CorrectCare

The Nurse Is In: Designing Effective Nursing Sick Call Guidelines

by Sue Smith, MSN, RN

Nursing sick call is an autonomous nursing practice found in correctional and occupational health settings. In both of these nontraditional health care settings, the purpose is to assess and treat people who present with minor health complaints for which they would normally self-treat. Due to security concerns, inmates are not free to obtain over-the-counter medications at will; they must rely on the institution’s medical department for access to OTCs and other types of treatment that they may need but that are not available to them.

Few other situations in nursing allow a nurse to independently assess a patient and develop a nursing diagnosis and a treatment plan that may involve administering OTC medications without direct oversight from an advanced provider. Strong protocols that support and direct the nurses’ clinical decision making are necessary for this level of autonomy.

Legal Considerations
Because this level of nursing autonomy is not commonly found in traditional health care settings, nurses and other health care providers have questioned whether the practice is legal. Certainly nursing, pharmacy and medical law vary from state to state, so applicable state practice acts should be reviewed for specific direction.

Generally speaking, over-the-counter medications are regulated by the Food and Drug Administration via the Federal Food, Drug and Cosmetic Act and do not require prescription by a licensed provider. However, nursing sick call interventions do require a high level of clinical assessment and decision making, so it is prudent to have strong nursing protocols that include a properly authorized list of interventions developed in collaboration with the institution’s licensed medical providers.

Whenever nurses assess patients, and particularly when administering or delivering OTC medication, they must practice in accordance with the standards of safe practice. This includes a thorough assessment of the patient with a detailed health history and careful physical assessment, development of a nursing diagnosis and the nurse’s actions and treatment plan that are based on the assessment. Also, it is important for nurses to understand that they are not merely assessing and treating minor health complaints, but will be screening for the possibility of more serious health problems that will need advanced provider intervention.

To determine what involvement licensed practical nurses may have in nursing assessment interventions, it is wise to review state nurse practice acts to understand what physical examination techniques are permitted by LPNs. However, most state nursing practice laws do not permit LPNs to independently develop a nursing diagnosis or treatment plan.

Finally, when determining the scope of nursing protocols, consider consulting with the nursing practice consultant on your state board of nursing or state nurses organization. This type of collaboration and transparency will strengthen the support of these organizations and will help to reassure new correctional nurses.

Protocol Development
Each protocol should address only one complaint and all assessments and assessment data should be related to that complaint. Nursing protocols should contain the following components:

• Definition of the problem/complaint and its etiology
• Subjective information, including detailed health history data to be collected and the expected findings
• Objective information/physical assessments to be conducted, with the expected findings
• A nursing diagnosis appropriate to the complaint; additionally, consider including differential diagnoses
• A list of interventions the nurse will consider based on assessment findings, including criteria for referral to advanced care
• Patient education
• Potential dispositions of the patient when the assessment is complete

Consider using a flow sheet or algorithm design for nursing protocols. This type of format makes efficient use of page space so that a lot of information can be included in a relatively small space. If designed well, the flow of information can be intuitive and easy to follow. Correctional nurses are more likely to read and use protocols that are concise and easy to read.

There are numerous resources that may be tapped to determine the content for nursing protocols. Handbooks developed for advanced practice nurses can be particularly helpful. The content of these handbooks includes many of the minor health complaints seen in nursing sick call and is often presented in the logical, stepwise fashion familiar to nurses. However, care must be taken to remove language and interventions not within normal RN scope of practice.

 It is also very important to collaborate with correctional nurse experts and correctional physicians to contribute to the protocol content and to review the protocols as they near completion. Remember that nursing protocols must be reviewed and approved by the department or facility’s medical director.

(For a sample protocol on athlete’s foot, click here.)

Training
Specific training in the use of the protocols and in the nursing sick call process is important and should be mandatory and documented. Optimally, this would be done for all new hires. The training should be developed centrally or by a group of experienced correctional nurse experts and then made available systemwide (for those systems having more than one facility) to ensure that all nurses are trained to carry out the protocols in a consistent manner.

Training content should include specific instruction about the use of the protocols and assessment forms and review of the assessment techniques required in the protocols. It cannot be assumed that all nurses are equally comfortable and proficient with all the assessment techniques included in most nursing protocols. Following training in the use of the protocols, all nurses must be evaluated for competency before being allowed to conduct nursing sick call independently.

Evaluation/Continuous Quality Improvement
Evaluation is a necessary part of any clinical process. Chart audits of nursing sick call and other nursing assessment interventions (emergencies, walk-ins, chronic care) should be a regular part of the institution or department quality assurance calendar. Process indicators should include the following:

• Appropriate protocol selection
• Protocol compliance
• Appropriate assessment
• Appropriate referrals to advanced care
• Appropriate disposition of the patient
• Patient education
• Accurate and complete documentation

Solid Support

— About the author: Sue Smith, MSN, RN, is a correctional nurse educator (now retired) who worked for 20 years with the Ohio Department of Rehabilitation and Correction.

[This article first appeared in the Summer 2009 issue of CorrectCare.]