What can coronial cases tell us about the quality of emergency healthcare for prisoners in Australia?

Objective

This research aimed to examine the legal and regulatory obligations of authorities and healthcare professionals in the provision of prison emergency health services and to identify problems in the provision of emergency care to prisoners by using case examples from coronial findings.

Methods

Review of legal and regulatory obligations and a search of coronial cases for deaths related to the provision of emergency healthcare in prisons in the past 10 years in Victoria, New South Wales and Queensland.

Results

The case review identified several themes – issues with prison authority policies and procedures that delay access to timely healthcare or compromise the quality of care, operational and logistical factors, clinical issues and stigmatic issues including prison staff attitudes to prisoners requesting urgent healthcare assistance.

Conclusion

Coronial findings and royal commissions have repeatedly identified deficiencies in the emergency healthcare provided to prisoners in Australia. These deficiencies are operational, clinical and stigmatic and not limited to a single prison or jurisdiction. Applying a health quality of care framework focussed on prevention and chronic health management, appropriate assessment and escalation when urgent medical assistance is requested, and a structured audit framework could avoid future preventable deaths in prisons.     

Assisted suicide for prisoners? Stakeholder and prisoner perspectives

For a wider project on aging in prison, the authors interviewed 35 older prisoners and 24 stakeholders (prison staff, prison healthcare professionals, and policy makers) about healthcare for prisoners. In all, 6 prisoners and 3 stakeholders spontaneously expressed their attitudes concerning assisted suicide. Some prisoners seek assisted suicide for medical reasons and others because they regard spending the rest of their lives in prison as undignified. However, stakeholders identified several ethical and practical challenges in providing assisted suicide to prisoners. This article presents these perspectives on assisted suicide in prison and provides an ethical analysis of the issues raised.     

Prison health care: work environment and the nursing role

This article, the first in a new series on prison nursing, gives an overview of the world of prison nursing and the environmental factors that make it so different from other types of nursing. It welcomes the recommendation in the report 'Patient or Prisoner: A New Strategy for Health Care in Prisons' (HM Chief Inspector of Prisons for England and Wales, 1996) that the NHS should be responsible for providing health care for prisoners and the recent publication of the report of the Joint Prison Service/NHS Executive Working Group 'Future Organization of Prison health Care' (Department of Health, 1999), which endorses a formal partnership between the NHS and prison service. The article highlights the benefits that this will have for prison nurses who often feel professionally isolated. The role of the nurse working in the prison healthcare environment is outlined. The work of prison nurses differs from the role of nurses working in other healthcare situations as it is controlled by environmental factors associated with regimes, security and the prison culture. However, changes are taking place and a closer link with local services is envisaged. These changes are an excellent opportunity for nurses and nursing to establish a clear role in prisons and to develop further healthcare standards in the prison service.     

A review of prison health and its implications for primary care nursing in England and Wales: the research evidence

Aims and objectives. To provide a systematic overview of the policy and practice literature concerned with the primary healthcare needs of prisoners in England and Wales and to address the implications of these health needs for nurses working in prisons. Background. The recent reorganization of the prison healthcare system, which has brought prison health services in England and Wales within the National Health Service, has major implications for the role of prison nurses. Nurses in prisons are increasingly providing services to promote the health of prisoners, in addition to making assessments of health need and treating health problems. Methods. The review examined literature from 1995 to date using standard review techniques adapted to be both sensitive and inclusive and with high recall because of the unexplored nature of primary health care in prisons. Results. Findings are identified in three main areas: the general health needs of prisoners, health promotion and chronic disease management. In all these areas, the health needs of the prison population are much greater than the community as a whole, resulting in a high demand for primary care services in prison. However, the prison setting can militate against providing good primary care services in prison. Conclusions. More research has been carried out into the health needs of prisoners than into the provision of primary care nursing services in prisons. Further research is needed into primary care nursing in prison to meet the health needs of prisoners effectively. Relevance to Clinical Practice. With the reorganization of prison health services, health provision in prisons is increasingly primary care focused. This presents new challenges to nurses working in prison to provide a primary care service, which meets the identified health needs of prisoners.     

ACE: a peer education and counseling program meets the needs of incarcerated women with HIV/AIDS issues.

In this article, female prisoners who are peer educators and counselors in an HIV/AIDS program at Bedford Hills Correctional Facility, New York State's only maximum security prison for women, describe the positive role of a peer support program. Using examples from their own experiences, the women discuss the strengths of the AIDS Counseling and Education Program (ACE) in meeting the medical and psychosocial needs of the prison population concerning HIV/AIDS. The role of nurses in a correctional setting is discussed throughout the article and a final section discusses how nurses working together with peer health workers can create an effective team to meet the challenges of the AIDS epidemic within a correctional setting.     

Towards safer interprofessional communication: Constructing a model of “utility” from preoperative team briefings

“Improved team communication” is broadly advocated in the discourse on safety but rarely supported by a precise understanding of the relationship between specific communication practices and concrete improvements in collaborative work processes. We sought to improve such understanding by analyzing the discourse arising from structured preoperative team briefings among surgeons, nurses, and anesthesiologists prior to general surgery procedures. Analysis of observers' fieldnotes from 302 briefings yielded a two-part model of communicative “utility”, defined as the visible impact of communication on team awareness and behavior. “Informational utility” occurred when team awareness or knowledge was improved by provision of new information, explicit confirmation, reminders, or education. “Functional utility” represented direct communication – work connections: many briefings identified problems, prompting decision-making and follow-up actions. The crux of the model is an elaboration of the causal pathway between a specific communication practice (the team briefing), intermediary processes such as enhanced knowledge and purposeful action, and the quality and safety of collaborative care processes. Modeling this pathway is a critical step in promoting change, as it renders visible both the latent dangers present in current team communication systems and the specific ways in which altered communication patterns can impact team awareness and behaviors.     

Users' views of prison health services: a qualitative study

AIM: This paper is a report of a study of the views of prisoners about health services provided in prisons. BACKGROUND: Prison provides an opportunity for a 'hard to reach' group to access health services, primarily those provided by nurses. Prisoners typically have high health and social needs, but the views and experiences of prisoners about health services in prison have not been widely researched. METHOD: Semi-structured interviews were carried out with 111 prisoners in purposively selected 12 prisons in England in 2005. Interviews covered both prisoners' views of health services and their own ways of caring for their health in prison. Interviews were analysed to develop a conceptual framework and identify dominant themes. FINDINGS: Prisoners considered health services part of a personal prison journey, which began at imprisonment and ended on release. For those who did not access health services outside prison, imprisonment improved access to both mental and physical health services. Prisoners identified accessing services, including those provided by nurses, confidentiality, being seen as a 'legitimate' patient and living with a chronic condition as problems within the prison healthcare system. At all points along the prison healthcare journey, the prison regime could conflict with optimal health care. CONCLUSION: Lack of autonomy is a major obstacle to ensuring that prisoners' health needs are fully met. Their views should be considered when planning, organizing and delivering prison health services. Further research is needed to examine how nurses can ensure a smooth journey through health care for prisoners.     

Exposure to Traumatic Events and the Experience of Burnout,Compassion Fatigue and Compassion Satisfaction among Prison Mental Health Staff: An Exploratory Survey

Psychiatric morbidity is high in the prison population and prisoners with mental health problems present with complex needs. Working within the stressful prison environment and exposure to traumatic events may make prison mental health staff and correctional officers vulnerable to burnout, compassion fatigue, and reduced compassion satisfaction. This issue has not previously been explored in the prison setting. In this exploratory study, 36 mental health professionals and correctional officers were recruited from a prison in England and completed a series of questionnaires on their demographic and professional characteristics, exposure to traumatic events, support from managers and colleagues and on levels of burnout, compassion fatigue, and compassion satisfaction. Staff had high levels of exposure to traumatic events and the level of support provided by managers and colleagues was mixed. The majority of staff were not at high risk of burnout, compassion fatigue and reduced compassion satisfaction but higher levels of burnout, compassion fatigue and reduced compassion satisfaction were found to be associated with a range of factors including staff characteristics, exposure to traumatic events, and working environment. These findings should be interpreted with the small sample size and limited power in mind and larger surveys of staff working in prison mental health settings are needed to confirm these results across a wider number of sites but nonetheless this study highlights the need for providers to consider staff’s exposure to traumatic events and to promote supportive working environments.     

A review on adherence management in patients on oral cancer therapies

PurposeThere is currently an ongoing paradigm shift in cancer treatment from intravenous (IV) chemotherapeutics to oral therapies. Additionally, the increased use of long-term maintenance therapy with oral targeted agents or chemotherapy is contributing to a shift toward a chronic-disease model. This shift is creating challenges and responsibilities for health care professionals in patient adherence management. This article will inform health care professionals of current trends and describe ways that they can overcome common barriers to adherence. A comprehensive review of recommendations and evidence derived from oncological studies describing adherence to oral targeted therapies and maintenance chemotherapy will provide guidance for the use of emerging oral maintenance therapies.MethodsArticles in the scientific literature were reviewed if published between January 1985 and November 2010. Searches were conducted using the PubMed database—search terms included “oral therapy,” “chemotherapy,” “cancer,” and “adherence” or “compliance.”ResultsThe change from IV therapy administered and monitored in hospitals or clinics to self-administered outpatient oral treatments decreases the likelihood of adherence. Methods, such as patient education and monitoring and involvement of family or caretakers, can improve adherence in patients undergoing treatment.ConclusionsAt treatment onset, oncology nurses can engage patients directly in a collaborative dialogue, and when issues affecting adherence arise, oncology nurses may limit nonadherence by providing individually tailored educational material. A practical approach to patient education, along with building strong health care provider–patient relationships, can help patients overcome nonadherence to new oral anticancer therapies and treatment paradigms.     

Seeing is believing: The effect of prison-based insight-days on student nurses’ perceptions of undertaking practice placements within a prison healthcare environment

Prisoners' access to healthcare should mirror that of the general public, but is adversely affected by challenges in recruiting nurses to work in custodial settings, potentially impacting on prisoner well-being. To address this issue prison-based insight-days have been developed jointly by one university and prison to positively influence students’ views of undertaking placements in custodial settings because nurses are known to subsequently seek employment in areas where they have had positive student placements.A phenomenological investigation explored student nurses' lived experiences of prison-based insight-days. Questionnaires and interviews were used to gather qualitative data about students’ feelings both prior to and following the insight-day (n = 17). All data was thematically analysed resulting in four themes: pre-placement curiosity, escalating admission anxiety, calming down inside and post-placement decision making.The empirical findings showed that first-hand exposure to prisoners, and to the realities of a working prison, were crucial factors in dispelling stereotypes and addressing negative preconceptions of prison healthcare environments, as students could find prison placements unexpectedly appealing. Drawing on the findings, this paper recommends that facilitating prison insight-days within custodial settings may be one way to encourage students to undertake prison placements.     

From the nurses' station to the health team hub: how can design promote interprofessional collaboration?

Interprofessional practice implies that health professionals are able to contribute patient care in a collaborative environment. In this paper, it is argued that in a hospital the nurses' station is a form of symbolic power. The term could be reframed as a "health team hub," which fosters a place for communication and interprofessional working. Studies have found that design of the Nurses' Station can impact on the walking distance of hospital staff, privacy for patients and staff, jeopardize patient confidentiality and access to resources. However, no studies have explored the implications of nurses' station design on interprofessional practice. A multi-site collective case study of three rural hospitals in South Australia explored the collaborative working culture of each hospital. Of the cultural concepts being studied, the physical design of nurses' stations and the general physical environment were found to have a major influence on an effective collaborative practice. Communication barriers were related to poor design, lack of space, frequent interruptions and a lack of privacy; the name "nurses' station" denotes the space as the primary domain of nurses rather than a workspace for the healthcare team. Immersive work spaces could encourage all members of the healthcare team to communicate more readily with one another to promote interprofessional collaboration.     

Psychometric validation of team experiences questionnaire in preregistration Chinese health and social care students in Hong Kong

The complexity of patients’ healthcare needs can be addressed more adequately by professionals working as a healthcare team. In view of this, it is important to prepare students for collaborative work when they become professionals through a students’ team training at the preregistration level. As intervention programs are implemented to promote students’ collaboration, instruments like Team Experiences Questionnaire (TEQ) are needed. In this connection, this study which involved 335 Chinese students enrolled in eight health and social care programs from two universities in Hong Kong investigated the factor structures of the TEQ using construct validation approach. Using confirmatory factor analysis, we examined the fit of three competing models: unidimensional model, first-order correlated model, and second-order hierarchical model. The results demonstrated that the second-order hierarchical model obtained the best fit, with a higher-order construct called total team experiences subsuming the following first order factors: overall satisfaction with team experiences, team impact on quality of learning, satisfaction with team evaluation, team impact on clinical reasoning ability, and professional development. The “total team experience” construct explained from 21.1% to 35.7% of the variance in predicting students’ future perception of team competency and autonomy, perceived need for cooperation, and perception of actual cooperation. Results support the applicability of the TEQ second-order hierarchical model. Implications are discussed.     

Bedside nurses’ roles in discharge collaboration in general internal medicine: Disconnected,disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals’ roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses’ interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in‐depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty‐five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses’ absence from morning rounds, one‐way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision‐making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse–physician interactions and the current context of nursing care.     

Hierarchies in interprofessional training

ABSTRACT

Adverse patient outcomes are often the result of conflict or poor communication among healthcare professionals. Use of interprofessional care teams can improve healthcare and delivery of services. Healthcare systems have been historically hierarchical in nature with physicians regularly taking a leadership position. The presence of hierarchy can be a source of conflict in interprofessional healthcare teams. This article analyzes qualitative data from a four-day interprofessional training for family medicine residents, pharmacy students, nurse practitioner students, and counseling psychology students. Data was collected through journals, participant observation, and focus groups. Findings from this study demonstrate three key themes related to hierarchy: (1) tension regarding the idea that the physician is the team leader or “quarterback,” (2) experiences of marginalization by team members while working in interprofessional teams, and (3) the tendency for issues regarding hierarchy to go unresolved. Additionally, authors briefly address structures within healthcare that contribute to hierarchy as well as a discussion of alternative models of teamwork and healthcare delivery.     

A multi-method evaluation of interprofessional education for healthcare professionals caring for women during and after pregnancy

This multi-method evaluation assessed the perceived impact of interprofessional workshops targeting enhanced collaboration between healthcare professionals who care for women during and after pregnancy. Current policy recommends partnership working to improve care for women and babies, however, there is little interprofessional education in this area. Five one-day workshops were delivered to 18 healthcare professionals (47.4% of the 38 healthcare professionals registered). The workshop was evaluated through questionnaires before and after the workshop measuring attitudes and willingness towards collaboration; observations of the workshops by a researcher and follow-up interviews 2 months’ post-workshop to explore changes in practice. Workshops were attended by midwives, health visitors (trained nurses specialising in community care for children 0–5 years), dietitians, nurses, a general practitioner and a breastfeeding specialist. Attitudes and willingness to participate in interprofessional collaborative practice improved after the workshop. Observations made at the workshop included engaged participants who reported numerous barriers towards collaboration. Follow-up contact with 12 participants identified several examples of collaboration in practice resulting from workshop attendance. These findings suggest that the workshops influenced attendees to change their practice towards more collaborative working. Future work needs to confirm these results with more participants.     

Impact of a newly opened prison on an accident and emergency department

Objective: To determine the impact of a newly opened prison on an accident and emergency (A&E) department.

Method: A new category B prison opened in April 1999, the first privately run prison in Scotland and the third largest in population. All prisoners referred to the A&E department for treatment were identified prospectively during the first year after the opening of the prison.

Results: 99 prisoners and four members of staff attended during the one year period. Ages ranged from 18–64 years with a mean age of 29.8 years. Presentations were as a result of deliberate self harm (22%), injury after violence (18%), sports injury (15%), surgical condition (15%), medical illness (13%), accidental injury (9%), ENT problem (2%), and miscellaneous (6%). Thirty seven prisoners (35.6%) were admitted to the hospital. Further review at outpatient clinics was arranged for 15 prisoners. One prisoner died, the result of suicide by hanging. The remaining prisoners were returned to the prison for further management by the prison medical and nursing team. Twelve prisoners re-attended a total of 37 times, ranging from twice to a maximum of eight visits. Some 42.3% of attendances were during "working hours" (09.00–17.00) and 57.7% attended "out of hours" (17.00–09.00). Twenty four referrals (23.1%) were deemed inappropriate by the prison medical team on retrospective review. Sixteen of these occurred "out of hours". Forty one prisoners (39.4%) were known to have a history of injecting drug misuse. Including re-attenders, 59 presentations (56.7%) to the A&E department had a history of injecting drug misuse. Of these 41 prisoners, 11 (26.8%) were hepatitis C positive, with eight of these having a positive polymerase chain reaction test. No prisoners had HIV and only one prisoner was hepatitis B positive.

Conclusion: The opening of the prison resulted in only a slight increase in the workload of the A&E department. A significant proportion of prisoners were admitted to the hospital highlighting the practical and logistical problems of managing people restrained and in custody. Most cases can be safely referred back to the prison. Increased input is required from the prison medical team when dealing with deliberate self harm, frequent attenders, and "out of hours" referrals. All A&E staff must be aware of the increased risk of hepatitis C infection when dealing with a confined prison population.