I’m Gonna Hurt Myself

An inmate arrives at medical with head lacerations from repetitive head banging against a cell wall. Another is found opening an abdominal wound stitched up after the trauma of a car-chase crash. Still another is admitted to the infirmary having sliced arms and chest with a razor in the shower. Self-injury behavior (SIB) is a misunderstood phenomenon that is quite prevalent in the inmate population. A recent report on SIB in prisons estimates 2-4% of the general prison population engage in the activity. The most common forms of self-injury in the correctional setting are cutting, inserting or swallowing objects, head banging, and opening old wounds. As a nurse in corrections, you will definitely be confronted with patients who have self-inflicted bleeding, bruising and burning damage.

Of course, nursing care for SIB physical wounds is quite straightforward and based on the actual injury. However, understanding the potential causes of the behavior will help you to constructively deal with your patient as you mend their self-inflicted wounds.

Why are they doing this?

Experts have a variety of theories on the origins and treatment of this behavior.  Although staff may initially see SIB as a desire for attention or a response to boredom, some mental health experts are finding the behavior to be motivated by a ‘coping deficit’ when dealing with feelings of depression or powerlessness. Many who self-injure have a history of childhood physical or sexual abuse. As you may already know, children experiencing repeated abuse often cope by dissociation from the physical and psychological pain. This same dissociation from pain is seen in some who self-injure.

They must be suicidal

Other explanations for the phenomena include the use of SIB to ‘manage the strong emotions that lead one to consider dying’ (Mazelis). It is questionable whether self-injury is a suicide attempt or an attempt to quell suicidal thoughts. Janis Witlock, PhD, Cornell suggests that self-injury acts as a ‘drug’ to release endorphins that calms the individual, thereby relieving stress for a time.

What can be done?

No matter the cause of the behavior, a concerted, multi-disciplinary response to SIB in the correctional setting is highly advocated. Suggested interventions include intensive therapy, group sessions and careful treatment planning. SIB must be treated as more than a disciplinary issue to be controlled. A collaboration of custody and treatment efforts is warranted.

Much is still to be learned about assessing, intervening and preventing SIB. A recent call was made for national standards to  address the condition in the corrections community. In the meantime, understanding the potential causes of the behavior will help you to be a part of the team approach to treating this complex condition.

Correctional Nursing Webinar

Complimentary Nursing CE Webinar

Inmate Healthcare Interactions: Guarding Your License and Safety

Tuesday, February 2, 2010

2pm Eastern

Presenter: Lorry Schoenly, PhD, RN, CCHP-RN

Register Here: http://bit.ly/bhxHeC

The History of Correctional Nursing

Correctional Nursing Today – Radio Talk Show

via The History of Correctional Nursing.

Help! My Patient is a Psychopath!

Unfortunately, your psychopathic patient is not as easy to identify as the fellow in the pix. He or she will be quite charming and attentive. If you aren’t careful, you will be drawn right into his current scam. Nurses working medical are not always savvy about the ways of the criminally insane. Always be on the alert for the subtle manipulation of the psychopath. There are many of them to be found in corrections. Although an estimated 1% of the general population have this condition, between 15-20% of your inmate-patients could be classified as psychopathic. Become familiar with the characteristics so you can be on guard.

What to Look For

Robert Hare, PhD, considered the top expert on the Psychopathic Personality, created a list of common characteristics. How many of them describe patients arriving at your sick call or medication line?

Characteristics of a Psychopath

• superficial charm
• self-centered & self-important
• need for stimulation & prone to boredom
• deceptive behavior & lying
• conning & manipulative
• little remorse or guilt
• shallow emotional response
• callous with a lack of empathy
• living off others or predatory attitude
• poor self-control
• promiscuous sexual behavior
• early behavioral problems
• lack of realistic long term goals
• impulsive lifestyle
• irresponsible behavior
• blaming others for their actions
• short term relationships

Protect Yourself

Unless you are working the mental health side, your job is not to ‘treat’ the psychopathy, but to be aware of it and protect yourself. Psychopaths will use every interaction to their advantage. They are astute at discerning another person’s vulnerabilities and they prey on hurting people. Staff members who are lonely, insecure or self-involved are good candidates for the manipulation of a psychopathic inmate. Nursing careers have ended when nurses have been drawn into sexual relationships or nefarious activities such as smuggling contraband or diverting narcotics for these individuals. Guard yourself. Know the characteristics. Keep yourself and your teammates accountable to stop potential issues before they move to a dangerous level.

Firm, Fair, Consistent

Protect yourself by treating all inmate-patients with strict professional behavior and demeanor. Follow all security rules of conduct. Here are a few tips.

• Don’t get personal. If an inmate comments about your hair or your figure, call them on it. If the comments continue, report them.
• Do not perform even the smallest ‘extra’ activity for an inmate. That cotton ball or paperclip is the first step down a slippery slope.
• Treat all inmates with equal respect and professional distance. Do not show any favoritism and do not allow any in return.
• If you think you may have already been compromised, report it immediately to your supervisor and take actions to halt the progression. This may include reassignment to another care unit to break the connection.

Have you come across psychopaths as described above in your practice? Tell us your experiences in the comments section of this post.

Is My Patient Faking It?

Unfortunately, correctional nurses must be wary of a variety of motives behind inmate-patients seeking medical or mental health treatment. Malingering is defined as the intentional falsification or exaggeration of symptoms for external motives or secondary gain. There is a high incidence of malingering in jails and prisons. A reported 20% of mental illness in corrections is malingering.

Reasons to Fake Illness

There are many reasons an inmate may fake a mental or medical condition. The first that usually comes to mind is to procure drugs. Separated from preferred mood enhancers such as alcohol or barbiturates, inmates seek other avenues of relief. Seroquel (Suzie-Q) is an example of a current favorite that may be sought through feigning mental illness or psychosis.

However, in the prison system secondary gain can include other, more benign desires such as special creams, lotions, or supplements. One prison system I worked in had a problem with overuse of nutritional supplements (such as Ensure). It was discovered that it brought a high price on the facility black market as bodybuilders thought it would help them bulk up.

Illness can also bring desirable housing locations or work release. Trips to hospital or specialists provide avenues for escape attempts or a chance for a ‘vacation’.

Some inmates may exaggerate symptoms because they think they will not get attention in the system unless they are in severe distress. A true medical condition exists but not as intense as it is being portrayed.

A Nurse’s Best Response

A good principle to follow is to “Trust no one but give everyone the benefit of the doubt”. This is key to maintaining the right level of professional objectivity, writes Melissa Caldwell, PhD, in a recent article for the Society of Correctional Physicians. Here are some tips to help you maintain objectivity in the face of potential malingering:

• Do a complete nursing assessment. Do not disregard any medical complaint as faking. Always respond.
• Thoroughly document all objective and subjective data. Repeated questioning now or later may reveal inconsistencies or validate findings.
• Review prior documentation and history for comparison or evidence of drug-seeking behaviors.
• Portray empathy. You do, in fact, want to get to the bottom of the issue and provide correct treatment.
• Avoid giving clues that will make them a better malingerer.
• Err on the side of safety. Provide a period of observation (such as in the infirmary or holding area).
• Always question yourself. After 3 false ‘chest pain’ complaints – this could be the real one.

Remember, determining malingering is not a nursing function. Assessment, referral or treatment based on protocol is nursing functions. As in the game of baseball – play your position.

Why It‘s Important

Getting to the bottom of potential malingering is important in order to eliminate the  waste of valuable resources and time that could be more effectively used elsewhere. Correctional nurses can help eliminate inmate malingering by taking careful histories and assessments, documenting responses for comparisons over time, and collaborating with medical and mental health staff to develop appropriate interventions.

More Resources on Malingering

Lockup Doc http://lockupdoc.com/tag/malingering

All Nurse:  http://allnurses.com/correctional-nursing/print256963.html

CorrDoc: http://www.corrdocs.org/framework.phppagetype=newsstory&newsid=12160&bgn=2

Lawofficer.com: http://www.lawofficer.com/news-and-articles/columns/Kulbarsh/malingering.html

Journal of Family Practice: http://www.jfponline.com/Pages.asp?AID=2821#1

Psychopharmacology: http://www.acbhcs.org/Psychopharmacology/2005/June2005.pdf

Interview Guide – Part II

Potential Interview Questions

Earlier I posted on what you should look for when interviewing for a correctional nursing job. Here in Part II, I’ll help you prepare for the interview by developing responses to some common interview questions. These questions were suggested by members of the Specialty Forum for Correctional Nurses at the All Nurses web community. I highly recommend that website and forum for more interview help.

How do you feel about providing care for inmates?

This is a good question to ponder before you apply for a position in corrections. The environment is challenging and you want to be sure there is a good match. Many who thrive in the corrections specialty consider their role in caring for the disadvantaged or their impact on public health.

Why do you want to work in a correctional facility?

Develop some positive and constructive answers to this question. Some possibilities might be enjoying a challenge, desiring to work in a close-knit team, enjoying variety in the type of care delivered and making an impact on a needy and disadvantaged population. Choose one or two reasons and develop a 3-4 sentence response.

Describe your background in nursing and how this will compliment the duties for a Correctional Health Nurse.

Working in corrections involves medication administration, patient teaching, ambulatory care visits, emergency response, therapeutic communication and dealing with behavior and psychiatric issues. Think carefully through your past nursing experiences and have a story or two to share about your background that highlights one or more of these areas.

Manipulative behavior is very common among the inmate population. What are some nursing skills that are helpful in dealing with this behavior?

Do some reading about manipulative behavior such as this article on Medscape. Develop ideas for responding to this behavior from inmates – it is pervasive. Generally, combat manipulative behavior by being alert to it and responding in a firm, fair, and consistent manner. Also, treat all inmate-patients with professional respect.

Nursing in a correctional facility requires specialized skills, knowledge and work behaviors. Describe what you think they are.

Skills might include excellent objective assessment, communication, emergency response, and organization skills to shift gears quickly while still getting required work done. Knowledge might include understanding of communicable diseases, the health needs of the inmate population, and safety procedures. Work behaviors would include being reliable, always letting team member know where you are, good follow-through, and being firm, fair and consistent with inmates and staff.

How would you do patient teaching for an inmate on how to manage diabetes?

In answering any question about patient teaching, be sure to mention the need to present the material in easy-to-understand language. In addition, be sure to note that some patients may not be able to read, making written material less helpful.

What would you do if you found an inmate down?

The important concern in corrections is always safety. Therefore, your response would be to summon help and proceed only after custody officers indicate that it is safe to begin care. It seems counter-intuitive to wait, but with the inmate population you need to be sure you are secure before assisting someone. Of course, once safety has been established you would initiate all the standard emergency medical assessments and procedures like airway, breathing, circulation, etc.

General Nursing Questions

Other general nursing questions may be asked such as the 5 rights of medication administration, infection control procedures, assessment and emergency situations. These are some of the main areas of correctional nursing. The same principles used in acute care or other healthcare settings would apply to the correctional setting.

I hope these sample questions will assist you in landing a correctional nurse position that will meet your career goals. As you interview for corrections positions, add new question examples and responses in the comments section of this post. You will be helping those who follow you into the specialty!

Prison Tattoos – What Nurses Need to Know

Photo by Viet Tieu

Tattoos have been a part of prison culture for some time. Prison tattoos are most often obtained to identify allegiance to a particular gang. Tattoos (also called Tats or Ink) can identify skills, specialties, or convictions.  Read about ways tats communicate information. Tattooing is usually forbidden in the prison system, making it a daring task, as well as making it a potentially dangerous one.

Dangers of Prison Tattooing

The major danger of prison tattooing (aside from bad art work!) is blood-born pathogen (BBP) transmission. Typical methods for tattooing include use of common ball-point pen ink and crude make-shift needles. Sterilization is not performed between uses. Although most inmates fear HIV transmission, the most likely BBP is Hepatitis B. The Hepatitis B virus is extremely contagious. Hepatitis C and resulting liver damage can also be transmitted through the prison tattooing process.

A controversial program in Canadian prisons was piloted to decrease the transmission of BBP by employing inmates to provide tattoos within the facility using good technique and sterilized equipment.

Other complications from prison tattooing are allergic reactions to the pigment, aggravation of existing skin diseases, or keloid scarring. You may see these conditions during a sick call visit.

Education Opportunity

Consider adding disease transmission information about prison tattooing during the intake process. Let incoming inmates know of the dangers of submitting to the tattooing process behind bars. Other education opportunities may come during sick call or cell-side rounds. Add tattoo information to regular infection control education and information materials.

Nursing Care Dilemma

An ethical dilemma can ensue if you are asked to assess a tattoo for age. Correctional nurses have been asked to determine if a tattoo is recent (and therefore ‘illegal’). This situation places the nurse in a position to be part of a punitive action. Since correctional nurses must maintain a care-giving status with inmates alternative methods are needed for assessing and staging tattoos within the facility.

How are prison tattoos handled in your workplace? Share your story in the comment section for this post.

Responding to Inmate Sexual Assault & Prison Rape

Fear by Tetine

The statistics on prison rape are shocking.  According to the 2007 Department of Justice study, 4.5% of all state and federal inmates experienced at least one incident of sexual victimization. That is nearly 1 in 20 inmates. My first reaction to the information was to assume this was inmate on inmate victimization, but this is only part of it. More assault is reported involving facility staff (2.9%) than inmate perpetrators (2.1%).

The Prison Rape Elimination Act (PREA) was passed by the US Congress in 2003 and legislates actions to be taken by corrections personnel to prevent and respond to sexual assaults. PREA also established a Commission to monitor the process of preventing rape in the country’s jails and prisons. How can correctional nurses respond?

 What is Considered Prison Rape?

Any unwanted sexual contact between inmates is considered prison rape. This can include fondling of genitalia or even instilling fear of rape. It does not necessarily have to be full penetration and does not require force to be defined as prison rape.

There is an even higher standard for staff on inmate sexual contact. ANY sexual contact between a staff and inmate – even if consensual – is considered prison rape and can be prosecuted. Be clear for yourself and your work-mates – there is NO permissible level of sexual contact with an inmate. Staff members have been prosecuted and sentenced for writing sexually explicit letters to inmates. A recent example of progression into illegal sexual contact is described in this article.

Who is a Likely Rape Candidate?

As you might expect, studies confirm that the likely inmate sexual assault victim is young, a first time offender, and of small build. In fact, juveniles in adult prisons have a 5 times higher chance of being a rape victim. If you have juveniles in your facility, keep this in mind when you are providing care. Be on the look-out for indications of having been assaulted. Some prisons automatically take protective actions for any juveniles who have received adult sentencing. This is also true for transgender, mentally ill, or developmentally disabled inmates. Be alert when assessing and evaluating any of these categories of inmates.

Impacting Healthcare

Every one of our inmate-patients is at risk for sexual assault or rape and may seek medical treatment for it. We need to be alert to the possibility and ready to respond.  Here are a few clinical situations to consider

• An inmate arrives in sick call with a vague complaint – she is depressed, nauseous, agitated, or exhibit other traumatic stress responses
• While working in the segregation unit, you see a generally compliant inmate break rules toward the end of his seg stay, seemingly intent on extending his time
• A young inmate begins covering himself with feces. After mental health evaluation it is discovered that he uses this as a protective mechanism against repeated rapes by his cell mate

 Action You Can Take

Be familiar with your DOC procedures before you are confronted with a sexual assault situation. That way you will know what mechanisms to put into action. For example, you may need to inform the shift commander. Many places have a sexual assault response team consisting of a mental health provider, law enforcement professional and medical provider.

Document clearly the statements made by the individual.  Allow them to vent without moving into investigative mode and asking questions. Asking questions too early may cause a victim to retreat and close down.

Arrange for a sexual assault evaluation, including a rape kit if the report is within 96 hours of the assault. A specially trained individual should perform this function as forensic evidence will be obtained. In some facilities arrangements must be made to send the inmate-patient out to a hospital emergency room for this procedure.

Arrange frequent mental health follow-up for post traumatic stress responses.

Unfortunately, not all healthcare staff, correctional officers or administrative staff consider sexual assault an important issue. You may encounter conflict in your attempts to advocate for the victim. Be reminded, and remind your corrections colleagues, that being aware of the situation and not responding is both unconstitutional  (Eighth Amendment) and illegal (PREA). In addition, as nurses, we have a moral obligation to act in a rape situation. Sexual assault is not a part of the punishment. We need to respond compassionately as any prudent nurse would in a community situation.

Have you have an experience with a prison rape situation? Share your story in the comments section.

Watch Your Mouth – Inmate Dental Issues

Meth Mouth

Unlike almost any other specialty area, correctional nurses get involved with dental issues. Whether during intake assessment or as a sick call request, we must initiate treatment and referral for a variety of oral conditions. It is important to determine which are emergencies requiring an immediate dental evaluation and which can await a standard dental visit.

Meth Mouth and other Drug Issues

Generally speaking any substance abuse is not good for mouth health. Drug abusers are not focused on dental care and often don’t even notice tooth pain until they are in jail and withdrawing. Mouth infections or abscesses can go on without notice while they have access to the drugs.

Meth mouth is a particularly unattractive mouth condition brought on by the common circumstances of methamphetamine use.  The drug decreases the production of saliva, a natural tooth enamel protector. Meth users crave sugary drinks and foods and the drug induces clenching and grinding of the teeth which leads to cracking and wear.

Oral Cancer

Heavy drinking and smoking, common behaviors for the inmate population, are significant contributors to oral cancers. Chewing tobacco and snuff increase the risk of oral cancer by 80% according to a World Health Organization report. These products are popular with inmates in some parts of the country.  Surprisingly, oral cancer is the sixth most common cancer in white males and the fourth most common in black males. Be alert for growths in the mouth when performing intake assessments and screenings. Common areas are under the tongue and the upper lip.

Oral Infections

Poor nutrition, substance abuse, and negligent dental hygiene leads to oral infections. Left unattended, a simple oral condition can turn into a systemic emergency. Oral infections can encompass the entire face and extend to sinuses or lead to airway obstruction.

When is Emergency Treatment Needed?

Emergency treatment is needed for a dental condition any time the patient is having difficulty breathing or swallowing. If the mouth cannot be opened or there is facial space involvement, immediate treatment is necessary. A ‘toxic’ appearance with a high fever would also be an indicator. In any of these situations immediate intervention should be sought.

Have you experienced dental emergencies in your practice? Share your story in the comments section below.

Inmate Seizures – They Aren’t All Fake!

Correctional nurses can get jaded about treating inmate seizure disorders. After all, many perks can be claimed by those diagnosed with the condition including a coveted lower bunk and some real nifty medications. So, it would be easy to think that any inmate coming in with a history of seizures or appearing with seizure activity is merely faking it.

Inmates Have More Seizures

Around 1% of the US adult population will be diagnosed with a seizure disorder (1 in 100). In contrast, 4% of the US inmate population has a seizure disorder (1 in 25). That is a huge disparity and gives greater understanding to the frequency of seizure history or activity in our patient population. This patient community has several risk factors which increase the likelihood of seizure activities.

Head Trauma

The incarcerated have a background with greater violence and traumatic injury than the general population. In fact, recent studies indicate that 25-87% of inmates report having experienced a head injury or traumatic brain injury (TBI) as compared to 8.5% in a general population reporting a history of TBI. Head trauma increases the potential for seizure disorders.

Drug and Alcohol Withdrawal

Drug and especially alcohol withdrawal can lead to seizures. These seizures are not chronic in nature and require a specific treatment regimen. Seizure activity in withdrawal can be intensified if the inmate already has a background of epilepsy or TBI. Alcohol withdrawal can increase inmate seizure activity, especially in jails. The Federal Bureau of Prisons recently released revised Detoxification Guidelines.

Domestic, Child and Sexual Abuse

Past traumatic psychological stresses such as domestic, child or sexual abuse can produce a seizure disorder known as psychogenic seizures. These seizures have been described as a physical manifestation of a psychological disturbance and have received increased attention recently. Up to 1/3rd of patients sent for EEG-video diagnostics for seizures are diagnosed with the disorder. These seizures are of psychologic rather than physical origin; however, they are not being faked. Like other stress-induced conditions such as stuttering or fainting, psychogenic seizures are a physical response with only minor controllability from the individual. Psychogenic seizures do not respond well to epileptic medications, but rather to counseling and other psychotropics.

Treat all Seizures as Real

As healthcare professionals, correctional nurses must treat all seizures as valid until proven otherwise. If a witnessed event seems questionable, there are a few easy maneuvers to take in the post-seizure period including raising a arm over the chest and letting it drop (The non-seizing person will guard/the true seizing person will not) or using smelling salts (not effective for true seizing person). It is not recommended to do a sterna rub as this can cause unnecessary injury.

 What are your experiences with inmate seizures and how does your facility deal with them? Post a response in the comments section.