Med Line Tips

Simple expressionist image of people with their hands in the air

Medication line can be daunting for nurses new to the correctional setting. The American Nurses Association Scope and Standards of Professional Practice describe medication administration as a defining feature of correctional nursing and make the point that while the methods of nursing in this setting may differ, the standards of practice remain the same (2013). The correctional nurse may administer medication to a line of 200 or more inmates who gather two, three or four times a day. In addition, the nurse may run med line from a medication cart stationed near the dining hall or by the rec yard or to roll the cart from housing unit to housing unit. Clearly this is not like how medication administration is done in most other clinics, emergency rooms, hospitals or nursing homes. Here are some tips from a previous post by Lorry to make running med line go more smoothly:

  1. Make sure the medication cart or area is stocked with the things you are likely to need including:
  • Patient medications
  • Medication administration records (MARS)
  • Pen, highlighter and notepad
  • Current drug reference book
  • Calculator
  • Pill crusher and packets if needed
  • Pill cups
  • Water and drinking cups
  • Waste receptacle
  • Keys needed to access the medication room, cart, and narcotics container

 2. Take these steps before med line:

  • Scan the MARS for any new medication orders, any new patients, that each MAR indicates whether the patient has allergies and if so, what the allergy is.
  • Check to see that any new medications are available (in the cart or medication room) and if not where it is in the process of getting dispensed and delivered.
  • If there are any medications, you are unfamiliar with check the drug reference.
  • Make any calculations you need to administer the correct dose.
  • Clean the surfaces of the cart and make sure that the water receptacle is washed and ready for use.
  • Perform hand hygiene.

3. Follow the steps each time at med line:

  • Following the same steps is called habituation and helps you not forget a step, if distracted. When you are consistent in practicing this way it is also easier to manage inmate behavior.
  • Use two forms of identification to ensure it is the right patient. Do not rely on your visual memory of what the patient looks like.
  • Locate the MAR corresponding to the patient’s name and identification.
  • Scan the MAR for medications due.
  • Locate the medication and check the medication name, dose, time and route against the MAR.
  • Put the medication in a cup.
  • Repeat for each medication that is due.
  • State the name of each medication to the patient as you prepare to put it into the cup. If it is a new medication confirm that the patient knows its purpose, major side effects or precautions.
  • Recheck the MAR and medications in the cup.
  • Ask the patient if they have any questions about the medications.
  • Watch the patient take the medication, watch for palming and check the patient’s oral cavity for cheeking. Beware of any distractions at this point; diversion is likely.
  • Have the patient put the medicine cup into the waste before leaving the medication cart or window.

When med lines are too long: Sometimes nurses are pressured to abandon the rights of medication administration (right patient, right medication, right dose etc.) in the interest of speed because there are too many inmates to medicate in the time available.  Here are some options to manage this problem without abandoning your accuracy and jeopardizing the patient’s safety.

  • Create a separate time and line for certain medications, like insulin, or those that have tight dosing schedules or certain groups of patients like those just starting a new medication, those on mental health medications etc.
  • Suggest establishing a self-administration program if one does not exist.
  • Deliver KOP medication in another line.
  • Spread patients who are on once daily dosing out among several med lines rather than all in one.
  • Collaborate with providers to reduce the volume of prescriptions and dosing. Can a medication be provided once a day rather than twice? Are there prescriptions that could be eliminated, treated with over the counter preparations, or delivered in long lasting form?
  • Suggest using the commissary or some way to provide over the counter medications other than med line.

What tips would you give to new nurses about passing medication in the correctional setting?  What solutions have you found for the problem of long med lines? Please share your tips and solutions with other correctional nurses by replying in the comments field of this post.

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

References not hyperlinked in the blog post:

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

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Is it time for a Change? If so, what’s next?

Occupation Job Careers Expertise Human Resources Concept

A friend of mine just sent an announcement for a position opening with the Washington Department of Corrections and asked if I would distribute it to prospective candidates. I said I would and so here it is-it is for the Director of Nursing a position responsible for standards of nursing practice at each of twelve prisons in the state of Washington. The prospect of recruiting for this position has made me think about who would be interested in a key leadership position like this? You may never have given it a thought and yet have many of the qualifications and expertise that are required.

The New Year is a time when many of us take stock of ourselves and make resolutions for the year ahead. Perhaps it would be a good time to consider your career plans as well? Human resource experts and job coaches recommend having a career map that identifies an individual’s career goal for the next three to five years. They also recommend reviewing and revising the map annually. Career planning gives nurses control over their own professional path and increases job satisfaction (Hall et al. 2004 and Chang et al. 2006). The steps to making a career plan are not complicated and each is described in the next several paragraphs.

  1. Understand yourself. Begin by assessing and listing out your strengths and weaknesses. What are the things you like to do and do well? How do you like to work and what types of work environments do you thrive in? Using myself as an example-I do best in environments where I can predict or anticipate to some extent what the day will be like and I like to work quietly and at a steady pace. The emergency room is not a place for me and I have the experience to know it! I also know that I like to work autonomously and don’t appreciate close supervision. It can be harder to identify weaknesses accurately. A suggestion is to think about this as the areas of practice that you want to develop expertise in. One way to help do this is to use a tool like the American Nurses Association Scope and Standards of Professional Practice for correctional nurses, which lists competencies for each of the standards.Finally describe in writing the kind of nursing practice you want to have three to five years from now. Some authors have suggested that nurses think too narrowly about their career options. As a correctional nurse you already are experienced finding jobs off the beaten path. Answer these questions: What do I want that is different in my career? What would I be responsible for? What kind of hours, days off and commute do I want? What type of boss, co-workers and team do I want? What type of organization and culture do I want to work in? Where do I want to live and what salary and benefits are wanted? Answering these kinds of questions helps to concretize your career goal and make it more specific to your needs and desires.
  2. Know the job market. Now that you have a more specific goal and description of your career goal for the next few years begin looking for organizations and positions that are available. Nearly all job opportunities are on line now so it is possible to research possibilities worldwide from the comfort of your home. The internet is also a source of information about organizations you may be interested in and professional associations provide valuable information about specialty areas of practice. One author suggested using You Tube as a resource to explore non-traditional careers in nursing. Identify organizations and professional associations that are recognized for an area of nursing practice that you are interested in pursuing and use these resources to identify potential mentors, professional contacts and learning opportunities. You should know the job market and professional landscape in the area of practice you are interested in even if you are not actively looking for another position at the moment. You may know someone who would be a good fit for the job or you may come across an opportunity to expand your knowledge or skills that you wouldn’t otherwise know about.
  3. Draw a map of the path to your goal. Start with your career goal and then lay out the steps to get there. The contacts and resources you developed in Step 2 can help you identify those steps. Perhaps you want to be the Chief Nursing Officer at a correctional facility or the whole state prison system as in the one Washington is recruiting for now. The recruitment announcement itself lists the types of experience they are looking for. Talk about your career goal with someone you consider a mentor and ask them to help you identify the steps that will build your knowledge, skills and experience. Many nurses are overly modest about their experience and fear failure when considering change. A mentor can help identify skills and experience you have already that with only modest enhancement would move you toward your goal. There are lots of resources on line about how to map a career, just type Career Map in the search line. Here is one resource and here is an example that University of Colorado Hospital developed for its nurses to show paths to various positions within the organization and the development resources available. A career map is really just a set of strategic steps to move from today toward the goal. Steps should identify ways to develop skills and competencies that were identified in step 1. A career map may include things like identifying a mentor or coach, taking classes, joining an organization, volunteering for certain experiences, applying for a position that provides experience necessary for the next professional position, getting certified in a specialty (like correctional nursing or nursing administration), and building a network of colleagues who know and support your career plan. By building the career map you may identify opportunities to grow in your current position that you were not aware of that will move you incrementally forward. Without a plan, professional growth and development is chaotic and may not contribute to your goal
  4. Focus and target opportunities. Now you have a clear picture of the type of professional practice you want to have in the near future and know the steps you are going to take to get there. You also are familiar with the field of organizations and professional associations and so as opportunities come up that are consistent with your map you are ready to take advantage of them to progress toward that goal. Even if you are perfectly happy today with what you are doing professionally having a career plan ensures that three years from now you are still as happy with your work.

What advice do you have for correctional nurses who are interested in career growth? Please share your advice by responding in the comments section of this post. Also the people in the Washington DOC would love to hear from you if you are interested in the position!

For more about management and leadership positions, as well as professional development in correctional nursing see Chapters 17 and 19 in our book the Essentials of Correctional Nursing. Order a copy directly from the publisher or from Amazon today! Happy New Year from both of us! Looking forward to new opportunities for all our blog post readers in the coming year!

References not hyperlinked in the blog post:

Chang P.L., Chou Y.C., Cheng F.C. Designing career development programs through understanding of nurses’ career needs. Journal of Nurses Staff Development 2006; 22 (5):246-253

Hall L.M., Waddell J., Donner G., Wheeler M.M. Outcomes of a career planning and development program for registered nurses. Nursing Economics 2004; 22 (5):231-238

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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!

 

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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

An overview of medication management in correctional settings

Isolated, whitespace, copyspace.

The roles and responsibilities of correctional nurses for medication management are broader in scope than other practice settings. In health care settings many other professional and support personnel contribute to delivery of patient care.  However in correctional facilities nurses are relied upon to deliver care without the availability of these other types of personnel. The result is that correctional nurses often work in professional isolation and may feel like they are in a foreign country (Muse, 2012). I think traveling in a foreign country is a good analogy for correctional nursing. Doing this well involves preparation by learning something about the sights to see, building skill using a little of the language, familiarizing yourself with the rules, particularly which side of the road people drive on and finding out how to avoid being robbed or harmed in some way. The thrill of correctional nursing, like the thrill of foreign travel, comes when you realize how much you are enjoying it, especially the independence of professional nursing practice in this field. This post is the first part of a guidebook for your journey managing medication in correctional settings.

State law, rule and regulation

State law serves as the basis for nearly all of the practices and procedures involved in medication management. Most nurses are familiar with the nurse practice act in their state. If not, this is the place to start by reviewing it for definitions and references to medication. The nurse practice act will be especially helpful in describing the training and supervision requirements if non-licensed personnel, such as nursing assistants, administer medication at the correctional facility.

The pharmacy practice act is the most important resource to review. These laws will define how to obtain, store, dispense and account for medication which are often the responsibility of nurses when there is no pharmacist on site.  Even if there is a pharmacist at the facility, being familiar with the law that governs their practice is helpful in understanding the recommendations pharmacists make about drug storage, packaging of medications and accountability.

The medical practice act provides important information about how a physician’s order for medication is lawfully carried out. The medical practice act also has information about how medical assistants and paramedics work as well as the requirements for training and supervision which need to be followed if these personnel are involved in medication management.

This is not interesting reading but it does provide information that nurses can use in determining the responsibilities of personnel for medication management. It also provides definitions and terminology to accurately communicate with the pharmacy that provides medication to the facility and with providers about implementation of orders. Finally it provides nurses a basis to knowledgably resist inappropriate requests from custody and other personnel not familiar with health care laws to carry out tasks that are inconsistent with state law.

Accreditation standards

The National Commission on Correctional Health Care (NCCHC) and the American Correctional Association (ACA) are organizations which accredit correctional facilities for providing services and programs consistent with national standards. The standards are also used by most correctional facilities in developing policy and practices even if accreditation is not sought. Both organizations have standards related to medication management which are summarized in Figure 1. This list is a handy description of all the moving parts and pieces of medication management in correctional settings and nurses are involved in all of these components. This list can be used to review how medication management is handled at a facility and identify areas that may need attention.

Figure 1:   Standards for medication management in correctional facilities
NCCHC ACA
Applicable standards C-05, D-01, D-02 4-4378, 4-4379
1. Facility operates in compliance with state and federal laws regarding medications. Similar
2. There is a formulary and method to obtain non-formulary medication. Similar
3. Policy and procedures address how to procure, receive and account, dispense, distribute, store, administer and dispose medication. Similar
4. Medications are under control of appropriate staff and accounted for. Secure storage and perpetual inventory of controlled substances, syringes and needles.
5. Medication is only prescribed as clinically indicated after provider evaluation. Similar
6. Providers are notified of medication needing renewal prior to expiration. Similar
7. Staff are properly trained to administer or distribute medication. Similar
8. Inmates do not prepare, dispense, or administer medications. Self-carry medication programs are allowed.
9. There are no outdated, discontinued, or recalled medications at the facility.
10. If there is no on-site pharmacist, a consulting pharmacist is available for advice and makes inspections of the facility’s medication program at least quarterly.

Nursing standards

The American Nurses Association (ANA) has recognized correctional nursing as a specialized field of practice since 1995. The ANA publishes a reference that describes the scope and sets standards for the practice of correctional nurses. With regard to medication management the role and responsibility of correctional nurses is as follows:

  1. To be knowledgeable of medications administered, including dosages, side effects, contraindications and food and drug allergies.
  2. Practices with regard to medication management in the correctional setting meet the same standards as in the community. To do so nurses must be knowledgeable about state practice acts (as suggested earlier in this chapter).
  3. Ensure that patients know what medications they are taking, the correct dosage and potential side effects.
  4. If patients are expected to take medications without supervision the nurse evaluates the patient’s competence to self-manage and takes steps to protect those who are not competent to do so.
  5. Work with custody staff so that patients receive medication in a timely and safe manner (ANA, 2013).

This overview makes me reflect on my first experience with medication management in correctional nursing. I was being oriented to administer medications on the evening shift at a maximum custody men’s prison. A technician rolled a grocery cart filled with stock bottles of all kinds of medication out to me. The cart was full. In giving me the cart he said “You roll this along the tier and stop at every cell. Ask the inmates what meds they want. When you give them the medication then you record it on one of these index cards that has the medication listed at the top.” I remember being shocked and asked the technician why they did it that way. He shrugged his shoulders and went on with his tasks. While this experience is pretty extreme you might use it to review against the ANA nursing standards of practice, the accreditation standards and state law that were reviewed in this post and identify the inconsistencies. Being knowledgeable about the standards and requirements for medication management prevents erosion of professional practice and ultimately protects patients from harm.

Going back to the travel analogy, knowing state law, the national standards for correctional facilities as well as the standards of practice for correctional nurses is like having a guidebook to review the sights to see in place you have selected to travel to. These become a reference point to plan so you can make the most of your time as well as an expectation for what will take place while on your journey.

Is medication management a troublesome area where you practice correctional nursing? Have you looked at the problem through the lens of applicable state law, corrections standards and the nursing practice standards? If so, what have you identified as the problem areas? Please comment 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.

Muse, M. (2012). Professional role and responsibility. In C. Schoenly L. & Knox, Essentials of Correctional Nursing (pp. 364-377). New York: Springer.

National Commission on Correctional Health Care. (2014). Standards for Health Services. Chicago: National Commission on Correctional Health Care.

American Correctional Association. Performance Based Standards for Correctional Health Care. Retrieved August 19, 2015 from http://www.aca.org/standards/healthcare/

Photo credit: © BillionPhotos.com – Fotolia.com

How punishment affects our practice

Close-up Of Brown Gavel And Medical Stethoscope

Currently I am working on understanding more about the challenges of providing culturally competent nursing care in correctional settings. The population of patients we serve are not only culturally diverse but also some racial and ethnic groups are disproportionately represented. Many will agree that the prison, jail or detention facility is a culture as well, the culture of incarceration. Culture is described by Madeline Leininger, a well-known nursing theorist as “the learned, shared, and transmitted values, beliefs, norms, and lifeways that guide thinking, decisions, and actions…” (2006).

We all know that correctional settings have their own vocabulary, rules, practices and expectations that prisoners, correctional officers, nurses, and visitors must comply with to survive in the environment. These values, beliefs, norms and ways of being arise from philosophies about punishment in our society. The culture of incarceration and our beliefs about punishment in civil society affect how individual nurses provide “care” in the correctional setting.

Today I came across a tremendous article by Sally Gadow, Professor Emerita at University of Colorado College of Nursing that describes how different philosophies about punishment are manifest in the practice of correctional nurses (2003). Ascribing to a belief about the role of punishment and incarceration in society is necessary for nurses to address the ethical conflict between care and punishment.

It has made me consider how my nursing practice is affected by my beliefs about the role of incarceration and punishment. Here is a summary of the article.

Punishment as an immediate or reflexive consequence of wrong doing: The violation of community values, morays or laws results in an automatic or reflexive consequence for a wrongful act. In this system of beliefs the punishment occurs automatically and enforcement of the law or rule is unquestioned; there is no consideration of the circumstances or characteristics of the situation. Punishment for violation of norms in this system of beliefs require practices that exile the offender, deny freedom and loss of respect for the individual.

Nursing practices that are congruent with this philosophy about punishment include those that assert the authority of the law, morale principle or norm. In other words, nursing care that extends the interest of punishment. An extreme example would be participation in an execution. Other examples are writing infractions, participating in disciplinary hearings, collecting forensic evidence and approving use of force. When nurses comply with the expectations of the correctional system uncritically, they are at risk of providing care that advances the system perhaps at the expense of the individual. The American Nurses Association provides guidance in professional practice standard 11 on Communication stating that correctional nurses must be competent in questioning the rationale of processes and decisions when they do not appear to be in the best interest of the patient (2013).

Punishment as a logical consequence of wrong doing: An emotionally detached and reasoned approach to punishment and it’s meaning in relation to wrongdoing. Punishment still serves to exile the offender, deny freedom and express loss of respect for individuals who violate society norms and laws. Included in this category are the philosophies of “just desserts” which may also be known biblically as “an eye for an eye”. This is a belief that the degree of punishment should be equal to the severity of the violation. An example of this is the death penalty sentence for murder. Another belief is that of “fair play” when the benefits for a group (society) are achieved only when all comply with the rules. When someone fails to respect the rules a debt to society is owed and punishment is necessary to repay the debt. When we say that incarceration is the punishment, not the further denial of health care or programming during incarceration, this is an example of “fair play.” The last belief in this subset is that of “deterrence” which is to establish punishment severe enough to prevent harm or to protect the community. The punishment chosen is not constrained by the concept of fairness or reciprocity. An example of this would be three strikes laws which serve to deter recidivism and to remove repeat offenders from the community.

Correctional nursing practices consistent with this set of beliefs suppress emotion, embodiment and relationships with patients. The practice of nursing is with objective detachment. By being disengaged the nurse avoids being influenced in a negative or positive way by their personal knowledge of the offender. Many nurses adopt this approach to nursing practice believing that the best way to avoid being “conned” or manipulated by a patient is to rely solely on the nurse’s objective data discounting the patient’s report. With-holding analgesia because of a patient’s history of drug abuse is an example. Delays in responding to requests for health care attention because the problem is not significantly urgent would be another example. However there are numerous competencies listed in the ANA Scope and Standards of Practice (2013) that call for nurses to do more than adopt this disengaged approach to correctional nursing practice. The ANA standards for delivery of care in the correctional setting require nurses to elicit the patient’s personal experience and preferences with regard to illness, discomfort or disability and to partner with them to evaluate their care (Standards 1, 5-7) in a manner that preserves and protects the patient’s autonomy, dignity, rights, beliefs, and values.

Engagement as a paradox of punishment: Punishment is not an essential feature of justice but instead the focus is to restore trust and engagement between the offender and society. Detention may be necessary to engage the violator in the actions that are necessary to restore trust. The offender is not objectified and exiled but is made to relate in meaningful ways with the community. Examples of these beliefs in action include strengths based programming, drug and alcohol rehabilitation, probation and community corrections, half way houses and work camps. The meaning of the experience for offenders is the product of their engagement with others rather than an absolute defined by society.

A correctional nurse under this set of beliefs accepts the contradiction between care and punishment and does not need to embrace a particular viewpoint to resolve the conflict. The nurse assumes responsibility for defining their practice in the interest of the patient and does not accept someone else’s interpretation of how their practice should conform to some moral or ethical norm. Nursing actions are designed to assist prisoners to recover their ability to participate in the community and use their relationship with the patient as the crucible for this work. Engagement is characterized as accepting the possible validity of the patient’s perspective and the potential that the nurse’s opinion can be altered by the patient’s perspective. The nurse’s opinions or beliefs can be held firmly (not to be manipulated) but they are not absolute and open to the possibility of revision based upon experience with the patient or their situation. Dignity and respect for the patient is recognized as necessary to the caring relationship. An example is when nurses individualize a patient’s plan of care rather than apply the same intervention for all patients with the same condition. Patients are regarded as individuals rather than inmates. The ANA’s Standard 13 on Collaboration is explicit in that nurses promote engagement and participate in building consensus in the context of care for the patient (2013).

Conclusions: Correctional nurses often talk about the conflict between care and custody. Custody is a manifestation of beliefs about punishment. Nurses in correctional settings are influenced by the correctional culture, affecting their relationship with patients and ultimately their practice. I was surprised at the extent to which beliefs from all three of these descriptions have affected my practice environment. It is a relief to know that it is enough to recognize the care and custody conflict in order to find my way practically in this field. It is not necessary or even recommended that the conflict be resolved in order to provide ethical nursing care.

I suggest that correctional nurses reflect on the ways in which beliefs about punishment are manifest in their nursing practice. Reflection may suggest areas of practice that warrant more review and development. There may be aspects of practice that are unintentionally harmful or conflict with an ethical premise related to the nursing imperative of care. This material has been provided in the interest of stimulating dialogue among correctional nurses not to suggest a particular standard of practice.

For more on the ethical issues in providing nursing care in the correctional setting see Chapter 2 in our book, Essentials of Correctional Nursing. Order your copy directly from the publisher or from Amazon today!

 

Photo credit: © Andrey Popov – Fotolia.com

 

 

References

American Nurses Association (2013) Correctional Nursing: Scope & Standards of Practice. Silver Springs, MD: Nursesbooks.org.

Gadow, S. (2003) Restorative nursing: toward a philosophy of postmodern justice. Nursing Philosophy. 4: 161-167.

Leininger, M. M. & McFarland, M. R. (2006) Culture care diversity and universality: A world wide nursing theory. Boston, MA: Jones and Bartlett.