Jail psych nurse ethics question

Jailhouse nurse · Nov 4, 2009

wow.

that has not been my experience anywhere i've worked, be it prison, jail, psych unit (in or out of a detention facility), private hospital, public hospital...

honestly, it sounds pretty scary. supposing just for the moment the md decided to not sign the order, and left the nurse holding the bag?

sounds like you're in a tough spot there. i wish you the best.

mary

rpe · Nov 4, 2009

Perhaps they are just being a little flippant when they describe the order process. I don't know about the Mental Health aspect but for medical at our jail, we have about a 1 1/2" thick binder of Standard Orders that the RNs can use for evaluation and can even use to issue medication orders. This isn't an aberration but just an extension of a process that is used elsewhere. At the local hospital, many physicians had standing preop orders for all of their patients. You didn't have to call the physician for orders on those patients as long as everything fit the baseline. At the long-term care facility that I worked, certain physicians also had standing orders for certain situations.

The Standard Procedures we use are structured almost as a decision tree. The process used is that if these conditions are met then you may administer this drug. If these conditions are not met then call the on-call provider. If an MD doesn't like any aspect of the Standard Procedure then, with the proper review process, they can change it. However, the Standard Procedures have to be adhered to strictly. We did have a nurse that got fired for, among other things, not adhering to the Standard Procedures.

Guest371144 · Nov 5, 2009

I agree that this would be practicing without a medical license unless there are written protocols signed off by the physician allowing administration of specific medications based on objective assessments.

Let us know how it turns out....

Orca, ADN, ASN, RN · Nov 5, 2009

I work for a state prison system. We have numerous protocols for dealing with various situations, which have been approved by the appropriate physicians. The purpose is to allow nurses to deal with minor medical issues without having to call a physician every time. We have a physician on call after hours for situations that exceed what can be dealt with using a protocol. However, none of our protocols involve psychotropic medications.

I would be very leery of this job, because it sounds like a setup. I see some very serious scope of practice issues in the protocols you are describing. Many psychiatric medications can have very serious side effects, and even with my many years of mental health nursing I would not be comfortable ordering the medications myself.

amyphee · Nov 6, 2009

I agree with you all. I talked to the administrator the other day about my concerns. She said that they did have numerous protocols and that I would have to order within their formulary. She acted like it was me being uncomfortable rather than the situation she described being odd. The funny thing is, she had pretty much hired me the week before, even giving me new hire forms, even though I was waiting on a background check, salary quote, etc. Then, a few hours after our phone conversation, she called me back to say that the corporate office had asked her to interview more people, so she would have to get back to me after her interviews were complete. Everyone I've told about it said it sounded like she didn't like me questioning things. I am still very interested, and feel fine working under a good protocol. However, I'm not going to do anything I feel is unethical, especially when it is my license on the line.

Orca, ADN, ASN, RN · Nov 6, 2009

To clarify, the vast majority of the medications we give from protocol orders would not require a prescription if the inmate were in the community (diphenhydramine, ibuprofen, acetaminophen, etc.). One of the few exceptions is antibiotics, for things like abscessed teeth and suspected MRSA.

elkpark · Nov 6, 2009

She acted like it was me being uncomfortable rather than the situation she described being odd. The funny thing is, she had pretty much hired me the week before, even giving me new hire forms, even though I was waiting on a background check, salary quote, etc. Then, a few hours after our phone conversation, she called me back to say that the corporate office had asked her to interview more people, so she would have to get back to me after her interviews were complete. Everyone I've told about it said it sounded like she didn't like me questioning things.

Call me a cynic, but this is a big red flag for me -- sounds like what they're looking for is a "warm body with a license" who won't mind being asked to do things that endanger her/his license (not to mention clients' well-being!). Is this one of those private-for-profit businesses that contract to provide health services in prisons? In my experience, private-for-profit companies are most interested in the financial bottom line, and don't like to let petty little things like rules and ethics get in their way ...

If it were me, I'd walk away and consider it having dodged a bullet.

Orca, ADN, ASN, RN · Nov 6, 2009

Having worked in mental health for a long time, to me it seems very irresponsible to have protocol orders for psychiatric medications. I would also be nervous about the doctor automatically signing the order "unless it is something crazy". This tells me that the doctor is not properly evaluating the inmates these medications are going to. I would not want to have to defend this practice in court - which is where they are headed if they keep issuing medication like this. Also - who defines "crazy"? If the doctor took a disliking to the nurse he could hang the nurse out to dry - not that it would be that difficult given how this company operates.

My take on it is that this outfit operates on the cheap. They don't want to pay the money for a decent doctor, so they have found someone who cares little enough about his/her license to blindly sign off on orders written by someone not qualified or licensed to prescribe medication. If something goes wrong, you can bet that the nurse will be the first one to fall - and you would have no real defense.

Everyone I've told about it said it sounded like she didn't like me questioning things.

They're looking for a lap dog who will just blindly go along with the program and not rock the boat. I could not run away from this job fast enough.

amyphee · Nov 7, 2009

Wow, thank you all for the input and advice. What a great coomunity! This is a for-profit company contracting with the county. I never had a good feeling about it, even though I would get to set my own hours and work within walking distance from my home. Everyone else I've talked to about this agrees that it sounds fishy, but they aren't nurses, and I wanted some professional opinions. Thank you all! The last thing I want to do is jeopardize my license, especially since I'm planning on going back to school for my masters in PMH nursing next year.

military spouse · Nov 9, 2009

To clarify, the vast majority of the medications we give from protocol orders would not require a prescription if the inmate were in the community (diphenhydramine, ibuprofen, acetaminophen, etc.). One of the few exceptions is antibiotics, for things like abscessed teeth and suspected MRSA.

We're about the same.................

crystalwomn · Dec 2, 2009

You are absolutely right. If there are standing orders it might be appropriate. Some jails/prisons use standing orders. The National Commission on Correctional Health Care frowns on standing orders except in an emergency. If the employer is a good one and is using standing orders, I would expect to see rigorous training in the protocols and some type of testing for competence in the use of the protocols. If you don't find this to be the case I wouldn't touch the job with a ten foot pole. The standards for nurses in jail/prison is the same as that in the community. If in actuality nurses are ordering meds willy-nilly the state regulatory agency should be notified.