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Contributors
MargaretM.Collatt,BSN,RN,CCHP-RN,CCHP-A, TrainingandDevelopment SpecialistII,OregonDepartmentofCorrections,HealthServices,Salem,Oregon
RosanneE.Harmon,MN,RN, PsychiatricMentalHealthNursePractitioner,Oregon DepartmentofCorrections,HealthServices,OregonCity,Oregon
SusanLaffan,RN,CCHP-RN,CCHP-A, ConsultantinCorrectionalHealthCare, TomsRiver,NewJersey
JacquelineMoore,PhD,RN,CCHP-A,CCHP-RN, CorrectionalHealthCare Consultant,JacquelineMoore&Associates,Greenwood,Colorado
MaryMuse,MS,RN,CCHP-A,CCHP-RN,ChiefNursingOfficer,Wisconsin DepartmentofCorrections,CorrectionalHealthCareConsultant,Madison, Wisconsin
EllynPresley,RN,CCHP-RN, NursingSupervisor,PrinceWilliamCountyJuvenile DetentionCenter,Manassas,Virginia
SueSmith,MSN,RN,CCHP-RN, ClinicalNursingInstructor/AcademicCoach, ChamberlainCollegeofNursing/InstructionalConnections,Columbus,Ohio
PatriciaVoermans,MS,RN,APN,CCHP-RN, NursingCoordinatorandMedical Consultant,WisconsinDepartmentofCorrections,Madison,Wisconsin
Reviewers
PatriciaBlair,PhD,LLM,JD,MSN,CCHP, NurseAttorney,PatriciaBlairLawFirm, AdjunctAssociateProfessor,UniversityofTexas,TylerSchoolofNursing,Tyler, Texas
MadeleineLaMarre,MN,FNP-BC, CorrectionalHealthCareConsultant,Madeleine LaMarrePC,Atlanta,Georgia
LindaLawrence,RN,CCHP-RN, RegionalClinicalCoordinatorforAlabama, Corizon,Calera,Alabama
SusanJ.Loeb,PhD,RN, AssociateProfessor,SchoolofNursing,Departmentof Medicine,ThePennsylvaniaStateUniversity,UniversityPark,Pennsylvania
PeggyMinyard,BSN,MSHCA,CCHP-RN, RegionalDirectorofNursingfor Alabama,Corizon,Calera,Alabama
DeniseM.Panosky,DNP,RN,CCHP,FCNS, AssistantClinicalProfessor,University ofConnecticut,Storrs,Connecticut
BeckyPinney,MSN,RN,CCHP-RN, ChiefNursingOfficer,SeniorVicePresident, Corizon,Nashville,Tennessee
DeborahShelton,PhD,RN,NE-BC,CCHP,FAAN, E.JaneMartinProfessor& AssociateDeanofResearch,WestVirginiaUniversity,SchoolofNursing,Morgantown,WestVirginia
SueSmith,MSN,RN,CCHP-RN, ClinicalNursingInstructor/AcademicCoach, ChamberlainCollegeofNursing/InstructionalConnections,Columbus,Ohio
KathleenTauer,MSN,RN,PNP, PediatricNursePractitioner,DepartmentofJuvenileJustice,CommonwealthofVirginia,Richmond,Virginia
ContextofCorrectionalNursing LorrySchoenly
Correctionalnursingis“... thepracticeofnursingandthedeliveryofpatientcare withintheuniqueanddistinctiveenvironmentofthecriminaljusticesystem ... ” (ANA,2007,p.1).Thiscriminaljusticesystemincludescountyjails,stateandfederal prisons,juveniledetentioncenters,andsubstance-abusetreatmentcenters.
Correctionalnursespracticeinaspecializedenvironment,onethatdoesnot embracehealthcareasitsprimarymission.Thepatientpopulation,inmatesand detainees,isuniqueaswell.Althoughprofessionalnursingpracticeisbasedonuniversalconcepts,theapplicationofthesecareconceptsinthisspecializedenvironment tothisuniquepatientpopulationprovidestheprimarycomponentsofthenursing specialty.Anunderstandingofthecareenvironment,patientpopulationdemographics,andthecultureofcorrectionalprofessionalshelpstoframethepracticeof acorrectionalnurseandinformsthecareprovided.
Therearebothrewardsandchallengestothepracticeofcorrectionalnursing. Initialinvestigationofthecorrectionalnursingroleindicatesthatnurseresponsibilitiescanvarygreatlydependingonthesizeandtypeoffacility.Therolecan provideincreasedautonomyofpracticeandpotentialforreducedconflictwith otherhealthcareprofessionals(Flanigan&Flanigan,2001; Shelton,2009; Smith, 2005).Themajorityofjailnursesrespondingtoasurveydescribedthereactionof theirpeerswhenthenursesaidthattheyprovidedhealthcaretooffendersasmost oftenconsistingofrespect,interest,andfascination(Hardesty,Champion,&Champion,2007).Theseresearchersalsofoundthatsocializationtotheroleofcorrectional nurses(suchasarotationduringschoolorhavingamemberofthefamilywhoworks inacorrectionalfacility)andpriorworkexperienceinemergencyormentalhealth environmentscontributedtojailnursejobsatisfaction.Thevarietyofdailyactivities
TABLE1.1DailyFunctionsofCorrectional HealthCareNurses
Source:Adaptedfrom FlaniganandFlanigan(2001)
andpotentialfornovelsituationscanalsobeattractive.Table 1.1 describesthetypes ofactivitiesinwhichthenursesrespondingtothissurveywereengagedandhow oftentheyperformedeachactivity.
Correctionalnursingpracticeisachallengingnursingspecialtyforseveral reasons.Healthcareunitsinjailsandprisonsareoftenunderequippedanddonot haveappropriatespacefordeliveryofhealthcare.Thelocationofthehealthcare unitmayhavebeenanafterthoughtinfacilitiesthatwerebuiltbeforetheadvent oforganizedonsitehealthcare.Somecorrectionalfacilitieswerebuiltinisolated, rurallocations,makingitdifficulttorecruithealthcareprofessionals.Professional isolationcanbeaprobleminretainingnursesoncerecruited.Manycorrectionalfacilitiesareovercrowded,leavinglittleroomforprivacyindealingwithhealthcareconcerns.Privacyissuesarealsoincreasedbytheneedforcorrectionalofficeroversight ofthehealthcaredeliveryareasinordertomaintainsafetyofstaffandotherinmates. Someinmatesmustbeisolatedinhighersecurityunitswithrestrictedmovement, makingitnecessarytodeliverhealthcareinthehousingarea.
Theimplicationsofacaringrelationshipbetweenthecorrectionalnurseandthe inmate-patientalsocreateachallengetopractice.Correctionalnursesmustestablish atherapeuticrelationshipwithindividualsconvictedofcrimes,someofaviolent nature.Reconcilingthehumanityofthepatientinneedofhealthcarewiththecriminalbehavioroftheinmateisanimportantaspectofprovidingcare.Correctional patientshavebeendescribedas“difficult,manipulative,aggressive,anddemanding”(Flanigan&Flanigan,2001,p.75).Asignificantnumberofinmate-patients seekhealthcareservicesforsecondarygainsuchasadditionalprivileges,reduced workassignments,orspecialclothing(Paris,2006).Thiscancloudthenurse’sevaluationandtreatmentdecisions.Theincreasedautonomyofthecorrectionalnurseand theneedtosortoutdesireforsecondarygainfromtruemedicalneedrequiressolid assessmentandcriticalthinkingskills.Finally,creativepatienteducationplansare requiredduetolimitedhealthylivingoptionssuchasfreshfruitsandvegetables oradequateexercise.
Negotiatingwithotherentitiesinthecareenvironmentalsobringschallenge. Strictboundariessetbythecorrectionssystemcanprovefrustratingtonurses
desiringtoshowcompassionforpatients(Weiskopf,2005).Inthecustodyenvironment,nursesmayfeelthattheyareforbiddenfromenteringintoacaringrelationshipwithaninmate-patient(Maeve,1997; Maroney,2005).Thenoncaringattitudes ofothersintheworkenvironmentsuchassecurityofficers,otherstaffmembers, andtheinmatepopulationcaninfluencenursingattitudesovertime(Weiskopf, 2005).Somecorrectionalnursesmustbalancetheconflictingrolesofbeing employedbyanorganizationwithamissionofpublicsafetyandsecuritywhile upholdingaprofessionalmissionofhealthandwell-beingfortheinmatepopulation(ANA,2007).
Finally,theneedtobeever-vigilantaboutpersonalsecurityinapotentially unsafeenvironmentcanerodethecaringrelationshipwithpatients.Unlikemany othercareenvironments,nursesmustawaitanevaluationofthesafetyofanenvironmentbeforeenteringtoassistinemergencytreatment.Thecontinualconcernfor personalsafetywhiledeliveringcarecanchallengebasicprinciplesofcaring.Therefore,ithasbeensaidthatcorrectionalnurses“walkatightropebetweenproviding therapeutictreatmentandmaintainingasecureenvironment”(Weiskopf,2005, p.341).
EXHIBIT1.1
PrinciplesofCorrectionalNursing
† Aregisterednurse’sprimarydutyinthecorrectionssettingistorestoreand maintainthehealthofpatientsinaspiritofcompassion,concern,and professionalism.
† Eachpatient,regardlessofcircumstances,possessesintrinsicvalueand shouldbetreatedwithdignityandrespect.Eachencounterwithpatients andfamiliesshouldportrayprofessionalism,compassion,andconcern. Eachpatientshouldreceivequalitycarethatiscosteffectiveandconsistent withthelatesttreatmentparametersandclinicalguidelines.
† Patientconfidentialityandprivacyshouldbepreserved.Nursesshouldcollaboratewithotherhealthcareteammembers,correctionalstaff,andcommunitycolleaguestomeettheholisticneedsofpatients,whichinclude physical,psychosocial,andspiritualaspectsofcare.
† Nursesshouldencourageeachindividualthroughpatientandfamilyeducationtotakeresponsibilityfordiseasepreventionandhealthpromotion. Eachnursemaintainsresponsibilityformonitoringandevaluating nursingpracticenecessaryforcontinuousqualityimprovement.
† Nursingleadershipshouldpromotethehighestqualityofpatientcare throughapplicationoffairandequitablepoliciesandproceduresincollaborationwithotherhealthcareservicesteammembersandcorrectionsstaff.
† Nursingservicesshouldbeguidedbynurseadministratorswhofosterprofessionalandpersonaldevelopment.Theseresponsibleleadersaresensitive toemployeeneeds;givesupport,praise,andrecognition;andencourage continuingeducation,participationinprofessionalorganizations,andgenerationofknowledgethroughresearch.
Source: Copyright2007byAmericanNursesAssociation.Reprintedwithpermission.Allrights reserved.
Correctionalnursesmaintaintheprofessionalnatureoftheirpracticethrougha principledapproachtopatientcare.TheseANA-affirmedprinciplesfocuscorrectionalnursingpracticeonthehealthandsafetyneedsofthepatientpopulation whileprovidingacompasstonavigatethecorrectionalsystemforthemselvesas wellastheirpatients.Theessenceofcorrectionalnursingiscaringforandrespecting thehumandignityoftheincarcerated(ANA,2007).Limitedresources,challenging patients,competingsecuritypriorities,andongoingconcernforpersonalsafety canmitigateagainstprinciplednursingpractice.Afrequentreturntothecore valuesandgoalsundergirdingcorrectionalnursingpracticehelpsre-centernurses onthemeaningandimportanceoftheirrole(Exhibit1.1).
HISTORYOFCORRECTIONALNURSING
AlthoughhealthcarehasbeendeliveredintheU.S.correctionalenvironmentasearly as1797withtheopeningofNewgatePrisoninNewYorkCity(ANA,2007),theestablishmentofthecorrectionalnursingspecialtycamemuchlater.Thecorrectional settingfornursingpracticebegantoemergeintheprofessionalliteratureinthe 1970sasnursesbecameinvolvedindevelopingworkingsystemsofhealthcarein thissetting(Murtha,1975).Prisonriots,thecivilrightsmovement,andcivillitigation shedlightontheinvisibleprisonhealthcaresetting.Inaddition,healthcareforthe incarceratedreceivedalegalmandatewiththe1976SupremeCourtdecisionof Estelle vGamble.Thiscaseestablishedtheconstitutionalobligationtoprovidehealthcareto anycitizeninthecustodyofthegovernment.
Whilestillinitsinfancyincomparisontomorematurenursingspecialties,correctionalnursinghasbeenrecognizedbytheAmericanNursesAssociation(ANA) since1985,whentheTaskForceonStandardsofNursingPracticeinCorrectional FacilitiesunderthedirectionoftheExecutiveCommitteeoftheCouncilofCommunityHealthNursespublished StandardsofNursingPracticeinCorrectionalFacilities (C. Bickford,personalcommunication,July1,2011).Professionaldevelopmentofthe specialtyhasincludedcertificationthroughatleasttwomultidisciplinarygroups (AmericanCorrectionsAssociation,NationalCommissiononCorrectionalHealth Care).Mostnurseswhohaveworkedintraditionalsettingssuchasahospitalor clinicbeforeenteringcorrectionsfindthespecialtytobeunique.Othershave describeditassimilartonursingcaredeliveredinapsychiatric,military,orpublic healthclinicsetting(Flanigan&Flanigan,2001).
Nursesarethepredominanthealthcareprovidersinthecorrectionalsetting. Theyareoftenthefirsttoseeapatientinneedofserviceaswellastheonesto assurethatappropriatetreatmentisreceived.Thelimitedandfragmentednature ofhealthservicesincorrectionsrequiressolidcaredeliveryprocessesandreliable follow-through.Nursesareoftenthemanagersofcaredeliveryprocessesinthis setting.Establishingefficientandeffectivecaredeliveryinthemidstoftheconditions citedmakesthisspecialtybothchallengingandrewarding.
CAREDELIVERYENVIRONMENT
Over7.2millionpeopleareundersomeformofcorrectionalsupervisionintheUnited States(Glaze,2010).Thesizeandtypeofcorrectionalfacilityandthelevelofsecurity canaffectthetypesofhealthcareservicesdeliveredandthereforetheprovisionof
nursingcare.Generally,nursingcareisnotdeliveredinparoleandprobationsettings. Individualscompletethesesupervisedexperiencesinthecommunityandhaveaccess tocommunityorpublichealthserviceresources.Correctionalnursingtakesplacein jails,prisons,andjuveniledetentionsettings.
CorrectionalNursinginJails
Localjailsaremanagedbycountiesorcitiesandholdindividualsawaitingcourthearings,trials,orsentencing.Inaddition,individualsmayremaininthejailsettingtoserve outsentencesof12monthsorlessratherthanbeprocessedandclassifiedintoastateor federalprisonsystem(Minton,2011).Thetemporaryandtransientnatureofajailstay lendsanemergentnaturetothehealthcaredelivered;however,chronicconditions muststillbeconsideredandtreated.Drugandalcoholwithdrawalisafrequentissue andpatientswithmentalhealthconditionsmaynotbecurrentlytakingtheirmedications.Stabilizingthehealthconditionofnewlyenteringinmatesisapriority.
Rapidturnovercanresultinincompletetreatments,misseddiagnoses,and uncontainedcommunicablediseases.Itisimportantfornursesworkinginajailsetting tohavestronglinkswithlocalcommunityandpublichealthservicestoextendtreatmentpastthefacilitywalls.
CorrectionalNursinginPrisons
Prisonshouseindividualswhohavebeenconvictedofacrimewithsentencesgenerallylongerthan12months.Theextendednatureofthestayleadstohealthmanagementofamorelong-standingnaturethatcanincludemanagingchronicconditions andsurgicalprocedures.Therearetwosystemsmanagingprisonsbasedonsentencing.TheFederalBureauofPrisons (FBOP) managesaprisonsystemof102facilities housinginmatesservingsentencesrelatedtoafederalcrime(BureauofJustice,2008). ThesefacilitiesarespreadthroughouttheUnitedStatesbuthavecentralizedmanagementandsimilarstandardsofpractice.
Bycontrast,stateprisonsystemsareunderthejurisdictionofthestate’sgovernmentandpracticestandardsareconsistentthroughoutthenetworkofstatefacilities butmaydifferamongthestates.Severalstates(Delaware,RhodeIsland,Massachusetts)havecombinedjailandprisonfacilities,wherebothdetaineesandsentenced inmatesreside.
CorrectionalSecurityLevels
Inmatesarebroughtintoaprisonsystemfromjailcustodyaftersentencing.Stateand federalprisonsystemsdesignateintakefacilitieswhereincominginmatesareevaluatedandclassifiedonanumberoffactorsthatleadtoafacilityassignment.Intake facilitiesarearrangedtorapidlyevaluateanindividual’spsychological,criminological,andmedicalstatusforplacement.Nursesworkinginaprisonintakefacility developexcellentassessmentskills.
Althoughterminologycanvaryfromstatetostate,prisonsarecategorized bythedegreeofsecurityneededtomaintainthesafetyofinmates,staff,andthe public.Securityleveldesignatesthedegreeofexternalandinternalenvironmental controlsinplace,aswellasthesecuritystafftoinmateratio.Higherlevelsofsecurity requirelowerratiosandgreaterenvironmentalcontrols.
Thesecuritylevelofaprisonwilldeterminethedegreeofrestriction,particularlyonthemovementofinmatestoandfromthemedicalareaandthelevelof
custodyinvolvementinthemedicalunit.Somelargeprisoncomplexesmayhavea mixofsecuritylevelsamongbuildingswithinacommonexternalperimeter.Itis importanttoknowthesecuritylevelofafacility,asthisindicatescharacteristicsof thepatientandthenursingcareenvironment.
MinimumSecurity
Minimumorlowsecurityfacilitieshouseinmatesdesignatedaslowriskforviolence orelopement(FBOP,n.d).Minimumsecurityfacilitiesfocusonpersonalresponsibilityandinmatesmaybeinvolvedincommunityworkassignments.Minimumsecurityfacilitiesmayalsoincludeworkingfarms,machineshops,andmilitary-styleboot camps(NorthCarolinaDepartmentofCorrections,n.d.).
Healthcaremayonlybeavailablepartofthetime.Nursesworkinginthese facilitiesareinvolvedinmedicalclearanceforworkprograms.Inaddition,care activitiescanincludeevaluationandtreatmentofwork-relatedinjuries.
MediumSecurity
Inmatesdesignatedforamediumsecuritysettinghavebeendeterminedtobean escaperiskandposeathreattoothers(ExecutiveOfficeofPublicSafetyandSecurity, n.d.).Inmatesinthesefacilitieshavemoredirectsupervisionandmorerestricted movement.Mediumsecuritysettingshavemoreworkandself-improvementprojects withintheexternalsecurityperimeterandfewerpatienttransportsorcontactwith thepublic.
HealthUnitsinmediumsecurityprisonsareusuallystaffed24hoursadayand involveafullarrayofambulatoryservices.Theyaremorelikelytoincludeinfirmary careandinitiatetreatmentssuchasIVtherapyandtubefeedingsasneeded.Health careisdeliveredprimarilyinthehealthcareunit,althoughnursingstaffmustbeable todealwithemergencies(man-down)inthehousingandexerciseareas.Permanent securitystaffsareoftenassignedtothehealthcareunitsinmediumsecuritysettings andinmate-patientsareobservedatalltimes.
HighSecurity(Maximum)
Inmatesdesignatedforhighsecuritysettingshavebeendeterminedtobeaserious escapeorviolencerisk.Highsecurityprisonshaveavarietyofdescriptorsincluding penitentiary,maximum,supermax,andclosesecurity.Deathrowinmatesandthose convictedofparticularlyviolentorheinouscrimeswillbeassignedtohighsecurity prisons.Theinternalenvironmentofhighsecuritysettingsincludesagreaterdegree ofphysicalbarriersandcheckpoints.
Nursesworkinginmaximumsecurityprisonsmustdeliveragreaterpercentage ofcarecell-sideduetothesecuritynatureofthesetting.Inmatemovementislimited andsecuritystaffescortsarerequiredformovementtothehealthcareunit.Sentences aretypicallylonginmaximumsecurityprisonsandsothehealthcaretrajectorycan alsobelongerthaninothersettings.Afullarrayofhealthcareservicesisprovided includingambulatorycare,infirmarycare,andchronicdiseasemanagement.
SpecialHousing
Correctionalfacilitiesalsohavespecialhousingareasforincreasedsecuritypurposes orforvulnerableinmatepopulations.Correctionalnursesmayhaveresponsibilities forprovidingnursingcareinthesespecializedenvironments.Terminologymay
differacrosssystemsandwithinvariousregionsofthecountry.Itisimportant,therefore,tounderstandthemeaningofthevariousspecialhousingsituationswithinthe systemorfacilityofemployment.
Segregation
Thisspecializedunit,alsocalledSeg,AdministrativeSeg,ProtectiveHousing,or SecureHousingUnit(SHU),isarestrictedsecurityareawithinajailorprisonfor inmateswhocontinuetoviolatesecurityrules,threaten,orotherwiseplaceother inmatesandstaffmembersindanger.Inmatesplacedinsegregationhavetheirmovementseverelyrestricted.Healthcaremustbeprovidedinthehousingareawithan escortbycorrectionofficers.Deliveryofmedicationandtreatmentscanbechallengingandifappropriatefacilitiesandequipmentarenotavailable,nursesmaybe expectedtodeliversuchcarecell-side.Nursesmustbepreparedforthepossibility ofverbalabuseorattemptsatphysicaldisruptionsuchasspittingorthrowingof bodilyexcrement.Patientprivacyduringexaminationandhistory-takingcanbedifficult.Specialarrangementsandadditionalsecurityarerequiredwhensegregated inmatesaretransportedtothemedicalunitforevaluationortreatment.
Medical,Sheltered,orProtectiveHousing
Medical,sheltered,andprotectivehousingunitsarecreatedinlargecorrectional institutionsorsystemstoprovideaddedsafetyforinmateswithphysicalormentalimpairmentthatcouldleadtovictimizationinthegeneralinmatepopulation. Theolderinmate,adolescentssentencedasadults,andthosewithsignificantdisabilityrequireextraprotection,asdothosewithseverementalhealthissuessuchas schizophreniaorpsychoses.Medical,sheltered,andprotectivehousingunitsare oftenlocatednearthehealthcareunit.
Prerelease
Prereleasefacilitiesandhalf-wayhousesareusedtoprepareinmatesnearingtheend ofincarcerationbydevelopingindependentskillsforcommunityliving.Prerelease facilitiesgenerallyhaveminimalhealthcarestaffandfrequentlyreferinmateswith chronicorseriousacuteconditionstoanearbyhigher-levelprisonmedicalunit fortreatment.
CORRECTIONALMANAGEMENTSTRUCTUREANDHEALTHCAREDELIVERY
Correctionalhealthcareunitscanbemanagedinseveralways.Unlikehospitalsor clinicsinthecommunity,thehealthcarestaffinacorrectionalsettingmaynotreport directlytothesameleadershipasotherstaffinthefacility(Table 1.2).Havingan understandingoflinesofauthoritywithinthefacilitycanimproveeffectiveness anddecreasemessageconfusion.
GovernmentalAgencies(Self-Operated)
Themajorityofnursesworkingincorrectionsareemployedbythesamegoverning bodyastheircustodypeers.Alsocalledself-operatedorself-op,healthcaremanagers inthismanagementstructureareapartoftheorganizationalhierarchyandreporting framework.Thisorganizationalframeworkhasadvantagesinallowingforparity
TABLE1.2ManagementSystemsforCorrectionalHealthCare Units
MANAGEMENTTYPE
Source:Adaptedfrom Corizon(2011)
amongtheservicesandcanfostersupportforinmatemedicalneeds.Althoughthe wellbeingoftheinmatepopulationisacommongoalforbothcustodyand nursingstaff,professionalframeworksandguidingprinciplescandiffer.Nursesin theseorganizationsmustbevigilanttomaintainprofessionalnursingjudgmentin allmattersofcaredelivery.
IndependentHealthCareServiceCompanies
Anotherwaycorrectionalhealthcareisprovidedthroughcontractswithindependenthealthcareservicecompanies.Thesecompaniescontractwithcountyorstate governmentstodeliverneededhealthcareserviceswithincorrectionalfacilities. Nursesaremostoftenemployeesofthehealthcareservicecompanyandreportto managerswithinthecompany.Whenworkingforacompanyindependentofthecorrectionalauthority,nursesmustunderstandthecontractualrelationshipwiththe DepartmentofCorrectionsandthecommunicationandreportingstructure.Health carestaffinthissituationareguestsinthefacilityandmuststrivetodevelopcollaborativeworkingrelationshipswithcustodystaff.
StateUniversityMedicalSystems
Severalstateprisonsystemsprovidehealthcaretoinmatesthroughthestateuniversitysystem.Forexample,inConnecticut,inmatesreceivecarethroughtheUniversity ofConnecticutmedicalsystem,andinNewJersey,healthcareservicesareprovided throughthestate’sUniversityofMedicineandDentistry.Nursesworkinginthese systemshavetheadvantageofaccesstoacademicresourceswhilenursing,medical, anddentistrystudentshaveanopportunitytoexperiencethecorrectionalenvironment.Thecorollaryinjailsisforthecountyhealthdepartmenttoprovidethe healthcareatthejail.Inthiscircumstance,nurseshavetheadvantageofaccessto resourcesofthecountyhealthdepartment.Althoughhealthcarestaffarenotemployeesofthesameentityascorrectionsstaff,acommonrelationshipexistsamongthe governmentbodies.
CORRECTIONALOFFICERDEMOGRAPHICS
Theenvironmentinwhichcorrectionalnursesprovidepatientcareisshapedbythe professionalsmanagingtheprimaryserviceofsecuritywithinthefacility.Correctional officers,alsocalledCO’s,custodyofficers,orsecurityofficers,areprofessionalswith theirownperspectiveandworldviewgainedduringtrainingfortheirroleand
assimilationintotheirworkenvironment.Primaryconcernsofcorrectionalofficersare order,control,anddiscipline(Maroney,2005).Thesethemesprovideaframeworkfor thesystemsandprocessesthathelpmanagethecorrectionsenvironment.
Theworkenvironmentshapestheactionsandreactionsofcorrectionalofficers. Highlevelsofworkstress,ongoingpotentialforworkplaceviolence,andaperceived lackofpublicsupportcancreatebondsofsolidarityamongthecustodystaff(Garcia, 2008).Correctionalnursesmustsomehowbridgethissolidaritywithoutcompromisingnursingprofessionalprincipleswhencollaboratingwithcustodystafftoaccomplishcaregoals.
FromtheExperts ...
“Mutualrespectwillgoalongwaytofacilitatecollaborationwithsecuritystaff. Correctionalofficersandadministratorshaveahardjob.Correctionalnurses needtorecognizethisandrefrainfrombeingoverlycriticalorjudgmental aboutsecurityperspectivesaboutprisoners—withoutsacrificingtheirnursing perspective.Simplyput—thewords“please”and“thankyou,”professional courtesy,andconsiderationwillhelpnursescollaboratewiththeirsecurity colleagues.”
SueSmith,MSN,RN,CCHP-RN Columbus,OH
PATIENTPOPULATIONDEMOGRAPHICS
Individualsdetainedorinthecustodyofthecorrectionssystemhaveseveralterms usedasidentifiers.Individualsheldinpretrialsettingssuchascountyjailscanbe calleddetaineesorarrestees.Oncesentenced,themostcommonterminologyisoffenderorinmate.Forthepurposesofthisdiscussion,thetermsinmateorpatientwillbe usedtodesignatethepatientpopulationreceivingcorrectionalnursingcare.
TheU.S.inmatepopulationhasgrownconsiderablyoverthelastthreedecades foravarietyofreasons.Infact,theUnitedStateshasthelargestincarceratedpopulationintheworld,at2.3millioninmates.Thesecondlargestinmatepopulation, China,isfarbehindwith1.5million.Russiaisadistantthirdwithlessthanamillion behindbars.Reasonsgivenforthehigherincarcerationrateincludetoughersentencing rules,three-strikesmeasures,andreductionofmentalhealthhospitalizationoptions (The PEWCenterontheStates,2008; Torrey,Kennard,Eslinger,Lamb,&Pavle,2010).
Slightlymorethanoneinevery100Americansisbehindbars (Pew,2008).The incarceratedpopulationdoesnotmirrorgeneralpopulationstatisticsastogender, race,education,orage.Thecontrasthelpstoframethetypeofnecessaryhealth careservicesprovidedbycorrectionalnurses.
Gender
ThemajorityofincarceratedAmericansaremaleadults.TheBureauofJusticeStatisticsfor2009indicatesmaleindividualsareimprisonedatarate14timestherate forfemaleindividuals.Localjaildetaineepopulationsare,onaverage,almost88%
male(Glaze,2010).Maleinmatesaremorelikelythanfemaletobealcoholdependent (Binswangeretal.,2010).Althoughwomenmakeuponly10%ofthoseincarcerated, theirnumbersareincreasingnearlytwiceasfastasmen (Pew,2008).Strictersentencinglawsbringinagreaternumberoffemaleindividualswhowerepartofadomesticviolencedisturbanceoranaccomplicetoamale-directedcriminalactivitysuch asdrivingaboyfriendorspousetoatheftordrugdeal(Kelly,Parlaz-Dieckmann, Chang,&Collins,2010).
Femaleinmatesaremorelikelythantheirmalecounterpartstohavecustodyof theirchildrenandtohavebeenavictimofsexualabuseordomesticviolence (Belknap,2006; Kellyetal.,2010).Thehealthissuesofincarceratedwomenexpand toalsoincludereproductivehealthissues.Inaddition,womenhaveadisproportionatelyhigherrateoftreatedmentalillness(Binswangeretal.,2010)withincreasedprescriptionofpsychotropicsandtranquilizers(Belknap,2006).Thoseprovidinghealth careinfemaleinstitutionsfindahigheruseofmedicalandpsychiatricservicesthan similarlysizedmaleinstitutions(Binswangeretal.,2010; Drapalski,Youman, Stuewig,&Tangney,2009).
Race
AfricanAmericansandHispanicsaredisproportionatelyrepresentedintheU.S. inmatepopulation.AlthoughBlackAmericansmakeup12.6%ofthegeneralpopulation,theymakeup39.3%oftheincarceratedpopulation(West,Sabol,&Greenman, 2010).Whileonein106Whitemenoverage18areimprisonedinAmerica,onein15 Blackmeninthisagegrouparebehindbars (Pew,2008).Likewise,onein36Hispanic menaged18orolderareincarcerated.Hispanic/Latinosmakeup15.8%ofthejail population(Minton,2011)and21%oftheprisonpopulation(Westetal.,2010).
Disproportionatelyhighernumbersofminorityinmateswillimpactthefrequencyofcertainmedicalconditionstreatedincorrectionalsettings.Notonlyare BlackAmericansthreetimesmorelikelytohavediabetesandstroke,buttheyare 11timesmorelikelytodieofHIVdisease.Blackmenhavehigherratesofprostate, lung,stomach,andcolorectalcancers.Blackwomenaremorepronetoprenataldiseasesandcancersofthecolon,pancreas,andstomach(CDC,2005).
HealthdisparitiesintheLatinocommunityalsoimpacttheinmatepopulation. Hispanicshaveadisproportionatelyhigherdiseaseprofilewithincreaseddeathfrom stroke,chronicliverdisease,diabetes,andHIVdisease.Also,thispopulationsegment hasamuchhigherrateofcancersofthestomachandcervixthanthegeneralpopulation(CDC,2004).
Education
EducationlevelsoftheU.S.inmatepopulationarelowerthanthegeneralpopulation. Harlow(2003) reportslessthan50%ofthetotalincarceratedpopulationhaveahigh schooldiploma.Thisfigureisunder20%forthegeneralU.S.population.Inmatesare morethantwiceaslikelyasothercitizenstohavelearningdisabilities(Greenberg, Dunleavy,&Kutner,2007a).
Literacy,acomponentofeducationlevel,thatisofparticularimportancefor healtheducation,isalsobelownormallevelsintheinmatepopulation.Usingathreefactorscaleofliteracyevaluation(prose,document,quantitative),researchersfound inmates,onaverage,weremorelikelytohaveonlybasiclevelsofliteracyandbelow comparedtothegeneralpopulation.Inaddition,veryfewprisonerswereabletoread andcomprehendatthehighestlevel(Greenberg,Dunleavy,Kutner,&White,2007b).
Basicliteracyallowsinterpretationofsimpleinstructionandgraphicmaterial. Specialconsiderationshouldbegiventothereadinglevelofprintedhealthinformationprovidedtotheinmatepopulation.Inaddition,correctionalnursesneedto evaluatethepatient’sunderstandingofhealthinformationprovided. CaseExample 1.1 providesanopportunitytoapplythisinformation.
CASEEXAMPLE1.1
Nursesatalargemaximumsecurityprisonareteachingpatientsaboutsexually transmitteddiseases.Whiletheinmatesawaittheirchroniccareappointmentin theclinicholdingarea,theyaregivenwrittenmaterialfromtheCentersfor DiseaseControlwebsite.Duringthenurseportionofthechroniccarevisit,each inmateisaskediftheyreceivedthematerialandiftheyhaveanyquestions.Ifthey havenoquestions,thenursedocumentssuccessfulpatientteachingonthetopicin themedicalrecord.Describeflawsinthisprocessandsuggestimprovementsin theteachingmethod.
Age
Generallyspeaking,themajorityofinmatesinadultfacilitiesareyoungmaleindividuals.Forexample,theaverageinmateageinthefederalprisonsystemis39years (BureauofPrisons,2011).Inmatesaged20to39makeup64%ofthe1.45millionsentencedprisonersattheendof2009(BureauofJustice,2011a).Thegrowingedgesof theagecontinuum,youthandelderly,havespecifichealthneedstoconsider.
Elderly
Byallaccounts,theU.S.inmatepopulationisagingalongwiththegeneralpopulation asbabyboomersmoveintoretirementandgeriatriccare.However,duetomany factors,inmatesageearlierinlifeandelderinmatesaregrowinginnumberbehind barsduetomaximumsentencingformulasdevelopedinpriordecades(Aday,2003). Althoughthedefinitionofelderlydiffersacrosssystems,thereisgeneralagreement thatinmatesintheir50sareconsideredtobeinthiscategory(Anno,Graham,Lawrence,&Shansky,2004; Loeb&AbuDagga,2006).Elderlyinmatesusemoremedical andmentalhealthresources.Theyrequireadditionalprotectionfromabuseandpredation.Theyoftenneedprotectivehousingandassistivedevices.Bothcorrectional officersandnursesmustbevigilanttoidentifydecreasingfunctionalityandincreasingdiseaseburdeninthissegmentoftheinmatepopulation(Annoetal.,2004).
Youth
Theyouthorjuveniledesignationisgenerallygiventothoseunder18yearsofagein theU.S.prisonsystem.Themajorityofyoutharedetainedandservesentencesin residential-styledfacilitieswithanenvironmentcreatedtomeettheneedsofadolescents.Correctionalnursesworkinginjuvenilefacilitiesdealwithgrowthanddevelopmentissues,psychosocialconcerns,andparentalcustodymatters.
Agrowingnumberofyoutharegivenadultsentencesandsenttoadultfacilities toserveouttheirtime.Upwardsof25%ofjuvenileoffendersareinadultprisons. Younginmatesinadultprisonshaveincreasedratesofsuicideandprisonrape(CampaignforYouthJustice,2007).Youngoffendersareavulnerablepopulationthat
shouldhaveadditionalprotectionsfromthegeneralprisonpopulation.Itisimportantforcorrectionalnursesinadultfacilitiestoknowaboutandmonitortheyouth segmentoftheinmatepopulation.Youthnutritionalneedsandmedicalconditions areuniquetotheirseasonoflifeandshouldbeconsideredateveryhealth careencounter.
PHYSICALHEALTH
ChronicIllness
WhenageisstandardizedwiththeU.S.generalpopulation,inmatesinjailsand prisonswerefoundtohavehigherratesofdiabetes,hypertension,priormyocardial infarction,andpersistentasthma(Wilperetal.,2009).Detailsofthisdifferenceare foundinTable 1.3.Correctionalnurseshaveanopportunitytoimproveinmate healthandtherebypublichealththroughtheevaluationandtreatmentofthese chronicconditionsduringincarceration.
InfectiousDiseases
Poornutrition,substanceabuse,homelessness,lackofmedicalcare,andriskysexual behaviorsleadtoadisproportionatelyhigherratesofHIV,HepatitisC(HCV),sexuallytransmittedinfections(STIs),andtuberculosis(TB; Hammett,2006).RatesofHIV infederalandstateprisonsarenearlyfourtimesthegeneralpopulation,whileupto 35%ofinmateshavechronicHCVinfection(Goughetal.,2010).Tuberculosisinthe correctionspopulationisagrowingconcern,withreportedratesatleast3timesthat ofthegeneralpopulation(MacNeil,Lobato,&Moore,2005).STIsarealsocommonin thispatientgroup.Syphilis,chlamydia,andgonorrhearatesamongjailandprison inmatesaresurprisinglyhighcomparedtothegeneralpopulation(Table 1.4).
Awarenessoftheincreasedlikelihoodofanyparticularpatienttohaveoneor moreoftheseconditionscanleadtoearlyidentificationandtreatment.Correctional nursescanhelplimitthespreadofthesediseasesthroughpatienteducationand encouragementofrisk-reductionpractices.
MENTALHEALTH
Mentalillnessamongtheinmatepopulationisalsomorefrequentthaninthegeneral population(Table 1.5).While11%ofAmericansmeetcriteriaforamentalhealthdisorder,morethanhalfofthejailandprisonpopulationhaverecenthistoryor
TABLE1.3Age-StandardizedPrevalenceofSelectedChronicConditionsAmong AdultFederalandStatePrisoners,JailInmates,andtheNoninstitutionalizedU.S. Population
Source:Adaptedfrom Wilperetal.(2009)
symptomsofamentalhealthproblem( James&Glaze,2006).Thisalmostfivefold differenceincludessymptomsofmania,majordepression,andpsychoticdisorders.
BorderlinePersonalityDisorder(BPD)isalsooverrepresentedintheinmate population.Thismentalhealthconditionischaracterizedbypoorimpulsecontrol, self-injury,andsubstanceabusewithincreasedratesofdiagnosisinthefemalepopulation(NationalInstitutesofMentalHealth,n.d.).Studiesvarywidely;however,BPD ratesinthegeneralU.S.populationarewellbelow5%,whileestimatesinthejailand prisonpopulationvaryfrom25%to50%(Sansome&Sansome,2009).
Correctionalnursesneedtounderstandmentalillnessestoidentify,refer,and supportthepatient’streatment.Nursesmustalsounderstandtheimplicationsof mentalillnessco-morbidityinmanagingothermedicalconditions.Vigilantmonitoringfordrug–druginteractions,preventingadversereactions,andhelping patientstotolerateandmanagesideeffectsarekeyaspectsinnursingcareof thispopulation.
TraumaticBrainInjury
Traumaticbraininjury(TBI)anditseffectsarecommonintheinmatepopulation. Althoughanestimated2%ofthegeneralpopulationhassustainedaTBIwithcontinuingdisability(Langlois,Rutland-Brown,&Wald,2006)ametaanalysisof studiesintheinmatepopulationindicatesaprevalenceofover60%(Shiroma,Ferguson,&Pickelsimer,2010).Thisconditioncanbecausedbyavarietyofbrain traumassuchasassault,falls,motorvehiclecrashes,andmilitarydutyblasts (CentersforDiseaseControl,n.d.).TBIcanleadtodepression,anxiety,failedanger TABLE1.5DiagnosedMentalConditionsAmongInmatesofStateandFederal
Source:Adaptedfrom Wilperetal.(2009) TABLE1.4ComparisonofSexuallyTransmittedInfectionsAmongU.S.
managementcontrol,andsubstanceabuse.Itcanalsopredisposetoseizuredisorders,Alzheimer’s,andParkinson’sdiseases(CentersforDiseaseControl,n.d.). CorrectionalnursesmustconsidertheimpactofTBIaftermathonthefunctioning ofthepatientpopulation. CaseExample1.2 providesopportunitytoapplythis information.
CASEEXAMPLE1.2
A23-year-oldmaleisbeingmedicallyevaluatedinalargeurbanjail,detainedfordisorderlyconductatalocalbar.Theinmateisbelligerentandargumentativeduringthe assessment.Heisalargeman,wasalinebackerforhishighschoolfootballteam,and hasamilitaryhistorywithdeploymentinAfghanistan.Basedonhishistory,what primaryandsecondaryconditionsmightthenurseassessforinthispatient?
PosttraumaticStressDisorder
Anotherconditioncommonintheinmate-patientpopulationisposttraumaticstress disorder(PTSD).PTSDisananxietydisorderthatdevelopsfollowingaterrifying eventorwhenanindividualisfrequentlyplacedindangerousordeadlysituations (NIMH,2011).Inmatesenterthesystemwithavarietyofbackgroundsleadingto thiscondition,suchashighlevelsofphysicalorsexualabuseandinvolvementin violentcrime(Haugebrook,Zgoba,Maschi,Morgen,&Brown,2010).Addedto thisisthetraumaofincarcerationwithconcernsovervictimization,coercion,and assault.Militaryveteransmakeup13%ofstateand15%offederalprisonpopulations andhavehighratesofPTSDfromcombatduty(BureauofJustice,2000).Thisconditionisalsocommonamongfemaleinmatesdue,inpart,tothehighlevelofchild, domestic,andsexualabuseintheirhistory(Binswangeretal.,2010).PTSDsymptoms canaffectthenurse–patientrelationship.Triggerssuchasconfinement,perceived coercion,andloudaggressivevoicetonescancausePTSDvictimstoexperienceflashbacksandrespondtoperceivedthreatinnontypicalfashion.Anunderstandingof thisconditionanditsprevalenceinthepatientpopulationcanaidthedeliveryof nursingcareinthecorrectionssetting.
DrugandAlcoholInvolvement
Astaggering84.8%ofallU.S.inmatesaresubstanceinvolved,whetheralcoholor illegaldruguse(NationalCenteronAddictionandSubstanceAbuse,2010).Even thoseservingtimefornonsubstance-relatedoffenseshaveextremelyhighratesof dependence.Morethanhalfofthoseconvictedofviolentorpropertycrimewere alcoholinvolvedatthetimeofthecrime.Inaddition,substanceinvolvementisfrequentlyfoundtoco-occurwithmentalhealthproblems.Nearlyoneinfourinmates havebothasubstanceusedisorderandadiagnosisofmentalillness (NationalCenter onAddictionandSubstanceAbuse,2010)
Alcoholanddrugwithdrawal,therefore,isamajorconcernforcorrectional nursesworkingincorrections,particularlyjails.Regardlessofthesettingforincarceration,inmatesshouldbesupportedinthedevelopmentofalternativecoping
mechanismsbecausetheevidenceisclearthattreatingsubstanceabusereducescriminalrecidivism.
FromtheExperts
“Inthejailenvironment,nursesarechallengedtotreatindividualswhoare comingstraightfromthestreetandinmanycaseshavehadnohealthcare priortoincarceration.Theymayhavedrugoralcoholaddictionsinaddition tootherchronicillnesses.Intheprisonpopulation,thepatientshavehad theirchroniccareneedsidentifiedandatreatmentplanhasalreadybeenestablishedbythetransferringjail.Jailswouldthereforebecomparedtoanacute caresettingandprisonswouldbeconsideredmoreofalong-termcarefacility inregardstohealthcare.”
DyniBrookshire,RN,MSN,CCHP-RN Lumberton,TX
TobaccoUse
Thoseenteringthecorrectionsystemaremorelikelytosmoketobacco.Atleast one-thirdoftheprisonpopulationwassmokingatthetimeofarrest,comparedwith one-quarterofthegeneralpopulation(TheNationalCenteronAddictionandSubstanceAbuse,2010).Ofparticularnoteisthehighrateofsmokingamonginmates withothersubstanceissues.Withthecurrenttrendforcorrectionalfacilitiesto becomesmoke-free,correctionalnursesmustlookforwaystoassistinmate-patients tocopewithnicotinewithdrawal.
Suicidality
Theinmatepopulation,especiallyinjails,hasgreaterpotentialforattemptedand completedsuicidethananyotherpopulation(Hayes,2010).Althoughtheratehas droppedsignificantlysincefirsttrackedin1980(seeTable 1.6),itisstillamajor concernthatshouldbeattendedtobyallcorrectionalstaff.Correctionalnursesmust considersuicidepotentialinallinmatecontacts,butespeciallyonintake,aftersentencingorwhenat-riskforinthreatswhileincustodysuchasrape,gangactivity,orpersonalviolence(Hanson,2010).
Source:Condensedfrom BureauofJusticeStatistics(2011b), CentersforDisease Control,NationalCenterforHealthStatistics,NationalVitalStatisticsSystem(2002)
SUMMARY
Correctionalnursesworkinthechallengingenvironmentofjails,prisons,andjuveniledetentionfacilities,sometimeswithlittleresources,respect,orrecognition.The correctionalenvironmentincludingtheleveloffacilitysecurity,correctionalofficer, andadministrativestaff,andtheinmate-patients,createaframeworkfortheprovisionofnursingcare.Anunderstandingoftheuniqueneedsofthepatientpopulationandthespecificrestraintsofthecorrectionsenvironmentallownursestobe effectiveinmaximizinghealth,decreasingillness,andreducinginfection.Correctionalnurseschoosetousetheirknowledgeandskillstocareforamarginalizedcommunityofvulnerablepatientswhoareoftendifficulttocareforandcareabout.Many nursesfindthisarichandfulfillingcareerchoice.
DISCUSSIONQUESTIONS
1.Whataresomedifferencesinjailandprisonnursingbasedoninformationinthis chapter?
2.Basedonthecontextofcorrectionalnursing,whatwouldbekeyskillsand characteristicsfornursesinthisenvironment?
3.Whatchallengestocaredeliveryarefoundintheinformationinthischapter?
4.Whatarethesimilaritiesanddifferencesbetweenthepopulationatyourfacility andthestatisticsdescribingtheinmatepopulationinthischapter?
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EthicalPrinciplesforCorrectionalNursing
LorrySchoenly
Ethicalissuesaboundinanynursingpracticeandmaybeacuteincorrectional nursing.Correctionalnursescanuseprofessionalcodesandvaluestoguide theiractionsinanethicallychallengingenvironment.Byunderstandingtheethical foundationsofprofessionalpractice,nursesworkingincorrectionscanmakethoughtfulpatient-centereddecisionsabouttheirresponsibilitiesinanyparticularsituation.
TheCorrectionsNursingScopeandStandardsofPractice(ANA,2007)provides aframeworkformakingappropriatedecisionsinthefaceofethicaldilemmasinpractice.Ethicsisastandardofprofessionalcorrectionalnursingpracticeandismultidimensional(Exhibit 2.1).Thisstandardwillguideadiscussionofprofessionalnursing ethicsinthecorrectionalsetting.
CODESOFETHICSFORNURSES
Foremostinthepracticeofethicalnursingistheuseofaprofessionalcode.Aprofessionalcodedistinguishesprofessionalpracticefrommereoccupationalpursuit. Itestablishestheresponsibilitiesandobligationsaprofessionalhastowardthose theyserve(Davis,2008).Codesofethicsprofessionalizemoralvaluesandmakeexplicitthe“ethicalvirtues,values,ideals,andnormsofaprofession”(Fowler,2008a, p.xvii).ThenineprovisionsoftheCodeofEthicsforNursescanbecategorized intothreethemes:fundamentalvalues,dutyandloyalty,andexpandedduties beyondpatientcare(Table 2.1).
AlthoughtheANACodeofEthicsisexplicitlycitedintheCorrectionsNurse ScopeandStandardsasthebasisforethicalpractice,twoothercodesareavailable forconsultationandcanprovideadditionalsupportforpracticedecisions.The InternationalCouncilofNurses(ICN)CodeofEthicsforNurses(2006) guides
EXHIBIT2.1
CorrectionsNursingScopeandStandardsofPracticeStandard12:Ethics
Thecorrectionsnurseintegratesethicalprovisionsinallareasofpractice
† UsesCodeofEthicsforNurseswithInterpretiveStatementstoguide practice
† Deliverscareinamannerthatpreservesandprotectspatientautonomy, dignity,andrights
† Maintainspatientconfidentialitywithinlegalandregulatoryparameters, consideringtheuniquecorrectionsenvironment
† Servesasapatientadvocateandassistspatientsindevelopingskillsfor self-advocacy
† Maintainsatherapeuticandprofessionalpatient–nurserelationshipwith appropriateprofessionalroleboundaries
† Demonstratesacommitmenttopracticingself-care,managingstress,and connectingwithselfandothers
† Contributestoresolvingethicalissuesofpatients,colleagues,orsystemsas evidencedinsuchactivitiesasparticipatinginethicalcommittees
† Reportsillegal,incompetent,orimpairedpractices
Source:Copyright2007byAmericanNursesAssociation,p.40.Reprintedwithpermission.All rightsreserved.
internationalnursingpractice.Ethicalprinciplesarecategorizedaccordingtothe nurserelationshiptopatients,coworkers,theprofession,andthepractice.A commonthemeintheANAandICNethicalcodesistheprimeimportanceofcompassionatenursingcareandthealleviationofsuffering(Butts,2008).
TheCodeofEthicsforCorrectionalHealthCare (ACHSA,n.d.) provides ethicalguidelinesfornursesandothersworkingincorrectionalhealthcare (Table 2.2).ManyofthebasicprinciplesandvaluesfoundintheANAandICN codesaretranslatedfortheuniquecorrectionsenvironment.Keyelementsofthese twoadditionalcodeswillbementionedinthecontinuingdiscussionofcore themesoftheANACodeofEthicsforNurses.
FUNDAMENTALVALUESOFTHEPROFESSIONALNURSE
ThefirstthreeprovisionsoftheANACodeofEthicsspeaktofundamentalvaluesof theprofession.Thesevaluesarefurtherdevelopedbythe AmericanAssociationof CollegesofNursing(2008) toincludefiveessentialvaluesfornursingpractice (Table 2.3).ThesevaluesareappliedtocorrectionalpracticeasnursesusetheCode ofEthicsforNurseswithInterpretiveStatementstoguidepracticeanddeliver careinamannerthatpreservesandprotectspatientautonomy,dignity,andrights (ANA,2007).
Altruism
Altruismisanoutward-facingvaluespeakingtothedirectionofinterestsheld bythenurse.Altruismisdescribedasseekingthewelfareandwell-beingofothers (AACN,2008).Professionalnursingpracticeisaltruisticinmaintainingaprimary
TABLE2.1ProvisionsoftheCodeofEthicsforNurses FundamentalValuesoftheProfessionalNurse
Provision1Thenurse,inallprofessionalrelationships,practiceswithcompassionand respectfortheinherentdignity,worth,anduniquenessofeveryindividual, unrestrictedbyconsiderationofsocialoreconomicstatus,personal attributes,orthenatureofhealthproblems.
Provision2Thenurse’sprimarycommitmentistothepatient,whetheranindividual,family, group,orcommunity.
Provision3Thenursepromotes,advocatesfor,andstrivestoprotectthehealth,safety, andrightsofthepatient.
DutyandLoyalty
Provision4Thenurseisresponsibleandaccountableforindividualnursingpracticeand determinestheappropriatedelegationoftasksconsistentwiththenurse’s obligationtoprovideoptimumpatientcare.
Provision5Thenurseowesthesamedutiestoselfastoothers,includingtheresponsibility topreserveintegrityandsafety,tomaintaincompetence,andtocontinue personalandprofessionalgrowth.
Provision6Thenurseparticipatesinestablishing,maintaining,andimprovinghealthcare environmentsandconditionsofemploymentconducivetotheprovisionof qualityhealthcareandconsistentwiththevaluesoftheprofessionthrough individualandcollectiveaction.
ExpandedDutiesBeyondDirectPatientCare
Provision7Thenurseparticipatesintheadvancementoftheprofessionthrough contributionstopractice,educationadministration,andknowledge development.
Provision8Thenursecollaborateswithotherhealthprofessionalsandthepublicin promotingcommunity,national,andinternationaleffortstomeethealthneeds.
Provision9Theprofessionofnursing,asrepresentedbyassociationsandothermembers, isresponsibleforarticulatingnursingvalues,formaintainingtheintegrityof theprofessionanditspractice,andforshapingsocialpolicy.
Source:Adaptedfrom ANA(2001) and HookandWhite(2009).
commitmenttothepatient(Provision2)ratherthantootherpossiblecompetingconcerns.Altruismasaprofessionalvalueleadstoseeingpatientsasendsinthemselves ratherthanmeanstoends.Correctionalnursesreflectthevalueofaltruismwhen seekingthewell-beingoftheinmatecommunityfrombothahealthimprovement anddiseasetreatmentperspective.Whenconfrontedbyadilemmaofcompetingpriorities,evaluatingthesituationfromtheperspectiveofthepatient’swelfarecanoften leadtoanappropriatenursingaction.
Autonomy
ThevalueofautonomyasitrelatestothepatientisalsoaffirmedintheANACodeof Ethics.Autonomyisdescribedasarightofself-determination(ANA,2001).Muchof aninmate’sautonomyhasbeenabrogatedbytheincarcerationexperience.However, autonomyasitregardshealthcaredecisionsandactionscanstilloftenbemaintained.
TABLE2.2ACHSACodeofEthics
PreambleCorrectionalhealthprofessionalsareobligatedtorespecthumandignityandact inwaysthatmerittrustandpreventharm.Theymustensureautonomyin decisionsabouttheirinmatepatientsandpromoteasafeenvironment PrinciplesThecorrectionalhealthprofessionalshould:
† Evaluatetheinmateasapatientorclientineachandeveryhealthcare encounter.
† Rendermedicaltreatmentonlywhenitisjustifiedbyanacceptedmedical diagnosis.Treatmentandinvasiveproceduresshallberenderedafter informedconsent.
† Affordinmatestherighttorefusecareandtreatment.Involuntarytreatment shallbereservedforemergencysituationsinwhichthereisgravedisability andimmediatethreatofdangertotheinmateorothers.
† Providesoundprivacyduringhealthservicesinallcasesandsightprivacy wheneverpossible.
† Providehealthcaretoallinmatesregardlessofcustodystatus.
† Identifythemselvestotheirpatientsandnotrepresentthemselvesasother thantheirprofessionallicenseorcertificationpermits.
† Collectandanalyzespecimensonlyfordiagnostictestingbasedonsound medicalprinciples.
† Performbodycavitysearchesonlyaftertraininginpropertechniquesand whentheyarenotinapatient–providerrelationshipwiththeinmate.
† Notbeinvolvedinanyaspectofexecutionofthedeathpenalty.
† Ensurethatallmedicalinformationisconfidentialandhealthcarerecordsare maintainedandtransportedinaconfidentialmanner.
† Honorcustodyfunctionsbutnotparticipateinsuchactivitiesasescorting inmates,forcedtransfers,securitysupervision,stripsearches,orwitnessing useofforce.
† Undertakebiomedicalresearchonprisonersonlywhentheresearchmethods meetallrequirementsforexperimentationonhumansubjectsandindividual prisonersorprisonpopulationsareexpectedtoderivebenefitsfromthe resultsoftheresearch.
Source: ACHSA,n.d. Usedwithpermission.
Limitstoautonomycanhappeninsomesituationswherethewelfareofthelarger communityisjeopardizedbythedecisionofanindividual.Anexampleofthisis theneedtotreatacontagiousdiseasesuchastuberculosissothatspreadtoother inmatesandstaffisreduced.
TABLE2.3FiveEssentialValuesofNursingPractice
DEFINITION
AltruismConcernforthewelfareandwell-beingofothers
AutonomyRighttoself-determination
HumanDignityRespectfortheinherentworthanduniquenessofindividualsand populations
IntegrityActinginaccordancewithanappropriatecodeofethicsandaccepted standardsofpractice
SocialJusticeActinginaccordancewithfairtreatmentregardlessofeconomicstatus, race,ethnicity,age,citizenship,disability,orsexualorientation
Source:Adaptedfrom AmericanAssociationofCollegesofNursing(2008)
Informedconsentisfundamentaltoethicalcaredeliveryandsupportspatient autonomy(Hook&White,2009).Correctionalnurses,inparticular,haveaneedto assurethepatienthasfullunderstandingofthepatientdecisioninquestionandconsequencesofvariousoptionswhendetermininginformedconsent.Theliteracylevel oftheinmatepopulationcanaffectcomprehensioninthehealthcaredecisionmakingprocess.Attendancetothenursingvalueofautonomywillleadnursesin thissituationtoseekadditionalmeansforobtainingpatientunderstandingsothat aninformeddecisioncanbemade.
TheACHSACodeofEthicsappliesthevalueofautonomyinassertingthat inmateshavearighttorefusecareandtreatment.Thisrightisovershadowed inoccasionswherethereis“immediatethreatofdangertotheinmateorothers” (ACHSA,n.d. p.1).
HumanDignity
Professionalnursesvaluethehumandignityofeveryindividualintheircare,no matterthesocioeconomicstatus,personalcharacteristics,orlifechoicestheyhave made.Humandignityisdescribedas“respectfortheinherentworthanduniqueness ofindividualsandpopulations.Inprofessionalpractice,concernforhumandignityis reflectedwhenthenursevaluesandrespectsallpatientsandcolleagues”(AACN, 2008,p.26).Honoringtheinherentworthofeverypersonundergirdstheentire nursingprofessionandisofparticularimportanceasabasisforcorrectionalnursing practice.Correctionalnursesareoftenchallengedbytheneedtocareandrespond toindividualswhomayhavecommittedheinouscrimes,whoshowdisregard themselvesforbasichumanworth,orareguidedbyadestructivepersonalcode.It isthroughacontinualreaffirmationofthisbasicnursingvaluethatcorrectional nursescanhonestlycareforandaboutthepatientstheyserve.Provision1ofthe ANACodemakesclearthesignificantimportanceofhumandignityasanursing value.
Valuinghumandignityalsoconcernsinteractionswithothersinthecare community,whetherotherhealthcarestaff,support,orcustodystaff.Respectful communicationandactionsamongstaffmembersindicateavalue-basedperspective.
Integrity
Asaprofessionalnursingvalue,integrityreferstoconsistenthonestyofaction.This termalsoemphasizesactingonthebasisofaprofessionalcodeofconduct(AACN, 2008).Nursesactwithintegritywhenactionsareregularlybasedonanethical codesuchastheANACodeadvocatedbytheCorrectionsNursingScopeandStandardsofPractice(2007).Incrementaldeviationsfromprofessionalethicalprinciples canbedeemedacceptableinchallengingsituations,leadingtoaslowlossofintegrity overtime.Correctionalnursesmustbeespeciallyvigilantaboutprofessionalpractice inaprisonorjailsetting.Forexample,itmaybedifficulttomaintainaprimarycommitmenttopatientautonomywhenpressuredbyunrulypatientbehaviorandthe needbycustodytomaintaincontrol.Correctionalnursesineverysettingmustconsidertheirprofessionaldutywhenconfrontedwithethicalconflictencouragingan easyanswerthatmaybreachintegrityofpractice.
Actingwithintegrity,aswithallotherprofessionalnursingvalues,isimportant forthenurse–patientrelationship,butalsorelationshipswithothersonthehealth
careteam.Patientoutcomesareenhancedwhenteammembersaretrustworthyand sharethepatient’swelfareasacommongoal.
Integritycanbebreachedwhennursesareaskedtoactinconsistentlywith professionalbeliefsandvalues.Pressuretotreatinmatesinhumanelyorprovidesubstandardcarecancausemoraldistressandthreatenwholenessofcharacter.Correctionalnursesplacedinasituationofthisnaturecanusemoralreasoningtoguide actionsthatmaintainintegrityandprofessionalnursingvalues(Butts,2008).
FromtheExperts
“Trustworthinessisthefoundationforworkinginacorrectionalsetting.Never havethewords firm,fair, and constant beenasimportanttoachieveourgoals andsettheguidelinesforoursuccesswiththosearoundus.Patients,staff, andthecommunityseethatwhatwedoforone,wedoforall,andthis buildsrespectotherscandependon.Inmatesareourpatientsandweserve themaswellasourstaffmembersandthecommunitybybeingthebest nursewecanbe—todootherwiseisatravestyanddisservicetoour profession.”
RoyanneSchissel,RN,CCHP SantaFe,NM
SocialJustice
Theprofessionalvalueofsocialjusticeisofsignificantimportanceincorrectional nursingpractice,wherethereisincreasedcontactwithvulnerableandmarginalized peopleandpopulationgroupsinadehumanizingenvironmentdevoidofmany comforts.Thevalueofsocialjusticeguidescorrectionalnursingpracticeasthe basisforfairtreatmentthatlooksbeyondtheoutwardcharacteristicsor“labels” ofanindividualtothecorehumanwhodeservesthebesttreatmentthatcanbe offeredthem.Nursesmaybecalledupontoadvocateforbasicrightsandneeds forpatientsinthecorrectionalsetting.Abalancemustoftenbestruckbetween nursingcaredeliveryandcriminaljusticerequirements.Whenfacedwithan ethicaldilemmaamongconflictinggoals,correctionalnursescanbeguidedbythe valueofsocialjustice,alongwithotherprofessionalnursingvalues,indetermining appropriateaction.
Provision3ofthe ANACodeofEthics(2001) givesvoicetotheneedforall nursestopromote,advocatefor,andstrivetoprotectthepatient’shealth,safety, andrights.Inaddition,the ICNCode(2006) encouragesnursestopromotean “environmentinwhichthehumanrights,values,customs,andspiritualbeliefs oftheindividual,familyandcommunityarerespected”(p.2).Theseconceptsare appliedtothecorrectionalsettingthroughtheACHSACodeinElement5— providehealthcaretoallinmatesregardlessofcustodystatus.Correctionalnurses haveasignificantopportunitytoimprovethewelfareoftheinmatepopulation throughavalue-basedapproachtonursingpractice.
