- Email: [email protected]
OR nursing in correctional facilities
am a prison nurse. I have worked in a prison setting for 15 years. In 1965, I answered a n advertisement i n a newspaper for a surgical nurse in Minnesota’s largest adult male correctional facility. Thinking the position was in an emergency room I applied for and received the appointment only to find I was the only applicant for the position. And I did not have a n emergency room-I had a n operating room. What did I do? I panicked. I hadn’t been in an OR for 20 years, and my last remembered experience in operating room nursing had been as a student, washing tubing to be used for transfusions. I called my operating room supervisor from nurse training, who was as surprised as I, and she advised me to get Berry and Kohn’s Introduction to Operating Room Technique and start reading. My inservice instructor at the prison was an inmate, who shared only as much information as he wanted me to have. I found out he was the operating room supervisor, and I was a civilian assigned to his domain. The surgeons were residents at the University of Minnesota Hospitals, Minneapolis, and
I
0R nursing in correctional facilities Marquetta M Origer, RN
Marquetta M Origer, RN, is medical services coordinator for the Minnesota Department of Corrections in St Paul. A diploma graduate of St Johns Hospital, Fargo, ND, she received a baccalaureate in correctional administration from Metropolitan State University in Minneapolis.
308
AORN Journal, February 1981, Vol33, No 2
the prison was part of their rotation. My surgical suite was one OR plus a multipurpose workroom. Since I had committed myself to a prison environment, and because I was curious about the entire operation and didn’t want to make another job change, I stayed. I had a feeling I had embarked on the most interesting and challenging opportunity in my nursing career. I had. We have come a long way since then. The operating room and equipment at the prison were substandard when I arrived. I began a campaign to upgrade or close the OR. Improvements were made, but finally in January 1974, we closed the prison OR, and a transfer program to community facilities was initiated. My role has changed and expanded over the years, and I have made a career of corrections nursing. A prison nurse at a recent meeting in Chicago stated, “I stay in corrections because it’s the only field left in nursing where I can personally provide a service to my patients.” I like corrections nursing because it is a challenge. I have never worked harder anywhere. A day hasn’t gone by without a problem to be solved-from a relatively minor one, like a clean mop head, to a major one, like placement in a nursing home. Correctional nurses are the last frontier of nursing. We do not have the luxury of aides, orderlies, technicians, and readily available services from physicians, practitioners, clinicians, and auxiliary sources. All correctional institutions have a medical director or a health authority, who is technically in charge of the infirmary and on call for emergencies. Larger institutions employ a full-time physician who, in addition to his routine duties such as admission, physicals, and daily sick call, is expected to function on an administhative level on the warden’s staff. Because the physician is expected to be involved actively in the daily institutional opera-
tions, the correctional nurse doesn’t always have the physician readily available when an opinion is needed or a decision has to be made. The corrections nurse must function in an expanded role, making independent health decisions that would not ordinarily be expected of her in an outside facility. Frustration is the major problem facing the correctional nurse. The nurse knows a service must be provided. Getting the service to the inmate may take hours, days, or weeks. I asked the correctional nurses in our system what frustrated them the most, and the answers varied. One nurse said, ‘‘It’s our pharmacy program. Will the difficulties we are having ever be resolved?’ Another nurse said, “It’sgetting enough food for the diabetics on weekends. You know they only serve two meals a day on Saturday or Sunday.’’ A third nurse stated, “The inmates don’t tell the truth; they lie about their drug use. I think I have their problem identified, and then I find out much later that the problem they were complaining about wasn’t the problem at all. It was their old drug problem resurfacing. It’s so frustrating; I wish just once they would tell me the truth.” Frustration leads to “burnout,” a term that is being used with increasing frequency in correctional facilities. We feel much of the burnout syndrome can be avoided if the correctional nurse has a peer to work with and to share her anxieties and frustrations. Notwithstanding the problems the correctional nurse encounters, she still must thoroughly understand the nursing process and be able to apply problem-solving techniques in the delivery of nursing care and related services to confined clients. Nurses who need the support of a structured organization find correctional nursing difficult and threatening. Nurses who enjoy working independently rise to the
d) 310
AORN Journal, February 1981, V o l 3 3 , No 2
ealth care for inmates is a right, not a privilege.
H
challenge and develop their own nursing styles. The correctional nurse learns quickly to make objective nursing assessments, develop and implement nursing care plans, make nursing decisions, and evaluate the plan she has suggested and developed for her patients. Nurses i n private hospitals and clinics take delivery of nursing service for granted. In a medical facility, medical services and practices prevail. In a correctional facility, however, security is the number one priority. Prisons are constructed to protect society from the offender. Our practice of nursing must conform to security policies and regulations without jeopardizing or compromising the standard of care the patient is entitled to receive. Health care for the incarcerated client is a right, not a privilege, and at times, the task of providing this service is overwhelming. To explain how medical services are provided to a confined population, I will describe what happens to an inmate when he arrives at our institutions. This may differ slightly in each correctional facility, but basically it is the same. When an inmate arrives at a correctional facility, he is placed in a reception and orientation unit. In this unit, he is separated from the general population for a week to two months, depending on the institution. The inmate is introduced to institution policy and eval-
314
uated medically and psychologically. His past social and criminal histories are reviewed and documented, and he is observed by the receiving and orientation unit staff for unusual behavior patterns. At this time, he has the opportunity to express educational and occupational preferences or experiences. Here he adjusts to a confined environment while separated from the main living units. During the orientation, the institutional staff has the opportunity to gather information about the inmate from other sources. Initial medical screening is usually done by correctional staff. Immediate health needs are communicated to the medical staff by the custody officer taking the initial medical history. The admission system’s assessment is done by the institution’s physician or physician’s assistant from within 24 hours to 14 days after admission, depending on institution policy. The inmate cannot be placed in a work or general living unit or participate in any programs until he is cleared medically by the physician. In addition to the physical examination, the inmate is given vision and audiometric testing, a venereal disease check, complete blood count, urinalysis, Mantoux test, a chest x-ray if indicated, and dental and mental health screening. A tetanus toxoid immunization is also given on admission. Special medical problems are identified at the time of the physical exami-
AORN Journal, February 1981, Vol33, No 2
nation, and referral to an appropriate specialist is initiated. If the institution is fortunate enough to have consultants come to the prison, the inmate’s name is placed on the consultants’ list for one of the upcoming clinic visits, depending on the urgency of the problem. If a specialist does not come to the correctional facility, the inmate is taken in restraints to an outside clinic by specially trained escorting officers. Return trips to clinics or admission to outside hospitals continue until the problem is resolved. If an emergency problem cannot be handled in the prison infirmary or hospital, the inmate is taken, under guard, to an outside facility that has contracted with the correctional facility to provide emergency medical-surgical services. If the institution does not have its own ambulance, this service is also contracted from the community. Our correctional institutions operate on schedules, and our medical units sometimes threaten to disrupt the order that has been established. We call the inmate to the infirmary or hospital for dressing changes, treatments, special counseling, admissions, preoperative work-ups, health teaching, and diets. Our nursing actions are often misunderstood and misinterpreted by custody staff. We spend a great deal of time explaining our actions and justifying not only our reasons for being in the facility but also our rationale for the intended procedure. Special treatment and special diets cause us no end of problems. We learn to improvise, and we learn to supervise departments that we always felt belonged to somebody else. Improvising becomes necessary when the prison budget does not allow for purchase of large equipment. I remember the time I found a large institutional breadmaking trough, which I had brought to the prison hospital. I needed a whirlpool bath for a six-foot, five-inch inmate who
316
needed daily therapy. There was no money for a new whirlpool, and our bathtubs were too short. The bread trough worked fine with a rented whirlpool machine. The inmate did not have to make daily trips to an outside hospital for hydrotherapy. A diet manual prepared by the Twin Cities Dietetics Association allowed us to supervise our inmate cooks in the preparation of special diets. We later hired a consultant dietitian, but I still refer to my diet manual when our surgical patients are returning to the institution and have special dietary needs. Medications are always a problem in the prison community. Limited formularies are now appearing in many of the correctional facilities to discourage the use of mind-altering drugs. Minor tranquilizers, sedatives, and narcotics, improperly prescribed, jeopardize the order of the institution and alter the behavior of the inmates. Inmates on long-term, mind-altering medications are difficult to manage in a n institutional setting and have a difficult time adjusting to the reality of prison. The limited formulary allows the inmate to make a realistic institutional adjustment and prepare for his eventual release with a clear head. There is always the problem of contraband medication, a reality in a prison environment. The infirmary or hospital staff is responsible for patient teaching and education. There is no special service or department we can call on for this need. If we have a patient with a health problem who is in need of patient teaching, it is our responsibility to see the teaching occurs. Our patients do not respond well to our efforts, and our attempts to develop a “wellness model” often fall on deaf ears. The inmates are quick to tell us they will take care of their health problems when they get out and can see “real” medical personnel. One example is the incarcerated
AORN Journal, February 1981, Vol33, No 2
had no recovery room, and inmate nurses provided the postoperative care.
I
diabetic. He knows he has diabetes and must take his insulin and stay on his special diet. Provisions are made for him to come to the infirmary for meals and insulin. Considerable time is spent assessing the problem, talking to the inmate, and developing and implementing an individualized nursing care plan. We notify the custody office and the cell hall sergeant that the inmate is to report to the infirmary for diet and insulin and suggest to the assignment committee that the inmate’s diagnosis of diabetes be considered when he is given a work assignment. It is frustrating when, in spite of our teaching and careful planning, the inmate fails to arrive at the infirmary. Our only alternative is to start all over again, this time stressing responsibility for his own health status. In spite of the inmate’s reluctance to take responsibility for his own health, some need continued medical care and follow-up on discharge from the facility. Although our responsibility for the inmate stops when he is discharged or paroled, we encourage the client to continue the treatment we have initiated. We inform the inmate he is to keep his appointments and offer assistance to him i n obtaining services through community resources and medical assistance. Discharge planning for a n inmate with complicated medical problems is as important to us as it is to other nurses and their private patients.
318
In 1968,an energetic young physician became our medical director. We saw many changes, and he allowed me to hire professional scrub nurses from the community. He also contracted for the services of a board-certified surgeon who resided i n the community. Although the inmate remained as the first assistant, my operating room began to have some order. We provided surgical services to the inmates at the Minnesota State Prison and the St Cloud Reformatory for Men until J a n 1, 1974, when my OR was closed. All inmates requiring surgery were sent to the University of Minnesota Hospitals until our new facility was opened at St Paul-Ramsey Medical Center in December 1974. Prior to the OR’S closing, we had been doing major surgical procedures in a nonaccredited and nonlicensed facility. I had no recovery room, and inmate nurses provided the postoperative care. There was no anesthesiologist; a certified registered nurse anesthetist gave all the anesthesia. I was assigned one inmate to work with me in the OR and one inmate as my clerk. Fortunately, I still had the on-call scrub nurses, which brought some professionalism to the department. Some of the surgeons were afraid of the inmates, both the patient and the first assistant. I always had to plan my time to include reassuring the surgeon he wouldn’t get hurt. I had one set of general surgery instruments and two Boston Consoli-
AORN Journal, Februaly 1981,V o l 3 3 , No 2
dated steam sterilizers-circa 1890. Replacement parts for the sterilizer were unavailable from the factory, so the parts were made in the prison foundry. We operated four to five days a week on most of the major services excluding chest and neurosurgery, but many of the procedures seemed to be in the specialty the surgeon was interested in. I wondered early in my prison nursing career about conservative management of patients with ulcer disease, as one shelf in the laboratory contained nothing but specimen jars with stomachs. Our inmates began demanding services from the University Hospitals and the Mayo Clinic, Rochester, Minn. Prisoner advocacy groups appeared, and the Department of Corrections appointed a n ombudsman for corrections. A class-action lawsuit was initiated by a group of inmates alleging substandard medical practices. Our progressive medical director was suggesting major changes. Not only was it necessary to think about closing our operating room, it was also necessary to begin changing our entire system of health care delivery. After an extensive study and investigation of the prison health services in Minnesota, we presented our plan to the legislature. They agreed with our suggestions and gave us the money to go ahead with our proposal. In December 1974, we moved our services to St Paul-Ramsey Medical Center, a community hospital that was willing to provide us with the services we needed: clinics, inpatient hospitalization, emergency room services, and a medical director. We constructed a 15bed hospital unit on the sixth floor of the medical center, which we share with Ramsey county. We staffed it with specially trained correctional officers employed by the Department of Corrections. Our nursing staff is employed by
320
the medical center. Our patients are evaluated by the prison’s physician, and a working diagnosis is established. The patient is then brought to Ramsey where he is seen by the surgeon and placed on the schedule. The day before the scheduled procedure he is admitted to our security unit where his preoperative work-up is completed. On the day of surgery, he is escorted to the OR by the correctional officers assigned to the unit. An officer remains in the surgical suite until the patient is anesthetized. The patient is allowed to wake up in the hospital recovery room. When he is ready to return to the unit, the custody officer returns to the recovery room and escorts him back to the unit. The inmate returns to the correctional facility two or three days after surgery. He returns to the medical center for postoperative follow-upin the outpatient clinic until he is discharged from the surgical service. This system has worked best for our needs. We were fortunate to get the funding we needed from the legislature when we needed it. Our inmates receive a standard of health care services equal to or better than services provided to residents in the community. Our officers work cooperatively with the nursing staff. We have had no lawsuits for inadequate health care services in five years. Standards for health care in correctional facilities and jails are being developed by several national agencies, and these standards, which must be met if the institution is to be accredited, will do much t o raise the level of care. I believe that we prison nurses created the perioperative role but didn’t know what to call it. We see our patients preoperatively, intraoperatively, postoperatively, and for a long time before and after their surgical procedures. We have the opportunity to follow their progress for years, which makes our program unique. If something goes
AORN Journal, February 1981, Vol33, No 2
nity and t h e m e d i c a l facility. My pat i e n t s come f r o m all t h e correctional ins t i t u t i o n s in M i n n e s o t a p l u s w o r k r e -
w r o n g , w e can’t close t h e o p e r a t i n g r o o m door and f o r g e t a b o u t t h e problem, because t h e n e x t day o r w e e k w e w i l l p r o b a b l y b e assigned t o s i c k c a l l and w i l l h a v e t o d e a l with t h e patients’ anxiety, f r u s t r a t i o n , anger, displeasure, o r m a y b e satisfaction. My p o s i t i o n h a s also changed since t h e closing o f my o p e r a t i n g r o o m at t h e prison. I m o v e d f r o m t h e p r i s o n t o t h e c o m m u n i t y h o s p i t a l as t h e m e d i c a l s u r g i c a l services c o o r d i n a t o r for t h e D e p a r t m e n t of Corrections. I serve as
lease p r o g r a m s and i n c l u d e p a r o l e violators. My expanded r o l e s t i l l includes t h e s u r g i c a l p a t i e n t , and I a c t i v e l y part i c i p a t e inpreoperative, i n t r a o p e r a t i v e , and p o s t o p e r a t i v e planning f o r my clients. Because my w o r k l o a d h a s increased s i g n i f i c a n t l y since 1974, I n o w h a v e a partner. Together we facilitate m e d i c a l - s u r g i c a l and emergency services f o r o v e r 2,000 c l i e n t s in t h e Min-
t h e liaison between t h e prison commu-
nesota system.
0
Coronary patients’ wives need sex counseling Additional counseling is needed to explore the sexual concerns of wives of postcoronary patients, if normal sexual activity is to be resumed. The concerns of these women are explored in an article in a recent issue of Archives of Internal Medicine. Interviews with 100 wives of postcoronary patients show that the wife plays a major role in the patient’s readjustment in his future physical and emotional health. Attention to her sexual concerns and needs is vital, the article concludes. Interviewing the wives, who ranged in age from 26 to 73 years, Chris Papadopolous, MD, found that few of the women had received sexual instructions from a physician. A significantly higher percentage of wives who had received instructions feared sexual activity following myocardial infarction. Fear is probably intensified or dampened by other factors such as age, previous sex drive, performance, anxiety, cardiac symptoms, personality changes, and interpersonal communications. Fear, however, “may have played a role in affecting the frequency and quality of sexual activity.” The study showed wives wanted sexual instruction to be given by a physician or a nurse, but at the same time it concluded the health professional must be trained to
322
meet this challenge. The health professional, by anticipating questions dealing with sexual concerns, “can do much to alleviate anxiety, shame, and despair.” The results of the study, among other things, showed that several women in the group who did not resume sexual activity at all and others who tried and failed to have sexual intercourse expressed sexual anxieties and frustration. “This may cause a wife to react with despondency or anger to her mate’s illness and change in sexual pattern and, in return, may have a disorganizing effect on him and his performance.” During the course of the study, concerns about inadequate sexual instructions, risk of sexual activity, sexual difficulties of the husband, change in sexual patterns, patient’s symptoms during intercourse, and emotional relationship of the couples were demonstrated. Of the 100 couples, the study showed 76 resumed regular sexual activity. Twenty-two couples maintained the precoronary frequency of sexual activity, five couples increased, and 49 decreased their frequency. Of the 24 couples who did not resume, 10 never tried, and 14 couples tried t o have intercourse, but were unsuccessful due to the husband’s impotence.
AORN Journal, February 1981, V o l 3 3 , No 2
I
0R nursing in correctional facilities Marquetta M Origer, RN
Marquetta M Origer, RN, is medical services coordinator for the Minnesota Department of Corrections in St Paul. A diploma graduate of St Johns Hospital, Fargo, ND, she received a baccalaureate in correctional administration from Metropolitan State University in Minneapolis.
308
AORN Journal, February 1981, Vol33, No 2
the prison was part of their rotation. My surgical suite was one OR plus a multipurpose workroom. Since I had committed myself to a prison environment, and because I was curious about the entire operation and didn’t want to make another job change, I stayed. I had a feeling I had embarked on the most interesting and challenging opportunity in my nursing career. I had. We have come a long way since then. The operating room and equipment at the prison were substandard when I arrived. I began a campaign to upgrade or close the OR. Improvements were made, but finally in January 1974, we closed the prison OR, and a transfer program to community facilities was initiated. My role has changed and expanded over the years, and I have made a career of corrections nursing. A prison nurse at a recent meeting in Chicago stated, “I stay in corrections because it’s the only field left in nursing where I can personally provide a service to my patients.” I like corrections nursing because it is a challenge. I have never worked harder anywhere. A day hasn’t gone by without a problem to be solved-from a relatively minor one, like a clean mop head, to a major one, like placement in a nursing home. Correctional nurses are the last frontier of nursing. We do not have the luxury of aides, orderlies, technicians, and readily available services from physicians, practitioners, clinicians, and auxiliary sources. All correctional institutions have a medical director or a health authority, who is technically in charge of the infirmary and on call for emergencies. Larger institutions employ a full-time physician who, in addition to his routine duties such as admission, physicals, and daily sick call, is expected to function on an administhative level on the warden’s staff. Because the physician is expected to be involved actively in the daily institutional opera-
tions, the correctional nurse doesn’t always have the physician readily available when an opinion is needed or a decision has to be made. The corrections nurse must function in an expanded role, making independent health decisions that would not ordinarily be expected of her in an outside facility. Frustration is the major problem facing the correctional nurse. The nurse knows a service must be provided. Getting the service to the inmate may take hours, days, or weeks. I asked the correctional nurses in our system what frustrated them the most, and the answers varied. One nurse said, ‘‘It’s our pharmacy program. Will the difficulties we are having ever be resolved?’ Another nurse said, “It’sgetting enough food for the diabetics on weekends. You know they only serve two meals a day on Saturday or Sunday.’’ A third nurse stated, “The inmates don’t tell the truth; they lie about their drug use. I think I have their problem identified, and then I find out much later that the problem they were complaining about wasn’t the problem at all. It was their old drug problem resurfacing. It’s so frustrating; I wish just once they would tell me the truth.” Frustration leads to “burnout,” a term that is being used with increasing frequency in correctional facilities. We feel much of the burnout syndrome can be avoided if the correctional nurse has a peer to work with and to share her anxieties and frustrations. Notwithstanding the problems the correctional nurse encounters, she still must thoroughly understand the nursing process and be able to apply problem-solving techniques in the delivery of nursing care and related services to confined clients. Nurses who need the support of a structured organization find correctional nursing difficult and threatening. Nurses who enjoy working independently rise to the
d) 310
AORN Journal, February 1981, V o l 3 3 , No 2
ealth care for inmates is a right, not a privilege.
H
challenge and develop their own nursing styles. The correctional nurse learns quickly to make objective nursing assessments, develop and implement nursing care plans, make nursing decisions, and evaluate the plan she has suggested and developed for her patients. Nurses i n private hospitals and clinics take delivery of nursing service for granted. In a medical facility, medical services and practices prevail. In a correctional facility, however, security is the number one priority. Prisons are constructed to protect society from the offender. Our practice of nursing must conform to security policies and regulations without jeopardizing or compromising the standard of care the patient is entitled to receive. Health care for the incarcerated client is a right, not a privilege, and at times, the task of providing this service is overwhelming. To explain how medical services are provided to a confined population, I will describe what happens to an inmate when he arrives at our institutions. This may differ slightly in each correctional facility, but basically it is the same. When an inmate arrives at a correctional facility, he is placed in a reception and orientation unit. In this unit, he is separated from the general population for a week to two months, depending on the institution. The inmate is introduced to institution policy and eval-
314
uated medically and psychologically. His past social and criminal histories are reviewed and documented, and he is observed by the receiving and orientation unit staff for unusual behavior patterns. At this time, he has the opportunity to express educational and occupational preferences or experiences. Here he adjusts to a confined environment while separated from the main living units. During the orientation, the institutional staff has the opportunity to gather information about the inmate from other sources. Initial medical screening is usually done by correctional staff. Immediate health needs are communicated to the medical staff by the custody officer taking the initial medical history. The admission system’s assessment is done by the institution’s physician or physician’s assistant from within 24 hours to 14 days after admission, depending on institution policy. The inmate cannot be placed in a work or general living unit or participate in any programs until he is cleared medically by the physician. In addition to the physical examination, the inmate is given vision and audiometric testing, a venereal disease check, complete blood count, urinalysis, Mantoux test, a chest x-ray if indicated, and dental and mental health screening. A tetanus toxoid immunization is also given on admission. Special medical problems are identified at the time of the physical exami-
AORN Journal, February 1981, Vol33, No 2
nation, and referral to an appropriate specialist is initiated. If the institution is fortunate enough to have consultants come to the prison, the inmate’s name is placed on the consultants’ list for one of the upcoming clinic visits, depending on the urgency of the problem. If a specialist does not come to the correctional facility, the inmate is taken in restraints to an outside clinic by specially trained escorting officers. Return trips to clinics or admission to outside hospitals continue until the problem is resolved. If an emergency problem cannot be handled in the prison infirmary or hospital, the inmate is taken, under guard, to an outside facility that has contracted with the correctional facility to provide emergency medical-surgical services. If the institution does not have its own ambulance, this service is also contracted from the community. Our correctional institutions operate on schedules, and our medical units sometimes threaten to disrupt the order that has been established. We call the inmate to the infirmary or hospital for dressing changes, treatments, special counseling, admissions, preoperative work-ups, health teaching, and diets. Our nursing actions are often misunderstood and misinterpreted by custody staff. We spend a great deal of time explaining our actions and justifying not only our reasons for being in the facility but also our rationale for the intended procedure. Special treatment and special diets cause us no end of problems. We learn to improvise, and we learn to supervise departments that we always felt belonged to somebody else. Improvising becomes necessary when the prison budget does not allow for purchase of large equipment. I remember the time I found a large institutional breadmaking trough, which I had brought to the prison hospital. I needed a whirlpool bath for a six-foot, five-inch inmate who
316
needed daily therapy. There was no money for a new whirlpool, and our bathtubs were too short. The bread trough worked fine with a rented whirlpool machine. The inmate did not have to make daily trips to an outside hospital for hydrotherapy. A diet manual prepared by the Twin Cities Dietetics Association allowed us to supervise our inmate cooks in the preparation of special diets. We later hired a consultant dietitian, but I still refer to my diet manual when our surgical patients are returning to the institution and have special dietary needs. Medications are always a problem in the prison community. Limited formularies are now appearing in many of the correctional facilities to discourage the use of mind-altering drugs. Minor tranquilizers, sedatives, and narcotics, improperly prescribed, jeopardize the order of the institution and alter the behavior of the inmates. Inmates on long-term, mind-altering medications are difficult to manage in a n institutional setting and have a difficult time adjusting to the reality of prison. The limited formulary allows the inmate to make a realistic institutional adjustment and prepare for his eventual release with a clear head. There is always the problem of contraband medication, a reality in a prison environment. The infirmary or hospital staff is responsible for patient teaching and education. There is no special service or department we can call on for this need. If we have a patient with a health problem who is in need of patient teaching, it is our responsibility to see the teaching occurs. Our patients do not respond well to our efforts, and our attempts to develop a “wellness model” often fall on deaf ears. The inmates are quick to tell us they will take care of their health problems when they get out and can see “real” medical personnel. One example is the incarcerated
AORN Journal, February 1981, Vol33, No 2
had no recovery room, and inmate nurses provided the postoperative care.
I
diabetic. He knows he has diabetes and must take his insulin and stay on his special diet. Provisions are made for him to come to the infirmary for meals and insulin. Considerable time is spent assessing the problem, talking to the inmate, and developing and implementing an individualized nursing care plan. We notify the custody office and the cell hall sergeant that the inmate is to report to the infirmary for diet and insulin and suggest to the assignment committee that the inmate’s diagnosis of diabetes be considered when he is given a work assignment. It is frustrating when, in spite of our teaching and careful planning, the inmate fails to arrive at the infirmary. Our only alternative is to start all over again, this time stressing responsibility for his own health status. In spite of the inmate’s reluctance to take responsibility for his own health, some need continued medical care and follow-up on discharge from the facility. Although our responsibility for the inmate stops when he is discharged or paroled, we encourage the client to continue the treatment we have initiated. We inform the inmate he is to keep his appointments and offer assistance to him i n obtaining services through community resources and medical assistance. Discharge planning for a n inmate with complicated medical problems is as important to us as it is to other nurses and their private patients.
318
In 1968,an energetic young physician became our medical director. We saw many changes, and he allowed me to hire professional scrub nurses from the community. He also contracted for the services of a board-certified surgeon who resided i n the community. Although the inmate remained as the first assistant, my operating room began to have some order. We provided surgical services to the inmates at the Minnesota State Prison and the St Cloud Reformatory for Men until J a n 1, 1974, when my OR was closed. All inmates requiring surgery were sent to the University of Minnesota Hospitals until our new facility was opened at St Paul-Ramsey Medical Center in December 1974. Prior to the OR’S closing, we had been doing major surgical procedures in a nonaccredited and nonlicensed facility. I had no recovery room, and inmate nurses provided the postoperative care. There was no anesthesiologist; a certified registered nurse anesthetist gave all the anesthesia. I was assigned one inmate to work with me in the OR and one inmate as my clerk. Fortunately, I still had the on-call scrub nurses, which brought some professionalism to the department. Some of the surgeons were afraid of the inmates, both the patient and the first assistant. I always had to plan my time to include reassuring the surgeon he wouldn’t get hurt. I had one set of general surgery instruments and two Boston Consoli-
AORN Journal, Februaly 1981,V o l 3 3 , No 2
dated steam sterilizers-circa 1890. Replacement parts for the sterilizer were unavailable from the factory, so the parts were made in the prison foundry. We operated four to five days a week on most of the major services excluding chest and neurosurgery, but many of the procedures seemed to be in the specialty the surgeon was interested in. I wondered early in my prison nursing career about conservative management of patients with ulcer disease, as one shelf in the laboratory contained nothing but specimen jars with stomachs. Our inmates began demanding services from the University Hospitals and the Mayo Clinic, Rochester, Minn. Prisoner advocacy groups appeared, and the Department of Corrections appointed a n ombudsman for corrections. A class-action lawsuit was initiated by a group of inmates alleging substandard medical practices. Our progressive medical director was suggesting major changes. Not only was it necessary to think about closing our operating room, it was also necessary to begin changing our entire system of health care delivery. After an extensive study and investigation of the prison health services in Minnesota, we presented our plan to the legislature. They agreed with our suggestions and gave us the money to go ahead with our proposal. In December 1974, we moved our services to St Paul-Ramsey Medical Center, a community hospital that was willing to provide us with the services we needed: clinics, inpatient hospitalization, emergency room services, and a medical director. We constructed a 15bed hospital unit on the sixth floor of the medical center, which we share with Ramsey county. We staffed it with specially trained correctional officers employed by the Department of Corrections. Our nursing staff is employed by
320
the medical center. Our patients are evaluated by the prison’s physician, and a working diagnosis is established. The patient is then brought to Ramsey where he is seen by the surgeon and placed on the schedule. The day before the scheduled procedure he is admitted to our security unit where his preoperative work-up is completed. On the day of surgery, he is escorted to the OR by the correctional officers assigned to the unit. An officer remains in the surgical suite until the patient is anesthetized. The patient is allowed to wake up in the hospital recovery room. When he is ready to return to the unit, the custody officer returns to the recovery room and escorts him back to the unit. The inmate returns to the correctional facility two or three days after surgery. He returns to the medical center for postoperative follow-upin the outpatient clinic until he is discharged from the surgical service. This system has worked best for our needs. We were fortunate to get the funding we needed from the legislature when we needed it. Our inmates receive a standard of health care services equal to or better than services provided to residents in the community. Our officers work cooperatively with the nursing staff. We have had no lawsuits for inadequate health care services in five years. Standards for health care in correctional facilities and jails are being developed by several national agencies, and these standards, which must be met if the institution is to be accredited, will do much t o raise the level of care. I believe that we prison nurses created the perioperative role but didn’t know what to call it. We see our patients preoperatively, intraoperatively, postoperatively, and for a long time before and after their surgical procedures. We have the opportunity to follow their progress for years, which makes our program unique. If something goes
AORN Journal, February 1981, Vol33, No 2
nity and t h e m e d i c a l facility. My pat i e n t s come f r o m all t h e correctional ins t i t u t i o n s in M i n n e s o t a p l u s w o r k r e -
w r o n g , w e can’t close t h e o p e r a t i n g r o o m door and f o r g e t a b o u t t h e problem, because t h e n e x t day o r w e e k w e w i l l p r o b a b l y b e assigned t o s i c k c a l l and w i l l h a v e t o d e a l with t h e patients’ anxiety, f r u s t r a t i o n , anger, displeasure, o r m a y b e satisfaction. My p o s i t i o n h a s also changed since t h e closing o f my o p e r a t i n g r o o m at t h e prison. I m o v e d f r o m t h e p r i s o n t o t h e c o m m u n i t y h o s p i t a l as t h e m e d i c a l s u r g i c a l services c o o r d i n a t o r for t h e D e p a r t m e n t of Corrections. I serve as
lease p r o g r a m s and i n c l u d e p a r o l e violators. My expanded r o l e s t i l l includes t h e s u r g i c a l p a t i e n t , and I a c t i v e l y part i c i p a t e inpreoperative, i n t r a o p e r a t i v e , and p o s t o p e r a t i v e planning f o r my clients. Because my w o r k l o a d h a s increased s i g n i f i c a n t l y since 1974, I n o w h a v e a partner. Together we facilitate m e d i c a l - s u r g i c a l and emergency services f o r o v e r 2,000 c l i e n t s in t h e Min-
t h e liaison between t h e prison commu-
nesota system.
0
Coronary patients’ wives need sex counseling Additional counseling is needed to explore the sexual concerns of wives of postcoronary patients, if normal sexual activity is to be resumed. The concerns of these women are explored in an article in a recent issue of Archives of Internal Medicine. Interviews with 100 wives of postcoronary patients show that the wife plays a major role in the patient’s readjustment in his future physical and emotional health. Attention to her sexual concerns and needs is vital, the article concludes. Interviewing the wives, who ranged in age from 26 to 73 years, Chris Papadopolous, MD, found that few of the women had received sexual instructions from a physician. A significantly higher percentage of wives who had received instructions feared sexual activity following myocardial infarction. Fear is probably intensified or dampened by other factors such as age, previous sex drive, performance, anxiety, cardiac symptoms, personality changes, and interpersonal communications. Fear, however, “may have played a role in affecting the frequency and quality of sexual activity.” The study showed wives wanted sexual instruction to be given by a physician or a nurse, but at the same time it concluded the health professional must be trained to
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meet this challenge. The health professional, by anticipating questions dealing with sexual concerns, “can do much to alleviate anxiety, shame, and despair.” The results of the study, among other things, showed that several women in the group who did not resume sexual activity at all and others who tried and failed to have sexual intercourse expressed sexual anxieties and frustration. “This may cause a wife to react with despondency or anger to her mate’s illness and change in sexual pattern and, in return, may have a disorganizing effect on him and his performance.” During the course of the study, concerns about inadequate sexual instructions, risk of sexual activity, sexual difficulties of the husband, change in sexual patterns, patient’s symptoms during intercourse, and emotional relationship of the couples were demonstrated. Of the 100 couples, the study showed 76 resumed regular sexual activity. Twenty-two couples maintained the precoronary frequency of sexual activity, five couples increased, and 49 decreased their frequency. Of the 24 couples who did not resume, 10 never tried, and 14 couples tried t o have intercourse, but were unsuccessful due to the husband’s impotence.
AORN Journal, February 1981, V o l 3 3 , No 2