Sunday December 28th 2014

Ensuring standards are standard behind bars

Nurses work to review ANA document, promote corrections nursing practice

Both Pat Voermans, MSN, CCHP-RN, ANP, and Mary Muse, MSN, CCHP-RN, CCHP-A, were long-time hospital nurses. But when they each had an opportunity to explore correctional nursing, they leaped.  And since then, they have never looked back.

Correctional nursing involves providing ongoing and, at times, emergency care to persons incarcerated in jails, prisons, substance abuse treatment facilities, juvenile detention centers, and other facilities. It’s a rewarding and much needed specialty, but also one that is often misunderstood and devalued, the nurses contend.

“Correctional nursing is an emerging nursing specialty, and it is like no other due to the constraints we face, such as safety, security, and resources issues,” said Voermans, who represents the American Nurses Association (ANA) on the board of the National Commission on Correctional Health Care (NCCHC). That said, she also describes it as a specialty in which nurses can use their full range of nursing skills, expand their horizons, and have a great degree of independence when it comes to their practice.

Working on the inside

Muse, chief nursing officer for the Wisconsin Department of Corrections, said that there are about 18,000 RNs working at correctional facilities, based on a national workforce survey. It’s a segment of the nursing workforce that’s growing. (Reports indicate there are about 2.2 million people behind bars in the United States.)

There is demand for nurses with expertise in gerontology, psychiatric-behavioral health, women’s health, and child and adolescent care. And advanced practice registered nurses have key roles in the corrections environment in defining and managing care for the diverse populations in these settings.

Yet it’s a specialty that still suffers from a negative image.

“People think that nurses who are working in corrections can’t get a job anywhere else,” said Voermans, a Wisconsin Nurses Association member who has been a nurse for 50 years, the past 25 in corrections nursing. “It’s simply not true.”

Many nurses go into it for altruistic reasons — providing access and health care services to a population that is often disadvantaged and certainly disenfranchised. Others, like  Voermans, happen upon it.

After moving to another part of Wisconsin, Voermans decided to try something new and started working at a juvenile detention facility.

“I soon realized what an impact I could have working with this population,” said Voermans, who now provides primary care services to adult inmates and is a health services coordinator for the Wisconsin Department of Corrections. “Many people who are incarcerated have no clue about conditions, like Type 2 diabetes, and how to take care of themselves.

“When you take the time to talk with them and explain things, they often will tell you that you’ve made a difference in their lives.”

Muse agreed, saying, “So many are truly appreciative of nurses and the care we provide. As a whole, individuals who are incarcerated have not had a lot of access to health care throughout their lives or been treated with respect.

“Many of the people who are incarcerated have mental health issues or are from other disenfranchised groups, who then go on to make bad choices. There also are others who came out of the foster care system. It’s a sad statement that their lives spiraled down with no safety net to catch them, but corrections.”

The 2007 Corrections Nursing: Scope and Standards of Practice also described the inmate population as older, sicker, and requiring longer hospitalizations when compared to the inmates of the previous 20 years. Further, they have a disproportionately greater number of chronic illness and infectious diseases, such as HIV/AIDS, hepatitis C, and tuberculosis, than the non-incarcerated population. The 2007 document also noted that women were a fast-growing segment of the correctional population, including those who needed high-risk pregnancy care.

As for what work is like for a correctional nurse, it can vary greatly — depending on the type of facility, its location, and the culture and leadership.

Correctional nurses working at small facilities might come in once or twice a week to perform inmates’ intake health assessments, address an acute issue, monitor chronic conditions, and set up inmates’ medications for a week for correctional officers to pass. Nurses can also work in large prisons that have onsite infirmaries, where certain acute care needs are met.

Because nurses’ have such a high degree of responsibility in many correctional settings, they need to have strong assessment and critical thinking skills — knowing that a headache can mean an aneurysm, for example — and solid nursing judgment and advocacy abilities. They must be knowledgeable and prepared to address emergencies and mental health issues, among other chronic conditions, according to Muse.

Voermans said that those assessments can make the difference between life or death. She recalled a couple of cases in which people were arrested for being inebriated. In reality, they were hypoglycemic and died because they were not assessed or treated.

“Correctional nurses have an obligation to be responsive to health concerns and not arbitrarily decide someone does not have a legitimate concern,” Muse added.

Lack of policies, procedures hurdle to care

Muse can recall when she first started working in one of the county jails in Illinois in 1995 and was stunned by the lack of policies and procedures for nursing care.

“As I worked to improve the image and practice of nursing or address patient care delivery, I was frequently told ‘This is not a hospital,’” said Muse who also is a surveyor and member of NCCHC, whose aim is to provide quality health care in correctional facilities. (A number of prisons, jails, and juvenile confinement facilities voluntarily have their health services systems accredited to meet the NCCHC Standards for Health Services.)

Over time, nursing care and health care have improved in correctional facilities, but Voermans and Muse believe more changes are needed.

“We know that correctional facilities are security-focused,” Voermans said. And indeed, she and Muse identified nurse safety as a workplace concern — although safety threats can be minimized by following certain precautions.

“But that kind of focus lends people to think that nursing care and other health care are ‘incidental’ or should be less than what people receive in the community,” Voermans said. “We as nurses are dealing with a person, and we must not introduce biases into that care.”

Texas Nurses Association member and NCCHC board member Patricia Blair, PhD, LLM, JD, MSN, CCHP, a nurse attorney who also conducted research on ethical and legal issues within corrections, agreed.

“One of the top issues in correctional nursing is nurses’ ability to keep clients as their primary focus in a setting that is so restrictive,” she said. “Some nurses don’t feel safe, so they might co-opt their nursing standards for security.

“I’m also a firm believer in a health team approach. Nurses in corrections must have the authority to communicate to other health care providers to make sure the patient gets the care they need.”

Patient health information also must be kept confidential and not arbitrarily shared with security personnel unless there is a compelling reason, according to Blair.

Additionally, nurses in some facilities may be reluctant to advocate strongly for inmates’ care because of the workplace culture. Muse noted that correctional nurses often report to a warden, and not a health administrator, and can find themselves having to negotiate care policies.

“I have found that when [non-nurse] corrections leaders embrace the benefit of health care delivery, they are more open to address inmate health issues, and nurses are valued,” Muse said.

Muse and Voermans both want to ensure that there is an emphasis on implementing high quality standards of care at all correctional facilities — just like in other settings in which nurses practice. They also want more nurse managers and directors of nursing hired at these facilities to lead quality efforts, advocate for care, and ensure a healthy work environment.

Standards specifically for correctional nursing do exist. Muse was involved in the ANA workgroup that first created them, and now Voermans is part of a workgroup that will be reviewing and revising the 2007 Corrections Nursing: Scope and Standards of Practice, as needed.

“ANA is the steward of the corrections nursing scope and standards, and on Oct. 11, the association brought together a workgroup of corrections nurses from around the country to begin re-examining the document,” said Carol J. Bickford, PhD, RN-BC, CPHIMS, senior policy fellow in ANA’s Department of Nursing Practice and Policy. The workgroup will be responsible for describing trends and issues that are important for this nursing specialty, as well as identifying standards of practice and professional performance, and applicable competencies.

The 2007 principles, which serve as the underpinning for corrections nursing, include the following:

• An RN’s primary duty in the corrections setting is to restore and maintain the health of patients in a spirit of compassion, concern, and professionalism.

• Each patient, regardless of circumstances, possesses intrinsic value, and should be treated with dignity and respect.

• Each patient should receive quality care that is cost-effective and congruent with the latest treatment parameters and clinical guidelines.

Blair, who previously worked on the ANA standards and is now on the current workgroup, said she will be looking at all parts of the document during the revision process — with an eye toward legal implications of practice and historical details.

“Correctional nurses must really watch their Ps and Qs and adhere to standards of care and the Code of Ethics for Nurses,” she noted. “I’ve seen how courtroom judges look at how health care was delivered — or not delivered  — in correctional facilities.”

The revision process will last about 12 months and will include a public comment period.

Despite its challenges, Voermans and Muse encourage nurses to consider their nursing specialty. Said Voermans, “It is work worth doing.”

— Susan Trossman is the senior reporter for The American Nurse.

ANARadio: On the air!

For more on correctional nursing, listen to an ANARadio podcast featuring discussions with Pat Voermans and Carol Bickford. To access, listen, or download this edition of ANARadio, go to the ANARadio podcast.

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