Dangers of Labeling Inmates - Stories Sought

Jaila · Sep 30, 2009

I think we have all run across a time or two when an im may have been "faking" it...but you do your assessment with the equipment and skills that you have. We have very limited equipment at our facility, not even an ekg. Basically we have our nursing skills, equiptment for vital signs, and gut instinct. There have been times when I have sent an im out for assessment and they have come back with nothing wrong, not often, but it happens. Or someone I have declined at intake d/t extreme intoxication, potential head injury, etc... Some people are just borderline wether they are honest in what is happening or just wanting a nice warm bed, tv, and cup of juice at the hospital. And you have to keep in mind what happens to custody when you send someone out...that is staffing is affected, cost, etc....but sticking with good assessment skills and your duty as a nurse I always stick to one motto....."if in doubt, ship em out"...it's not worth my licensce.

tbrd450 · May 27, 2010

Lorry wrote: "If a nurses do this one time too many it could lead to a case of negligence or even malpractice."

Orca wrote: "The inmate may have done the same thing 20 times, but on time #21 it might be the real thing. Ignore it and you could find yourself on the witness stand explaining why you failed to act."

Lorry, if a nurse does this, it could lead to a person not getting the treatment he/she deserves. It could lead to further health deterioration for the patient. Which could be serious and even life-threatening. Isn't that the real potential consequence of failing your patient. The negligence or malpractice consideration would also be a potential outcome. But, in the end, as a nurse your patients' health is on the line. A seriously injured inmate that is disliked and turned away (as one poster wrote in here) for "refusing treatment," despite everyone knowing he really wasn't refusing treatment, is having his basic human rights denied. His medical care is the issue...right? As a nurse you bring that perspective to those whom you care for, right?

Orca, in addition to having to explain why you failed to act, you could also be facing each new day with a troubling concious-nibbling guilt complex because you failed your patient. The ramifications of not treating a trapped human being (it's not exactly like he can take his business elsewhere) with the medical care he deserves and is entitled to by law are far more serious and far-reaching than the inconvenient and awkward position you may find yourself in one day on the witness stand. Don't you agree?

mikethemurse, BSN, RN · May 27, 2010

Not only do we as nurses in corrections have to protect our licenses, we also have to protect our jobs. What I mean is, the when in doubt send um out rule is hard to follow when you have to defend to the powers that be, the reason for sending out an IM. At my facility, they really don't want to send anyone out to the hospital unless it is an emergency that we can't handle. You really have to trust your assessment skills, write meticulous notes, and be ready to defend your actions.

I have been lucky enough to have a medical director that trusts nursing judgment, and will go to bat for us even if we send someone out and they turn out to be okay.

Which brings a question to this discussion, has anyone had to justify sending out an IM that wound up being okay?

I think that this is a great in service that you are doing. Because I have been to many in services that have been geared towards figuring out how they are faking.

Orca, ADN, ASN, RN · May 28, 2010

I received a man down call from one of our housing units regarding an inmate with intractable abdominal pain. I went to the unit with my escort officer and found the inmate in a fetal position on the floor and yelling, in obvious discomfort. With some assistance we got him onto the carrier to take him to the infirmary for further evaluation. I asked him how long his condition had been this bad. "Several hours" was the reply. I took vitals and his temp was significantly elevated. I called the physician on call and he asked me what I wanted to do. "I don't like this", I said. "I want to get this guy out of here (to the hospital)." He had an appendix that was on the verge of rupturing when they got him into surgery.

I later found out that he had come to the infirmary during the previous shift with symptoms almost as severe as they were when I saw him. He was told to fill out a kite for an appointment with the doctor.

tbrd450 · May 29, 2010

The dangers of labeling anyone, but especially those most vulnerable and in need of advocacy, are that you, as the potential labeler, become desensitized to those different than yourself. You begin to see them as slightly less deserving. You begin to assume everything they say is a lie. You run the risk of beginning down a path toward dehumanization of people under your watch. It can, for some, become nothing but an endless parade of faceless orange jumpsuits marching through their minds as they tick off the days until retirement. While everyone working in the correctional facility has a moral and ethical obligation to guard against that, it is especially true of the nurses and other medical staff. You are on the ethical front line. When you have role in a correctional situation, you are on the ethical front line -- not the correctional officers. Society looks to you to deliver service from a perspective of high morality, care, consideration and advocacy on behalf of your patients.

Those particularly vulnerable to nurses' choices and their outcomes deserve extra consideration to be measured according to

i) the level of their vulnerability to those choices

ii) the level of their affectedness by those choices and no one else's

There is a clear need to attend to the contextual details of the situation (correctional environment)in order to safeguard and promote the actual specific interests of those involved (suffering inmate).

When a person is incarcerated, he is essentially trapped. He suffers or doesn't, thrives or rots, and lives or dies based mostly on the choices of those people who essentially control his life (the nurses, the correctional officers, other inmates, etc.). Where he lives (clasification), where he eats, what time he eats, what rehab activities he is entitled to, when he is given medical treatment (or not), etc.... these are all out of his control.

When an inmate presents to the infirmary suffering "severe symptoms" and is told to go fill out paper to request to see the doctor, the patient was failed. We, in society, that gave that person that job -- taxes, hiring, screening, or lackthereof -- are all responsible for the failing. The person who almost cost that man his life really needs to get another job and, possibly, be criminally prosecuted.

What is the danger is assuming these guys are telling you the truth? Is the worts possible thing that could possibly happen be a full exam at the hospital resulting in him being "ok?" Is that really so horrible?

Maybe instead of endless inservice training sessions trying to learn new ways to identify new and improved inmate strategies/manipulations, maybe a few inservice sessions could be devoted to learning and embracing moral and ethical obligations and standards -- learning, for example, the dangers of labeling inmates.

Just a thought.

tbrd450 · May 29, 2010

Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly. --- Martin Luther King, Jr.

Ten million people cycle through our jails every year. The abuses they endure, the diseases they contract, the traumas they suffer inevitably come back to haunt the rest of society. There is no Iron Curtain separating them from us. They are us. -- Alan Elsner.

suesmith48 · Jun 3, 2010

Hi Lorry,

After 20 years of correctional nursing, I could go on and on and on - here are a couple stories that come to mind (and please keep in mind that these nurses were both known as good nurses):

A nurse from one of our county jails told me this story and another confirmed it. They had a man frequently arrested for various charges, usually drunk and disorderly. He liked to play "tricks" on the nurses and would complain of chest pain, knowing that they would have to see him. Sometimes he'd even laugh and admit to it. One night, a CO came to the booking nurse saying that this man was again complaining of chest pain. She was busy and told the CO that she would see the inmate when she finished seeing the booking detainees. The CO summoned her again in less than an hour - the man was unresponsive. He had suffered a heart attack and did not survive. The family sued the county jail and her (resulting in her termination) and reported her to the state board of nursing (where she did have to defend her actions).
One evening in one of our state prisons, a nurse received a call from one of the housing units - the CO said a young inmate was complaining of an asthma attack. The nurse was busy with other duties, but did review the inmate's medical record. She found no history of asthma and told the CO to have the inmate sign up for the next day's sick call to be evaluated. The CO called back about an hour later - the inmate was unresponsive - he did not survive either. The nurse was disciplined for her actions.

Sometimes inmates do complain of symptoms they are not really experiencing (so do patients on the "outside"). However, the only reliable way to make sure is to see and assess the patient - which takes less time than responding to an emergency, enduring the resulting investigation, defending your actions at work and potentially before your Board of Nursing and explaining it to any subsequent employer.

Orca, ADN, ASN, RN · Jun 4, 2010

Bottom line: I had far rather be accused of doing too much than doing too little.

One night, a CO came to the booking nurse saying that this man was again complaining of chest pain. She was busy and told the CO that she would see the inmate when she finished seeing the booking detainees. The CO summoned her again in less than an hour - the man was unresponsive. He had suffered a heart attack and did not survive.

Exactly why I redirect my staff if one of them tries to dismiss a man down call regarding one of our "frequent Fliers" (or "platinum card members", as I call them). You never know when something is the real thing (and you certainly can't tell it over the phone or the radio). The one time you don't respond it may be the real deal - and in that case everybody loses.

Jaila · Jun 4, 2010

Not only do we as nurses in corrections have to protect our licenses, we also have to protect our jobs. What I mean is, the when in doubt send um out rule is hard to follow when you have to defend to the powers that be, the reason for sending out an IM. At my facility, they really don't want to send anyone out to the hospital unless it is an emergency that we can't handle. You really have to trust your assessment skills, write meticulous notes, and be ready to defend your actions.
I have been lucky enough to have a medical director that trusts nursing judgment, and will go to bat for us even if we send someone out and they turn out to be okay.
Which brings a question to this discussion, has anyone had to justify sending out an IM that wound up being okay?
I think that this is a great in service that you are doing. Because I have been to many in services that have been geared towards figuring out how they are faking.

I have never (yet) felt that I had to justify having sent someone out and it turned out in the end they were ok. And I would agree good documentation is key. I do my job to the best of my ability for not only liability reasons but inmates health--that is my job. I work alone on nights and with very limited equipment I have to rely greatly on assessment skills. In those situations ( and there are times when you just can't know for sure ) where it is a potentially dangerous scenario for the inmate and I can't be certain (doubt) then I do send them out. There have also been times when I have placed a call to the MD and reviewed the inmate complaint, my assessment findings, anything I didn't look at that they think is key?...and let them make the call. Having to defend to someone that I sent an inmate out seems absurd to me. I imagine it would really get my hackles up.

Now that said, at the department I work at they don't like you sending out for other than emergencies. You have to be comfortable with saying this can wait til morning or this can't.

suesmith48 · Jun 4, 2010

I believe that there are many reasons for this type of behavior on the part of the nurses, and that there is some variation in the reasons from one nurse to another. Certainly one reason is that it is so easy to become overidentified with the dominant custody culture, but I recently heard a presentation on

"Failure to Rescue" (based on hospital incidents, not correctional incidents) that offered another, very important reason. The presenter reported that root cause analysis done at the hospital found that the nurses had become overly task-oriented and had lost their ability to stand back and see the big picture for their patients. In our setting, it is extremely easy to become task-oriented - considering the 3 hour (and longer) pill-calls, huge sick calls, relentless intake procedures and endless paperwork. The hospital system making the presentation I attended did a number of things to address this, including the Failure to Rescue presentation.

tlc365 · Jun 5, 2010

This is one topic that I am so glad I came across because I find it to be the most challenging part of my job. As a "pill call" nurse I am responsible for admin meds and in this process I am in contact with all IM as I walk around the dorms distributing pills. I am often stopped by IM to assess various issues from a cut /dental issues/pharmacy issues/IM not receiving KOPs and having IM report they received a response to an issue by being told they are "scheduled" to be seen by an MD 2 months ago and still not seen, etc.......

I also seen IM who are transitory from other facilities and will be moving to another facility sooner or later no idea how long they will be at our facility who run out of meds and their current orders are not transferrable to our facility so I have diabetics and epileptics and TB pts needing INH not getting meds are renewal of scripts because the appt list to see the MD is too long for them to be seen and by the time they can be seen and receive meds they could be gone on to their destination.

I always feel so frustrated and helpless and if I truly took the time to address each issue each day I would NEVER get pill pass completed. I also have to track down the IM meds who have moved within our facility and make sure each has their meds. I often have IM not receiving meds because no one realized they moved from building to building.

Back on topic...I did send an IM up to medical who was complaining of heat related issues and the CO wanted to just have him drink water and relax in the dorm..I wanted him sent up because he was vomiting and was dizzy he ended up staying 6hrs in medical with an IV to replace fluids d/t dehydration. I had another IM show me blisters on his hands who reported "red streaks" going up his arm from infection..the blisters were not infected and did not appear to have streaks up his arm so I let that one go to have him put in a HNR (heath needs request).

Orca, ADN, ASN, RN · Jun 6, 2010

I also seen IM who are transitory from other facilities and will be moving to another facility sooner or later no idea how long they will be at our facility who run out of meds and their current orders are not transferrable to our facility...

If you work at a county jail I can understand this. If you work for a state department of corrections I don't. Our doctors' orders are valid regardless of where the inmate is transferred, for the duration of the order. If one of our docs wants to change the order, he just writes one that supersedes it.