ca forensic nurses’ practices & views with inmates with serious mental illness: medication...
TRANSCRIPT
CA Forensic Nurses’ Practices & Views With Inmates with Serious Mental Illness: Medication Compliance
Phyllis M. Connolly, PhD, APRN, BC, CNSProfessor, San Jose State University
Chia-Chen Lee, MS, RN, FNPSanta Clara County Custody Facilities &
NP Crestwood
The Problem
Estimated 283, 800 mentally ill inmates is US (Sniffen, 1999)
547,800 mentally ill offenders on probation every year (Sniffen, 1999)
Non compliance with psychiatric medications most significant predictor of arrest (McFarland, 1989)
1/3 discharged from psychiatric hospitals lose contact with services within a year (Barr, 2000)
Costs California, $40,000,000 annually (MIOCRG, 2002)
Solutions
Increasing compliance with psychotropic medications
Improving compliance
↓ relapse, ↓ hospital
readmission and ↓criminal transgression (Dubyna & Quinn,1996)
Research Questions
What do forensic nurses believe about medication compliance?
What information do forensic nurses collect during their assessment of inmates’ medication compliance?
What barriers do forensic nurses identify related to medication compliance after inmates are released?
What are the self care behaviors? Do they have concerns for their safety?
Methodology
Exploratory mail survey Questionnaire developed based on
literature review and Scope and Standards of Forensic Nursing Practice (IAFN & ANA, 1997)
Experts utilized to develop and pilot tool
Human Subjects Protected by meeting IRB requirements, SJSU
31 jails or prisons with population over 500 in CA were targeted
Final Instrument
Survey design expert formatted the final 60 questions in a 4 page questionnaire
Piloted by 10 forensic nurses not part of the final study
Procedure
Phone call made to medical directors/or directors of nursing stratified nonrandom sample of 31 CA jails or prisons with populations over 500
3 facilities could not obtain administrative approval
Surveys were mailed to 28 sites in CA Forensic nurses: RNs, NPs, & CNSs Each nurse was supplied pre-stamped,
pre-addressed envelope A follow up phone call was made 1
week after mailing
Response & Data Analysis
14 facilities participated (50%) 55 Forensic nurses returned
questionnaires Question #50 asked for the exact number
of forensic nurses & based on self-report there were 86 potential participants
64% response (55/86) SPSS was used to compute frequencies
and percentages
Institutional Characteristics N = 14
Average inmate population
Ranged from
500 – 6,000
Separate units for inmates with MI
66%
Located in urban areas 46%
Located in suburban areas
33%
Located in rural areas 20%
Demographic Characteristics: Gender, Age, Education N = 55
0 5 10 15 20 25 30 35 40 45 50
Males
Females
Age 25 -45
Age 45 - over 50
EDU AA
EDU Dip
BS Nurs
BS other
MS Nurs
MS other
Doctorate
Other
Other2%
African Am9% Chinese
5%Filipino
9%
White75%
Ethnicity N = 55
Nursing Experience N = 55
Less than 5 yrs. 3 (6%)
5 -10 yrs. 8 (15%)
11 – 15 yrs. 9 (16%)
16 – 20 yrs. 7 (13%)
More than 20 yrs. 28 (51%)
Nursing Experience as Forensic Nurse N = 55
Less than 5 yrs. 16 (29%)
5 – 10 yrs. 18 (33%)
11 – 15 yrs. 12 (22%)
16 - 20 yrs. 7 (13%)
More than 20 yrs. 2 (4%)
Experience With Inmates With Mental Illness N = 55
Less than 5 yrs. 14 (26%)
5 – 10 yrs. 16 (29%)
11 – 15 yrs. 8 (15%)
16 - 20 yrs. 11 (20%)
More than 20 yrs. 6 (11%)
Medication Compliance Views (N = 55)Very important to Important
Importance ↓ recidivism
51 (99%) n = 52
Follow up after release 53 (96%) n = 55
Educating inmates SE psychotropic meds
51 (93%) n = 55
Teaching disease mgt 51 (93%) n = 55
Therapeutic relationship ex-inmates
45 (88%) n = 45
Assessment of Medication Compliance
Name of Med 44 (80%)
Last dose 39 (71%)
Explored issues related to noncompliance 38 (69%)
Financial issues 16 (29%)
Side effects 43 (78%)
Memory impairment 24 (44%)
Inmate doesn’t believe s/he needs 38 (69%)
Doesn’t like to take along with street drugs/alcohol
23 ( 42%)
Lack of support system 25 (46%)
Lack of money for medication 26 (47%)
Medication Compliance Nurse Behaviors N = 55
How often review SE of psych meds with inmates
Always 8 (16%)
Frequently 14 (28%)
Occasionally 24 (42%) n = 51
Most important nursing skill
Communicating with patient 45
( 88%)
Teaching 3 (6%)
Administration meds. 3 (6%) n = 51
Greatest influence over pts
Nurses in jail 19 (42%)
Family 10 (22%)
Peers 7 (16%)
Psychiatrist 6 (13%)
MFCC 3 (7%) n = 45
Perceived Barriers Referrals to Outside Agencies N = 55
Lack of resources 24 (44%)
Lack of time 21 (38%)
Length of custody 11 (20%)
Stigma criminal record 11 (20%)
Out of judicial area 10 (18%)
Budget limit 9 (16%)
Confidentiality 9(16%)
HIPPA regulations 9(16%)
Barriers Providing Discharge Summaries to Outside Psychiatrist and/or Medical Clinic
Lack policy & procedure
19 (35%)
Lack of Time 17 (31%)
HIPPA Regulations
16 (29%)
Fee 6 (10%)
Fee charge to ex-inmate
2 (4%)
Barriers When Providing Medications at Discharge
Lack policy & procedure
25 (46%)
Budget 14 (26%)
Suicide risk 10 (18%)
Lack of time 8 (15%)
Lack of psychiatrist
7 (13%)
Inmates don’t feel they need it
6 (10%)
Barriers When Providing Prescription Prior to Release
Lack policy & procedure
33 (60%)
Lack of psychiatrist
10 (18%)
Lack of time 6 (11%)
Inmates feel they do not need it
6 (11%)
Self Care Practices N = 55
Engaged in support groups Never 35 (70%)
Sometimes 12 (24%)
Most of time 2 (4 %)
Always 1 (2%) (n = 50)
Get Adequate rest Never 13 (25%)
Sometimes 14 (16%)
Most of time 23 (44%)
Always 3 (6%)
Engage in leisure activities Never 13 (25%)
Sometimes 21 (41%)
Most of time 15 (29%)
Always 3 (6%)
Personal Safety N = 55“While on duty, I am concerned about my personal safety”
Strongly agree 9 (16%)
Agree 23 (42%)
Disagree 14 (26%)
Strongly disagree 9 (16%)
“Debriefing services are important for nurses after critical incidents (death, violence, suicide, riots, hostages)”
Strongly agree 37 (67%)
Agree 15 (27%)
Disagree 1 (2%)
Strongly disagree 2 (4%)
Limitations
Nonrandom sample Survey tool lacked established
reliability & validity Study population in California
only Participants well educated &
experienced and may not be representative of all forensic nurses
Self-report and may not match actual practice or behaviors
Conclusions
55 well educated, experienced, caucasian forensic nurses in 14 jails & prisons in CA believe that medication compliance is very important in reducing recidivism & crime
Believed that forensic nurses had the most influence over inmate’s medication compliance
Believed that the therapeutic relationship was very important to medication compliance
Identified many barriers to medication compliance after release
58% were concerned about their personal safety Self care behaviors are not engaged in frequently 94% believed that debriefing services were important
Recommendations Repeat study with larger random sample in
multiple states Maintain high percentage of baccalaureate
and advanced practice nurses employed in jails and prisons
Increase self care practices Increase ethnic diversity of nurses CA specific recommendations:
Add regulation to Title 15 California Code of Regulations to include discharge plans, follow up care, medications or prescriptions upon release, visits by forensic nurses after release
A Vision
Mandating discharge medications and ensuring follow up treatment, along with well-educated, experienced, compassionate, and dedicated forensic nurses practicing in CA jails and prisons may lower rates of crime, recidivism and reduce costs. Furthermore, ex-inmates with serious mental illness may have an opportunity for improved quality of life and increased tenure in the community