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In a Spirit of Restoration: A Phenomenology of Nursing Practice and the Criminal Justice System

Gorman, Geraldine, PhD; Singer, Rebecca, M., ND; Christmas, Erin, MS; Herbstritt, Catherine, MS; Miller, Layne, MS; Murphy, Mary, MS; Shannon, Cailan, MS; Wyss, Katrina, MS

doi: 10.1097/ANS.0000000000000210
Special Issue Topic: Crime, Justice and Health

Conditions within jails and prisons are a public health crisis, necessitating critical reform measures. An innovative collaboration between a Midwestern College of Nursing and Cook County Department of Corrections provides students with the opportunity to develop health education for both those detained in the jail and the corrections officers. A phenomenological approach, recognizing the importance of intuitive and cognitive understanding, is offered as a framework for practice in complex environments. Principles of restorative justice provide a bridge between primary, secondary, and tertiary prevention and the nursing practice possible within these institutions of incarceration and the communities to which people return.

University of Illinois at Chicago College of Nursing.

Correspondence: Geraldine Gorman, PhD, University of Illinois at Chicago College of Nursing, 845 South Damen Ave, 10th Floor, Chicago, IL 60612 (ggorman@uic.edu).

The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

OUR criminal justice system demands our attention. Gun control, racial profiling, the psychology of violence, and establishment of a “new Jim Crow”—the term used by legal scholar Michelle Alexander1 to describe the racial inequities in our criminal justice system—dominate our news cycle and fuel public debates. Within this crucial dialogue, our nursing voice must resonate with clarity and authenticity. As a profession that stands with and witnesses to suffering and which purports to address issues affecting people where they live, languish, and hope, nursing's approach to criminal justice can span all levels of prevention—primary, secondary, and tertiary. In this article, we describe the partnership between our College of Nursing (CON) and the Cook County Department of Corrections (CCDOC). This collaboration exemplifies both nursing's professional mandate and van Manen's philosophical construct of “pathic” knowledge2 (p20) intrinsic to competent practice. We do not present research findings but rather offer our unfolding experience as a catalyst for discussion and analysis. As faculty, we had strong embodied responses to the work and found that response mirrored in the written words of the students. We honor their insightful contributions as our coauthors.

We believe a phenomenological approach is well suited to examining the complexity of the lived experience of working inside the correctional system. It allows us expression as we grapple to understand our place as a healing profession operating within a punitive environment and the intrinsic ethical tension that ensues. Phenomenological interpretation also honors the innate wisdom of our bodies, arising as antecedent to cognitive understanding. Sometimes, we feel the impact of ethical dissonance before we can identify its source.

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Statements of Significance

What is known or assumed to be true about this topic:

It is widely accepted that conditions within our jails and prisons have become a public health issue necessitating critical reform measures. As nurses, educators, and scholars, we have a responsibility to address the social determinants of health and their impact upon our burgeoning incarcerated population.

What this article adds:

In this article, we describe a recent collaboration between the College of Nursing at Illinois, the largest public university, and the Cook County Department of Corrections. For the past year, we have been bringing students into the jail to provide health education. We suggest that we need a phenomenological approach to guide this practice, one which recognizes the limits of what we can know with certainty and what we can control.

We also briefly describe some promising trends in criminal justice reform and consider how nursing can collaborate in these efforts. Emancipatory nursing practice and knowledge span all 3 levels of engagement—from community to incarceration and back again—offering a blueprint for prevention. If we are to address the challenge of criminal justice reform, we must seek avenues of redress, working with our students in the communities as a first line of prevention, helping them mitigate the damage perpetrated within our prisons and jails, and standing ready to welcome formerly incarcerated citizens as they begin to rebuild their lives within our communities. Finally, we explore restorative justice (RJ) and its core principles of respect, responsibility, and relationship. These mirror the core values of nursing and provide another guidepost as we navigate the stark environment of corrections.

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BACKGROUND: COLLABORATION WITH COOK COUNTY DEPARTMENT OF CORRECTIONS

In late fall of 2016, our CON began discussion with the CCDOC regarding a collaboration in which our students would provide health education to the men and women detained within the jail. Often referred to simply by its location, 26th and California, Cook County, Jail is one of our nation's largest single-site predetention facilities. More than 100 000 people pass through the 96-acre facility annually as detainees; on a daily basis, an average of 9000 men and women reside there. The facility has 10 divisions, health services provided by Cermak Health Services of Cook County, and a privatized food service and commissary.3

Approximately 15% of men and 30% of women booked in our nation's jails suffer from mental illness.4 The CCDOC estimates that up to a third of all detainees struggle with a form of serious mental illness, rendering the jail among the largest residential treatment centers for mental illness in our nation.5 This is not a health facility designed to address the specialized needs of those suffering from mental health problems; it is a facility entrenched within the criminal justice system.

The CCDOC is under the supervision of Sheriff Tom Dart, who was first elected in 2006.5 Recognizing the reality of running a criminal justice system that is also a mental health facility, Sheriff Dart has made a name for himself as a progressive reformer. He has put in place systematic mental health screening of new detainees and a 24-hour care line for mentally ill former detainees and the families of current detainees. Furthermore, he has developed a template for how jails in our country can address mental health needs.6 In addition to his focus on psychological health, he oversees the development of programs to enhance the well-being of those detained at the jail. He expanded the jail garden, allowed in beehives and chicken coops, encouraged chess, and creative writing; the jail now boasts a flourishing pizza bakery. Recognizing that a jail is a high stress work environment, resources have also been dedicated to improving the working conditions for the correctional officers (COs), including a program called EMPOWER to address the health and wellness concerns of the staff. Our presence in the jail is part of this series of innovations.

While Dart receives local and national accolades for his innovative approaches to transforming the CCDOC, make no mistake, it is still a jail where people are detained, away from their family, friends, and communities, where their freedom of movement is taken from them, and where their sense of control has been nullified. It has been important for us to keep in mind that the jail houses individuals who, for the most part, have not yet been convicted of a crime. According to our criminal justice system, the men and women at the CCDOC are innocent, until proven guilty.

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METHODS: ENTERING CONFINED SPACE

In January 2017, we offered the jail as one of the clinical sites available in our Population Health Nursing course. This class is a prelicensure requirement for students in our accelerated master's program. In the summer of 2017, we continued with the jail as a site for a clinical synthesis course for the same cohort. Generally, they are older and more experienced than traditional BSN students, with an already established appreciation of the impact of the social determinants of health and with prior degrees in varied disciplines. Regardless of our backgrounds and the innovative reforms taking place at the CCDOC, none of us were adequately prepared for what we encountered. In hindsight, it is doubtful that we could have been.

We divided the semester into two 7-week rotations, with 7 to 8 students in each group. With one exception, all the students were female. We began working with 3 groups on separate tiers (the CCDOC term for a unit) and in different divisions: a group of older male veterans, a disparate and ethnically diverse group of women held on charges related to substance abuse, and a mixed population of men ranging in age from early 20s to 60s, all enrolled in a substance abuse response program. Students queried the women and men on their needs and interests and designed 90-minute educational modules based on the information gathered. Topics ranged from cardiovascular function and pathology to stress reduction to community college entrance requirements. Frequently, we incorporated physical exercise and mindfulness meditation practices. The group participants were quite receptive, but the external obstacles were often formidable.

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SIGNIFICANCE: WORKING WITH DETAINED INDIVIDUALS

On the men's substance abuse tier, half of detainees in the population frequently were confined to their cells during our teaching time. This often resulted in a cacophony of protestations and pleas from unseen men behind locked doors, sometimes humorous, occasionally profane, and on one occasion, quite disturbing, as one yelled repeatedly, “I need medical assistance.” The COs assured us he had the opportunity to go to the clinic before we arrived and he refused. Nonetheless, a disembodied voice crying out for help is not easily ignored, bracketed, or forgotten. The other men on the tier were embarrassed and apologetic, and when we finally had to abort our teaching, all were deeply shaken. When we returned the following week, he was gone. We were told simply that he was “transferred.”

On another occasion, the obstacles we encountered were more internal barriers of understanding. The students presented on “addiction and the brain,” a topic requested by the women. Cocaine was the drug on which the students focused, but the women politely explained that this was largely irrelevant to their experience. When asked what they wanted to learn about, they replied in unison, “heroin.” One older woman with a weathered face and deeply set eyes explained to us that heroin “is the only thing that makes us forget, or helps us to endure, the trauma.” As if on cue, a young woman returned to the tier, holding a photograph and blowing her nose. She had just returned from a brief visit with her 3 children—a 6-month-old infant and 2-year-old twins—and she held the Polaroid the CCDOC staff had taken of the 4 of them. The children were all under the care of the Department of Children and Family Services, relegated to 3 separate foster homes, whereas she was on her way to a downstate prison in the morning. The other women gathered round her, admired the photograph, stroked her hair, and passed around a roll of toilet paper in lieu of Kleenex, one more trauma collectively endured.

Postconference discussions took place in the officers' dining room, an environment usually as noisy as the tiers. Large-screen TVs blared from each wall, and the correctional staff came and went quickly, having only 30 minutes to eat, their lunches punctuated by brief conversations and laughter. Seated among them we attempted to process what we had seen, smelled, heard, and felt on the tiers and in the long subterranean tunnels that linked together the various divisions. Although we spent much time discussing the effects of institutionalized racism in our Population Health Nursing class, we had not truly metabolized it until we witnessed the endless lines of manacled, dark-skinned men being moved through, or left shackled to the wall of, those vast tunnels. Even on the worst days, when the chaos on the tiers crescendoed and the CCDOC staff cautioned us once again “not to be naive,” we never doubted that we should be there. In all our collective privilege and uncertainty, it was right and good to be where we were. This truth we felt in our gut even when words failed us.

At first, I was nervous to be teaching in CCDOC. I thought I had an idea of what people would be like there but that ended up being completely wrong. They were just people like any other people you walk by on the street. Many ... struggled with addiction and a lack of opportunity in daily life. Around this time I read Between the World and Me by Ta-Nehisi Coates and then I couldn't shake his words about the black body in America: “There is nothing uniquely evil in these destroyers or even in this moment. The destroyers are merely men enforcing the whims of our country, correctly interpreting its heritage and legacy. This legacy aspires to the shackling of black bodies.... But a society that protects some people through a safety net of schools, government-backed home loans and ancestral wealth but can protect you only with the club of criminal justice has either failed at enforcing its good intentions or succeeded at something much darker.”7 I heard stories of the trauma many in the jail experienced, and how drugs were just an escape from the reality of their lives. When you hear someone say that being held in captivity is jail is nothing compared to the captivity of their mind, it makes you wonder what it is that jail is really accomplishing. (M.M., nursing student)

Our nursing identity anchors our mandate to stand among those detained, detoured, and derailed within our criminal justice system. Nursing, the American Nurses Association reminds us, is the “protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response....”8

What does it mean to alleviate suffering within a rigid institution designed to punish? How can we treat the human response to systemic degradation—the response of those detained and our response to them? The challenges are multidimensional and complex. We are far from definitive solutions but are becoming more comfortable with the poignancy of the questions. More definitively, we understand that our witness within the jail allows for the formation of such inquiries. Human responses are rife with ambiguity, so we seek, to paraphrase Rilke, to live out the questions until we ‘live along some distant day’ into the answers.9

As students, practitioners, educators, and nursing scholars, we require a philosophical framework that supports us in honoring our nursing mandate however corrosive the practice environment. Until the distant day when criminal justice reform promotes healing and restoration and prohibits the shackling of men in subterranean tunnels, we seek to sustain the innate tension that arises between what we encounter and our subsequent human response. Fortunately, a generous phenomenology of practice offers a middle path suitable to such complex navigation.

According to van Manen, the phenomenology of practice is a “project of sober reflection on the lived experience of human existence,” one which opens up “possibilities for creating formative relations between being and activity, self and other, interiorities and exteriorities, between who we are and how we act.”2 (p12)

The lived experience of the jail demanded sober reflection as we were pulled between the poles of those relations. Caught in the chaos of the moment, always captive to unpredictability, somatic reactions were immediate while understanding emerged more slowly. When repeatedly counseled by CCDOC officials to be wary, to mistrust those whose suffering we hoped to help alleviate, we knew in our gut what felt wrong but articulation proved elusive. Only after individual reflection and group discernment could we assert our identity as practitioners seeking a therapeutic relationship where trust is requisite. We sought a balance between how we knew ourselves to be as nurses and how the CCDOC required us to act within the environment they controlled. Between being in relation with our group participants and acting within the rigid regulations of our institutions. Between honoring how this foreign environment made us feel on the inside and how we were advised to act on the outside. While the CCDOC prioritized rules and regulations and the CON demanded clear-cut guidelines and competencies, we who were in the jail encountered through our bodies' porous membranes an abundance of discordant stimuli.

Physically the jail is sparse ... and grimy. In response to my surroundings, my body felt tense and guarded. Walking around in our blue school-issue scrubs we were either recognized as the nurses or mistaken as inmates.... This unpredictability of how we are perceived in the hallways added to my tension: I often found myself walking slightly hunched over with my arms crossed, something I do when I don't want to be noticed—trying to disappear in a way. (E.C., nursing student)

To understand the multidimensional experience of intersecting with suffering within a draconian environment of confinement, we need a framework sufficiently fluid and generous to embrace conflicting responses. A phenomenology of practice allows for the metabolism of disquieting experiences.

The competence of professional practitioners is itself largely tied to pathic knowledge. Professional knowledge is pathic to the extent that the act of practice depends on the sense and sensuality of the body, personal presence, relational perceptiveness, tact for knowing what to say and do in contingent situations, thoughtful routines and practices and other aspects of knowledge that are in part prereflective, pre-theoretic, pre-linguistic.2 (p20)

That comes close. As nursing educators and clinicians, we want to anticipate all contingencies, identify and possess a competency for every action. But that is not how life unfolds amidst the chaos of detainment. To remain where we need to be, we embrace this philosophical framework that supports us even as we falter.

Once you walk through the door you quickly realize that security isn't a suggestion there—cans, pens with metal components, paper clips—all have to be thrown away. The guards (understandably) have a certain disposition towards a gaggle of young female nursing students dressed in ceil blue scrubs that isn't exactly welcoming. I felt out of place, nervous, like some naive spectacle. (L.M., nursing student)

van Manen elucidates that “...there are other modalities of pathic understanding. But the first important point is that the terms empathy and sympathy suggest that this understanding is not primarily gnostic, cognitive, intellectual, technical—but rather that is, indeed, pathic: relational, situational, corporeal, temporal, actional.”2 (p20) It supports the human response wherever it is situated and without judgment.

How I felt standing in front of the detainees: even though I experienced stage fright to some degree, our audience was consistently warm, supportive, and welcoming. We started each lesson with some light exercising and stretching, a ritual I treasured selfishly because it gave me a moment to let my body relax and breathe before we began. The detainees' involvement with the content put my nurse-self at ease; my heart rate slowed. (E.C., nursing student)

Equally important is the implicit validation of unfolding knowledge. Understandably, both the CCDOC and the CON favored a well-defined game plan—each intervention plotted out ahead of time, each securely anchored by a competency to please our accrediting affiliates. Such certainty, however, proved elusive in the jail where unpredictability reigned as inevitably as sensory overload. In ways that stretched both students and faculty, we confronted the limits of our critical thinking and came to renewed respect for intuitive wisdom. Stopped in the corridor by a young woman who asked about her cutting behavior, we recognized there was no privacy, no way to ensure confidentiality. She asked how she could cut herself safely and prevent infection. As health care practitioners, all of the internal alarms went off—she is in pain, she is struggling with mental health issues, she must stop hurting herself. How do we discuss her pain in a way that honors our professionalism and our shared humanity? We drew on harm-reduction practices and quietly, gently encouraged the use of soap and water as we held her gaze. van Manen recognizes that we discover “what we know in how we act and what we do,” how the seemingly innate “gestures, the way we smile, the tone of our voice, the tilt of our head and the way we look another in the eye” become the building blocks for cognitive knowledge, for the “way we know our world and comport ourselves in this world.”2 (p22)

This was certainly consistent with our lived experience in the jail.

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WORKING WITH THE CORRECTIONAL OFFICERS

The primary emphasis of our collaboration with the CCDOC was educational programming for the detained women and men. In addition, we were asked to provide support to the COs. While their circumstances are not as constrained as those confined, they suffer from similar physical and psychological health disorders. They have among the highest rates of illness and injury of all occupations10 and a lower life expectancy than other public safety officers or similarly aged state employees.11 Corrections officers present with higher rates of prehypertension, hypertension, and obesity than the general population,11 higher rates and intensity of musculoskeletal symptoms,12 and increased risk for depression, posttraumatic stress disorder, substance abuse, and suicide.13 , 14 They are also at high risk of developing diabetes, gastrointestinal problems, headaches, and sleep disorders.15 Our experience in the jail confirms what these studies have found. Officers regularly complained of hypertension, diabetes, fatigue, difficulty sleeping, headaches, body aches, and pains. Many were overweight and unable to lose weight. The officers displayed the signs and symptoms of working in a constrained, violent setting in which they ostensibly have the power, yet feel a lack of control.

Consequently, each week 2 of the students spent one of our designated days with the COs. Initially, they set up an informational table in the officers' dining room with posters and handouts on hypertension, nutrition/exercise, smoking cessation, and stress management. Always they provided blood pressure screening. Initially, this was met with some measure of mistrust, which we eventually connected with the presence of yet another uniform—one bearing a distinct resemblance to that of the female detainee population—showing up in their dining rooms for reasons they did not understand. The students also expressed misgivings about working with the offices whom they viewed as complicit in an oppressive system. With time, suspicions on both sides lessened. During the summer rotation, we began making rounds through the various divisions, working one on one with the officers where they were stationed. This small adjustment had profound effects.

Our group was at all times guests and we were privileged to be at Cook County Jail.... Therefore, we needed to respect the people who were allowing us to have the experience. We were given tours and escorted through the jail.... We also gained a lot of respect for the employees and the work they do for the inmates on a day-to-day basis.... (K.H., nursing student)

Once again, there was no way to anticipate the depth of this learning experience. The critique of our flawed criminal justice system seldom considers the plight of those who work within it to support themselves and their loved ones. Many live in or have roots in the very communities from which the detainees come. They shared a home zip code and now share the same address at 26th and California. We were surprised and touched by the demonstrations of respect and affection the officers often displayed toward those whose security they are empowered to maintain. By the time we concluded our rotation during the summer, the COs were as familiar to us as the men and women on the tiers. They greeted us with warmth and humor as we made our way through the various checkpoints, called out, and waved when we passed them in the subterranean tunnels. It was an unanticipated lesson in commonality and prevention: they experience many of the same external stressors that impacted those detained, and it became clear that any lasting reform measures must take into consideration the attitude and well-being of the many employees of the correctional system.

The guards work long hours, IN A JAIL. A place devoid of any sort of aesthetically pleasing stimuli, where they endure abuse and have many professional and personal limitations as far as making healthy choices for themselves. ...you had to get past their outer shell. At first they made me feel so much more insecure than the detainees did. Again, I felt so naive and ridiculous even trying to get them to open up and talk about stress or health.... However, there was a day I set up a clinic-like setting in an office with a peer, with an open door in a windowless room. The guards came in and talked with the door closed.... It was like a therapy session. We ... handed them information on diabetes and reducing sugar and healthy ways to cope with stress but it was the listening and attention that made the biggest impact. (L.M., nursing student)

Cognitive and pathic knowing: the treatment of the human response.

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EXPLORING PREVENTION: FROM THE JAIL TO COMMUNITY

To broaden our understanding of the lived experience of incarceration, as well as the levels of prevention to which criminal justice reformers and advocates must attend, we supplemented our jail time with excursions into the community. While our examination was cursory at best, it provided a snapshot of the dedicated work bringing hope and healing to some of the most violence-ridden neighborhoods of Chicago. It was energizing and an antidote to the hopelessness and despair endemic to incarceration.

Students attended Community Support Advisory Council meetings where a consortium of service providers gather each month to provide updates on the work they are doing with “returning citizens,” some of whom also provide testimony and feedback. At one such meeting on the west side of Chicago, the students presented on the work they had been doing with the CCDOC. They received a warm reception and invitations for future collaboration. In addition, they visited residential communities for those leaving incarceration, such at St Leonard's Ministry, located only a few miles from our university campus.16 They spent time with the staff of Treatment Alternatives for Safe Communities, which provides health and recovery services for those involved in the criminal and juvenile justice systems.17 And they received a taste of both the gratification and challenges endemic to small community-based nonprofits, such as Curt's Café, which confront recidivism by offering creative alternatives for community engagement.18

I had a very illuminating experience with a coffee shop owner who employed young adults returning to society after incarceration. We visited her café and were greeted by two young men serving coffee and making food.... She told us that before an incarcerated individual can interact with the general public in a work setting they must first go through special classes on etiquette, communication, work ethic, and appropriate response to stressful situations.... Yet, the non-profit coffee shop struggles to continue.... One of the biggest struggles is finding grant money. ...typically, grants are given to organizations that employ the lowest-hanging fruit: individuals who are least likely to return to jail. However, she knew that those needing the most help were those MOST likely to return to jail.... (C.S., nursing student)

We found it essential to step back from the jail to gain this broader perspective of what is possible once one leaves confinement. There is much to be remedied within our correctional facilities, but if one never looks beyond the walls it is difficult to nurture the optimism requisite for the long haul toward reform. We needed to witness and understand what was available to the men and women residing behind the barbed wire once they returned to their neighborhoods. The excursions into the community provided the requisite balance to continue the work in the jails.

As nurses[we] treat the whole person. A person is a product of the environment and we aim to mitigate the ill effects of the environment. This includes speaking out on the failings of our society and how these negatively impact the health of a population. Walking around the CCDOC, it's hard not to see how society is failing our marginalized populations and it is imperative that the [health care] community speak out against the racial injustice of the criminal justice system and the locking up of the mentally ill and addicted. There is power in giving back knowledge to the disempowered about their own bodies. There is power in teaching people how to be healthier in ways that work for them. There is power in forming partnerships with communities to provide the services they request to live their healthiest lives. This social engagement and community empowerment are what kept me going back every week and what I will try to carry forward into my practice. (M.M., nursing student)

The John Howard Association of Illinois received a MacArthur Foundation grant for its work in providing oversight to the state's correctional facilities. Deriving its name and spirit from an 18th-century activist, it draws on the principles of RJ to provide oversight over our jail and prison system.19 The John Howard Society of Alberta (JHS) provides a concise and inspiring introduction to the principles, one of the most promising strategies for criminal justice reform and one harmonious with nursing's mandate to facilitate healing and treat the human response. It defines RJ as “a process to repair that harm that arises from an offence [sic] or incident. The restorative justice process can be used between any two people or groups where harm has been caused.”20 According to the JHS, 3 underlying values provide the foundation for RJ work: respect, responsibility, and relationship.

Such core principles, firmly rooted in nursing, certainly reflect what we felt to be guiding priorities in our evolving work within the CCDOC.

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AND BACK AGAIN

As might be expected, respect is a lightning rod in Cook County Jail. Offered the opportunity to give collective voice to their feelings around respect, individuals often form a chorus of harmonious outrage, building and embellishing on the expressions of others. This seemed most acute among the women, who saw the total lack of “niceties” or what others might deem the bare necessities—combs, brushes, contact lens solution—as the CCDOC'S statement of disrespect. “The water here is rust-colored,” proclaimed one of the women, to which her cellmate replied, “They [CCDOC] have a duty to return me as you found me.” Occasionally, the complaints take on a disembodied quality: “A lack of respect has been observed by me between inmates and inmates and counselors. Shouting, screaming, loud music has been observed by me on a daily basis.” The older men, particularly the veterans, tend to be more philosophical: “We get as much respect as can be expected. Some of us may not be lifelong criminals but the officers don't know that. So we get treated like some real scumbags.”

Students were acutely aware of the importance of respect. When the CCDOC officials told us not to reveal our real names, we discussed what that conveyed and concluded that the lack of respect trumped safety issues; we went forward with our first names intact. On the basis of the feedback we received from the detained men and women, we understood that wearing our own clothes reduced the distance between us while uniforms were simply another manifestation of authority and control. In accordance with the wishes of our CCDOC host, however, students went back to wearing scrubs even when they seemed counter to the trust we hoped to build. Always, the challenge of demonstrating respect rooted us in the larger issues of social justice.

I know that a lot of people would say that people who are being detained in a county jail haven't necessarily earned respect. I believe respect is a human right and someone doesn't need to earn it; rather, they have it from me until they do something to lose it. The individuals I worked with at CCDOC were inquisitive, funny, caring, and doing the best with the hand they were dealt—all things that I respect. ...seeing that not only did they not give up but rather that they were using this experience as a way to better themselves [inspired] respect from the deepest place within me. Working with the folks in CCDOC allowed me to understand that someone's situation isn't what defines the respect they are owed but rather what that person is doing and where they are going. (K.W., nursing student)

Most of the group participants exhibited a finely honed sense of responsibility. Enforced time away from loved ones, work and education result in the sort of sober reflection conducive to coming to terms with the consequences of one's actions. Quick to acknowledge that “I am responsible for the actions that led me here and have no one to blame but myself, “some also express an understanding of their responsibility toward one another: “It is the responsibility of all to show some common courtesy to others. Everyone being detained here is not a bad person or even guilty of the crimes they are being charged with.” While we knew this and tried diligently to keep it in mind, such reminders are important.

Relationships weigh heavily on the minds of the incarcerated—relationships with their mothers, children, spouses, and loved ones. And relationships are rife with loss: “The time away from my family has been the ultimate betrayal. Not being there for my wife and kids leaves me feeling like I have failed them.” Losses can be stark and complete: “I have lost my job and my children in this time period.” Their relationships with their bodies are also altered: “I have lost a lot of weight, I've stressed and cried but. ...I am here and those sensations won't set me free.” However, there is also evidence of looking out for one another, particularly strong among the women and the veterans: “We forge friendships in the jail. Most incarcerated folks have more in common with each other than with the outside because people outside have no clue what reality is.”

Despite the restrictions, the rules, and the warnings, we naturally developed relationships with the participants. When one of us thought we had left our jacket in the women's tier, we returned to quickly pick it up. It was not there, resulting in barked demands from the COs to “return her coat to her now or else!” The patiently constructed relationship built on sharing knowledge and experience seemed to evaporate in the confusion around a missing jacket. As it turned out, another student had innocently picked it up. The tension was palpable despite sincere apologies. When we returned the following week, however, no signs of dissonance remained. The experience brought home for us the fragility and importance of the authentic relationship in this confined space.

These core values of RJ—respect, responsibility, and relationship—are consistent with the priorities of the women and men detained in the jail and reflect the characteristics of therapeutic professional nursing. They also anchor the work of the RJ “hubs” that are found in community centers. We can build upon these principles and use them as both guidelines in our work within correctional facilities and offer them as a bridge to the returning citizens seeking sustainable stability within their communities.

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IMPLICATIONS FOR NURSING PRACTICE/PRAXIS: LOOKING FORWARD

Soon we will bring a new group of students into the CCDOC as part of their Population Health Nursing course. They will benefit from what we have learned thus far and from the experiences of the students who preceded them. Despite all the unanticipated contingencies and ever-present unpredictability, the students gained a great deal. We know this because they told us.

I have had the opportunity to experience a variety of clinical settings but I think I learned the most during this experience at Cook County Jail. I found confidence in providing education in a unique environment and I was touched by the response and feedback from inmates. My main objective was to be a positive ... spot in the inmates' otherwise negative experience and I am confident we were that bright spot during our short time at Cook County. (K.H., nursing student)

Seeing young black men who have been handed nothing but low-paying jobs, polluted and dirty neighborhoods, gun violence, and now the horror of jail, smile and ask questions about their aging mother's health or their unborn child's development has changed my life. It has taught me that as a human and a citizen of the world I am responsible for the way people are treated everywhere.... Working with the detainees of the CCDOC and hearing their life stories took everything I've read and created an in-color picture of the social injustices happening around us every single day. I will never make assumptions about any patient after this experience because if I have learned one thing from the men and women in the CCDOC it's that one life event doesn't define a person, but rather the rich quilt of their entire being defines a person—their likes, desires, dreams, fears, mistakes, successes, and so much more define a person. (K.W., nursing student)

This knowledge gained is not without the twinge of guilt for those of us who freely come and go.

I always walked out of the jail feeling better than when I arrived. Although physically tired—sore legs, sleepy brain—emotionally I felt fulfilled and motivated. But this feeling was always short lived as I remembered that at the end of the day I am free to leave this place, while those I shared a connection with will stay there, likely for an undetermined length of time. (E.C., nursing student)

We acknowledge that in entering the CCDOC, we intersect with a rich history of those calling for a reexamination of our correctional system and of the ethical consequences of cooperation. From within the philosophical tradition, the French postmodernist Michel Foucault21 illuminated the link between capitalist culture and abuse of power in ways that continue to resonate for those concerned with criminal justice reform. More recently, the role of health care professionals within this system came under particular scrutiny when it was revealed that American Psychological Association officials collaborated to develop efficacious forms of “enhanced interrogation” with Department of Defense officials at Guantanamo Bay detention center. Just the act of entering these correctional institutions projects health care providers into a skewed moral landscape, an environment “designed to punish rather than to heal.”22 (p2) Fortunately, within our own body of nursing scholarship, we find signposts to guide us as we make our way forward.

Drawing and expanding upon the emancipatory pedagogy of Paolo Freire,23 nursing scholars issued a “Nursing Manifesto” designed to provide a pathway of emancipation for nursing research, education, and practice.24 It drew upon what has become a familiar feminist critique directed at a profession perceived to emphasize acute care and technological interventions at the expense of “social environmental complexities.”25 (p70) Using the mission and principles of the International Council of Nurses as foundation, the manifesto exhorts nurses to exercise our “ethical responsibility to work toward humanizing healthcare practices and promoting ideals of social justice.”25 (p68) Furthermore, the manifesto offers guidance to nurses caught within the snare of conflicting ideologies by encouraging us to “develop practice methodologies underpinned with nurses' ethical obligation, agency and moral authority to attend to care of persons rather than to any other authority.”25 (p74) In other words, we have the right to assert our nursing mandate within any environment of practice, and as educators working with students, we must model how to summon the courage and professional conscience to do so. The manifesto provides a framework to approach the logistical and ethical challenges we confronted in the jail. We then applied our nursing knowledge to develop actions designed to address what we encountered. Finally, this emancipatory approach to nursing practice/praxis recognizes truth “as experiential”25 (p77) and thus affirms the importance of our words and the validity of the phenomenological approach that honors the lived experience. Emancipatory nursing scholars invite us to share in a “hermeneutic circle” that links philosophy and theory to practice and that recognizes that the “process of study [is] at least as important as specific findings, if not more so.”25 (p72) This rings particularly true to our experience in the jail. Its exploration and intersection with the lived reality of the people who reside and work at the CCDOC enhanced our nursing practice. The process has been reciprocal: as we implemented health education for the men and women of the CCDOC, we discovered much about ourselves. Findings will accrue as the process continues to unfold.

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CONCLUSION

We now know how to navigate the tunnels. We know we cannot bring in spiral notebooks, paperclips, or cans of water or soft drinks. We understand that all tattoos must be covered and all bags must be clear plastic. We gained a deepened understanding and respect not only for the men and women detained within the jail but also for those charged with their supervision. Clearly, correctional reform is a social justice issue of enormous complexity and magnitude and, just as clearly, nursing has a voice in the treatment of this vulnerable population. Our scholarship and vision of emancipatory praxis support us as we move forward.

Our introduction to the principles of RJ will help guide our practice in the future. We witnessed how essential are the core values of respect, responsibility, and relationship—both to the women and men detained and to the COs. Certainly, they are compatible with our identity as health care practitioners. We have come to know more of the important RJ work being carried out in communities. Small neighborhood cafes offer those at risk for recidivism a chance to learn the skills they need to construct a stable life. In the violence-ridden Chicago community of North Lawndale, a new RJ community court has been established. In announcing its opening last July, Chief Judge Timothy C. Evan stated, “As a court system we must work to end the cycle of recidivism. Our new Community Court empowers victims and residents to work as our partners to help restore nonviolent individuals back to society, provide restitution to victims and improve our overall quality of life.”26 In another south-side neighborhood, the historic Back of the Yards, one of the RJ hubs, offers peace circles for youth at risk and for those who have entered the juvenile justice system.27 They also hold healing circles for women whose children have been ensnared within the criminal justice system, either serving time or having lost their lives to violence. We have sat among them to listen and understand more deeply. Moving forward with our students, we need to intersect with the 3 levels of prevention, to know where the seeds of hope and transformation are planted and to be part of that harvest.

Perhaps, the greatest lesson we have learned, however, is how much we cannot know. There is only so much we can anticipate with certainty and to which we can assign a competency controlled by a regulation. The criminal justice system, as exemplified by our lived experience in Cook County Jail, is a microcosm of the social determinants' sequelae, a mirror held to the inequities of our American society. We were continually surprised, caught off guard, and bombarded by sensations and insights for which we were not—could not be—prepared. We move forward not only with broader understanding of what the jail holds for us but also with deepened humility regarding what we cannot control but must address. We acknowledge our need for pathic understanding to complement our critical thinking and for emancipatory scholarship to guide our praxis. The human spirit is both fragile and complex. Its restoration demands multifaceted interventions.

We have learned much; we have far to go. In all ways, nursing stands at the intersection of RJ, mercy, and healing. With humility and conviction, we practice in faith that we will “live along some distant day into the answer.”

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REFERENCES

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Keywords:

correctional health nursing; pathic understanding; phenomenology; public health nursing education; restorative justice

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