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Spotlight on the Standards
Teamwork
Vital to Meeting the Medical Autonomy Standard
A nurse
recently called NCCHC to complain that medical autonomy was
being challenged at her prison. It turned out that she was upset
about a new directive that health staff must use the
facility’s punch-card system to record work attendance. While
requiring professionals to use this method of tracking
attendance may not be the best idea, personnel practices such as
this are unrelated to medical autonomy.
A core
principle of correctional health care, medical autonomy
(essential standard A-03) is addressed in all current versions
of the NCCHC Standards for Health Services in this manner:
“Clinical decisions and actions regarding health care provided
to inmates to meet their serious medical needs are the sole
responsibility of qualified health care professionals.”
To quote the
standard’s Discussion section, the intent is “to ensure that
clinical decisions are made for clinical purposes and without
interference from other personnel.”
Many view this
standard as a one-way street, health staff to corrections:
“Now hear this.” What’s often overlooked is the implicit
directive that in security and all other nonhealth matters,
correctional health staff must adhere to the same rules and
regulations as all other facility staff members. This is spelled
out in two complementary Compliance Indicators:
No. 3. Custody staff supports
the implementation of clinical decisions.
No. 4. Health staff is subject to the same security
regulations as other facility employees.
This column will reflect
upon the roles and responsibilities of health staff as facility
employees.
Building
Professional Teamwork
Health staff choose a
correctional career for various reasons. Certainly the
significant progress over the past 30 years in the quality and
quantity of correctional health services highlights
opportunities to “make a difference” for both the
inmate-patient and the continuum of public health. Nevertheless,
some health staff find it difficult to view the correctional
setting with the same open attitude as at a community hospital
or health clinic setting, and may feel isolated from coworkers
whose primary concern is security.
In many ways,
the correctional environment is a militaristic one in which
clarity of roles and assignments is highly valued. It can be,
simultaneously, one of the most difficult or challenging and yet
exciting places to practice the science and art of healing.
To succeed in
correctional health care, it takes all the skills needed to
practice competently in the community, and then some. But
clinical skills are not enough. Of the many variables that can
make or break a successful work environment for the correctional
health professional, interpersonal skills are as essential as
professional accomplishments.
For patients,
the level of respect and cooperation between correctional and
health staff can make the difference between disjointed,
crisis-prone health services and professional, proactive care.
For staff in either group, the nature of day-to-day working
relationships can result in feelings of accomplishment or
continual headaches.
Security
Is Everyone’s Task
In any correctional facility,
health staff must earn respect and cooperation through their
work and readiness to complete the team that keeps the
environment safe and secure. They must develop an understanding
of custodial safety and care issues, not only through the formal
“new employee” orientation provided by custodial
representatives but also through continuing education.
Regulations
that relate clearly to security or safety are easy to
understand. For instance, inmates are not told the exact date of
outside dental appointments so that arrangements for escape
cannot easily be made; inmates working in the health services
department do not clean the pharmacy area without direct
supervision.
The reasons for
other rules are less obvious. Why not mail a letter for an
inmate? What is the harm in discussing personal business in
front of inmate workers? Health staff members who don’t
understand the intent behind the rules may inadvertently, or
even intentionally, bend them, raising the chances of adverse
consequences and jeopardizing their careers.
In
the free world, the ability to navigate one’s profession and
to come out ahead, no matter what, is often admired as
“savvy.” Those same skills are usually termed
“manipulation” in the incarcerated population, where
survival tactics may include placing staff in a position of
indebtedness. A seasoned sergeant once offered this simple yet
powerful caution: “Never do anything for or with an inmate
that you would not want to tell me about.”
In addition,
inmate culture has many nuances of which staff may be unaware.
There is a fine line between positive inmate-peer programs and
relationships that place inmates in positions of power and
negative influence over their peers. As with other facets of
security, health staff should be aware of these dynamics and
heed rules and regulations governing such interactions.
Talking with
custody staff about why things are done in a particular way can
clarify issues and lead to joint problem-solving as opposed to
attribution of blame. Health staff are as obligated to listen
and to learn from their corrections colleagues as they are to
share medical news and information. Information and knowledge
are wedges to drive out distrust and rumor.
The corollary,
of course, is that professional correctional staff do not want
unreliable peers at their side. It is every employee’s
responsibility to report unprofessional behavior— whether it
is an officer’s use of excessive force in controlling an
inmate or a nurse’s dismissive response to a sick inmate—as
well as inmate misbehavior, such as sexual harassment of another
inmate.
A
‘Community’ Approach
In community health care,
the patient’s family and significant others may need to assist
with a treatment plan, especially when the illness itself (e.g.,
some mental disabilities) might cause the patient to resist
treatment. A correctional facility is a community that includes
not only inmates but also staff and visitors. Correctional
officers form a kind of extended family structure, and often are
the first to notice when an inmate needs help.
Likewise,
through infection control efforts, health staff can alert
custody to actions needed to address the “public health”
concerns of the correctional facility community.
Even deeper
collaboration can be achieved by having correctional
representatives participate in the health services continuing
quality improvement program. Such initiatives foster healthy
team functioning in which both corrections and health staff
contribute expertise to identify and solve problems from a
systems standpoint. Similar positive results will come from
involving custodial staff in the mortality review process,
cooperative review of health-related grievances, sharing of
necessary health and security alerts on inmates, and other joint
activities.
Yeast in the
Mix
Experienced cooks will
attest to the efficacy of a small amount of yeast to a batch of
bread dough. Health staff, whether one or two members in a small
jail or a full team in a large prison complex, can have the same
healthy effect on an organization when, in all but clinical
decisions, they fulfill their unique role within the parameters
of the correctional facility’s professional team.
(This article first appeared in the
Fall 2004 issue of CorrectCare.)
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National Commission on Correctional Health Care
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Chicago, IL 60614
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