Dangers of Labeling Inmates - Stories Sought - page 3

by LorrySchoenlyRNPhD 6,734 Views | 29 Comments

:typing I'm developing an inservice program for correctional nurses about the dangers of 'labeling' inmates. For example, always assuming that the inmate is 'faking' the health issue (although we know that many times this is... Read More


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    Quote from mikethemurse
    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.
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    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.
    tbrd450 likes this.
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    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).
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    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.
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    I work at a state facility and due to privatization of some state facilities we do not talk to their computers.
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    Quote from suesmith48
    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.
    Absolutely!... You touched on some very good points. The "dominant custody culture" is very powerful. It can be dangerous. A study in conformity was conducted back in 1951. A social psychologist--Solomon Asch--devised an experiment to examine the extent to which pressure from other people could affect one's perceptions. In the experiment only one lone subject (real subject) is joined with 7 others play-acting as subjects (they are control subjects associated with the experimenter). The lone true subject doesn't know the 7 others are plants, or setups, in the experiment. All 8 people were presented with a card containing one (1) vertical line on the left side of the card and three (3) vertical lines of varying lengths on the right side of the card. The experimenter asked everyone to identify the vertical line on the right side of the card that is the same length as the line on the left side. The experimenter ensures they all individually are aware of the choices being made by the others. As instructed by Asch, the seven control subjects all intentionally pick a line on the right that is clearly not the same length as the line on the left. The task is repeated several times.

    Asch discovered after conducting this experiment multiple times, with numerous exercises, that about one third (33.33%) of the subjects who were placed in this situation went along with the clearly incorrect line selection on the right side of the card simply because the majority did so. In other words, approximately 33 out of every 100 people will just conform to the group they find themselves in. Asch found that one of the situational factors that influence conformity is the size of the opposing majority. Surprisingly, he found that the subjects conformed to a smaller erroneous majority group of 3 or 4 as readily as they did to a larger majority group. Many subjects later indicated that they assumed the rest of the people were correct and their own perceptions were wrong (even when they clearly were not wrong). Others indicated they knew they were correct (and the majority was wrong) but didn't want to be different from the rest of the group. Still others insisted (even after learning of the experiment design) they actually saw the line length as the majority "claimed" to see it.

    However, one thing Asch found was that the rate of conformity to the erroneous majority drops dramatically when the subject has an ally. Asch concluded that it is difficult to maintain that you see something when no one else does. The group pressure implied by the expressed opinion of other people can lead to modification and distortion effectively making you see almost anything.

    It is incredibly easy to draw a parallel and application of what we already know about human behavior regarding group conformity, to the correctional environment. It takes a person of strong integrity, character and raw courage to swim up the "custody culture" stream, against the strong opposing correctional officer mindset current. As a nurse in the correctional environment, you have a moral obligation to advocate for your patients. That is why I try to remind new nurses and those seeking advice to hold on to their original nursing convictions (assuming they were there to start with), proclivities toward patient empathy (assuming it was there to start with), and fundamental instincts about humane treatment, and simple right and wrong. In no other place than corrections is such a staunch defense against losing sight of those convictions, caring proclivities, patient empathy and ethical standards more important. Failing to do so can not only mean the greatest ultimate tragedy for a fellow human being (an inmate patient) losing his/her life or further deterioration of his/her health, but it can also mean a sacrifice of the highest order for the failing nurse. He/she stands to lose an important part of him/herself.

    Correctional officers are programmed to view these guys differently (note: there are different dynamics at work with female inmates). They tend to universally view these guys through a single lens, a single perspective -- one that is premised on custody first and foremost and almost exclusive, at all costs, focus. It is one that permits them to rationalize a lot of things that would otherwise be difficult to rationalize (delayed responses to help, too much pepper spray, over zealous application of "attitude adjustment", etc.). They appear to far too often be programmed to, or simply accustomed to, viewing inmates as single-minded manipulators always devoted to lying about everything, all the time. I happen to believe it serves, for some, to help them to safely compartmentalize and simplify their responses and reactions. Hearing the whole story (from the inmate) becomes unnecessary and burdonsome. And, by keeping a clear line drawn between "us" and "them," a double standard is easily cultivated and justified, even a double standard that sometimes crosses the line into dehumanization. They often convince themselves that such a narrow perspective isn't narrow, and it is one that is necessary to keep everyone, but mostly themselves, safe from the boogy man.

    Task-oriented -- Absolutely, I agree. To settle in to a task-oriented approach in handling crisis, one has to detach a little from engaging otherwise natural and organic emotive responses to fellow humans in need. For example, the incarcerated man with a blocked Foley suffering needlessly through the night and next morning in his cage is nothing more than a numbered orange jumpsuit representing an unannounced MD order. One the order comes, then he is human again.

    Task-oriented blindness and overidentification with custody culture are different fruits from the same poisonous tree.

    Those correctional nurses that establish high ethical standards, hold on to nursing convictions, and dare to see the card's line length for what it really is, are swimming up the fast moving custody culture stream. Make no mistake about it, the opposing current can be very strong.
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    All of your very well-reasoned responses lead us to one thing - the importance of the CQI process in helping us to resolve our dilemmas...
    tlc365 - you discuss near constant distractions that delay your med administration process. First, the fact that you are having so many distractions is more than just an inconvenience that slows you down. Accordng to the Institute of Medicine (in the To Err is Human report) distractions during the med administration process is a major contributor to medication error. Some hospitals have moved to place a "NO DISTRACTION" zone around med carts. It sounds like you have some process problems, like medication distribution and communication. Addressing the problems has the potential to save med administration time (which will save $$) and decrease medication errors (which cost $$).
    Orca - right on! We walk a fine line between respecting custody for the very difficult job that they have and losing our nursing values. Certainly we need to acknowledge the importance of safety and security, but we can do that and maintain our identity as nurses. It just takes some critical thinking (well, integrity and a good moral compass help as well).
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    i just passed my nclex and i'm considering working as a correction nurse..my husband doesn't like it but i think this is something different..
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    Correctional nursing is a good field to be in, but I don't recommend it as a first job in nursing. It requires a lot of independence, and without prior experience it is difficult to do well. Some agencies hire new grads, mine doesn't. Applicants are required to have at least a year of experience to hire on with us, and I believe that is a good idea given the environment.
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    Quote from suesmith48
    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.
    "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"

    AND IN SO DOING A FELLOW HUMAN BEING MAY NOT HAVE TO DIE!


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