Correctional nurses use specialized assessments to screen, triage and evaluate patients to determine the correct level of health care services needed. The reason for the assessment governs the focus and direction of the service.

Screening
Nurses in correctional settings use many screening techniques and tools to examine, identify and act upon certain clinical conditions or needs that an inmate may have. The key concepts of screening are that it takes place very quickly, it identifies all that it should identify, the tools and process are standardized, it uses the least amount of resource for the most gain, and errors made are on the side of overidentification and patient safety.

The correctional nurse must be knowledgeable and competent to complete various screening processes. This means knowing the purpose, focus of data collected and time frame for screening to take place. Reasons for screening include the following:

• Intake or admission
• Work clearance
• Assessment for segregation
• Referral to alcohol or drug treatment
• Transfer to another facility or to court
• After a use-of-force incident

In the correctional setting, nurses must be able to screen inmates for a broad range of things, including need for urgent dental or mental health care and preventive care. However, screening of an inmate in segregation, for example, is very different from screening to decide whether an inmate can be assigned to work in the kitchen.

Assessment in segregation is to identify and address any inmate whose health status (medical and mental health) is deteriorating. The nurse will ask questions and use observation to identify cognitive and affective changes, note any bruising or signs of injury and identify any other physical changes from the inmate’s norm. This screening is conducted either every day or several times a week, depending on the degree of isolation.

In comparison, screening before work assignment in the kitchen is to identify any infectious condition that could be transmitted to others by a food handler. In this context, the nurse will consider the inmate’s communicable disease history and immunizations and examine the inmate for skin and respiratory conditions.

Quick and effective screening is aided by use of standardized tools and techniques, which enable the nurse to focus on the results gained from each step in screening rather than what question to ask next. Also, screening is simply to identify an inmate with a condition, characteristic or change that needs attention, but it does not need to be addressed comprehensively at that moment, unless it is a life-threatening emergency. The quality of subjective and objective information gained from the inmate is better when the encounter provides auditory and/or visual privacy and the nurse’s demeanor is calm, professional and nonjudgmental. The nurse must be able to factor in the degree to which these elements influence the quality of information obtained.

Nurses use professional judgment to determine the disposition of each inmate screened. With intake screening, nurses decide if an inmate has an urgent condition that needs immediate attention and referral. If the inmate has a condition that needs ongoing treatment but it is not urgent, the nurse will make arrangements to continue care until the provider appointment takes place. The types of decisions made by nurses as a result of intake screening include any particular housing assignments or accommodations; notifying custody personnel of special equipment (e.g., a wheelchair), supplies (e.g., keep-on-person medication) or other important information (e.g., suicide potential); referral and appointments for follow-up by medical, dental and mental health personnel; and initiating arrangements to provide continuity of care (e.g., requesting health records from previous provider, verifying prescriptions). In such decisions, it is important that screening overidentify and/or overrefer in favor of the patient and safety.

The nurse has a responsibility to communicate the findings and conclusions of screening. This includes providing custody or other personnel who are not part of the health care team with sufficient information so that the inmate and others are safe. The nurse also needs to convey the screening results to the inmate so he or she knows what to expect and how to request additional assistance, if needed. Finally, the nurse communicates to the other members of the health care team the screening results and subsequent decisions through documentation in the health record.

Sick Call
Correctional health care is guided by several fundamental principles. Inmates may make a request for health care attention at any time. Requests that are emergent are attended to immediately. Requests that are not emergent are reviewed every day; this often is called sick-call triage. Nurses usually are the professionals responsible for reviewing and responding to requests for health care attention via sick call. If the request describes a clinical symptom, the inmate must be seen in a face-to-face sick-call encounter within the next work day (24 hours on weekdays and no longer than 72 hours on the weekend). Any triage of a request for health care attention should include a review of the inmate’s health record.

Nurses may use protocols for the face-to-face evaluation of requests for health care attention. Requirements for the use of protocols are as follows:

• Protocols are jointly developed by the nurse and physician administrator.
• They are reviewed annually.
• They comply with the nurse practice act.
• They do not include use of prescription drugs except for emergencies.
• They provide guidelines for referral to higher level care.

Every nurse must be trained in use of the protocols initially, with annual skill review thereafter. Training must take place whenever a protocol is revised or before a new protocol is introduced. Nurses should have knowledge of normal anatomy and physiology as well as common abnormalities, communicable disease, substance abuse, psychiatric conditions and oral health. Nurses must also demonstrate skill in focused physical assessment.

Evaluation of requests for health care attention should take place in an area appropriate for delivery of health care. The area must be of adequate size, provide auditory or visual privacy, have a sink and water, and have washable hard surfaces. Equipment nurses use for sick-call evaluation includes the health record, thermometer, stethoscope, sphygmomanometer, handheld light, exam gloves, dressing supplies, germicidal solution and reference material.

A face-to-face evaluation of a request for health care attention includes several steps:

• Welcome the patient (establish therapeutic milieu)
• Elicit and listen to the patient’s description of the health concern (subjective data)
• Examine the patient and collect data (objective data)
• Assess and diagnose (synthesis and critical judgment)
• Establish a plan of care (inform and educate the patient)
• Evaluate plan effectiveness (patient understands and consents)
• Follow through on the plan (patient advocacy)

Triage
Based on the assessment of the inmate and evaluation of the health complaint, the nurse may initiate treatment using the protocol, provide advice or recommend some form of self-care, educate or inform the patient about an aspect of care or symptom management, and/or refer for higher level care. Although the protocols guide the nurse’s judgment in whether to refer the inmate for higher level care, they are not always precisely applicable and definitive to the patient care situation. In addition to guidance in the protocol, the nurse should refer for higher level care when the patient has abnormal vital signs, when the evaluation requires diagnostics that exceed the limits of the protocol (radiographs, lab studies, etc.), when the nurse is unable to come to a diagnostic conclusion and when the patient’s complaint has not resolved (seen more than twice for the same complaint).

Know the Essentials
Nurses preparing to take the CCHP-RN exam are advised to know the purpose of the various activities nurses perform in the correctional setting and the fundamentals or principles of each activity as expressed in NCCHC’s accreditation standards. Nurses also should be familiar with national standards for nursing practice and professionalism.

— Catherine Knox, MN, RN, CCHP-RN, recently retired from California Prison Health Care Services and now does occasional work as a consultant and as an NCCHC accreditation surveyor; she is based in Arizona. She and column coordinator Lorry Schoenly, PhD, RN, CCHP-RN, are collaborating on a book titled “Essentials of Correctional Nursing.” For correspondence about this column, write to editor@ncchc.org.