The tension between custody and caring is particular to correctional nursing practice, including issues such as the correctional priorities of safety and security that often dominate nursing practice. The evidence that should underlie correctional nursing practice is regrettably sparse. “Correctional nursing” is a term that is often used interchangeably with “forensic (psychiatric) nursing” in North America (Kent-Wilkinson, 2009). For example, the International Association of Forensic Nurses (2017), based in the United States, reported that forensic nurses practice in various areas (e.g., corrections) and provide specialized care for victims and/or perpetrators of intentional and unintentional trauma. Forensic nurses who care for offenders in secure environments are most often identified as correctional or prison nurses and care for offenders in correctional institutions, such as jails and prisons (Shelton, 2009; Weiskopf, 2005). The American Nurses Association first recognized correctional nursing as a specialty in 1985 (Schoenly, 2015).
The purpose of this article is to highlight the uniqueness of correctional nursing and how it warrants exploration using qualitative research approaches and grounded theory (GT) in particular. The intent is not to fuel the qualitative versus quantitative debate or to claim that qualitative methods are more important than quantitative methods. Rather, insight is offered as to how correctional nursing practice can be advanced using a GT approach.
The Offender Population
The offender population is considered a “vulnerable” population (Maruca & Shelton, 2016); they frequently lack adequate health education and engage in high-risk activities, such as drug use (Flanagan & Flanagan, 2001). Offenders are often stigmatized because of their mental illnesses (Melnikov, Elyan-Antar, Schor, Kigli-Shemesh, & Kagan, 2017) and are not viewed as valuable within society (Maeve & Vaughn, 2001). Communicable diseases (e.g., HIV and tuberculosis) and chronic conditions (e.g., diabetes and hypertension) are common as well (Flanagan & Flanagan, 2001). The aging offender population is also a concern (Flanagan & Flanagan, 2001; Maroney, 2005).
Correctional healthcare is primarily a nurse-driven system (Flanagan & Flanagan, 2001; Maruca & Shelton, 2016). In correctional institutions, nurses are often the first healthcare providers whom offenders encounter (Muse, 2013). Nursing care (i.e., assessment) may be the initial point of offender contact to determine whether additional healthcare services are required (Schoenly, 2015). Physicians provide important medical care and leadership, yet their availability varies depending on the correctional institution (Muse, 2013). Instead, nurses are the primary healthcare providers in correctional institutions (Flanagan & Flanagan, 2001; Muse, 2013; White & Larsson, 2012) through which offenders access care (Muse, 2013). Providing primary correctional healthcare also allows nurses to engage in more autonomous practice in the institutions (Muse, 2013). As a result, correctional nurses are well positioned to impact healthcare services delivery for offenders.
The nursing role is executed within the context of correctional healthcare policies, professional standards, and correctional institution policies (Dhaliwal & Hirst, 2016). Nursing responsibilities depend on the size of the institution and type of offender population, such as male, female, or both, and adult or young offenders (Flanagan & Flanagan, 2001). Correctional nurses provide a variety of healthcare services to offenders, such as emergency, geriatric care, maternal health, mental health, and public health (Shelton, Weiskopf, & Nicholson, 2010). Because of their work with vulnerable populations, healthcare professionals (i.e., nurses) are not always honored for their efforts in providing care (Maeve & Vaughn, 2001) and experience professional isolation because of the limited recognition and support from other nurses outside corrections (Maroney, 2005).
While correctional nurses remain focused on providing quality care, they experience challenges in caring for offenders because of their practice environments. Correctional nursing practice encompasses “the coupling of two contradictory socio-professional mandates: to punish and to provide care” (Holmes, 2005, p. 3). Nursing practice in correctional institutions is complex due to various ethical issues (Brodie, 2001; Walsh, Freshwater, & Fisher, 2012), for example, respecting offender autonomy in environments that are designed to restrict daily life privileges, and addressing the institutional demands of control, coercion, and security while providing care (Walsh et al., 2012). Correctional healthcare is dominated by prison architecture focused upon surveillance and control (Doyle, 2003), including the “control of masses through the application of strict regulations” (Jacob, 2014, p. 49). As a result, nurses may experience difficulties in portraying caring toward offenders (Jacob, 2014).
This ongoing tension between custody and caring is particular to correctional nursing practice, including issues such as the correctional priorities of safety and security that often dominate nursing practice. As a result, correctional nurses may experience challenges in facilitating offenders' health and well-being (Weiskopf, 2005) and thus must possess the specialized knowledge to deliver quality care for offenders. However, the research to describe and support correctional nursing practice is still sparse (Schoenly, 2015). Advancing correctional nursing practice, including identifying, understanding, and addressing challenges, and promoting positive health outcomes for offenders require the pursuit of basic research.
Correctional Nursing Research
The available evidence for any discipline ought to provide the basis for developing guidelines and clinical recommendations (Evans, 2003) and understanding and addressing challenges to advance the discipline. Yet, there is a dearth of robust research that fails to provide an evidence base for correctional nursing practice (Schoenly, 2015). For example, a systematic search and narrative synthesis of international correctional nursing literature revealed 31 of the 42 identified publications were nonresearch (Dhaliwal & Hirst, 2016). Further research is required to improve correctional nursing care for offenders (Schoenly, 2015; Weiskopf, 2005).
The complexities, for example, the tension between custody and caring, that influence correctional nursing practice are absent or less in the forefront of other subspecialties of nursing. Therefore, correctional nursing practice warrants the development of its own knowledge base. White and Larsson (2012) argued that knowledge development, specifically research and its dissemination in correctional nursing, is required to keep pace with the progression of nursing science in more traditional practice areas. Correctional nursing researchers must develop specific knowledge to advance this subspecialty in all domains of nursing practice (administration, clinical practice, education, and research). Additional foundational knowledge is required to advance correctional nursing practice through the pursuit of basic research via qualitative approaches.
The Suitability of Qualitative Research and Correctional Nursing
Correctional nursing researchers can build foundational knowledge using rigorous qualitative research approaches. Qualitative research is appropriate when topics are minimally explored (Corbin & Strauss, 2015) and may reveal patterns and processes suggesting causal interpretations, which then can be systematically tested using more controlled methods of inquiry (Polit & Beck, 2017), such as quantitative methods (Corbin & Strauss, 2015). There are many topics within correctional nursing that remain unexplored or are minimally explored. For example, researchers are beginning to explore correctional nursing practice and its challenges (Schoenly, 2015). However, there is still a lack of knowledge about these nurses, specifically evidence to support their roles, functions (Maruca & Shelton, 2016), practices (Schoenly, 2015), and contributions to correctional healthcare services delivery (Maruca & Shelton, 2016). Moreover, research is required to address the ongoing tension between custody and caring (Maroney, 2005). As an example, these matters could be studied by focusing on the implementation of correctional nursing practice (i.e., how do correctional nurses implement their practice).
Using quantitative methods to understand the implementation of correctional nursing practice may not illuminate the full context of how correctional institutions impact nursing practice. On the contrary, qualitative research approaches help investigate the complexity of healthcare systems and other factors, including the sociopolitical context in which healthcare is funded, provided, and regulated (Greenhalgh et al., 2016). Likewise, correctional nursing practice is a complex process as it is regulated (either by correctional services or health authorities) and implemented in institutions whose primary purpose is not the promotion of health and well-being. GT is one qualitative research approach that can grasp the complexity of correctional nursing practice, specifically how these nurses implement their practice.
The Suitability of GT Research and Correctional Nursing
There are two reasons a GT approach is paramount for building foundational knowledge to advance correctional nursing practice. First, qualitative research approaches (i.e., GT) provide explanations about how or why phenomena exist or what they mean as a base for theory development (Polit & Beck, 2017). The development of theories regarding correctional nursing practice will provide an in-depth understanding of this subspecialty of nursing, including foundational knowledge to guide further research endeavors. A GT approach develops theories that explain human interaction (Hall, Griffiths, & McKenna, 2013), including noting changes in conditions and contexts (Holloway & Todres, 2003). For example, a substantive theory regarding the implementation of correctional nursing practice may provide an understanding of the interaction of correctional nurses with offenders and correctional services, including noting changes in nursing practice due to the correctional context.
Second, nursing practice is a process carried out in correctional institutions. The GT approach is “process oriented” and thus is appropriate for exploring how correctional nurses implement their practice. The GT approach can provide insights into the processes that individuals use to deal with situations that are not well understood (Benoliel, 1996). For example, how correctional nurses implement their practice, while experiencing the tension between custody and caring, could be explored using a GT approach. The use of a GT approach can enable the generation of a theory of process, sequence, and change pertaining to organizations, positions, and social interaction (Glaser, 1965), thereby enlightening “how” and “why” correctional nursing practice is implemented the way it is.
Barney Glaser and Anselm Strauss, two sociologists, published their first GT method book in 1967 (Glaser & Strauss, 1967). Glaser and Strauss argued that there was an overemphasis of theory verification as compared with theory generation (Cooney, 2010; Glaser & Strauss, 1967), yet both should receive equal attention (Kenny & Fourie, 2014). A GT method is an inductive process (Streubert & Carpenter, 2011), enabling the systematic generation of a substantive theory grounded in empirical data (Walker & Myrick, 2006). A GT approach provides researchers with the tools to synthesize data, including a precise way of thinking about the data (Morse et al., 2009). Researchers using a GT approach can gain deeper understandings of psychosocial processes as well as develop theories to explain what is going on (Morse et al., 2009; Streubert & Carpenter, 2011) and why and how something happens (Corbin & Strauss, 2015) or has happened (Morse et al., 2009). The focus of GT research is on developing theories that are informed by actual events and interactions of people and their communication with each other; for researchers, this means centering on processes (Holloway & Todres, 2003).
The extensive use of the GT method (Streubert & Carpenter, 2011) has resulted in the development of different approaches (Annells, 1996). The GT approaches have evolved since Glaser and Strauss first posited their classical approach. The current three common GT approaches (Glaser & Strauss Classical, Strauss & Corbin, and Charmaz Constructivist) retain a familial resemblance because of the use of certain procedures (Kenny & Fourie, 2015), such as simultaneous data collection and analysis, using theoretical sampling, constant comparison, memo writing, and data saturation (Glaser & Strauss, 1967).
The notion of theoretical sampling has changed over time among the GT approaches. Glaser and Strauss (1967) defined that “theoretical sampling is the process of data collection…whereby the analyst jointly collects, codes, and analyzes [the] data, and decides what data to collect next and where to find [it]” (p. 45). From a classical GT perspective, the basic question in theoretical sampling is “what groups or subgroups does one turn to next in data collection?” (Glaser & Strauss, 1967, p. 47). Clearly, Glaser and Strauss emphasized the need to focus on participants during theoretical sampling. In contrast, Corbin and Strauss (2015) later identified that the basis for theoretical sampling is concepts, not individuals. Corbin and Strauss (2015) reported theoretical sampling requires data collection be conducted based on previous collection and analysis to further develop properties, dimensions, and relationships of concepts; over time, theoretical sampling becomes more specific. Similarly, Charmaz (2006) indicated that theoretical sampling is conducted to develop the properties of categories with the goal of elaborating and refining these categories.
The GT approach uses a constant comparative method of data analysis (Charmaz, 2006; Glaser, 1965; Glaser & Strauss, 1967; Kenny & Fourie, 2015) to develop theories through systematic coding and analytic procedures (Glaser & Holton, 2004). Constant comparison is required during analysis to determine if data are conceptually similar or different (Corbin & Strauss, 2015). Data are compared to identify similarities and differences, such as initially comparing interview statements and incidents within the same interview (Charmaz, 2006).
Researchers reflect on the data by memo writing (Kenny & Fourie, 2015), which provides an analytic illustration for ideas (Glaser & Strauss, 1967). Researchers write memos throughout the data collection and analysis phases and use these in theory development (Kenny & Fourie, 2015). Memo writing denotes concepts and their relationships, thus moving the research from raw data to theory (Corbin & Strauss, 2015). Charmaz (2006) reported memo writing prompts researchers to analyze data; moreover, it provides a way to develop ideas.
Saturation occurs when no new data are identified (Glaser & Strauss, 1967). Data collection is completed upon saturation (i.e., no emergence of new concepts), and the concepts have been developed regarding their properties and dimensions (Corbin & Strauss, 2015). Similarly, Charmaz (2006) indicated that categories are saturated when data do not provide new theoretical insights or new properties of these core categories. Correctional nursing researchers must be mindful of how to use these procedures based on their selected GT approach.
Although the three common GT approaches retain a familial resemblance, they differ based on the philosophical underpinnings. Research approaches originate from different paradigms and assumptions about the nature of reality (ontology), the relationship between the inquirer and the subject of research (epistemology), and how the knowledge should be obtained (methodology; Hall et al., 2013). Researchers must be aware of the various philosophical underpinnings of the different GT approaches to effectively use the method (Hall et al., 2013). The differences in philosophical underpinnings can assist correctional nursing researchers in selecting a specific GT approach as these dictate some methodological variances. For example, the differing philosophical underpinnings impact the use of literature (Kenny & Fourie, 2015), which is a controversial issue in GT research.
The frequently cited philosophical underpinning of the GT method is symbolic interactionism (SI; Annells, 1996; Hall et al., 2013; Streubert & Carpenter, 2011). Informed by pragmatism (Charmaz, 2006), SI is a theory of human behavior and an approach to study human conduct and group behavior (Annells, 1996). There are three assumptions that underpin SI: Individuals act based on the meanings that things have for them, individuals act because they have agreed on the meanings attached to things in the environment, and meanings change via an interpretive process (Benzies & Allen, 2001).
Glaser and Strauss GT Approach
The Glaser and Strauss Classical GT approach is situated in the positivist paradigm (Charmaz, 2006; Ghezeljeh & Emami, 2009). Ontologically, positivists assert that the world is ordered and predictable, and a true reality is “out there” to be identified (Hall et al., 2013). Epistemologically, positivists are dualist and objectivist in which the focus of an inquiry exists independently of human interaction (Hall et al., 2013). The Glaser and Strauss GT approach is situated in the positivism paradigm because of its rigorous codified methods, emphasis on emergent discoveries, and language that echoes quantitative methods (Charmaz, 2006). Objectivist grounded theorists assume that data represent objective facts; thus, researchers find these data and discover theories (Charmaz, 2006). In contrast, some authors have claimed the Glaser and Strauss GT approach is situated in the postpositivism paradigm (Annells, 1996, 1997; Hall et al., 2013; Kenny & Fourie, 2015; McCann & Clark, 2003; Reay, Bouchal, & Rankin, 2016). Ontologically, postpositivists possess a critical realist ontology; a true reality exists, yet it is never fully understandable (Hall et al., 2013). Epistemologically, postpositivists are modified dualist and objectivist (Hall et al., 2013). Therefore, perfect objectivity cannot be fully obtained, yet it is possible to discover knowledge, which is separate from human minds (Hall et al., 2013).
The philosophical underpinnings for the Glaser and Strauss Classical GT approach are challenged within the literature. Hernandez (2008) argued that the underpinnings of the Glaser and Strauss Classical 1967 GT approach are methodological. Likewise, Glaser (2005) argued that the continued emphasis of SI diminishes the methodological power of GT. Nursing researchers “just want a theoretical perspective. SI institutionalizes GT as its own…it gives them an ontology and epistemology. The takeover becomes structurally induced by researchers, especially nursing, since they want a theoretical perspective in advance” (Glaser, 2005, para. 3). Glaser's rejection of SI aligns with the postpositivism paradigm and indicates his disassociation with other GT approaches (Kenny & Fourie, 2015).
Methodologically, positivist researchers attempt to avoid contaminating studies with their personal views (Hall et al., 2013). Glaser's emphasis on the need for verification research reinforces the postpositivist stance (Annells, 1996). Research questions and problems are not posed before initiating the research process; if posed, this will result in irrelevant GT research (Glaser & Holton, 2004). The theories are discovered; the knowledge exists apart from the researchers and can be obtained via observation of the data (Reay et al., 2016). Glaser's position regarding the avoidance of literature (Kenny & Fourie, 2015; Glaser & Strauss, 1967) aligns with his philosophical views to minimize researchers' assumptions (Kenny & Fourie, 2015) and ensure the emergence of the categories during analysis will not be contaminated (Glaser & Strauss, 1967).
Implications for correctional nursing research
Correctional nursing researchers should ensure that personal views, clinical experience, and knowledge of the literature are held in abeyance to avoid contaminating the research process. Posing specific correctional nursing research problems and questions is discouraged to ensure the emergence of accurate data. For example, studying how correctional nurses implement their practice may be an acceptable general topic. However, identifying the tension between custody and caring at the outset of the research project may risk contamination of the research process, regardless if this has been experienced by the researchers in practice or reviewed in the literature. Correctional nursing researchers must engage in an objective research process.
Strauss and Corbin GT Approach
The Strauss and Corbin GT approach is situated in various paradigms: constructivist (Annells, 1996, 1997; Cooney, 2010; Mills, Bonner, & Francis, 2006a), postmodernism (McCann & Clark, 2003), poststructuralist (McCann & Clark, 2003), and postpositivism (Hall et al., 2013; Kenny & Fourie, 2015). Ontologically, the Strauss and Corbin GT approach has shifted toward relativism (Annells, 1996, 1997; Ghezeljeh & Emami, 2009). “Reality exists only as multiple mental constructions…there is no differing social and natural world reality” (Annells, 1996, p. 386). Epistemologically, the Strauss and Corbin GT approach has moved toward subjectivism (Annells, 1996, 1997; Ghezeljeh & Emami, 2009; Hall et al., 2013). Most recently, Corbin and Strauss (2015) identified 13 philosophical assumptions driven by interactionist and pragmatist thoughts. Aligning with pragmatism, John Dewey and George Herbert Mead assumed that knowledge is developed through action and interaction (Corbin & Strauss, 2015).
Methodologically, the Strauss and Corbin GT approach allows researchers to initiate the research process with the identification of a problem and a question (Annells, 1997; Corbin & Strauss, 2015; Streubert & Carpenter, 2011). The research topic or problem can be selected from several sources: advisor or mentor, technical and nontechnical literature, personal and professional experience, and pilot projects (Corbin & Strauss, 2015). Corbin and Strauss (2015) acknowledged that researchers bring knowledge of the literature (technical and nontechnical) before engaging in any inquiry. The acceptance of literature by Strauss and Corbin aligns with their postpositivistic underpinnings (Kenny & Fourie, 2015). Finally, the Strauss and Corbin GT approach offers a myriad of structured data analysis tools that may be used by researchers (Corbin & Strauss, 2015).
Implications for correctional nursing research
Correctional nursing researchers can acknowledge their personal views, clinical experience, and knowledge when using the Strauss and Corbin GT approach. Exploring problems experienced in practice (e.g., tension between custody and caring) would be acceptable when studying how correctional nurses implement their practice. Likewise, correctional nursing researchers may benefit from possessing knowledge of the literature and any gaps to guide their research projects. The various data analysis tools may help correctional nursing researchers facilitate and structure their analytic thought processes. Correctional nursing researchers should possess an understanding of the philosophical underpinnings that are driven by interactionist and pragmatist thoughts.
Charmaz Constructivist GT Approach
Charmaz (2006) reported the Constructivist GT approach is situated in the interpretive paradigm and thus allows for the most interpretation during the research process as compared with the other GT approaches. Ontologically, the constructivist GT approach aligns with relativism (Mills, Bonner, & Francis, 2006b) and epistemologically aligns with subjectivism (Mills et al., 2006b). From a constructivist perspective, individuals, including researchers, construct their realities (Charmaz, 2006).
Methodologically, constructivist inquiry begins with the experience and asks how all those involved construct it (Charmaz, 2006). Specifically, researchers should pose a general research problem and question because their assumptions and disciplinary perspectives shape the topics of study and, based on the emergence of the data, influence the direction of the inquiry (Charmaz, 2006). Researchers can also use literature reviews for several reasons, such as identifying gaps in knowledge, and position new studies in context of the literature to show the contribution of their work (Charmaz, 2006). The use of literature reviews should not “stifle creativity or strangle the theory” and, in turn, can be “weaved throughout” the research process, including the final written work (Charmaz, 2006). Constructivist researchers gain multiple views of the phenomenon understudy and study how and why participants construct meanings and actions in certain situations (Charmaz, 2006). Researchers and participants mutually engage to co-construct the final GT (Mills et al., 2006a). The final GT is acknowledged as being influenced by researchers (Charmaz, 2006). Charmaz's perspective regarding GT is that data and theories are not discovered, but constructed (Charmaz, 2006; Ghezeljeh & Emami, 2009).
Implications for correctional nursing research
Correctional nursing researchers will integrate their personal views, clinical experience, and knowledge when using this approach. For example, correctional nursing researchers who have practiced in corrections and experienced the tension between custody and caring would bring rich insights into a study focused on how correctional nurses implement their practice. A lack of integration of the researcher into the research process would not stay true to the principles of constructivist inquiry. Correctional nursing researchers must engage with participants to construct the final theory and be open to a constructivist research process.
Implications for Correctional Nursing
The tension between custody and caring is particular to correctional nursing practice. The correctional nursing practice knowledge base requires further development. Correctional nursing researchers can benefit from using qualitative research approaches when studying unexplored or minimally explored topics. There are two reasons a GT approach is paramount for building foundational knowledge to advance correctional nursing practice. First, the development of theories regarding correctional nursing practice will provide an in-depth understanding of this subspecialty of nursing and lead to further research endeavors. Second, nursing practice is a process carried out in correctional institutions, and GT is “process oriented” and thus appropriate for studying how correctional nurses implement their practice. The Strauss and Corbin GT approach, and its philosophical stance, can allow correctional nursing researchers to be strategic in knowledge development: ability to select definite research topics, including posing questions and problems; possessing sound knowledge of the literature, especially to identify gaps; structured data analysis; and a more balanced integration of personal views, clinical experience, and knowledge in contrast to a highly objective or constructivist approach. Adopting a Strauss and Corbin GT approach to research not only will build foundational knowledge to advance correctional nursing practice but also may offer insights into promoting positive health outcomes for offenders.
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