by Shannon Mahoney
The role of a correctional nurse is one of the most misunderstood yet important roles in the prison system. This paper explores the different aspects of correctional healthcare nursing and the everyday challenges facing correctional nurses. This includes the ethical issues faced when caring for an inmate who has committed a crime the nurse feels strongly against and how this may potentially impact their ability to care for the patient after the fact. It also touches upon the current nursing shortage and the consequences this has for correctional healthcare. This paper emphasizes the importance of the correctional nurse and offers suggestions on how to maintain a higher retention rate among correctional nurses.
The Challenges of Correctional Nursing
The importance of healthcare in prisons has been highlighted in recent years by allegations of inadequate health services for prisoners mostly within the established private prison industry. There have been accusations in recent years that prisons have been cutting funding and healthcare amenities that are necessary to the health and survival of many inmates. These situations have brought to light the many facets of the corruption within the prison system in the United States and have emphasized the plight that many correctional nurses face. A specific example of this is a recent nurse in Arizona outing the negligence of healthcare within prisons in the state, explaining that the administration of the prisons have effectively given some prisoners a “death sentence” by denying them the proper forms of healthcare. She went on to say that it is “unconstitutional and inhumane” to knowingly not provide the proper standard of care to a person in prison (Lee, 2014). According to a 2014 study, there are approximately 2.3 million prisoners in the United States. This same study found that of those prisoners who had chronic illnesses, many of them failed to receive proper care for their conditions (Wilper, et al., 2009).
Part of problem contributing to this failure to provide adequate care to inmates is due to a lack of funding to prisons and jails, both federal and private. According to the Urban Institute, only about “9 to 30 percent of corrections costs can go toward inmate health care” (The Urban Institute, 2013). This decreases the number of employees prisons can dedicate to inmate health, decreases their pay, and creates limitations on the availability of proper supplies and technology needed for necessary care. It also places limitations on the types of medications available to those incarcerated. According to the Federal Prison guidebook there are only certain medications that are allowed to be dispensed within the facilities. If an incoming inmate is on a medication that is not on this list, it will either be substituted or not dispensed at all (Ellis, 2012). This creates issues for inmates who are in desperate need of that medication.
Another contributing factor to poor health care service in correctional facilities is due to an increasing shortage of medical staff that desire to be employed in such a setting or remain employed in this environment. The nursing shortage is a nationwide problem. Barack Obama identified that there are over 116,000 registered nursing positions that remain unfilled, as there are not enough registered nurses to fill the position (Chafin & Biddle, 2013). Filling these voids in correctional facilities is even more difficult than filling a hospital position due to the vast differences in the job description. One study conducted by W. Sue Chafin and Wendy Biddle found that the retention rate among correction health staff is extremely low, with only 20% of nurses who participated in the study remaining employed at the facility over a three year period. (Chafin & Biddle, 2013). This same study found that the reasons nurses decided to leave jobs in the correctional facility had less to do with the population and facility and more to do with insufficient pay, inadequate time with the patient, and improper treatment from physicians in the prison. (Chafin & Biddle, 2013). This inability to retain certified correctional nurses leads to discrepancies in nurse-patient relationships, the continuity of care, and the documentation of inmate health (Chafin & Biddle, 2013).
Understandably, working in the prison system is not easy. Prisons are one of the most complex and misunderstood parts of our society. Unless there is firsthand experience with the correctional system, it all remains a mystery that is shaped by television and movies. It is hard to even imagine that in an environment that so many people have been taught to fear and avoid that the tiniest aspects of nurturing and caring can exist. The employment of correctional nurses allows for this smallest amount of humanity to exist within the prison system. To some of these prisoners, the nurse they work with offers the only type of interaction they have where they feel safe or, in many cases, their only chance to receive health care inside or outside of prison as many times these people are overlooked when it comes to concern about their healthcare.
Nurses who work in the prisons face different kinds of challenges every day. They must be able to change from acting as an emergency room nurse to a psychiatric nurse in a matter of minutes because they never know what is going to come through their door. Within the walls of the prison a correctional nurse does not just take on the role of a nurse but also the roles of a therapist, dentist, caretaker, and friend. In some cases, the nurse may take on the role of the inmate’s family, becoming a person they feel like they can trust and rely on. Correctional nurses must also be able to adapt to using the equipment they are given, as resources are often not unlimited inside the prison. Along with these practical challenges, correctional nurses face many moral and ethical issues when caring for a person who is incarcerated. Oftentimes what is forgotten is that these incarcerated men and women have a legal right to have their health cared for while in custody.
One of the biggest moral and ethical issues nurses face while working in the prison system is the understanding that every person inside the correctional facility has done something that deemed them a danger to society in some way or another. Prison healthcare workers must decide whether or not they want to be informed on what crime inmates committed and how long they will be incarcerated for. They must also decide whether being privileged to this information will impact their ability to provide a high standard of care to these people. A 2014 study conducted by Ruth Crampton and de Sales Turner looked into the difficulties that come with caring for individuals who are incarcerated. They found that when it came to being informed on their patient’s crime, the answers varied greatly depending on the nurse (Crampton & Turner, 2014). Some nurses interviewed in the study never wanted to be informed of their patient’s crimes or actions. They felt as though knowing this information would interfere with their ability to give the best care possible (Crampton & Turner, 2014). One nurse in the study shared an experience of the difficulties that come with having knowledge of the crime the individual being cared for had committed. He said, “I did look at that patient differently. I just feel like I didn’t want to look after that person because of that. I did find it difficult to overcome” (Crampton & Turner, 2014). Other nurses wanted to know exactly what crime the inmate had committed before caring for them. These nurses felt that it was in the best interest of their safety in their work environment to be fully informed. Although these nurses differed in their desire to be informed, they all agreed that it was their job to remain non-judgmental and give the inmates the best care they could provide for them, as it is their legal right (Crampton & Turner, 2014).
This concern for safety by some nurses in the Crampton and Turner study is not unreasonable. There are a number of inmates that do have the capability of becoming violent, which is why correctional officers are always with an inmate while they are receiving medical care. While this may be the safest measure for the nurse and the inmate, the presence of another person in the nurse-patient relationship can hinder the trust and the ability of the patient to communicate freely and openly with the nurse (Foster, Bell, & Jayasinghe, 2013). Many prisoners view correctional officers as people of higher authority and thus do not feel as open to share their actual symptoms or what actually may have happened to them. This system of superiority does not allow for appropriate collaboration between prisoner officers and the healthcare workers which, in turn, causes deterioration in the level of care the inmate receives (Foster, Bell, & Jayasinghe, 2013).
Along with these moral issues that arise, practical and medical issues arise in correctional nursing as well. Correctional nurses work in a very unique setting where all patient history may not be directly at hand. Sometimes obtaining this information from an incarcerated patient can be very difficult (Williams & Heavey, 2014). They may not always possess the information or have the ability to communicate it to the nurse. It is the nurse’s job to find ways to obtain the necessary information from the patient (Williams & Heavey, 2014). Correct documentation may also not always be available. This has been improving with the introduction of the electronic medical record but this may not always be available due to funding (Williams & Heavey, 2014). In a correctional facility, a nurse may not always have access to necessary equipment, such as forceps or scissors, due to bans or restrictions. (Williams & Heavey, 2014). Since these patients are in the custody of the state or government it is often a challenge when a patient does need to be transported to the hospital as security must be provided at all times for the inmate at well as the healthcare providers (Williams & Heavey, 2014).
A nurse’s role within the prison system is very different from a nurse’s role in traditional bedside nursing. In traditional nursing, a nurse may be with a patient for a few weeks. In correctional nursing, a nurse could be caring for a patient for years depending on the length of their sentence (Gerber, 2012). In some cases the correctional nurse may serve as a primary provider for these patients in the absence of a physician. They may be called to assist in any number of different situations throughout the hospital. They do not have just one specialty within the prison (Gerber, 2012). Sometimes it may be difficult to understand the boundaries of nurse within a correctional facility. It is important for the nurse to remain within his or her own scope of practice (Williams & Heavey, 2014). Nurses should never participate in disciplinary actions and as of “2010 the American Nurses Association Code of Ethics condemned a nurse’s participation in lethal injections” (Gerber, 2012).
The culture within the prison system has a big impact on the prisoners, their health and the individuals who work in these environments. Margaret Leininger touched upon this in her theory of transcultural nursing. In her theory she states “nurses who are culturally competent are better able to provide optimal, holistic care that is considered to be ‘culturally congruent’ with their patients” (Christensen, 2014). By understanding the environment the prisoner was in before incarceration and now while they are incarcerated, a nurse in better able to relate to patients and for better relationships with them (Christensen, 2014). Leininger also notes that care is a universal trait and can be provided no matter what the setting is (Christensen, 2014). This is a theme commonly found among studies involving correctional healthcare. Nurses want to be able to provide the best care possible without the interference of judgment. Once a nurse is able to understand the patient they are able to fully provide for them.
Correctional nurses are a unique type of nurse and not all nurses have what it takes to become one. A correctional nurse must be able to advocate for what is best for the patient even if it goes against their own moral standards, have strong assessment and triage skills, possess excellent communication skills, and have the ability to work with a wide range of patients with different kinds of illnesses that may not be in the nurse’s specialty (Gerber, 2012). The National Commission on Correctional Health Care offers a certification to those nurses who are qualified in all of these areas. Correctional nurses must also be able to separate their work lives from their personal lives so they do not take what they see at work home with them (Crampton & Turner, 2014).
The position of a correctional nurse is one of the most important positions within the prison system. Without these nurses the patients in custody would never be able to maintain their health and would be sicker than they were when they came into the prison. The inmates would die from injuries sustained in custody if a nurse was not there to act right away. Some mental health disorders would go untreated if a correctional nurse did not identify them. It is the responsibility of society and prison administration to advocate for these nurses to make sure they want to continue working in these environments and provide them with the equipment necessary to provide proper care. Without correctional nurses, prisoners would not only get sicker but they would die.
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