthy Workplace = Quality + Patient Safety

Regulation of professional nursing practiceA few weeks ago we summarized features in the new edition of the Correctional Nursing: Scope and Standards of Practice (ANA, 2013).  The scope and standards are described first, as the foundation for professional nursing practice regulation because they define the specialty for nurses as well as the public. The are broad statements about the practice of the profession that transcend geographic location, type of employer and population served. The nurse practice act in the jurisdiction where the nurse is licensed provides the second level of specificity and guidance related to practice.  The employer, organization or institution  provides the third level of specificity by establishing policies, procedures and a work environment that supports professional nursing practice.  The final level in the regulation of professional nursing practice is the individual nurse who is responsible and accountable for their competence and nursing decisions (White & O’Sullivan, 2012).  This description is depicted in the diagram on the left of this post.

There is a strong link between work environments that support professional nursing practice, quality of care and patient safety.  The American Nurses Association (ANA), The Joint Commission (TJC 2012), the International Council of Nurses (ICN 2007) and the American Association of Critical-Care Nurses (AACN) are organizations that have used evidenced-based research to develop resources and establish standards for the workplace that support quality and patient safety. What are the characteristics of work environments that support nursing practice?  The AACN standards align with the core competencies for health care professionals recommended by the Institute of Medicine (IOM). The AACN provides many resources on the web and so their six standards for the healthy workplace were selected to highlight along with examples here:

  1. Nurses are as proficient in communication as they are in clinical care. Examples of practices that improve nurses’ communication skills include nursing grand rounds, assistance to publish articles and present at conferences.
  2. Nurses are relentless in pursuit of true collaboration. Examples of practices that improve nurses’ skills in collaboration include the development of nurse to nurse collaboration such as rapid response teams, development of clinical practice protocols, and participation in CQI activities.
  3. Nurses make policy, direct and evaluate clinical care, and lead organizations. Examples of practices that support nurses’ participation in the development of policy and other aspects of organizational leadership include membership on interdisciplinary committees such as Pharmacy and Therapeutics (P&T), Continuous Quality improvement (CQI), Ethics and Infection Control and other committees responsible for guidance regarding clinical patients care.
  4. Staffing effectively matches patient needs and nurse competencies.  An example of this are systems that acknowledge nurses for clinical expertise in direct patient care by rewarding advancement in clinical education and certification.
  5. Nurses are recognized and recognize others for the value they bring to the organization. Examples of practices that support meaningful recognition include clinical ladders, identification of expert nurses and publication of nurse’s advancement clinically.
  6. Nurse leaders authentically live and engage others in the achievement of a healthy work environment. Examples of practices that support authentic leadership include participation in key decision making forums, access to essential information and the authority to make necessary decisions regarding the professional nursing workforce (AACN, 2005; Vollers, et.al. 2009).

One of the distinguishing features of correctional nursing and indeed one of the challenges in the practice of correctional nurses is that prisons, jails and other correctional facilities do not have a health care mission but instead a mission of safety and security. A major role for correctional nurses is to negotiate with the correctional environment to support appropriate patient care delivered in ways that are consistent with the standards for professional practice. In order to support professional practice nurses must be knowledgeable of the state or licensing jurisdiction’s nurse practice act as well as the characteristics of work environments that are linked to quality patient care and patient safety such as the AACN described here.

What successes have you experienced supporting professional nursing practice while negotiating the differences in the mission of the criminal justice system and the delivery of health care?  Please share your experiences by writing in the comments section of this post.

For more on the topic of environments that support professional nursing practice in the correctional setting see Chapters 4, 17 & 19 of the Essentials of Correctional Nursing. The text can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 and shipping is free.

References and Resources:

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

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.

International Council of Nurses (2007) Positive Practice Environments: Quality Workplaces=Quality Patient Care. Geneva (Switzerland): International Council of Nurses. Accessed 6/10/2010 at http://www.icn.ch/images/stories/documents/publications/ind/indkit2007.pdf

American Association of Critical-Care Nurses. Accessed 6/10/2013 at http://www.aacn.org/wd/hwe/content/resources.content?lastmenu=#articles

The Joint Commission. Improving Patient and Worker Safety (2012).  Accessed 6/10/2013 at http://www.jointcommission.org/improving_Patient_Worker_Safety/

The American Nurses Association.  Accessed 6/10/2013 at http://nursingworld.org/MainMenuCategories/WorkplaceSafety/Healthy-Work-Environment/Work-Environment

Photo Credit:  American Nurses Association Model for Regulation of Professional Nursing Practice

The New Scope and Standards of Practice for Correctional Nursing

NSPS'10_Fig 4  Nursing Process  StdsOn May 27, 2013 the American Nurses Association (ANA) published the new edition of Correctional Nursing: Scope and Standards of Practice (2013).  These are broad parameters defining our specialty area of practice that transcend geographic location (south, east, west, midwest), type of employer (public/private, jail, prison, detention center), and the various populations served in correctional health care (sentenced, unsentenced, juvenile, female etc.).  The standards define who, what, where, when, why and how of nursing practice (ANA, 2010, p.2). The ANA standards are used to:

  • inform nurses and others about correctional nursing practice
  • guide nurse’s day- to- day practice and resolve conflicts
  • develop policy and procedure and other governance of  professional practice
  • reflect on professional practice and plan improvement

Correctional nursing was first acknowledged as a specialty practice by the ANA in 1985. At that time, the first standards for the specialty were published as: Standards of Nursing Practice in Correctional Facilities. Since 1985 the standards for correctional nursing have been revised four times.  This revision was the result of collaboration among seventeen correctional nursing leaders representing various settings and organizations. Input from correctional nurses was sought at various conferences, by survey, and during a public comment period over a period of eighteen months. The input from practicing nurses was incorporated into the description of the scope of correctional nursing practice.

Patricia Voermans MS, RN, APN, CCHP-RN, chairperson of the task force described this edition as “expanding the description of the patient population and addressing the challenges of delivering evidenced based care in the correctional setting.  It also discusses the evolving role of nurses in coordinating care, developing policy and continuing leadership in correctional health care” (April 22, 2013).

Correctional nursing is defined as… “the protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, advocacy, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system” (ANA, 2013).  It is the location of nursing care, with its unique population demographics, environmental constraints and ethical dilemmas that defines our specialty practice (Voermans, Schoenly & Knox, April 22, 2013).

There are sixteen standards of correctional nursing practice in the new edition. The first six standards delineate the steps used in the nursing process. The next ten standards define the professional role of nurses in the correctional setting. This edition emphasizes the importance of communication and collaboration in the delivery of safe and effective patient care. The areas covered by the standards are listed in the table below.

Table 1: Scope & Standards of Practice for Correctional Nurses
     Practice      Professional   Performance
1. Assessment 7. Ethics
2. Diagnosis 8. Education
3. Outcomes Identification 9. Evidence-Based Practice and Research
4. Planning 10. Quality of Practice
5. Implementation 11. Communication
6. Evaluation 12. Leadership
13. Collaboration
14. Professional Practice Evaluation
15. Resource Utilization
16. Environmental Health

Correctional nursing: Scope and standards of practice. (2013). 2nd Edition. Silver Spring, MD: American Nurses Association.

Each standard is further defined by the competencies registered nurses and graduate-level prepared or advanced practice registered nurses (APRN) are expected to demonstrate in meeting the standard. Competency is defined as the integration of knowledge, skills, abilities and judgment needed to achieve an expected level of performance (White & O’Sullivan 2012). The registered nurse is responsible for maintaining professional competence and accountable for each of the decisions made in their nursing practice.

Standard 16 on Environmental Health is a new standard and requires the correctional registered nurse to practice in an environmentally safe and healthy manner. Environmental health is the assessment and control of factors in the environment that can potentially affect health.  Two of the competencies of the correctional registered nurse in this area of practice are:

  • Knowledge of environmental health concepts, with implementation of environmental health strategies.
  • Reducing environmental health risks for workers, patients, and others in the correctional setting.

To experience how the ANA standards are applied in day to day practice they have been interwoven into every chapter of the Essentials of Correctional Nursing which can be ordered directly from the publisher. If you use Promo Code AF1209 the price is discounted by $15 off and shipping is free.

Copies of Correctional Nursing: Scope and Standards of Practice, 2nd Edition (2013) can be ordered from the ANA at http://nursesbooks.org/Homepage/Hot-off-the-Press/Correctional-Nursing-2nd.aspx. When you receive your copy of the new edition of the ANA standards one suggestion is to assess your competency to practice in conformance with each of the standards.  Select one or more areas that you would like to improve and develop a plan to do so.

We will share more about how to use the standards in correctional nursing practice in future posts.  In the meantime what experiences have you had applying the ANA Correctional Nursing: Scope and standards in your daily practice?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post.

References:

American Nurses Association. (1985). Standards of nursing practice in correctional facilities. Washington, DC: American Nurses Association.

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

Schoenly, L. (2013). Overview of Correctional Nursing. In Schoenly, L. & Knox, C. Essentials of Correctional Nursing. New York: Springer.

Voermans, P., Knox, C., Schoenly, L. (April 22, 2013). Correctional Nursing: Applying the New Scope and Standards of Practice. NCCHC Spring Conference 2013, Denver, Co. Accessed May 8, 2013 at http://ncchc.sclivelearningcenter.com/index.aspx?PID=4622&SID=172421

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.

Photo Credit:  American Nurses Association NSPS’10_Fig 4  Nursing Process  Stds

Caring in Correctional Nursing: Another Example

This guest post by Patricia Rolling, RN, is taken from her submission to the 2013 Correctional Nursing Celebration Essay Contest.

sunflowers grow in the prison in front of the barbed wireI remember on my first day of nursing school my classmates and me being asked what type of nursing we wanted to practice. I remember some of my classmates answering “pediatrics” and “mother/baby”; after all, babies are cute. The adrenalin junkies in my class answered “ER” or “ICU”. What I don’t remember is answering “correctional nursing”. That’s probably because I didn’t. I didn’t know what correctional nursing was. Fast forward to today and I can’t imagine myself doing anything else. All too often, nurses that choose to practice correctional nursing are viewed by their peers as misfits that somehow can’t make it anywhere else. This is so untrue!

It takes a special level of caring to be able to provide care for those people that society has deemed unworthy.   There is more to nursing, though, than just caring and the prison environment makes some of those other aspects a bit more challenging. Privacy is virtually impossible to come by in an environment where safety is and must be the primary objective. The nurse/patient relationship works best when it is one of equality and mutual respect. The inmate/correctional officer relationship by its very nature is one of inequality and hierarchy.  B. Jaye Anno states in her book Correctional Health Care   “The purpose of medicine is to diagnose, comfort, and cure; the purpose of correctional institutions, although sometimes rehabilitative, is to punish through confinement.” (B. Jaye Anno, 2001) In order for these two diametrically opposing concepts to coexist, a correctional nurse must have a strong, personal and ethical commitment to the patients she cares for. She must be committed enough to her patient’s welfare to be able to advocate for them when their needs and those of the correctional personnel are in conflict with one another.

The third element of Watson’s Transpersonal Caring states, “Care is authentic presence where the nurse honors the patient’s dignity and vulnerability.” Nowhere is this more evident than when working in the Receiving Room. In Delaware, where I practice, we have a jail/prison system. What that means is that because there are no county jails, when I see a patient in Receiving they have been in the custody of the State or local police for perhaps 6-8 hours. They are feeling scared, overwhelmed and very vulnerable. Within the few short minutes after their arrival and before they meet with me, they have been fingerprinted; strip searched and assigned a number that will effectively serve as their identity for the remainder of their stay in prison. In other words they have been stripped of their human dignity. Then I come along and ask them very personal questions such as have they ever been the victim of sexual or physical abuse, as well as asking whether they drink alcohol or do drugs. In order to get the honest responses that will allow me to render the appropriate level of care, I have to quickly establish a rapport that makes it clear that I can be trusted. I have a very short period of time to make it understood that I am NOT security and that what they say to me will be held to the same level of confidentiality as if we were in a hospital or a private doctor’s office. Since I am the first person from the medical department that they have any contact with, it is imperative that I set into motion a relationship based on honesty and respect that will last as long they are in custody. At the same time I have to make it clearly understood that I will not be manipulated or used by them to achieve their own personal goals. It is definitely a fine line to be delicately trod.

I have learned, and am still learning, how to give the level of caring, compassionate and medically appropriate care that I want to give and that my patients deserve to be given while also maintaining the necessary professional distance and keeping the necessary degree of personal safety. Which brings us back to the original question, “Do Correctional Nurses Care?” While I can’t answer for any other correctional nurses I can say unequivocally “This correctional nurse does”!

RollingPatricia Rolling, RN, is a relatively new correctional nurse having started at James T Vaughn Correctional Center in Smyrna Delaware just over a year ago. She has rotated through several positions at the facility and is currently the 11p-7a clinic nurse. She most enjoys working in intake where she is able to set the stage for the new inmate’s relationship with the correctional medical staff. Her next goal is to attain CCHP certification this summer.

Read more about caring in correctional nursing practice in Chapter 2: Ethical Principles for Correctional Nursing from Essentials of Correctional Nursing. Order your copy directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.

Photo Credit: © vipatter – Fotolia.com

The Five Rights of Delegation

Question listThe post last week included a case example about a licensed practical nurse (LPN) responding to a medical emergency after an altercation between two inmates. The LPN determined that neither inmate required further medical attention. Later in the shift one of the inmates was taken to the emergency room after being found unresponsive in the cell. The inmate subsequently died of the head injury that was sustained in the altercation. This example highlighted the registered nurse’s role in the assignment and supervision of patient care. Correctional nurses use their knowledge of state regulations defining the scope of practice for personnel assisting in the delivery of patient care as well as the employers’ expectations (job description, post orders, policy and procedure) to assign and supervise these personnel.

The American Nurses Association (ANA) describes correctional nurses as responsible for direction of patient care including the assignment and delegation of tasks to others (2007). These responsibilities are unchanged in the draft of the 2013 edition of the Correctional Nursing: Scope and Standards of Practice which was posted at http://www.nursingworld.org/Comment-Correctional-Nursing.html.aspx. Delegation has been described as an essential skill and yet is one of the most difficult responsibilities of a registered nurse. It is a complex process that requires sophisticated clinical judgment about the patient care situation, the competence of staff and the degree of supervision required (Weydt, 2010; NCSBN, 2005).

There are many resources available to help nurses build skill and competency in delegation of patient care tasks. The state board of nursing is an excellent first resource as well as the National Council of State Boards of Nursing (NCSBN) website which can be accessed at https://www.ncsbn.org. A resource suggested in the Essentials of Correctional Nursing is a framework for delegation from the NCSBN referred to as the Five Rights of Delegation (1997). These are discussed in relation to the case example from last week’s post.

1. Right Task: The nurse makes an assessment of the patient or a group of patients and determines that an activity can be delegated to a specific member of the health care team. Knowledge of state practice acts and agency directives are essential when making decisions about what patient care tasks can be delegated. In the case example the registered nurse’s decision to have the LPN respond to the medical emergency was problematic because the LPN was required to assess and make a complex clinical decision about the inmate’s need for medical care.

2. Right Circumstances: The nurse’s assessment of the patient or group of patients also identifies the health care need(s) to be addressed by the delegated task(s) and the goal or outcome to be achieved. The nurse’s decision about which task(s) to delegate matches the staff’s competency and level of supervision available. The registered nurse in the case example did not assess the patient’s needs or identify the outcome to be achieved by the task that was delegated to the LPN. The nurse also made no judgment about what level of supervision or monitoring would be appropriate in the circumstance.

3. Right Person: The registered nurse considers the skills and abilities of individual personnel in making decisions about delegation of tasks. The registered nurse works with each member of the team to improve performance and implements remedies when performance is below standard. In the case example the LPN had considerable experience responding to medical emergencies at the correctional facility and had worked in the emergency department at the local hospital. The registered nurse did not understand that monitoring or supervision of the LPN’s performance was required as part of the state practice act and expected by the employer.

4. Right Communication: The registered nurse communicates specifically what, how and by when delegated tasks are to be accomplished. Communication includes the purpose and goal of the task, limitations and expectations for reporting. In the case example there was no meaningful communication that took place between the RN and LPN. The LPN was not expected to communicate assessment data to the nurse and no limitations on the LPN’s actions were stipulated. The LPN reported the conclusion that both inmates were “okay” but was asked no follow up questions by the RN to amplify the basis for the decision. The LPN did not communicate with the registered nurse when the inmate was later found unresponsive even after the “on call” physician was called.

5. Right Supervision: The registered nurse monitors and evaluates both the patient and the staff’s performance of delegated tasks.  The registered nurse is prepared to intervene on behalf of the patient as necessary and provides staff feedback to increase competency in task performance. In the case example the RN had several opportunities to monitor the patient’s care and to intervene but failed to do so. The nurse was unaware of the responsibility to monitor and supervise the LPN in the performance of the delegated task. The nurse said that the LPN always provided the response to medical emergencies and did not think the RN could alter this “assignment”.

Conclusion of the Case Example: The agency policies, procedures and the description of job duties were consistent with state practice guidelines but were too general. The nurses were not familiar with the nurse practice act and had simply continued practices on the evening shift that had been in place at the time, including staff defining the duties that they were most comfortable performing. The “after action” review resulted in increased staff knowledge of the nurse practice act, coaching of the nurses on delegation of tasks, and increased communication between staff on shift about the goals and process of patient care.

Your thoughts about this subject are important to us. Have you had experience clarifying nursing scope of practice in correctional health care?  What tools or resources did you find most helpful? Please share your experience and advice in the comments section of this post. For more information and discussion about correctional nursing order your copy of the Essentials of Correctional Nursing directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

References:

American Nurses Association. (2007). Corrections Nursing: Scope and Standards of Practice. Silver Spring, MD: Author

National Council of State Boards of Nursing and the American Nurses Association. (2006). Joint Statement on Delegation. Retrieved December 31, 2013 at https://www.ncsbn.org/Delegation_joint_statement_NCSBN-ANA.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

Weydt, A. (May 31, 2010). Developing delegation skills. OJIN: The Online Journal of Issues in Nursing. Vol. 15, No. 2, Manuscript 1 

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Scope of practice, assignment and delegation of patient care in the correctional setting

Care teamIt is a weeknight shift at a 2000 bed male medium custody correctional facility. The health care staff on duty consists of a registered nurse (RN) who is “in charge” of the shift, three licensed practical nurses (LPN) and a clerk. The ten patients in the infirmary upstairs are cared for by a registered nurse, an LPN and a nursing aide.  A medical emergency is called following an altercation between two inmates and the assigned LPN responds to the housing unit. The LPN determines that the men involved are okay and each is taken to segregation. Later one of the men is found unresponsive in his segregation cell. The LPN calls the on-call physician who orders the inmate transported by emergency vehicle to the local hospital where he dies later of a head injury sustained during the alteration.

Were staff appropriately assigned and supervised on this shift? If the charge nurse asked your opinion about how the shift was managed what comments or advice would you offer? The nursing staff at the facility were so motivated by the experience that the “after action” review included consideration of the state nurse practice act. Nurse staffing and assignment practices at the institution were changed as a result.

Ambiguity in the scope of practice for practical or vocational nurses and unlicensed assistive personnel (UAP) as well as their supervision in patient care are among the most significant challenges of correctional nursing practice. This issue was first identified last spring when nurses discussed the draft revisions to the Corrections Nursing: Scope and Standards of Practice to be published by American Nurses Association in 2014. The problem was discussed more extensively at the National Conference on Correctional Health Care in October 2012. Correctional nurses are not alone in these concerns. The National Council of State Boards of Nursing, Inc. has documented wide variation among state practice acts and among employers in the scope of practice of vocational or practical nurses (2005).

A tragic patient outcome like the one described here can be avoided with attention to scope of practice, clear assignment and delegation and good communication between personnel.  The following are concrete steps that correctional nurses can take to begin to clarify and address concerns about patient safety related to the scope of practice of practical or vocational nurses as well as unlicensed assistive personnel.

1. Recognize that other personnel are necessary to achieve good patient outcomes. Correctional nurses are responsible for managing the health care of individuals who are incarcerated.  To do so nurses assign, direct and supervise others to ensure that appropriate, timely care is delivered as planned. These personnel may include other registered nurses, practical or vocational nurses, and unlicensed assistive personnel. The plan for delivery of care may also include emergency medical technicians and correctional staff. In hospice or palliative care programs inmate caregivers may be included as well. The support of these personnel enables the registered nurse to attend to more patients with complex care needs.  The registered nurse retains accountability for patient outcomes even when specific tasks of care delivery are the responsibility of others.

2. Be familiar with the scope of practice and regulations for registered nurses in the state where you are practicing. Correctional systems are not operated as health care organizations. Registered nurses must ensure that their practice is within the parameters allowed by state regulation because the correctional organization may be uninformed or naïve about the appropriate role or practice limitations of various health care personnel.  Also these regulations change so nurses should review the state practice act annually. Contact information for state boards is obtained at https://www.ncsbn.org/contactbon.htm.

3. Be familiar with the scope of practice and regulations of other personnel relied upon to deliver patient care in the setting.  In some states the nurse practice act also describes the scope of practice for practical or vocational nurses. It may also describe how and under what circumstances patient care can be provided by certified or unlicensed personnel. If not included in the nurse practice act, find and review other relevant information that defines the scope of practice for each of these types of health care providers allowed by state law or regulation.  The registered nurse needs this information to appropriately assign or delegate tasks to others.

4. Review the job description, policies, procedures and other written directives at your facility that delineate the roles and activities to be performed by health care personnel in the delivery of patient care.  This review is done to ensure that written directives of the agency are consistent with the state’s practice regulations and to identify more specifically how the nurse assigns, directs and supervises the delivery of patient care.  Any inconsistencies between the employer’s expectations and state law should be identified and clarified through the nursing chain of command.

Chapter 17 in the Essentials of Correctional Nursing describes the role of nurses in supervising and managing the delivery of patient care in the correctional setting and provides a case example for further discussion. Order your copy directly from the publisher. Use Promo Code AF1209 for $15 off and free shipping.

General guidelines published by the National Council of State Boards of Nursing (1997) for the types of activities that can be performed by LPN/LVNs or UAPs include those which:

  • frequently reoccur in the daily care of a patient or group of patients
  • do not require the exercise of nursing judgment
  • do not involve complex or multidimensional nursing process
  • the results are predictable or carry minimal risk
  • use a standardized and unchanging procedure.

Do you have concerns about scope of practice and the role of LPN/LVNs or UAP in your work setting? Share your thoughts in the comments section of this post.

References:

National Council of State Boards of Nursing. (2005) Practical Nurse Scope of Practice White Paper. Retrieved December 26, 2012 from  https://www.ncsbn.org/Final_11_05_Practical_Nurse_Scope_Practice_White_Paper.pdf

National Council of State Boards of Nursing. (1997) The Five Rights of Delegation. Retrieved December 26, 2012 from https://www.ncsbn.org/fiverights.pdf

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