CorrectCare

Nurse Consultants Integrate Medical and Mental Health Care
in California Prisons

by Deborah Lucas, RNC, MSN, CCHP

Nursing organizations in the hospital field talk openly and proudly about their multidisciplinary approach to patient care. Many prisons and jails would like to have the same approach, but environmental issues, short staffing, and sheer patient numbers and acuity tend to intensify the divisions. Correctional settings add a third element—custody—to the equation, which often further divides staff.

The California Department of Corrections and Rehabilitation nurses who provide care to patients in 33 prisons with approximately 175,000 inmates endure the same challenges. And they must do so in the context of two ongoing lawsuits that guide care provided in mental health and medical services.

The arrival of a new court-appointed receiver who values the integration of services in a collaborative forum has inspired hope among these nurses.

However, in the southern region, nurse consultants for program review (NCPRs) for both medical and mental health started that integration process long before the new receiver stepped in.

Diverse Challenges
During the post-lawsuit era, CDCR management recognized the difficulty of uniformly making changes and of communicating those changes across the system. In response, the NCPR position was developed to integrate, coordinate and evaluate health care in the system. The NCPRs take a major role in bridging the gaps. For instance, the NCPR has the opportunity to relate best practices used at one prison to others and to assure their implementation.

The CDCR employs both medical and mental health nurse consultants and assigns each to a specific region. Working as a nurse consultant in this system presents many diverse challenges that virtually assure job satisfaction. The NCPRs contact all prisons in their region and assist the health care staff in meeting the needs of their patients and facility. Troubleshooting, helping the staff to bridge gaps with custody, conducting and reviewing audits, and participating with the staff in meetings, staff interviews, quality management, utilization review and educational seminars are just some of the duties assigned to NCPRs.

But although they share many of the same duties, the NCPRs in the two programs were not unified. The mere size of each prison, number of potential patients and sprawling land surrounding multitudes of buildings make it difficult to communicate with nurses in another yard, let alone those in another discipline or department such as mental health.

In the southern region, the medical and mental health NCPRs recognized early on that although there are two lawsuits to which those services respond and two different budget processes overseen by the courts and state government, nursing did not have to follow that delineation. After all, the patient is still one and the same. Care delivery is moving forward to a quality model, so why shouldn’t nursing relationships move in that direction as well? Nurses in the facilities that NCPRs visit have many of the same concerns about the need for integration and collaboration to produce better patient outcomes.

This group of NCPRs and their regional director of nursing quickly realized that we wanted to work together, we didn’t want to duplicate work and we wanted to facilitate coordinated care by one discipline—and that each group had information and expertise that could complement the other. Even though mental health and medical NCPRs’ goals and directives were sometimes bipolar and often directed them away from physically working with each other, the commitment to collaborate continued.

Common Ground
Medical NCPRs are greater in number than mental health NCPRs and do not report through the same organizational structure, but the contributions of both groups are equally valuable. For instance, the task of medication management is important to medical and psychiatric patients alike in the prison, and it was a common starting ground for communication between NCPRs.

At the outset, the regional DON introduced the mental health NCPRs to the various on-site directors of nursing as a person with whom the local staff should work, which sends the message that the mental health NCPR is a person of value and knowledge. It clears the way for contacts and communication.

Now, the mental health NCPRs make a point to check in with the director of nursing at each visit and to inform the DON of their task for the day. When the regional DON holds monthly staff meetings, the mental health nurses are always invited and they do attend. Projects, common issues and resolutions are routinely discussed at those meetings. Information about changes in management, regional staff and local facility staff are also shared with each other.

Whenever possible the NCPRs visit the facilities together. This unity lends credibility to the NCPRs and promotes a sense of teamwork to the nursing and facility management staff. More concretely, NCPRs from medical and mental health use each other’s extensive specialized backgrounds to collaborate on educational in-services and in their contributions to nursing orientations.

Case in Point
A mental health NCPR was asked to intervene in a facility for a situation where registered nurses were being replaced with licensed psychiatric technicians for certain needs that are usually exclusive to the RN staff. Disagreements about which discipline was to be responsible for which assignments escalated into an issue with the RN labor union.

But the medical and mental health NCPRs jointly attended the next labor-management meeting and together came up with workable resolutions to which the union agreed that pleased nurses, technicians and management.

The mental health NCPR had experience writing exam questions for the LVN/LPT state board exams and is highly knowledgeable about their scope of practice. At the meeting, she clarified the LVN/LPT scope of practice for the department and for the union. The two NCPRs convinced the union that the LPT could and should complete the task under the direction of an RN. This solution not only adheres to practice guidelines but also gave both medical and mental health a role in the solution and in creating a shared vision for patient care.

A Bright Future
The southern region’s collaborative approach is now being shared with other regional groups at joint NCPR meetings, and these groups are looking forward to even more exciting endeavors in the near future. A new pharmacy system, new psychiatric technician job statements and joint educational endeavors are planned. Joint efforts have produced a new restraint and seclusion policy, identified new and expanded roles for facility nurses and presented an example of a true team approach for other prisons and jails to emulate.

— About the author: Deborah Lucas, RNC, MSN, CCHP, was a nursing consultant with the California Department of Corrections and Rehabilitation, Mental Health Services. She is now chief nursing officer at Gateways Mental Health Hospital and Community Mental Health Centers, Los Angeles. She can be reached at dlucas@gatewayshospital.org.

[This article first appeared in the Summer 2008 issue of CorrectCare.]