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Caring for...Incarcerated patients

Williams, Tommy BSN, RN; Heavey, Elizabeth PhD, RN, CNM

doi: 10.1097/01.NME.0000454750.80335.25
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While in prison, inmates require the same quality of care afforded to all patients.

Tommy Williams is an RN at Monroe County Correctional Facility in Rochester, N.Y. Elizabeth Heavey is an Associate Professor of Nursing at State University of New York in Brockport, N.Y.

This article originally appeared as Williams T, Heavey E. How to meet the challenges of correctional nursing. Nursing. 2014;44(1):51-54.

The authors have disclosed that they have no financial relationships related to this article.

Correctional nursing is a career choice that's filled with both challenges and rewards. At any moment, you could find yourself using nursing skills associated with one of many nursing specialties—medical-surgical, ED, critical care, mental health—or some combination of all of these roles. Add to that the dimension of providing caring, holistic, and patient-centered care within the confines of a locked facility, and even the most proficient nurse may be challenged.

However, nurses working in correctional facilities manage these challenges every day and successfully provide quality care by maintaining the perspective that underlies all professional nursing: All individuals deserve to be treated with respect, dignity, and compassion regardless of their lifestyle or individual values. This article describes the lead author's firsthand experiences with the many challenges correctional nurses face.

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Locked up

Even when incarcerated, an inmate retains most of the same rights as everyone else—the only exceptions being those rights that have legally been taken from him or her. Although it can be difficult to ignore, the magnitude of the offense or alleged crime must be irrelevant to a correctional nurse.

Correctional nurses are mandated not only by the tenets of nursing, but also by law to provide appropriate care. This care may be provided directly by the correctional medical staff or contracted out to private medical staff. Depriving incarcerated individuals of appropriate medical attention is considered excessive punishment exceeding the legally imposed sentence. Similarly, subjecting an inmate to unnecessary pain, deliberately inflicting pain because of the inmate's status, and deliberate indifference to serious medical needs violate the Eighth Amendment of the Constitution and may be considered cruel and unusual punishment.

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Navigating a difficult environment

Nurses work alongside correctional officers in a forensic setting, which can be challenging because each profession has its own set of priorities, occasionally causing conflict. Inherent tension between the two can arise from vast differences in approach, attitude, and even terminology. For the sake of convenience, labels used to describe the incarcerated may be interchangeable between the two professions; however, “inmate” is a legal term and “patient” is a medical term. An inmate is an individual confined in a correctional institution; a patient is a recipient of a healthcare service or a person in need of treatment and care. A great disservice is done to the nursing profession when we think of incarcerated patients only in legal terms. Regardless of the label used, providing nursing care to the incarcerated should be done as respectfully and professionally as in any other healthcare setting.

Some nurses in correctional facilities are privy to the legal charges against their patients. This can make it extremely difficult to provide objective care because such knowledge may create a biased perspective and diminish the quality of care provided.

Personally, I recognized the barrier this created for me and soon began making it a point to intentionally skip the legal portion of the individual's file and read the medical portion only. A comprehensive nursing assessment and identification of medical and nursing needs can supply all the relevant information necessary to provide optimal patient care. This approach ensures that legal charges don't cloud my nursing judgment.

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Obtaining an accurate health history

Obtaining a health history from incarcerated patients can be difficult because they may have limited knowledge or understanding of their health. Multiple redirections to the task at hand may help the nurse obtain a more accurate history. For example, when I asked one patient about current medications, he said that he took “peanut butter balls.”

It's very easy to disregard statements such as this one when you see individuals with mental illness; however, you must avoid making assumptions and ask for more information. With further questioning, the patient went on to explain that he takes the “peanut butter balls” because he falls down. As I continued the discussion, I determined that the patient had a seizure disorder and takes phenobarbital.

If I hadn't spent a few extra moments to clarify what the patient was trying to tell me, he might have been unmedicated during his time in jail and experienced a preventable seizure.

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Tough coworkers

Sometimes responsibilities and professional duties of correctional officers and correctional nurses come into conflict. What may be best for the patient may not be what's best for the institution, and vice versa. Correctional officers need to maintain order and physical security within what may be a chaotic, unpredictable, and potentially dangerous environment. Respect for their challenging responsibilities must be balanced with an understanding that the nurse has an obligation to continue to act as a patient advocate within this same environment.

Incarcerated patients may sometimes physically act out aggression, frustration, or confusion. To maintain safety for staff and inmates, correctional officers may need to rely on intimidation and grappling to exert influence and may be unaware that, at times, they're using similar tactics with the nursing staff. The primary focus of a nurse is advocacy and the well-being of an inmate, whereas correctional staff members are concerned primarily with safety. Recognizing the differing priorities between professions and the dangers faced daily by the correctional officers, nurses can understand why this behavior occasionally takes place and can work to build collegial and respectful relationships. When disagreements arise, using respectful, nonconfrontational language is helpful, as is active listening combined with a professional demeanor.

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Stay within your scope of practice

Discipline and enforcement of prison rules is a role that's clearly within the job description of correctional officers and shouldn't be delegated to correctional nursing staff. Nurses in correctional facilities must be extremely cautious to avoid engaging in any capacity outside their professional role and regularly assess their actions to determine if their behavior is appropriate for their role as patient advocate.

In a correctional facility, the nurse is responsible for determining if the patient is hemodynamically stable, screening for alcohol and drug use, assessing the risk of substance withdrawal, assessing for infectious diseases, and completing psychological screening. The nurse isn't responsible for breaking up fights, mediating disputes, or enforcing facility rules.

Nurses must also avoid dispensing legal advice (something frequently sought by inmates in my experience). The nurse must become adept at redirecting the patient to the nursing assessment at hand rather than legal concerns, which are beyond the scope of nursing practice.

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Getting in and out

Navigating the arrival and departure from the nursing workstation is another challenging experience. Upon entering a forensic setting, the nurse must typically pass through a metal detector; all contents of his or her person are subject to search. Every subsequent door and gate is locked. Passage is frequently gained through either one of many keys the nurse obtains at the beginning of the shift, an electronic swipe card, or identification by a correctional security guard (via a video camera) who then allows remote entry. Often all three means are required to pass from one area to another. Many of these same corridors and gates are also used by correctional officers for transferring the incarcerated.

When inmates are being escorted from one area to another (either individually or in groups), nurses must be aware of this and position themselves so they're out of the way. The physical challenges this type of environment poses can feel claustrophobic, intimidating, and frustrating until nurses realize how it contributes to their personal safety.

Healthcare providers are available for consultation, but nurses frequently care for patients when no healthcare provider is present. Voluminous standing orders streamline patient care, giving nurses a significant amount of autonomy.

Any incoming or outgoing items, including medications and medical supplies, must be screened through proper security channels. In many correctional institutions, basic nursing equipment such as forceps and medical scissors are labeled contraband and prohibited. Hand sanitizer may not be conveniently available in areas where it's needed most.

Locked corridors and difficulty obtaining access to equipment and supplies can affect the quality of care. For example, when responding to a code, the nurse may have to proceed through multiple locked doors to arrive at the patient's location. In our facility, it can take several minutes before someone can respond to an emergency.

Transportation of a patient to a hospital involves the same challenges of maintaining security while providing emergency medical care. Many codes in a correctional facility are triggered by familiar medical problems, such as cardiac arrest or respiratory failure, but some also involve seizures, hangings, or inmate violence, adding to the complexity of nursing care.

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Documentation challenges

Use of electronic medical record (EMR) technology in correctional facilities is on the rise as local and state governments mandate the adoption of computer-based medical software. Adoption of an EMR in any facility can be difficult, but correctional institutions possess unique challenges. In any healthcare facility, medical and nursing staff may receive only limited EMR training; correctional nursing is no different.

In addition, correctional officers may need to access the EMR despite having little or no training on the system. For example, in my institution, officers can't move an inmate out of the jail's receiving area unless the inmate's health record indicates that he or she doesn't have tuberculosis. And the only way to know that is through the EMR.

To complicate matters further, not all correctional institutions have wireless access throughout the building. Concrete and steel degrade the wireless signal, preventing Internet access in these “dead” areas. Portable units used for medication administration or assessments must then be hardwired with an Ethernet cable to update the EMR after a patient assessment. This late entry of data can be a source of problems with both medical and legal implications.

Basic principles of an effective EMR are simplicity, intuitiveness, and efficient sharing of data among subroutines (particular sets of instructions within code designed to perform an operation). Correctional EMRs must also adhere to these principles. Luckily, various correctional EMR programs are available with the ability to adapt to specific institutional needs.

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Uncertain situations

In general, nursing turnover rates are relatively high. Burnout in nursing as a whole is primarily due to insufficient staffing. In correctional nursing, other reasons unique to this setting also contribute to this specialty's turnover rate—for example, constant concern about personal safety. Nurses work in close proximity to alleged or convicted murderers and rapists, and individuals who may be mentally ill or prone to violent behavior. To remain safe, nurses must always be vigilant and aware of their surroundings.

Patients will present with a range of emotions, and assessment of their mental health status is important. Many have mental health disorders or, if they've recently arrived, may be under the influence of drugs and alcohol. Their behavior is frequently unpredictable, so the ability to deescalate and remain nonconfrontational contributes greatly to a nurse's safety.

When confronted with an agitated inmate, try to identify the source of escalation and eliminate or avoid it if possible. For example, if a mentally ill patient has been handled aggressively and sees the correctional officer as a threat, the nurse may decide to assess the patient when the environment changes and the officer leaves the room. Keep in mind, however, that all inmates have the potential to be aggressive. No inmates are assessed or examined if they exhibit aggressive behavior other than to establish hemodynamic stability. Reminding patients that you're there to help them and aren't part of the correctional staff can also be helpful.

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Keep it down!

An often-overlooked challenge and stressor for correctional nurses is the volume of noise experienced in daily practice. Most other nursing specialties place a premium on a quiet environment because noise can have a detrimental effect on patient healing. In a correctional facility, the constant noise has many sources and includes inmates talking among themselves, correctional officers communicating with inmates, screaming from the mentally ill or those going through withdrawal, announcements from the overhead loud speaker, constant radio chatter, and gates and doors slamming shut.

Nurses working in these environments may opt to manage these audible stressors by working 8-hour shifts instead of 12-hour shifts, taking their lunch break in the lunch area, ensuring bathroom breaks are available as needed, and developing the ability to block out some of the external noise and focus instead on establishing and addressing priorities. Unfortunately, however, the stress caused by environmental noise can adversely affect nursing retention in a correctional setting.

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Equal care for all

Crucial traits that promote success in correctional care nursing are adaptability, developing a “thick skin,” and a commitment to the ethical provision of care to all individuals. Correctional nursing serves a population that doesn't typically recognize or appreciate the care they receive. A “thick skin” is necessary to protect nurses from the harsh environment they work within. Nurses who can quickly adjust to a continually changing environment and rearrange their time accordingly often do well in a correctional setting. Prioritizing and multitasking can help nurses manage and complete tasks for the day.

As correctional nurses, we need to uphold the ethical principles of beneficence, nonmaleficence, fidelity, justice, and veracity to all individuals under our care. To give selflessly in the care of others—those who for one reason or another have been removed from the rest of society—is a noble endeavor that speaks volumes about an individual's character. Although most people try to avoid spending time in a jail, choosing to work in one professionally can be a satisfying nursing experience.

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consider this

Figure

Figure

At our facility, whenever an inmate is involved in a physical altercation, an urgent medical assessment form must be completed. I was warned ahead of time that they were bringing someone down to see me. When the inmate arrived, he was groggy and bleeding profusely from a laceration on his scalp. Stating that he was fine and in no pain, he wanted to return to his cell. The wound was deep and bleeding wouldn't abate. I recommended that he be sent out (to the hospital) for stiches and observation. The deputy questioned my decision, “He just said he felt fine. Can't we just put a bandage on his cut and bring him back to the floor?” Sending an inmate out can pose a safety risk and it requires a deputy to accompany the inmate to the hospital. I replied, “Ultimately, we'll do whatever you decide, but my recommendation is that he be seen in the ED and that's exactly what I'm writing in the report. If he starts seizing or goes into hypovolemic shock, you'll need to justify your decision.”

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consider this

Figure

Figure

While gathering medication information from an inmate, he stated that he took an unknown medication for his heart. He referred to it as his “happy heart pill.” I gave him a quizzical look and didn't even try to guess. My confusion was obvious and he stated, “You know...it's a laugh out loud drug.” Aha! LOL is a common ending for a class of heart medications. Although we couldn't determine the exact drug, I was fairly certain he was referring to a beta blocker.

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Learn more about it

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