Health Promotion and Maintenance
Correctional nurses have more opportunity than nurses working in other settings to influence patients’ health beliefs and behavior for several reasons:
• Every inmate sees a nurse at least once while in jail, prison or a detention facility.
• A nurse sees every inmate who makes a request for health care attention.
• Over the term of incarceration, nurses have more contact with every inmate than any other health professional.
• Nurses provide care in many of the same areas where inmates are held and so they are familiar with the living conditions and constraints of self-care.
Among the basic principles established by the American Nurses Association for correctional nursing is to “encourage each individual through patient and family education to take responsibility for disease prevention and health promotion.” Correctional nurses teach, promote healthy behaviors, assess risk factors and facilitate discharge planning. Health teaching and promotion is not limited to individual patients and can include families, health care colleagues and correctional personnel. Correctional nurses often oversee preventive health and safety measures for the benefit of inmates, correctional personnel and their families (e.g., vaccinations, standard precautions, postexposure prophylaxis and counseling, exposure control plans). The effectiveness of health promotion and teaching is evaluated and the nurse incorporates this feedback to improve the appropriateness and specificity of content, strategies and methods used, according to the ANA’s Scope and Standards of Practice for corrections nursing.
The NCCHC Standards for Health Services emphasize health promotion in standard F-01, particularly individualized education and instruction in self-care, preventing disease and healthy lifestyle choices. Several other standards include elements of health promotion, as well. Self-care instruction and preventive education is emphasized in E-06 Oral Care. B-01 Infection Control Program requires environmental inspections, exposure control plans, disease surveillance and an immunization program. E-12 Continuity of Care During Incarceration requires that periodic health assessments be offered to inmates consistent with recommendations of professional organizations. Finally, E-13 Discharge Planning requires that medications and referrals be provided to support continuation of inmates’ health care during transition to the community. Nurses are responsible for establishing and maintaining programs and practices consistent with each of these standards.
An Individualized Approach
Health promotion and education is more effective when it is targeted to specific health risks, appropriate to the situation and responsive to the patient’s interest. Information collected at intake and during the initial health appraisal (see table) addresses a patient’s health behaviors and family history of disease that create risk for disease or disability.
|Information Collected During Receiving Screening and Initial Health Assessment|
|Family History||Health Behaviors|
|Cancer (colon, breast, ovary)||
Tobacco use (how much, over how long)
|Coronary artery disease||
Injectable substance abuse (what, how much, last use)
|Stroke||Sexual activity (type and number of partners)|
|High blood pressure||Alcohol use (how much, last use)|
Violence (abuse, neglect, sexual assault)
Other information collected during initial evaluation and assessment—screening for infectious disease, diagnostic procedures to identify age- or gender-related diseases and checking the immunization history—also contributes to development of an individualized health promotion plan. The content of patient assessment and screening should be based on guidelines established by the facility physician and consistent with recommendations from organizations such as the U.S. Preventive Services Task Force and the Centers for Disease Control and Prevention.
These guidelines also help determine the frequency for follow-up and routine preventive care. For example, a juvenile who was a sex worker should receive rapid testing and follow-up to treat communicable disease as well as education and counseling to reduce risk of STDs. Effort should be made to update the juvenile’s vaccine record and provide any recommended vaccinations. In another example, a 40-year-old male with a family history of hypertension and cardiac disease who has a 25-year history of heavy smoking and is obese will need follow-up for cardiac disease. He should also receive at least some information on tobacco cessation and weight control. If he is to remain incarcerated for some time, he should also be offered education in self-care and behavioral counseling to make lifestyle changes.
Nurses should validate and summarize the results of the initial screening and health assessment with the inmate and then explain the recommendations for ongoing care. The ANA calls for actively involving the patient in validation of clinical findings and identifying outcomes for subsequent intervention. For many inmates, the health assessment may be the first time they have received information about their health risks and preventive care. Knowing what is recommended, when it should take place and its relative importance will assist the inmate in following up even if transferred or discharged. It is best to provide this information both orally and in written form for later reference.
Behaviors that contribute to significant morbidity and mortality include tobacco use, poor eating habits, inactivity, alcohol misuse, illicit drug use and risky sexual practices. The U.S. Department of Health and Human Services’ “Healthy People” initiative has targeted these areas for improvements for almost 30 years. There is increasing evidence that brief interventions during routine health care encounters to promote healthier lifestyles are effective in changing risk behaviors. Nurses have the opportunity during every patient encounter to provide health information, education and counseling that improves health and well-being.
The goals are to help inmates develop and maintain healthy behavior during incarceration and to increase their knowledge of self-care and appropriate use of the health care system. The ANAScope and Standards of Practice gives more guidance on the correctional nurse’s role in health teaching and promotion. The teaching addresses topics such as “healthy lifestyles, risk-reducing behaviors, developmental needs, activities of daily living and preventive self-care.” Teaching methods should be “appropriate to the situation and the patient’s developmental level, learning needs, readiness, ability to learn, language preference and culture.”
Simplicity and reinforcement are the two most important principles to remember in providing patient education. Present the simplest topic first, followed by progressively more complex material. Avoid use of medical terminology; instead, use words the general public would know. Provide the material in the language the patient best understands. Be concrete and explicit by telling the patient what you want them to do. To reinforce the information, teach the most important concept first and repeat it at the end of the encounter. Ask the patient to state what they understand and then use their description to emphasize key points, correct misunderstanding and answer questions. Provide information in auditory, visual, tactile ways to increase learning, understanding and skill acquisition.
Counseling for behavior change builds on the assessment of health status and advice or information given to promote health. The focus of counseling is for the patient to develop behaviors or skills that improve health. Effective behavioral counseling requires patient involvement; the health care team provides professional support for changes the patient elects to make. Readiness to change is assessed by asking the patient to describe how important the change is for them and how much confidence he or she has in mastering the skills and situations encountered in making the change.
Having the patient describe a typical day will identify barriers to change. Listening to the patient’s perspective may reveal barriers that are not apparent; it also helps build the rapport needed for a collaborative change relationship. The nurse should also work with the patient to identify environmental and interpersonal factors that support behavior change. Have the patient select a realistic therapeutic goal and assist them to resolve or avoid barriers. It also is important for the patient to identify reinforcements and support needed to initiate and maintain the change. Follow-up is most effective when it takes place relatively soon after counseling with follow-up at longer intervals. Follow-up provides support by acknowledging effort and success, modifying goals and interventions based on the patient’s experience and addressing relapse and its prevention.
At the follow-up encounter, the nurse should ask how the patient is doing on changing behavior and what they need help with. Provide additional information or assistance in a neutral, objective manner, then ask the patient to explain how they can use this information. Resistance to change can be reduced or avoided by not taking away control; instead, emphasize personal choice and control over one’s health. It may be that the patient is not ready for change but instead is thinking about or preparing for it. Support the patient’s need for information and consideration of lifestyle change; do not insist on it. If the patient verbalizes reluctance, avoid arguing for a specific change or action. Use of a relaxed posture and reflective listening or understanding of the patient’s perspective reduces resistance and can open up other avenues of discussion.
Nurses must address counterproductive aspects of the correctional setting such as fat-laden menus with few healthy alternatives, intimidating exercise yards, isolation from those who support lifestyle change and limitations on rewards or reinforcements for new behavior. Some inmates engage in health promotion activity for secondary gain such as better housing, preferred place in the meal line or to ingratiate themselves to a staff member. Finally, health information and education must be delivered during very brief encounters such as sick call and medication administration.
Many health education and promotion resources are available, including material or programs used at other correctional facilities. The local or state health department is an excellent source of resources linked to the inmates’ community. Finally, nonprofit and government organizations such as NCCHC, the American Heart Association and Healthy People 2020 have information for clinicians and patients that support adoption of healthy lifestyles.
— Catherine M. Knox, RN, MN, CCHP-RN, is an independent consultant with correctional health care administrative and clinical expertise. This column is coordinated by Lorry Schoenly, PhD, RN, CCHP-RN, an independent consultant specializing in correctional health care and social media; she is based in Pennsylvania. For correspondence, write to email@example.com.
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[This column appeared in the Spring 2012 issue of CorrectCare.]