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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

by

Christopher Veal

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

ABSTRACT

There are close to five thousand prisoners in custody in Queensland prisons and this number is on the increase. Prisoners have complex health needs and it is the role of the correctional health nurse to care for prisoner-patients and their health needs. Yet there is a paucity of research surrounding this topic. The purpose of this phenomenological study was to describe the lived experience of nurses caring for prisoner-patients. Five registered nurses, employed in correctional centres in Southeast Queensland were interviewed to illuminate the experience of caring for prisoner-patients. Data was analyzed using Colaizzi’s (1978) method of phenomenology. Textual analysis revealed two themes with five corresponding sub-themes that depicted the meaning of nurses’ caring for prisonerpatients. The experience of nurses caring for prisoner-patients was described by nurse

participants as ‘obstructive practices’ from the custodial officers, ‘decreased standards of care’ by nursing staff, ‘prejudice’ towards to prisoners, ‘increased level of mentally ill prisoners’ and a ‘lack of recognition’ for nurses working in the prisons. Amidst all these

difficulties, nurses who cared for prisoner-patients demonstrated courage in the work they did and persevered for the sake of the their prisoner-patients and the specialty that is correctional health nursing. Communication must continue between prison and health care administrators in order to identify conflicting issues that impact on the autonomy of nurses delivering health care to prisoner-patients. Further research must also be conducted into the level of mental illness in the prisoners and the health care that is needed for the mentally ill prisoner.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

TABLE OF CONTENTS

ABSTRACT........................................................................................................................ i LIST OF TABLES ........................................................................................................... iv 1. CHAPTER ONE: INTRODUCTION .................................................................1 1.1 Problem.........................................................................................................1 1.2 Background and Significance.......................................................................2 1.3 Purpose of the Study.....................................................................................5 2. CHAPTER TWO: LITERATURE REVIEW....................................................6 2.1 Introduction ..................................................................................................6 2.2 Nursing in correctional settings....................................................................6 2.3 The nature of nursing practice in prison settings........................................10 2.4 The clientele in prison settings and their health needs ...............................14 2.5 Nursing
Theories and how they underpin correctional nurse practice .......18 2.6 Caring as an inherent dimension to nursing practice..................................24 2.7 Summary.....................................................................................................30 3. CHAPTER THREE: METHODOLOGY ........................................................32 3.1 Introduction ................................................................................................32 3.2 Origins of Phenomenology.........................................................................32 3.3 Husserl’s Phenomenology ..........................................................................33 3.4 Essences......................................................................................................34 3.5 Intuiting ......................................................................................................35 3.6 Phenomenological Reduction .....................................................................36 3.7 Interpretive or Hermeneutic Phenomenology.............................................37 3.8 Phenomenological Method in Nursing Research .......................................40 3.9 Relevance to Nursing Practice....................................................................42 3.10 Sample Population for Research.................................................................45 3.11 Data Collection ...........................................................................................48 3.12 Data Analysis..............................................................................................51
3.13 Ethics ..........................................................................................................53 4. CHAPTER FOUR: FINDINGS.........................................................................55 4.1 Introduction ................................................................................................55 4.2 Theme One: Barriers to Caring ..................................................................55 4.2.1 Sub Theme: Obstructive Practices.................................................55 4.2.2 Sub Theme: Standards of Care ......................................................58 4.2.3 Sub Theme: Prejudice amongst others ..........................................62 4.3 Theme Two: Striving to Care .....................................................................65 4.3.1 Sub Theme: Against the Odds ........................................................65 4.3.2 Sub Theme: Who cares about us....................................................68 4.4 Summary.....................................................................................................70 CHAPTER FIVE: DISCUSSION......................................................................72 5. 5.1 Introduction ................................................................................................72 5.2 Barriers to Caring .......................................................................................72 5.2.1 Obstructive Practices.....................................................................72 5.2.2 Standards of Practice.....................................................................75
5.2.3 Prejudice amongst others ..............................................................78

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

Striving to Care...........................................................................................80 5.3.1 Against the odds.............................................................................80 5.3.2 Who cares about us?......................................................................82 5.4 Limitations..................................................................................................85 5.5 Implications ................................................................................................86 5.5.1 Collaboration.................................................................................86 5.5.2 Future Research Needs ..................................................................87 5.6 Conclusion ..................................................................................................88 REFERENCES.................................................................................................................90 APPENDIX 1: Consent Form APPENDIX 2: Ethical Approval from Central Queensland University APPENDIX 3: Application for Ethical Approval from Queensland Department of Corrective Services APPENDIX 4: Letter of advice from Department of Corrective Services APPENDIX 5: Letter from Chairman of Ethics Committee, Central Queensland University APPENDIX 6: Letter written by Christopher Veal APPENDIX 7: Letter from Chairman of Ethics Committee, Central Queensland
University

5.3

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

LIST OF TABLES

Table 1: Table 2: Table 3: Table 4: Table 5: Table 6:

Watson’s 10 Carative Factors (Watson 1985, pp75)......................................21 Assumptions for the Science of Caring (Watson 1979, p9) ...........................22 Age of Participants .........................................................................................46 Type of Prison Settings of Participants ..........................................................47 Years experience as a Registered Nurse prior to working in the prison system.............................................................................................................47 Years of experience working in the prison system.........................................48

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

1.

CHAPTER ONE: INTRODUCTION

1.1

Problem

There are approximately two hundred nurses that work in prisons in Queensland to care for prisoners. Their duty is to maintain and improve the standard of health care that is delivered to prisoners. Prisons are built for their geographical location and their symbolic isolation and this sense of isolation has been reportedly attached to nursing practice in prisons (Brown, 1992; Paskalis, 1993; Burrow, 1993; Hennakem, 1993; Doyle, 1999). The sense of isolation has been noted to effect nurses working in prisons with the powerlessness and the disempowerment felt by the prisoners been translated to nursing staff (Paskalis, 1993; Hennakem, 1993; Tarbuck, 1994; Osborne, 1995; Maeve, 1997; Carmody, 1998). Yet nurses continue to work in the prisons and deliver health care to people for whom the general public show no concern (Carmody, 1998, p1).

There is no formalized education for nurses wanting to work in the correctional system yet New South Wales and Victoria universities offer related courses. However Queensland has no university course for correctional health nursing. Doyle (1998) suggests that nursing staff working in the prisons come from a diverse range of practice backgrounds with rich clinical experience yet little research has been conducted to describe or investigate the special nature of this branch of nursing (Doyle, 1998). Saunders (2000) suggests that more research is needed to establish educational programs to contribute to role clarification, to develop practice standards and educate major stakeholders in the health and justice systems (Saunders, 2000).

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

The nurse working in the prison system faces isolation in the workplace and from colleagues a lack of definition and education for this specialized role yet they continue to care for their clients in an area foreign to most people (Carmody, 1998; Saunders, 2000). There is a paucity of research conducted that examines the way nurses provide care for prisoners.

1.2

Background and Significance

There are approximately five thousand prisoners in custody in Queensland and the number of people coming into the prison system is increasing (Australian
Bureau of Statistics [ABS], 1999; Queensland Department of Corrective Services [QDCS], 2000). Due to nature of their lifestyle that leads to them to prison (high risk and high illegal substance abuse) it has been found that prisoners are more likely to suffer from serious health problems (QDCS, 2000). Mental health, drug and alcohol abuse have been identified as the most common health problems of prisoners (QDCS, 2000). In developing the 10-year Mental Health Strategy for Queensland in 1996, Queensland Health (QH) reported that between seven to ten percent of the prison population had a major mental illness, either upon entering prison or developing whilst in custody (QH, 1996). The Australian Institute of Criminology (AIC) concluded in a study of drug use in prisons that there existed a direct link between illicit drug use and crime and the health implications related to substance abuse (AIC, 2000). Also, there was a direct link between heroin use and an increase in criminal activity (Hall, Bell & Carless, 1993). This high percentage of drug misuse amongst prisoners has led to an increased incidence of medical health problems.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

Human Immunodeficiency virus (HIV) and other blood borne pathogens, for example hepatitis contributes to major public health problems in prisons. In Australia, rates of infectious diseases can vary from one to ten percent of the prison population (AIC, 2000). The complications of HIV and hepatitis A, B, and C are an increased frequency of gastrointestinal disorders, endocarditis and/or seizures (Thornburn, 1995).

Longer mandatory prison sentences, truth-in sentencing practices and more restrictive release policies, combined with increased elderly in the free world population, suggest that the prison population is also aging. Elderly prisoners are the fastest growing group of the prisoner population and aging is associated with higher rates of chronic illness (QDCS, 2000). The Department of Corrections, Queensland, published statistics regarding the ages of prisoners in Queensland and found that five percent of prisoners were over 65 years of age. However this percentage is likely to increase by five percent to ten percent over the next twenty years (ABS, 1999). With the increase in overall age of the prison population comes an increase in the number of age-associated diseases. Subsequently, there is an increase in demand of health care required to treat prisoners with problems such as diabetes, cardiovascular and respiratory compromises, arthritis and other chronic or acute debilitating diseases.

These factors create a broad range of ongoing and prospective health care needs of prisoners. Therefore nurses that work in the prison setting face the daunting task of delivering health care to prisoners in the full context of their health care needs - medical, mental and/or psychological.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

Correctional nurses are professional nurses who deliver care to institutionalized populations in prisons or to populations that are housed in forensic facilities. Unique to this environment, the nurse must work within strict security regulations in sometimesovercrowded facilities and understand the legal and public health considerations of providing health care to prisoners (Veal, 2001). The correctional system presents unparalleled challenges. In traditional health care settings, the client generally volunteers for health care services but in the prison setting, prisoners who receive health care are involuntary residents of the facility. Therefore nurses who deliver health care to prisoners in correctional settings face fundamental differences in client-nurse relationships and in planning care for prisoner-patients. Prison nurses are challenged to practice with prisoners who have been convicted of crimes against society and to do so in a caring relationship that will facilitate the health and healing of the prisoners (Abeyta-Phelps, 1983; Caplan, 1993; Paskalis, 1993).

Over the last several years the nursing literature has begun to describe the role of the nurse and patient care in the practice setting. Only a limited number of studies have investigated the concept of caring as a lived experience from a nursing perspective (Forrest, 1989; Clarke & Wheeler, 1992; Bush & Barr, 1998).

While there are five thousand prisoners in Queensland and more than twenty thousand in Australia, studies related to nursing and the delivery of health care to this vulnerable group remain sparse. Only five studies addressing the issue of nurses caring for prisoners in prison have been identified.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

1.3

Purpose of the
Study

The purpose of this study was to explore nurses’ lived experience of caring for patients in the prison setting. A descriptive phenomenological design was employed as this

facilitated understanding the lived experience of the participants.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

2.

CHAPTER TWO: LITERATURE REVIEW

2.1

Introduction

The literature review for this study examined correctional/prison health nursing and the basis of planning care for prisoner/patients. The review included literature dated from early 1990s available in the English language. The majority of the available literature emanated from the United States of America (USA) and the United Kingdom (UK).

The review critically analyzed the literature on nursing in prisons, the nature of nursing in prisons and the clientele that nurses care for in prisons. This is followed by a review of the available literature on the basis of planning care for prisoner/patients and how this is underpinned by nursing theory. Finally the nature of caring is reviewed using selected sources from the literature that demonstrates how this is applied in nursing.

2.2

Nursing in correctional settings

The role of the nurse working in the prison has not been fully examined according to the available literature. The duties are complex and demanding and nurses in prisons face confrontation from many sources. Peternelj-Taylor (1999) highlighted in her discursive article on nursing in the prisons in the USA, the difficulty and lack of opportunity for nurses working in prisons to be allowed to establish therapeutic relationships with prisoners when society doesn’t see the need for prisoners to receive adequate health care as a priority. The challenge for nurses according to Peternelj-Taylor is whether to care for the prisoners or to maintain the custody of the prisoners (Peternelj-Taylor, 1999). This dilemma within the role

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

of nurses in their practice environment sees some of the nursing staff forget to re-establish their caring role within the prison. This particular aspect is argued to be essential so nurses working in prison have clear working goals and they understand their own role and the differing role of the custodial staff (Peternelj-Taylor, 1999).

This is supported by Osborne (1995, p5) who states:

The ramifications of this paradox are at best perplexing-if not disconcerting-and forensic nurses often feel torn between the needs of society and the needs of their clients, not suprising as the distinction between social necessity (custody) and social good (caring) is not always easy to discern.

Another of the issues surrounding nurses working in prisons is that nurses in this environment must continually ask themselves what the work really means and whose welfare they are serving. Evans and Wells (2001) argue that nurses working in the prison system are the social outcasts of the nursing world. A position supported by Doyle (1999, p7):

Prison nursing authors have also described themselves as isolated both socially and professionally because of the hidden nature of their practice, citing that society only wants those it pays to deal with its problematic elements

By examining this dilemma the nursing staff working in the prisons will be able to offer care to prisoners with their primary focus (care) in mind and avoid a custodial ‘mentality’ (Frank, 1999; Peternelj-Taylor, 1999; Gannon, 2000; Peternelj-Taylor, 2001).

Mercer, Mason and Richman (2001) in their discursive article examined the literature surrounding professional convergence in forensic practice in prisons in the UK. They

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

concluded that the role of the nurse had changed over the years within the prison system. The role of the nurse had changed from one of custodian to one of carer. Unfortunately not all nurses everyone had embraced this change (Mercer, et al 2001). It was suggested that more legislative and public relations work was needed to allow nursing in the prisons to move forward in both public and custodial eyes and allow the nurse working in prisons to remove the ‘shackles’ of custodian and gain the role of carer. By defining the role of the nurse within the prison setting, the authors suggested more credence could be given to the nurse in the prison and they could be left to undertake the task they were employed to do, to deliver health care to prisoners (Mercer et al, 2001).

Five discursive articles by Norman and Parrish have been written concerning the skills nurses need before they commence work in prisons. These authors have been employed by the Department of Prisons in the UK and regularly contribute to journals in the UK with insights on what it is like to be a nurse in a prison in the UK. They mention specialized skills, including separating the role of prison officer and nurse:

At the moment, nurses who are employed as healthcare officers-prison officers with an interest in health-also have responsibilities as prison officers. They are providing care but they get drawn into other duties, which are nothing to do with health care. That means the workforce is not always focused as perhaps we might chose it to be (Norman & Parrish, 1999c, p3).

Ethical and moral dilemmas can also present themselves. In the therapeutic interview with the nurse the prisoner can impart sensitive information regarding their crime or confidential information concerning another prisoner. This can create a serious problem for the nurse:

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

It is therefore essential that, if a supporting and professional relationship is to develop, clear and honest boundaries are laid down, (Norman & Parrish, 1999a, p5).

According to Norman and Parrish (1999a) nurses need to be non-judgmental people to work in a prison, they must also see the prisoner as a person whose punishment starts and finishes with the serving of their sentence. They argue that care cannot be delivered to prisoners when the nurse is always taking into account what the crime of the individual is (Norman & Parrish, 1999a). Further, the authors believe the maintenance of professionalism at all times is one the hallmarks of all nurses and especially those working in prisons (Norman & Parrish, 1999a).

An increasing number of mentally ill prisoners who are incarcerated means that specialized care must be provided (QDCS, 2000). Polczyk-Przybyla and Gournay (1999) analyzed psychiatric nursing in the British prison system and discovered that the increasing numbers of mentally ill prisoners resulted in an increasing demand for trained mental health nurses in the prisons. The recommendations of the report included that more trained nurses needed to be employed to properly care for the mentally ill offenders (Polczyk-Przybyla & Gournay, 1999). In addition they found the availability of education courses for nurses was limited and as a consequence:

Recruitment of qualified staff continues to be the main difficulty in this area and until there is a marked change in the image that forensic nursing has within the nursing profession, then there is unlikely to be a massive shift in attitude, ( Polczyk-Przybyla & Gournay, 1999, p899).

Evans (2000) also highlighted a lack of educational opportunities in her review of the literature surrounding educational preparation for nurses in the UK to work in the prison

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

system. Evans (2000) found that nurses working in small prisons had at times more need for education than those in the larger prisons due to lesser resources and they had less access due to the lack of relief staff to cover when someone attended a conference. Therefore the author argues courses need to be developed that bridge some of the skills and knowledge gaps between the requirements of a competent prison nurse and the existing competency levels of nurses entering prisons (Evans, 2000).

2.3

The nature of nursing practice in prison settings

Maeve and Vaughn (2001) conducted a hermeneutic study that examined the structure and development of caring practices in prisons and forensic mental health institutions in the USA. Supporting this study were several months of personal experience by the author’s correctional health nursing. However the report stressed that the study was ongoing and only one formal interview had been conducted thus the study was limited because the conditions that described caring appeared from the perspective of only one nurse.

The study concluded that the most significant obstacle to caring by nurses was that nurses were forbidden to enter into therapeutic relationships with prisoners (Maeve & Vaughn, 2001). The custodial officers commented that they were employed to maintain security therefore a healthy suspicion of any prisoner’s activities and interactions were paramount in performing their duties. Maeve and Vaughn (2001) commented that this tension between nursing staff and custodial officers within the jail was quite natural and to be expected.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

According to Maeve and Vaughn (2001) upon employment with the correctional facilities, nurses are taught not to hold conversations with prisoners and that empathy will be a downfall in practice. Training films warn new employees that prisoner politeness should always be viewed as a form of manipulation.
Therefore in the orientation phase, nurses are encouraged and directed not to care (Maeve & Vaughn, 2001).

Occupational socialisation in the prison system is intended to protect nursing staff from manipulative prisoners who might try to harm them. Maeve and Vaughn (2001) also suggest that under pressure from custodial staff some nurses lose sight of their healing and caring mission. However, the authors stress that it is important that the nursing staff never confuse the roles of nursing and custody (Maeve & Vaughn, 2001).

The opportunity to care for prisoners is not well supported in this preliminary study. It was identified that nurses and custodial officers tended to socialise together “on-the-job” and after work, therefore nursing staff had difficulty identifying their own role within the prison setting (Maeve & Vaughn, 2001).

Hammer (2000) when writing of the role of the forensic nurse in a discursive article described common themes surrounding caring that could be translatable to all facets of nursing. Actions that were synonymous with caring were:

• • • •

Being available to the client. Offering a presence to the client that conveys affection. Respecting the situation the client is in. Being willing to try to understand the client’s experience.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

• •

Possessing a genuine desire to help. In the course of being with the client, the intent of the nurse is conveyed quickly, unequivocally and genuinely (Hammer, 2000, p3).

Hammer (2000) did not detail how these actions could be translated into forensic nursing. However brief examples were given of how difficult it is to be a forensic nurse and care for prisoners. Hammer (2000) further argued that ethical and moral dilemmas faced by the nurse in a prison environment are one of the greatest challenges that they encounter in the workplace. Remaining professional and keeping the required boundaries when dealing with prisoners tests the nurse at all times:

For example, nurses practicing in correctional settings must recognise the need to maintain security, while avoiding identifying with the role of jailer. Forensic nursing consciously must direct its evolution toward maintaining true collaboration (Hammer, 2000, p2).

Doyle conducted two qualitative studies, (n=80; n=10) that focused on nurses caring for prisoners in an Australian prison (Doyle, 1998; Doyle, 1999). The earlier study with 80 nurse participants who were interviewed for the study. All of the participants had at least one year’s experience working in a prison. The data from this study evolved into four themes: a profound sense of isolation, stigmatization, marginalization and exclusion (Doyle, 1998).

The nurses interviewed in the study highlighted the “hidden” nature of their role and suggested reported that general society did not want to know about what prisoners suffered from (Doyle, 1998). Management and health care issues surrounding prisoners were reportedly not acknowledged by society and the participant nurses expressed the

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

view that a “good prison was out of sight out of mind” (Doyle, 1998). This philosophy led the nurses to see themselves as both isolated professionally and socially.

The participant nurses also talked about the compromises that existed in their role. The operational issues that surrounded prisoners, for example security and containment were seen by the nurses as far more important than any health issues that the prisoners experienced (Doyle, 1998).

The lack of privacy allowed by the custodial staff when nurses attempted to establish therapeutic relationships was seen as causing feelings of being “trapped” and was professionally intrusive. The omnipresence of the custodial staff, their personal ‘verbal bombast’ and the criticism and derogatory comments pertaining to nurse-prisoner interactions, contributed to feelings of entrapment (Doyle, 1998).

The sense of isolation of prison nurses was further highlighted by the lack of acknowledgement by nursing colleagues as to where they worked. Nurse participants commented that they did not tell social contacts that they cared for prisoners. They agreed that because prisons were full of people that were “society’s failures”, to be associated with this population was to have the same attributes (Doyle, 1998).

Doyle’s second study (1999) examined the factors that influenced mental health care for prisoners. A qualitative research design was utilised with ten psychiatric mental health nurses in a preliminary focus group. The emerging themes identified were explored further in semi-structured interviews with twenty nurses. The themes from the data

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

included ‘challenging patients’, ‘threats to personal safety’, ‘the technology and artifice of confinement’ and ‘conflicting values of nurse and prison staff’ (Doyle, 1999).

Conflicting values of nurses and prison staff were very apparent and participants reported the need to respond to executive directives and operational measures primarily designed to secure prisoners with the ever-present custodial staff. This led to nurses feeling that their practice of caring for prisoners was compromised by having to accommodate the values of security, segregation, discipline and regulation (Doyle, 1999).

This theme was also apparent in the observation that custodial officers viewed the interviewing of prisoners (for the purpose of eliciting mental health status) as an opportunity to substantiate that all prisoners were ‘after something’ and that prisoners would lie in the interview to ‘get what they wanted’. The participants believed that this attitude undermined their caring role and the custodial staff did not value the nurse-prisoner interaction as a therapeutic tool to establish the health of a prisoner (Doyle, 1999).

The overriding conclusion of this second study was that nurses compromised their caring role to accommodate the expectations of others in the delivery of health care (Doyle, 1999). Further research was suggested to find a way to alleviate this dichotomy: care or custody.

2.4

The clientele in prison settings and their health needs

A significant number of authors have reported on the health needs of prisoners in Australia and overseas. Mental illness, substance abuse, the medical and physical

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

consequences of risk-taking behaviors and sexual diseases are some of the more common health problems that face prisoners, either in the community or once in prison, (Harding, 1997; Lovell & Jemelka, 1998; Norman & Parrish, 1999b; Norman & Parrish, 1999d; Conklin, Lincoln & Tuthill, 2000; Yurkovich & Smyer, 2000; Norman & Parrish, 2001). Health professionals should also be aware that prisons are a part of the local community and with increasing rates of recidivism, the diseases that are treated in prisoners are also likely to occur in lower socio-economic areas from which the majority of prisoners hail (Conklin et al, 2000). Therefore nurses in prisons also perform the role of the public

health nurse. Queensland prisons are implementing health education and promotion into the role statements of the correctional health nurse (Veal, 2001). The need for education regarding basic health needs is paramount in working with prisoners. Those from disadvantaged backgrounds have reported that they have less access to health services in the community due to the nature of their lifestyle and occupations. Thus, these people are likely to present to prisons with complex health needs (Harding, 1997).

Nurses that work in prisons, developing health care have an opportunity to effect the well-being of prisoners during and after prison with possible flow on effects to the community (Veal, 2001). According to Gibson (2002) effective health care delivered in prison can make a significant contribution to the health of individuals, as well as improving their capacity to benefit from education, drug treatment and other programs.

Conklin et al, (2000) described the findings of a quantitative study conducted with 1198 prisoners (n=1198) on their self-reported health needs in a prison in western Massachusetts, USA. The authors reported that prisoners ranked their four most important health needs as: teeth/gums, bone/joints, back/neck and emotional/mental problems. The

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

researchers found that one third of the participants had not visited a medical provider (prior to prison) in the 12 months prior to the survey due to cost. It was apparent that the prison became the substitute health provider local general practitioner for these therefore the correctional health nurse must be able to diagnose, treat and refer common health problems (Conklin et al, 2000).

The conclusion reached was that,

…newly incarcerated correctional inmates have a high prevalence of health issues at admission, prior limited access to health care, very high rates of disease and unhealthy behaviour and a strong desire for help in improving their health and in changing health related behaviour…with additional prevention and education programs to modify risky behaviour (Conklin et al, 2000, p3).

The rates of mental illness in the prisons in the USA are reported to be four times that of the general population (Lovell & Jemelka, 1998). From a review of several USA studies Lovell and Jemelka (1998) concluded that
10 to 20 percent of the prison population was in need of psychiatric service due to major mental disorders. It could be concluded that nursing staff in the USA and potentially Australia have a need to be able to manage and treat prisoners who are mentally ill.

Yurkovich and Smyer (2000) conducted a grounded theory study in a North American prison to define health and health-seeking behaviors of incarcerated individuals experiencing severe and persistent mental illness. 19 prisoners were interviewed and the findings were presented as four themes: ‘relationships’, ‘feelings’, ‘attitude’, and ‘functional ability’.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

‘Relationships’ described how the prisoner used relationships to survive within the prison. Prisoner participants revealed that all relationships were superficial, as they did not want to get close to any one person who may ‘dob’ you in at any moment. Forming relationships with the staff was also reported to be perilous as they could also ‘dob’ you in for any misdemeanour (Yurkovich & Smyer, 2000).

‘Feelings’ and ‘attitude’ were inextricably linked. Feelings existed but were not displayed outwardly. Respondents maintained an ‘attitude’ otherwise they felt they would be ‘trampled over’ by the other prisoners. Weakness in a prison was considered a flaw and was the key to getting killed or seriously hurt. Seeking help when experiencing ‘bad feelings’ occurred on a superficial level.

Nurses in prisons can assist the mentally ill prisoner cope with their illness. The researchers suggested that examing the prisoners’ past behaviours and exploring how they related to the four themes of ‘relationship’, ‘attitude’, ‘feelings’ and ‘functional ability’, would help nurses to assist prisoners to adjust to a new constrictive environment (Yurkovich & Smyer, 2000).

Nursing staff in the prisons are also suggested by the study to be perfectly placed to assist inmates with mental illnesses to maintain a balance and to aid in the transition from the prison back to the community (Yurkovich & Smyer, 2000). Additionally nurses can bridge the gap between community health providers and prison health providers and their role is argued to be vital to maintain the well-being of their clients. An understanding of how the prisoner coped and prevented a loss of control before incarceration provides an

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

understanding of how behaviour can be managed in the prison system (Yurkovich & Smyer, 2000).

These authors have demonstrated that the health needs of prisoners are complex and demanding therefore the responsibility of the nurse to ensure that these health needs are met is difficult and challenging. The small amount of literature identified on this topic highlights the nature of delivering health care to prisoners and how challenged to care in a prison environment. the nurse is

2.5

Nursing Theories and how they underpin correctional nurse practice

Nursing theory has been described as a set of beliefs and abstractions that allow us to find knowledge about a social world (Neuman, 1997, p37). The purpose of nursing theory is to make scientific findings meaningful and generalizable and they are useful in conceptualizing the individual, family or community and in planning nursing interventions (Boyd & Nihart, 1998, p148). Theory can be further developed and refined in nursing practice because theory provides tools for reflecting on incidents that occur in practice.

There are no published nursing theories that directly describe or guide correctional health nursing. However there are theories developed in the context of nurses caring for the mentally ill patient. Four nursing theories lend themselves to examination as they have some application to correctional health nursing.

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

Hildegarde Peplau developed a theory for mental health nursing based on the nurse-client relationship; she led psychiatric nursing out of the confinement of custodial care into theory driven professional practice. The essence of psychiatric nursing is the nurse patient relationship (Peplau, 1952). The nurse has specialized knowledge and competence that is translated into the services the clients require. As a client describes an event, an incident or dilemma the nurse listens to verbal communication and observes nonverbal gestures and body movements to begin to understand the client’s relations (Peplau, 1986). Nurses interact with the patient to identify available resources, such as the quantity of food, availability of interpersonal support, as well as support for interaction patterns that help patients obtain what they need.

One example of the application of Peplau’s interpersonal nursing theory in the correctional environment was found in the literature. Schafer (1999) described through a case study how the employment of Peplau’s theory on the care of an aggressive prisoner in a prison enabled the prison authorities and nursing staff to better control and care for him when other methods had not worked. The author described four overlapping phases of establishing the therapeutic relationship with the prisoner. These phases are orientation, identification, exploitation and resolution. The author described how the nurse supported/facilitated changing the man’s behaviour from one of continual confrontation with the authorities to one of acceptance of his situation in jail (Schafer, 1999).

The conclusion of the case study was that nurses’ interactions with patients tend to occur more frequently, last longer and have more continuity than those characterized by other health care workers. Consequently the potential exists for nurses to have the greatest therapeutic impact (Schafer, 1999). Peplau’s interpersonal theory provided a useful

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A Phenomenological study describing the lived experience of nurses caring for prisoner-patients

framework for nurses working in a correctional environment with clients with a mental illness and guides the establishment of the therapeutic relationship.

In 1954 Ida Jean Orlando was awarded a project grant to study factors that enhanced or impeded the integration of mental health principles in the basic nursing cirriculum. Orlando believed that nursing was a distinct, autonomous profession responsible for ascertaining whether a patient’s needs are met either by direct or indirect means (Faust, 2002). Orlando developed her theory after studying the nursing care of medical-surgical patients and she identified three areas of nursing concern: the nurse-patient relationship, the nurses’ professional role and the identity and development of knowledge that is distinctly nursing (Orlando, 1961; Orlando, 1972).

Potter and Bockenhauer (2000) conducted a pilot study studying the application of Orlando’s nursing theory on a busy psychiatric ward in New Hampshire, USA. The facility decided to implement Orlando’s theory to guide nursing practice and consequently evaluated the implementation. The researchers examined whether nursing care based on Orlando’s nursing theory had a measurable impact on patient outcomes. Comparisons of patient outcomes with Orlando’s nursing theory were made with nonspecified nursing interventions.

The findings of the study were that Orlando’s nursing theory in guiding nursing care enabled the nurses to achieve excellence in their work. Alleviating patient distress by being more aware of patient stress and decreasing this stress was achieved, outcomes not previously attained. Furthermore Walker and Avant (1995) advocate the utilisation and implementation of nursing theory to provide a clear definition of the role of the

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Registered Nurse (RN), a process by which to identify patients’ immediate health needs and an affirmation of the value of nursing. Potter and Bockenhauer (2000) study findings affirmed the decision to use theory-based practice and affirmed that for clients with a mental illness application of Orlando’s nursing theory helped nurses achieve better health outcomes.

Watson’s theory of caring was first published in 1979. Watson believes that caring is the foundation of nursing and recommends that specific theories of caring be developed in relation to specific human conditions and health-illness experiences (Watson, 1990). Watson believes that caring is both an art and a science whose processes and transactions are necessary for nursing in order to attain its goals (Patistea, 1999). Watson developed ten carative factors, as presented in Table 1, through which nurses deliver caring transactions.

Table 1: Watson’s 10 Carative Factors (Watson 1985, pp75)
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Humanistic-altruistic system of beliefs Faith-hope Sensitivity to self and others Helping-trusting, human care relationship Expressing positive and negative feelings Creative problem-solving caring process Transpersonal teaching-learning Supportive, protective and/or corrective mental, physical, societal and spiritual environment Human needs assistance Existential-phenomenological-spiritual forces

These transactions allow the nurse to deliver human care for individuals, families and groups. This theory aims to help nurses to help people to gain a higher degree of harmony within the mind, body and soul.

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Watson (1979) explains that nursing is concerned with promoting health, preventing illness, caring for the sick and restoring health and to complete these tasks nurses use the carative factors as the basis for their work (Watson, 1979, p7).

Table 2: Assumptions for the Science of Caring (Watson 1979, p9)
1. 2. 3. 4. 5. 6. Caring can be effectively demonstrated and practiced only interpersonally. Caring consists of carative factors that result in the satisfaction of certain health needs. Effective caring promotes health and individual or family growth. Caring responses accept a person not only as he or she is now but as what he or she may become. A caring environment is one that offers development of potential while allowing the person to choose the best action for him/herself at a given point of time. Caring is more “healthogenic” that is curing. The practice of caring integrates biophysical knowledge with knowledge of human behavior to generate or promote health and to provide ministration to those who are ill. A science of caring is therefore complementary to the science of caring, The practice of caring is central to nursing.

7.

These assumptions of caring facilitate the nurse delivering care under the umbrella of the ten carative factors.

One example of the practical application of Watson’s theory was undertaken by Neil and Schroeder (1992).. Neil and Schroeder (1992) studied people living with Human Immunodeficiency Virus (HIV) and Acquired Immunodeficiency Syndrome (AIDS). Eight focus groups with a total of 51 participants, newly diagnosed clients and friends and relatives of the clients were conducted.

The research examined the caring perspectives of nurses who worked in an outpatient clinic and how they related to their clients. The results of this study indicated that through authentic caring relationships formed between the clients and the nursing staff, there was potential cost saving due to decreased hospital stays and the nurses also prevented many hospital admissions. The relationships formed between the clients and the nurses led to a

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more ‘open’ form of nursing care and many ‘taboos’ were broken down enabling better communication and therefore better nursing care (Neil & Schroeder, 1992). This

formation of the therapeutic relationship is the central tenet of caring as described by Watson (1990) and forms the basis of delivering nursing care in all fields of nursing, especially psychiatric nursing. In the literature there have been no studies using Watson’s theory to understand the basis of correctional health nursing. However the use of the therapeutic relationship in delivering nursing care to prisoners has been highlighted in studies examining nursing care to prisoner-patients (Doyle, 1998; Doyle, 1999; Maeve & Vaughn, 2001).

Leininger developed a nursing theory related to cultural care. She believed that effective care is linked to culture and defined culture as “the learned, shared and transmitted values, beliefs, norms and lifeways of a particular group that guides their thinking, decisions and actions in patterned ways” (Leininger 1991, pp47). Leininger’s Theory of Culture Care focused on delivering nursing care that is culturally appropriate and beneficial to a particular culture group’s health beliefs (McCance, McKenna & Boore, 1999). Leininger (1991) refers to cultural care universality as “the common, similar or dominant uniform care meanings, patterns, values, lifeways or symbols”, whereas cultural care diversity refers to “the variables and/or differences in meanings, patterns, values, lifeways or symbols of care” (Leininger 1991, p47). The basic tenets of Leininger’s theory are caring and nursing. The central focus of this nursing theory is that nurses always have to be aware of the cultural significance of their nursing actions. The definition of a relationship in certain cultures may take nursing staff time to understand and therefore they way in which they deliver their nursing care needs to be altered to fit into the particular culture they are caring for. Nurses have to be tuned into all cultural

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aspects of their clients to ensure that they deliver culturally sensitive nursing care, (Leininger, 1991).

Central to Leininger’s approach to care are the importance of incorporating culture and community into nursing care. Yurkovich and Smyer (2000) have likened the prison setting, as a community in itself and therefore nurses need to consider aspects of Leininger nursing theory when delivering care to prisoners.

An example of Leininger’s theory in action is demonstrated by Barry and Kronk (1993) who examined a group of Guatemalan refugees who had fled their country and were seeking political asylum in the United States of America. A qualitative research study involving observations, interviews with the refugees and direct participation with the people in the environment led to formation of measures to aid in health care delivery. Due to the language barrier, there were many difficulties in delivering culturally appropriate health care. The research examined the culture of the Guatemalans, including health care beliefs, concepts of health and barriers to health care. Examing these concepts improved the ability to deliver culturally appropriate care and improved health outcomes (Barry & Kronk, 1993).

2.6

Caring as an inherent dimension to nursing practice

Caring has also been defined by Larson (1986) as intentional actions that convey physical care and emotional concern and promote a sense of security in another. Six studies have been selected to review as they will explain and describe the concept of caring and how nurses perceive the concept of caring in the delivery of nursing care.

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Cheung (1998) used a qualitative study of the perspectives of caring from an Australian nurse’s view. 27 volunteer participants were selected including 10 clinical practitioners, nine undergraduate students and eight nursing educators. The fields of experience were varied, from clinicians in the city and country to nursing educators in universities. The practice areas included accident and emergency, aged care, acute critical care, general medical and surgical care, hospice care, palliative care, operating theatre and paediatric nursing. Unstructured interviews first explored, the personal definition of caring. Subsequent prompts to encourage elaboration were derived from the participants’ responses.

The findings from the data evolved into two themes with several subthemes. The first theme; Caring as a way of understanding the meaning and purpose of nursing had four subthemes : (a) caring as a way of being; (b) caring gives nurses motivation; (c) caring gives nurses the focus and direction of nursing; and (d) caring is to protect the patients. The second theme; Caring as a way of understanding the knowledge and skills of nursing had two associated subthemes: (a) caring as an experience; and (b) caring as a process (Cheung, 1998). The use of an interpretive approach allowed the researcher to gain an insight into how nurses believed they care for patients.

Nurse participants in this study discovered that by beginning to understand the concept of caring, nurses also begin to understand what it is to be a nurse and this discovery helps nurses develop the knowledge and skills to better care for patients. The participants believed that when a nurse engages in the process of caring and reflects on those experiences, they extend the practical knowledge base of the discipline of caring

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(Cheung, 1998). These conceptualizations of caring supports the view of Watson (1990) that caring is beneficial to patients and professionally and personally to nurses as well.

In a phenomenological study examining the caring skills of oncology nurses Rittman, Paige, Rivera and Godown (1997) found six experienced oncology nurses were asked their views on what best described oncological nursing and they were asked to write about how they cared for a dying patient and what this taught them about caring. ‘Knowing the patient’ was seen as the cornerstone and key to oncology nursing (Rittman et al, 1997). Knowledge of the disease process and how it affects the patient were important to gaining trust and establishing bonds with patients, the ability to understand all the stages of cancer and being able to accompany the patient and family through the course of the illness were also important to caring (Rittman et al, 1997). Allowing and encouraging the family to stay in the final stages of death was important. Finally the provision of privacy whilst dying was seen as one of the greatest caring actions (Rittman et al, 1997).

The establishment of the therapeutic relationship was very important to all participants. By gaining the trust of the client and the relatives, the nurses were able to deliver excellent nursing care to a dying patient. This was seen as the mark of the expertise of the oncology nurse. Furthermore the establishment of this relationship allowed the patient to die with dignity and with respect not just from the nursing staff but also from his/her relatives. Oncology nursing is very challenging, yet if the patient allows the nursing staff into their lives, the nursing staff experience greater more job satisfaction and the patient receives the respect they deserve (Rittman et al, 1997).

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Bush and Barr (1998) conducted a phenomenological study into the lived experiences of nurses working and caring in critical care unit. 16 female registered nurses aged 24 to 60 years were interviewed.

‘Caring’ in the critical care context was found to be:

A multidimensional, complex process involving assessing, and in priority, addressing patients and families unique needs with the goal of improving the patient’s condition and acknowledging nurses’ living out of caring ways in their own lives (Bush & Barr, 1998, p2).

Four categories emerged from the research: (a) nurses’ feelings; (b) nurses’ knowledge and competence; (c) nurses’ actions; (d) patient and families outcomes and nursing rewards (Bush & Barr, 1998).

Comments from the participants also included acknowledgment of the support from their colleagues and role modeling. These factors determined how the respondents provided nursing care. The level of support from their colleagues was vital in enabling nurses to come to work everyday and ‘care’ for their patients. This study found that critical care nurses who received social support from their nurse colleagues were more able to cope with stressors in the critical care unit as a result (Bush & Barr, 1998).

The acknowledgement of use of role models was also highlighted in this study. Role models need to be identified and encouraged, they need to know their colleagues perceive them as role models as this allows the nursing staff to request support from them as the need arises. The use of role models in the critical care units as demonstrated in this study

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gave the other nurses more work and social support thus allowing for delivery of better nursing care (Bush & Barr, 1998).

Similarly a study by Burnard, Morrison and Phillips (1999)

analyzed nurses’ job

satisfaction in a forensic unit in Wales (n=40) through a questionnaire exploring factors that contributed to job satisfaction. The overriding conclusion of the study was that no matter how stressful the job was, stress could always be mitigated by the support received from colleagues (Burnard et al, 1999). level of

McQueen (1997) used a qualitative approach to explore the experiences of twelve nurses delivering care to gynaecological patients. The data helped define the emotional work of caring from a perspective of gynaecological nursing. McQueen (1997) described certain situations that were relevant to empathy and emotional effort in gynaecological care. These included: caring for patients having a miscarriage, a pregnancy terminated, problems with fertility and caring for relatives and other nursing staff. One of the overriding conclusions of the study was that nurses who care for gynaecological patients are ‘invisible’. The nurses described how this type of nursing had a high emotional commitment and the potential for significant emotional ‘labour’. Related to this was the invisibility of much of the work of the nurses, (McQueen, 1997). This invisibility is also seen in the work of the nurse in the prison (Carmody, 1998) and how society does not want to know what lies behind the walls of the prison.

Forrest (1989) appears to be one of the first authors publishing a phenomenological study that examined the experience of caring. The study group (n=17) consisted of staff in positions on medical, surgical, paediatric or psychiatric wards. Participants’ length of

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experience was between 2 and 24 years. Findings from this study revealed the meaning of caring fell into two categories: “ What is caring?” with the subthemes : involvement’ and ‘interacting’; and “What affects caring”, with the subthemes : ‘oneself’, ‘the patient’, ‘frustrations’, ‘coping’ and ‘comfort and support’.

Genuine and deep interest in the people being cared for was one of the conclusions of this study. Forrest (1989) found that to demonstrate caring involvement and interaction, the nurse must actually want to “be with” the person they were caring for not just “doing for” the person in care. This is where the dichotomy of nursing in the prison presents itself, Rittman et al (1997), Doyle (1998), Doyle (1999) and Maeve and Vaughn (2001) express the difficulties that nurses in prisons have in establishing a therapeutic relationship. Nurses are continually being ‘watched’ by the custodial officers to see if they create any security concerns and face trials in attempting to establish any sort of meaningful caring relationship.

Clarke and Wheeler (1992) conducted a phenomenological study using six medicalsurgical staff nurses with the aim of examing the essential structure of caring. Four themes emerged from the data: ‘being supportive’, ‘communicating’, ‘pressures-work orientated’ and ‘personal influencing nurses’ caring and caring ability. This study on the descriptions of caring, saw ‘love’ take a prominent place. This is congruent with other authors such as Watson (1980) who believes that care and love are universal forces and human needs, and these constitute the most significant caring model (Patistea, 1999).

Finally Yam and Rossiter (2000) reported a small qualitative study into caring with ten Hong Kong Nurses. Content analysis resulted in categories emerging that helped describe

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how these nurses perceived they demonstrated and provided care for their patients. The overall finding of this study was that nurses considered expressive behaviors and interpersonal communication skills to be important aspects of the nurse-patient relationship and yet they found it difficult to achieve these goals (Yam & Rossiter, 2000).

2.7

Summary

This review of the literature was limited by the paucity of studies directly related to the study topic. Reviewing more broadly has highlighted a number of real and perceived challenges for the nurse in the prison setting. Maeve and Vaughn (2001) in their hermeneutic study came to the conclusion that nurses working with prisoners are attempting to care for patients but they face many challenges in their daily roles. One of these is the inability to establish therapeutic relationships with the prisoners. As Watson (1979) has highlighted, one of the central tenets of caring is the establishment of a relationship between the caring parties. This theme is also relevant to Schafer (1999) who attempted to utilize nursing theory to find a better way to provide care for prisoners in a prison in America. It was demonstrated in this study that Peplau’s nursing theory could be applied to the care of prisoners.

Leininger (1991) describes how the establishment of culturally appropriate relationships is vital in delivering culturally sensitive care. Doyle (1998) agrees but highlights the difficulty that the nurses face in establishing rapport with prisoners due to the presence of custodial officers within the prison and this limits the time with the prisoners. Hammer (2000) discovered that nurses working in prisons must always be aware of their

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professional boundaries and that they must never confuse their role in the prison. Nurses are to deliver health care and not to ensure that the prisoner is confined.

These studies give insight into what is known of caring and nursing practice in the prison system. Rittman et al (1997) found that knowing the patient and forming a relationship with the patient were vital to allow the nurse to deliver care. This is congruent with the work by Watson (1979) and further evidenced by the practical application of Watson’s theory by Neil and Schroeder (1992). A therapeutic relationship allows the nurse to form the bond that drives nursing care.

The literature reviewed suggests that significant challenges exist for the nurse working in the prison system. They also highlight the dearth of data that exists to explain the practice and practical experiences of the nurse dealing with these unique challenges.

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3.

CHAPTER THREE: METHODOLOGY

3.1

Introduction

This study used the qualitative research approach of phenomenology to explore the lived experience of nurses’ caring for prisoners, so that a description of the essence of nurses’ caring for prisoners could emerge. This approach was chosen because it identified as the most fitting way to answer the research question.

3.2

Origins of Phenomenology

Phenomenology is:

…the name for a philosophical movement whose primary objective was the direct investigation and description of phenomena consciously experienced, without theories about their casual explanation and as free as possible from unexamined preconceptions and presuppositions (Spiegelberg, 1975,p3)

Scientific inquiry, which was concerned with the study of the human realm, has long struggled with the question of an appropriate method for investigating human phenomena. A number of thinkers felt that the methodology of the natural sciences was inadequate for studying human phenomena and a new method was needed.

Phenomenology stemmed from the rejection of the scientific method of inquiry. The aim of phenomenology is to gain an understanding of the phenomena through a recognition of its meaning (Van der Zalm & Bergum, 2000).

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Previous to the move to qualitative methods researchers and philosophers used a “positive”
(the empirical, analytical paradigm) approach to inquiry about human experience. The concept of “post-positivist” developed to more fully understand human experience. Phenomenologists believed that under positive inquiry all human experience was reduced to only a small number of concepts. These concepts were identified prior to the research and this was tested and understood to be human experience. This was called ‘theory testing’ rather as than theory generating, the outcome of phenomenologists. By not making assumptions prior to conducting research, a broader picture of how human experience the world could be gained (Draucker, 1999). Phenomenology has been

described as involving broadly stated questions about human experiences and realities, studied through sustained contact with people in their natural environment and generating rich, descriptive data that helps us to understand the experiences of the participants (Boyd, 1990).

Two leaders of phenomenology were Franz Breatano and Edmund Husserl. Breatano was a philosopher who lived in the late 19th century and developed this method of inquiry. One of his students was the mathematician Husserl who further developed this philosophical approach to understanding the human experience (Streubert & Carpenter, 1999, p45).

3.3

Husserl’s Phenomenology

The origins of phenomenology have been attributed to Husserl. Husserl (1931) was concerned with the fundamental nature of reality. He established phenomenology as the true essence of “being”, dealing not with facts but with transcedententally-reduced

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phenomena. Husserl suggested that the truths lies in the study of things with human experience, because the meanings and truths that people attach to their existence is the essence of life (Roberts & Taylor, 1998).

Husserl’s phenomenological method focuses on the origin of knowledge that is embedded in everyday activities. He argued that real events, with real people living in the world create lived experience. In order to see the experience as it is, Husserl (1931) called for a breaking away from the positivist viewpoints. Husserl began to see the world from the standpoint of everyday life, looking at the world as it confronts us, from consciousness as it presents itself in everyday life. Husserl (1931) suggested that there is a body of knowledge, which is subjective and personal, and this body of knowledge provides insights and understandings to the human experience. It is the role of the qualitative researcher to explore these meanings and bring an understanding to the experience not gained by the scientific method of investigation (Graham, 2001).

Husserl (1931) believed that philosophy should be a rigorous science that would restore contact with deeper human concerns and that phenomenology should become the foundation for all philosophy and science. The concepts of essences, intuiting and phenomenological reduction were also enveloped by Husserl (Spiegelberg, 1965).

3.4

Essences

Essences are the elements that are related to the ideal or true meaning of something, the concepts that give common understanding to the phenomenon under investigation (Streubert
& Carpenter, 1999).

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According to Natanson (1973:14), “Essences are unities of meaning intended by different individuals in the same acts or by the same individuals in different acts”.

Polit and Hungler (1993) talk about the essence of a phenomenon as to what the researcher is trying to extract in the research. The essence of the experience has been called the “lived-in” experience (Polit & Hungler, 1993). The “lived-in” experience of the participants is the aim of this study. In this study, the purpose was to establish the experience of how nurses working in a prison care for the prisoners. This research then sought to discover how the participants defined themselves and the world they “lived-in”. The interpretations of these meanings by the researcher are the “Verstehen” or meaningful social actions which guide interpretation of others; described by Weber (1981). Neuman (1997) felt that humans must embrace the “Verstehen” as it helps us understand the personal reasons and motives that shape a person’s internal feelings and guides decisions to act in certain ways. The researcher sought to get ‘into’ the participants’ world and

provide an in-depth discussion of such interpretations. This study aims to understand the lived experience of nurses caring for prisoners within the confines of a prison. Therefore this research aims to identify the essences of caring for prisoners.

3.5

Intuiting

Intuiting is an eidetic comprehension or accurate interpretation of what is meant in the description of the phenomenon under investigation (Streubert & Carpenter, 1999). The intuiting process in phenomenological research requires the researcher to seek the common understanding of the phenomena under investigation. This is done by varying the questions or investigative process until a common thread appears. The researcher

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avoids all criticism, evaluation or opinion and pays strict attention to the phenomena under investigation as it is being described (Spiegelberg, 1965; Spiegelberg, 1975).

Through variation of the data, the researcher begins to gain an understanding of the phenomena in relationship to the descriptions generated. It is the main aim of

phenomenology to make transparent the essence of what is being investigated. Husserl (1931) explained “…the transition to pure essence provides a knowledge of the essential nature of the real” (Husserl, 1931: 45). Experiences contain essences and that is the aim of phenomenology is to extract these essences to give a clear picture of the phenomena under investigation.

3.6

Phenomenological Reduction

To see phenomena clearly in their essences, Husserl (1931) believed that it was necessary for the researcher to suspend preconceptions of the phenomena and deliberately abstain from them, so the phenomena could be seen through ‘fresh eyes’. To do this the researcher steps aside or ‘brackets’ his/her beliefs about the world to bring the lived experience into clearer focus. For the researcher, bracketing1 facilitates the kind of perception of experience that leads the researcher to formulate descriptions of meaning of the phenomena that subsequently leads to knowledge. Our relationship with the world is so profound and intimate Merleau-Ponty (1956) said that the only way for us to notice it is to suspend its movement. In order to describe lived experience the researcher needs to have an awakening sense of astonishment before the world. What are left after the

1 The process of identifying and acknowledging any preconceived ideas and opinions that the author may have regarding the subject matter.

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elimination of all assumptions are the given processes of human consciousness and their “intended objects” (Omery, Kasper & Page 1995).

For Husserl, phenomenology and science are bound and Husserl proposed that to become truly scientific, the natural sciences must begin with the phenomena and the problems themselves. For this purpose he developed the technique of “phenomenological reduction”. Husserl stated (1931:44):

Pure or transcendental phenomenology will be established not as a science of facts, but as a science of essential Being (as ‘eidetic Science’); a science which aims exclusively at establishing ‘knowledge of essence’ and absolutely no ‘facts’. The corresponding Reduction which leads from the psychological phenomenon to the pure ‘essence’, or, in respect of the judging thought, from factual (‘empirical’) to ‘essential;’ universality is the eidetic Reduction.

Reduction is the technical term that describes the phenomenological process that permits the researcher to discover what Merleau-Ponty (1962) called “the spontaneous surge of the life-world”. However complete reduction may never be possible because of the intimate relationship individuals have with the world and “the greatest lesson of the reduction is the impossibility of a complete reduction” (Merleau-Ponty, 1956:64).

3.7

Interpretive or Hermeneutic Phenomenology

Spiegelberg (1975) identified a core of steps or elements central to phenomenological investigations. Theses six steps are (1) descriptive phenomenology, (2) phenomenology of essences, (3) phenomenology of appearances, (4) constitutive phenomenology, (5) reductive phenomenology, (6) interpretive or hermeneutic phenomenology (Spiegelberg, 1975).

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Descriptive phenomenology refers to a group of research endeavors in the human sciences that focus on describing the basic structures of lived experience. Descriptive phenomenology directly explores, analyses and describes particular phenomena as free as possible from unexamined presuppositions, (Spiegelberg, 1975). However

phenomenology of essences involves probing through the data to search for common themes or essences and establishing patterns of relationships shared by particular phenomena. Probing for essences provides a sense for what is essential and what is accidental in the phenomenological description, (Spiegelberg, 1975). The phenomenology of appearances involves giving attention to the ways in which phenomena appear. Phenomenology of appearances “ can heighten the sense for the inexhaustibility of the perspectives through which our world is given” (Spiegelberg, 1975:70).

Constitutive phenomenology is the study of phenomena as they become established or “constituted” in our consciousness. Constitutive phenomenology “means the process in which the phenomena ‘ take shape’ in our consciousness, as we advance from first impressions to a full ‘picture’ of their structure” (Spiegelberg, 1975, p75). Finally within reductive phenomenology, the researcher continually addresses personal biases, assumptions and presuppositions and brackets or sets aside these beliefs to obtain the data in its purest form. Suspending judgement can make us more aware of the precariousness of all our claims to knowledge, “ a ground for epistemological humility” (Spiegelberg, 1975:70).

Another phenomenological approach, hermeneutic phenomenology is an interpretive methodology. phenomenology It was developed by combining two existing methodologies, (Heidegger, 1962) and hermeneutics (Gadamer, 1976). A

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phenomenological-hermeneutic approach is essentially the interpretation of the phenomena as it appears in text or the written word. Heidegger (1962) developed the philosophical standpoint that a person's experiences influence their interpretations of the world. He described the notion of pre-suppositions. These pre-suppositions mean that all human beings interpret the actions of others from their own experiences in the world. Everybody in the world have experiences that are relevant to them and it these that determine the way in which they interpret the actions of others (Geanellos, 1998). The methodology of phenomenological-hermeneutic inquiry works to support a method that allows an understanding of what the experience is like for someone looking from the outside to those involved in the situation (Robertson-Malt, 1999). These elements of Heideggerian philosophy are vitally important to the hermeneutical approach to phenomenological research, as the positivist social science is incompatible with Heideggerian phenomenology (Paley, 1998). “In other words, our everyday way of beingin-the-world is not one of detachment, but one of engagement”, (Johnson, 2000).

Gadamer (1976) developed the Heidegger principles to determine the ontological basis for peoples’ understanding of the world. In seeking to answer the question of how people understand the social reality of the world, Gadamer (1976) postulated that we understand others through interpretation of language, “language is the fundamental mode of operation of our being-in-the-world and the all-embracing form of communication of the world”, (Gadamer, 1976).

Hermeneutic phenomenology is a “special kind of phenomenological interpretation, designed to unveil otherwise concealed meanings in the phenomena”, (Spiegelberg, 1975). Due to the nature of this type research and the method used, there is no

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opportunity to remove the reactivity of the participants’ responses but acknowledge that it may be a factor in the data collected (Koch, 1995)

The researcher inevitability brings certain background expectations and frames of meaning to phenomenological studies (Poggeler, 1986; Koch, 1995; Koch, 1996). However these prejudices/values are useful to include in the study to assist us to understand when we are absorbed in the research process, (Koch 1995; Koch, 1996). Thus they cannot be ignored, forgotten or bracketed; in fact it is vital to acknowledge preunderstandings to keep in with the Heideggerian phenomenology, (O’Mahony, 2001).

Ignoring phenomenological reduction or bracketing is impossible as they constitute the essence of the phenomenology of Heidegger and Merleau-Ponty (Wimpenny & Gass, 2000). To fully understand, his process of moving between the parts and the whole of the text in the hermeneutic circle in which the parties involved in the research process are constantly engaging and interacting allows meaning and understanding of the subject at hand to evolve (Smith, 1998; Geanellos, 2000).

3.8

Phenomenological Method in Nursing Research

Phenomenology is both a philosophy and a descriptive, inductive method. The researcher must be able to use the phenomenological method to “describe experience as it is and to describe it directly, without considering the various casual explanations” (Merleau-Ponty, 1956,p59). This method of research seeks to uncover the meaning of humanly lived experience through the analysis of the participants’ descriptions to disclose the internal meaning of the lived experience. With its focus on human experience as it is expressed

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phenomenology is a method consistent with the values and beliefs of the humanistic discipline of nursing.

Nursing is a interpersonal practice therefore the experiences that are embraced by this profession aim to recognize the emotions and experiences that occur in the everyday context and therefore can be translated into meaningful text by using the grounding of phenomenology (Spence, 2001). The use of the phenomenological method grounded in the philosophy of Heidegger to underpin nursing research leads nursing to generate a wealth of data that can ultimately benefit the profession. As commented by Johnson (2000, p140):

Hermeneutic phenomenology can remind us that both the problems we are trying to solve and our understanding of these problems are grounded in situational, cultural and historical contexts that can be brought to the fore. Although this background can never be made completely explicit, an increased understanding of these situational, cultural and historical contexts could potentially lend new insight into the solution of problems that plague nursing.

Yegdich (2000) explored the issue of phenomenological method and how it related to nursing research in her discursive article. One of the conclusions of the article was that phenomenology was well suited to nursing because the methodology focuses on the problem of intersubjectivity and not subjects or objects. Therefore it affords insights into the nurse-patient study (Yegdich, 2000). Further comment on the nature of the method of research well suited to nursing is that by Graham (2001, p337):

The purpose of a phenomenological enquiry and its importance in clarify nursing practice, is the opportunity to interpret the meaning of a patient’s first-person experience of illness and care and the nurse’s first-person experience of the practice of caring.

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3.9

Relevance to Nursing Practice

For nurse researchers phenomenology provides the philosophical underpinnings for research methodologies. According to Cronin (2001:343)

Phenomenological research does not attempt to validate preconceived theories but rather provides descriptions of emotions (phenomena), which are faithful representations of nurses’ experiences.

Polit and Hungler (1993) highlighted that by using a phenomenological approach the emphasis of the research is the understanding of the human experience as it actually happens. Rejecting the scientific approach and focusing on the lived experience of

humans through the collection and analysis of narrative and subjective materials, allows the richness of the data to emerge. This in turn helps nurses to provide an accurate description of the phenomena of the lived world. Husserlian phenomenology seeks the meaning of human experience; the reality is the life-world (Koch, 1995).

Some nurse researchers rejected scientific inquiry, concerned with only with a small part of the human experience; it did not fully allow the complete understanding of the human experience. By placing the isolated private subject at the centre of nursing inquiry, nursephenomenologists were allowed to investigate the human experience within the framework of subjects’ lived experience rather than objective phenomena (Yegdich, 2000). By utilizing phenomenology researchers could examine the whole-lived

experience that would give truth to the meaning of existence (Polit & Hungler, 1993)

Phenomenological studies enabled nurses’ to describe the experience of caring, as “the aim of phenomenology is the understanding of a phenomena through the recognition of

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its meaning”, (Van der Zalm & Bergum, 2000), by interpreting nurses’ experiences of caring meaning can be made of what it is like to care for prisoners.

The phenomenological method was chosen for this study because it allows

the

examination of the holistic approach of caring for patients. Nursing grounds its practice in a holistic belief system that cares for the mind, body and soul. This holistic approach to nursing is rooted in the nursing experience and ensures that nurses care for the whole patient. Therefore any study of nursing must examine all parts of the lived experience of nursing, (Streubert & Carpenter, 1999, p56).

As mentioned previously Spielberg (1965) remarked that phenomenological method investigates subjective phenomena in the belief that essential truths about reality are grounded in lived experience. Therefore investigation of phenomena important to nursing requires that researchers study lived experience as it is presented in the everyday world of nursing practice, (Streubert & Carpenter, 1999, p56). Cutcliffe and Goward (2000: p592) state:

…it follows that if it is a natural process for mental health nurses to engage with people in the everyday experiences of life, it would also be natural for these nurses to conduct research that is concerned with understanding what happens in peoples’ everyday experiences of life.

Socorro, Tolson and Fleming (2001) explored the lived experience of seven emergency nurses caring for suddenly bereaved families in the clinical setting, particularly after they are informed about the loss of a loved one. The study used a hermeneutic phenomenological method as it best allowed the researchers to gain an understanding of each nurse’s behaviors and expressions. Heidegger’s (1962) phenomenology or

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interpretative approach not only recognized cognitive and sociological influences, but also allowed the study of the emergency nurse in context, for it was only there that what the nurses valued and found significant became visible, (Socorro, Tolson & Fleming, 2001). The researchers’ personal reflections were also included as sources of insights about the phenomena. The authors justified this by pointing out that as our prejudices or values assist us to understand when we are absorbed in the research process, they cannot be ignored, forgotten or bracketed out. Describing the world as experienced by the participants enables a holistic analysis, taking into account the perspectives and subjective reality of the informants (Duffy, 1985).

O’Mahony (2001) conducted a study to explore Irish women’s lived experience of breast biopsy with a view to gaining a deeper understanding of their individual experiences and the meanings that it held for them. Eight women aged between 22-54 years of age were interviewed. A phenomenological approach from a Heideggerian hermeneutical perspective was chosen to allow the researcher to gain an understanding of their lived experience of breast biopsy. This researcher chose phenomenology as it allowed her to grasp the uniqueness of each woman’s description of the experience of breast biopsy through in-depth interviewing and data analysis guided by Morse and Field (1996).

The phenomenological method was chosen to allow the participants to detail their experiences through documentation and analysis of their feelings, thoughts, behaviors and attitudes. These stories are told to reveal meaning (Johnson, 2000). The hermeneutics of Gadamer (1975) insist that the understanding of anything residing in the whole of a person’s precognitive awareness includes the cultural, historical and temporal context. Therefore in the research situation it is the encounter of ‘comparing the two

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interpretations for conflicts and for understanding the whole in relation to the parts and visa versa’. This dynamic process of moving between part and whole of the text is the hermeneutic circle in which the participant, the researcher and even the reader of the report are implicated in endowing meaning and understanding (Smith, 1998).

The researcher inevitability brings certain background expectations and frames of meaning to the study (Poggeler, 1986;
Koch, 1995; Koch, 1996). However these prejudices/values are useful to include in the study to assist us to understand when we are absorbed in the research process, (Koch, 1995; Koch, 1996). Thus they cannot be ignored, forgotten or bracketed; rather it is vital to acknowledge pre-understandings to keep in with the Heideggerian phenomenology (O’Mahony, 2001). Thus phenomenology provides a perspective that allows for the opportunity of illumination of some the central issues that surround nursing (Hallett, 1995).

3.10

Sample Population for Research

According to Morse (2000) purposive sampling requires selecting participants who are knowledgeable about the topic and are experts by virtue of their involvement in specific life events. They must have undergone or be undergoing the experience of the event being studied, be able to reflect on, and be willing to share detailed experimental information about the phenomenon. The data, not the sampling units must be representative and the number of participants cannot be recommended, this is made separately for each research project (Morse & Field, 1996).

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The number of nurses working within prisons in the locale of Brisbane’s “prison suburb” is four and the number of nurses working in this area amounts to over 70 full and parttime staff. Over twenty of these nurses were asked to participate in the research with the final number that volunteered as five.

The sample size needed for this study did not need to be extensive, as the nature of the was known and not hidden. Therefore the extraction of the data was anticipated to be straightforward. For this reason a purposive sample of five correctional nurses was chosen for the study. This number of participants allowed a significant of data to be generated, more than enough to deduce concepts and themes for the study. Morse (2000, p4) states that:

There is an inverse relationship between the amount of useable data obtained from each participant and the number of participants. The greater the amount of useable data obtained from each (as number of interviews and so forth), the fewer the number of participants.

The participants were asked to provide demographic data. This data is presented as Tables 1 and 2.

Table 3: Age of Participants Number < 30 years 30 – 40 years 40 – 50 years > 50 years TOTALS 0 2 3 0 n= 5 Total % of Sample 0% 40 % 60 % 0% 100 %

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Table 1 identifies that the majority of participants were aged between 30 –50 years. The Australian Institute of Health and Welfare (AIHW, 2001) Nursing Labour force report stated that the average age of all nurses employed in Queensland in 1999 was 41.3 years and the average age for Australia was 41.6.

Table 4: Type of Prison Settings of participants. Number Secure Forensic Facility Private Prison Government Prison Totals 1 2 2 n =5 Total % of Sample 20 % 40 % 40 % 100%

Table 2 identifies that the participants have been employed within a variety of organizations that compromise the prison system.

Tables 3 and 4 demonstrate years experience prior to working in the prison system and years of experience working in the prison system.

Table 5: Years experience as a Registered Nurse prior to working in the prison system Number. < 2 years 2 – 5 years 5 – 10 years > 10 years TOTALS 0 1 3 1 n=5 Total % of Sample 0% 20 % 60 % 20 % 100 %

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Table 3. The majority of the nurses had at least 5 years experience prior to working in the prison system. Therefore the majority of the participants coming into the prison system have at least a middle to moderate level of experience in the general nursing field. Unfortunately this survey did not ask what qualifications that the participants had prior to working in the prison.

Table 6: Years of experience working in the prison system Number 5 years TOTALS 0 5 0 n =5 Total of % Sample 0% 100% 0% 100 %

Table 4. The participants worked in the prison system from 2 to 5 years. Added to this prior working experience most of the participants have come from a general nurse background, with only one having solely a mental health qualification.

3.11

Data Collection

The researcher knew all of the participants, consequently the researcher believed that the participants would be able to relax and express themselves well in an interview. Therefore an unstructured interview method was chosen for this study. Unstructured interviews allow greater latitude in the answers provided, also they allow the researcher to clarify the responses of participants and the researcher can probe to understand why a participant answered in a particular way (LoBiondo-Wood & Haber, 1994,p 357). Unstructured

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interviews allow the interviewer and the participant to engage in conversation about a topic in response to the interviewer asking open-ended questions

(Streubert & Carpenter, 1999). In addition, unstructured interviews allow the interviewer to obtain the data from the participant’s perspective. The interview is considered the main method of data collection in phenomenological research as it provides a situation where the participants’ descriptions can be explored, illuminated and gently probed (Wimpenny & Gass, 2000). The task of the qualitative interview is to gather as much information as possible regarding the lived experience that the researcher is studying. The qualitative interview presumes that the researcher has an empathetic capacity and knowledge of the theme under question and can direct the unstructured interview when necessary (Hummelvoll & Barbosa da Silva, 1998). By following the participant’s responses the interviewer is not adhering to a rigid protocol in the interview and the direction of the participants’ story telling is not enforced. Therefore by not constraining participant responses , richer data is obtained (Moyle, 2002).

In her phenomenological study on premature menopause and the disruptions between the woman’s biological body experience and her lived body Broughton (2002) used unstructured interviews as this allowed the participants to voice their experiences without forcing a framework upon them. This provided an opportunity for the participants to emerge in the interview and the participant led the role of the researcher. This style of interviewing added depth and explanation to aspects of the woman’s experience that had not been gained before (Broughton, 2002).

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All interviews in this study were conducted in the participant’s own home, in out of work hours. The researcher travelled to the participant’s homes so as not to inconvenience the participants during work hours. The purpose and objectives of the study were explained to all participants prior to the commencement of the formal part of the interview. All of the participants were asked to sign the Consent Form (Appendix 1) and reminded that they could withdraw from the interview at any time. The interview began with the question, “What is it like to care for prisoners from your perspective as a nurse?” “Please describe the feelings, thoughts, and perceptions about your experience as a nurse who cares for prisoners”.

The participants were asked to share their stories and examples of how they cared for prisoners. The researcher clarified certain thoughts at times and included prompts at times to aid in the extraction of ideas. For example the researcher in responding to the participant’s answers said such things as, “what does this mean to you?” and “how does this make you feel?” and “why did you do this”.

Interviews ranged from 45 minutes to 75 minutes and were audiotaped. All participants were aware of the use of the tape recorder and were offered copies of the tapes. When verbal and/or nonverbal cues indicated that the participants were tired or finished the description of the experience the interview was finished. The author transcribed all of the interviews verbatim as soon as possible after the interview. The tapes were kept to further clarify the transcript if necessary.

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3.12

Data Analysis

The transcripts were analyzed using a phenomenological-hermeneutic approach described by Colaizzi (1978). The aim of this approach is to reveal the meaning of the lived experience through the interpretation of the text (Sundin, Jansson & Norberg, 2002). The aim of the interpretation is not only to understand the participants’ point of view but also to explore the interview texts from other perspectives (Berg & Hallberg, 2000). The goal of this method is to increase the understanding of meaning of human experiences and practices (Draucker, 1999). Whitehead (2002, p501) states:

…that the interpretation of the phenomenological data is interpretive and should occur directly through the deliberate act of describing experiences in written form, thus negating the need for any predetermined procedures.

Smith (1998), Burton (2000), Berg and Hallberg (2000), Atsalos and Greenwood (2001), O’Mahony (2001) are among the many researchers who have used hermeneutics to interpret text generated through unstructured interviews. By allowing freedom in the data analysis and using the interpretive method the true interpretation of the experience emerges. Colaizzi (1978, p305) stated, experienced implicitly in awareness”. “ Science formulates explicitly what was

This scientific awareness according to Colaizzi (1978) is performed in six steps. The procedure for this study involved:

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1. Reading each participant’s verbatim transcript carefully several times to ensure the accuracy of the transcript of the interview and then to acquiring a preliminary feeling for them and making sense of them (Colaizzi, 1978).

2. Underlining meaningful statements (sentences or phrases)

pertaining to nurses’

caring for prisoners and then extracting key statements from the transcript. These were placed on file cards with the code number of the participant. One hundred and twenty significant statements were extracted from the transcripts. The data is

presented in a fashion to allow the voices of each participant to present their lived experience of what it is to be a nurse caring for prisoners within the correctional setting2.

3. Formulating meanings from these significant statements and phrases. Creative insight was needed to use what the participants expressed to elicit the hidden meaning.

4. Identifying themes and sub themes

from the formulated meanings. Validation

occurred by referring these themes back to the original descriptions and involved repeated examination of the significant statements. The interpreted meanings evolved into the resulting themes. According to DeSantis and Ugarriza (2000:360),

A theme is an iteration or recurrence of a variety of experiences that is manifested in patterns or configurations of behaviour, that is, ways of thinking, feeling, or acting. As such, themes are embedded in repetitive or variant, often disparate expressions of social behaviour or verbal interaction.

2 The first digit ‘3’ is the participant code and the second, ‘55’ represents the number of the significant statement identified through data analysis.

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5. The results of the data analysis were integrated by the researcher into a description of the phenomena of the lived experience of nurses caring for patients in the prison setting.

6. Finally, all the participants were asked to review the evolving findings and were asked to comment and validate the discovered themes. Short telephone interviews were conducted with all of the participants to achieve this.

3.13

Ethics

As this study was undertaken as part of a nursing honours degree, ethical approval was sought from the Human Ethics Research Review Panel at Central Queensland University (Appendix 2). The certification statement from this committee was sent to the Queensland Department of Corrective Services to seek approval to interview the volunteering nursing staff (Appendix 3).

An initial telephone conversation with the Department Advisor of the Corrective Services in May 2002 indicted that there was ‘no problem’ with the research concept going ahead and it was a ‘mere formality’ for the application process to be approved. Upon this advice, interviews were conducted. In October 2002 the Corrective Services Department advised the researcher in writing that approval was not given for the research to proceed. The Department had appointed a new Advisor for research (Appendix 4).

This

was communicated to the

Chairman of the

Ethics Committee at Central

Queensland University. The committee withdrew ethical support for this study and has

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stipulated that no publication of the findings will be allowed and the data should be destroyed after the submission of the thesis (Appendix 5). An appeal was lodged with the Ethics Committee (Appendix 6) the decision was sustained and limitations that were initially placed on the thesis were ratified (Appendix 7).

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4.

CHAPTER FOUR: FINDINGS

4.1

Introduction

This chapter presents the findings of this study through the words and expressions of the participants. The data offers an insight into the lived experience of the five participants who practiced within the correctional setting. The two significant themes that evolved from the data analysis were; barriers to caring, with three sub themes; obstructive practices, standards of care, prejudice amongst others: and striving to care, with two sub themes; against the odds and who cares about us.

4.2

Theme One: Barriers to Caring

4.2.1 Sub Theme: Obstructive Practices

All of the participants were asked to describe if they were free to engage in the process of delivering health care to prisoners. All described how the Custodial Officers (COs) either ‘got in the way’ or ‘deliberately went out of their way’ to make it hard for the participants to engage in the delivery of health care to prisoners. As one of the participants explained:

I know of one casual nurse that sent an inmate to the hospital (outside of the jail) for treatment, the inmate was known to feign illness and this nurse got into trouble for sending him. I don’t think she was employed again. She wasn’t sure about the inmate’s illness and she did not want him to die on her. The COs criticized her all the while she

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was making her decision about the inmate. They also made a complaint about the cost of the Ambulance to send the inmate to hospital…. 3:55

All of the participants said they have had a ‘hard enough time’ working in the prison environment and the ‘last thing they needed’ was to do so without the support of their fellow workers. Participants said that the COs didn’t take the role of the nurse seriously and some COs were not fully aware of the role of the nurse within the prison. Before nurses were employed in prisons, the COs dispensed

the tablets and referred the prisoners to the visiting doctor. Some participants felt the “old school screw” resented the nurses’ presence in the prisons. One respondent illustrated the feelings expressed by others:

Custodial Officers have a different view of how inmates should be treated, they felt that the nurses were too caring and in the old days it was a lot tougher….4:80

Participants talked about working in an environment that is considered home to many prisoners. With life sentences, some of the prisoners may spend up to twenty years at the same prison, with the majority of that time in the same cell. One of the participants talked about not making life hard for the prisoners, “you are working in their home environment” ….5:101 and as a consequence “you get to know them”….5:102 and they can “trust you with certain things and you talk to them as everyday people”….5:103.

This ability to converse with the prisoners and treat them as “normal people”…. 4:88 was not appreciated by the custodial staff who believed that the nurses were

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extending the boundaries of their role. One of the participants explained this succinctly:

The whole environment is changing, you are no longer just the Panadol3 chick….5:123

All of the participants expressed the belief that some of the COs did not acknowledge the skills that nursing staff had and did not believe that nurses were ‘wise’ to the ways of prisoners. The ‘old school screw’ had been developing rapport with the prisoners for twenty years and did not believe that nurses could understand that prisoners were prone to manipulation and would try to ‘pull the wool over your eyes’. One participant related a CO response:

Don’t worry about that prisoner, he did that yesterday (complained of an illness). It is up to you as the nurse to use your judgement and assess the prisoner. The COs don’t have any thing to do with the medical decision; it is all the nurses’ decision.
I have seen COs obstruct nurses and try and get them to make a different decision….4:85

One participant said that it was very difficult to complete the task of delivering health care to prisoners when the prisoner was attempting to ‘con you’, meanwhile the COs were trying to get them to change their decision about the health care of the prisoners. As one participant explained:

Nurses aren’t considered at all. COs start Head Count without waiting for the nurses to come along. When you want them to do something for you or just wait while you get organized you are met with opposition and resentment. They don’t consider the nurse….1:19

3

Panadol, commonly used pain relief

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One of the participants expressed her feelings that sum up this sub-theme. She felt power was the reason for the lack of respect shown towards the nursing staff. She explained:

I feel the resentment from the custodial staff stems from the Correctional Health Nurses (CHNs) taking away their role as carers for the prisoners….3:68

4.2.2

Sub Theme: Standards of Care

All participants expressed dismay at the lack of opportunity to attend in-services, conferences and lectures to maintain and keep up-to-date with current trends in medical/nursing care. This was frustrating as for all the participants as they felt that nursing staff were considered as last on the list of prison staff for educational needs. Three responses illustrate this sub-theme:

Nurses need to continually update their skills due to the nature of their profession but due to lack of funding and covering staff, this is not seen as a priority….4:77 There is no recognition for further study. If you do further study it must be done in your own time and come out of your own money….5:100 When we first opened four years ago, there was money to attend in-services but now nobody goes because it costs too much money to cover the shift…2:35

One of the participants believed that ‘the department’ had the money for education, equipment and health care but had been told, “we are not going to spend it on rapists, murderers”….3:44 or as a CO had explained to her “ they wouldn’t get that on the outside”….3:45.

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One of the concerns expressed by the participants was the lack of qualified nursing staff recruited to work in the prison system. All of the participants expressed the belief that newly graduated Registered Nurses were being employed in the prisons because prison management could not fill the positions with

qualified and knowledgeable nursing staff. As a consequence they believed the standard of nursing care in the prison was poor and resulted in patient harm. As one participant explained:

A prisoner was taken off Clozapine4 and the nursing staff weren’t aware that Clozapine could stay in the blood stream for up to six months. The prisoner was experiencing side effects and the nursing staff were ignorant of the fact that this drug had major side effects, which needed to be checked and counter-checked. Also not all of the regular staff had had in-services regarding the drug….1:12

One participant explained how the lack of nursing experience can cause medical/nursing mishaps within the prison. She related her story:

A nurse was on a pill run when asked by a Custodial Officer to review a patient. She reviewed the patient and said to the officers to take him to the Medical Centre and then left the Unit. The officers could not get the prisoner into a wheelchair and he collapsed, a stretcher was sent for, they took the emergency equipment off the stretcher and went down to the Unit, the prisoner had an cardiac arrest and because the emergency equipment was left in the Medical Centre he died in the Unit….4:82

In this particular instance the prisoner died as a direct result of nursing inexperience.
4

Clozapine (anti-psychotic drug) is used in the treatment of Acute and Chronic Schizophrenia.

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A further example reinforces this point:

An inmate had sutures in his thigh and a casual nurse5 removed the sutures and his wound split open….1:2

All of the participants said that the varying standards of nursing care delivered by inexperienced staff made more responsibility fall back on the full-time nursing staff. This increased their stress levels consequently many of the experienced staff had left. As one participant explained:

One day twenty years of experience walked out the front gate and never came back and the new, young nurses who were fresh out of University were more concerned with how much money they would get rather than the prisoners….4:86

Some of the suggestions that were made by the participants to improve the health care delivery to the prisoners were: more time for nurses to attend in-services, recruiting more nursing staff to the prison and encouraging outside stakeholders from health bodies to attend the prison to deliver education seminars for the nursing staff. All these ideas would, according to the participants, empower the existing nursing staff with up-to-date knowledge of medical/nursing care, maintain the necessary skills to provide health care to a specialized population and give the nurses a chance to network and talk to other nursing staff. She felt this could encourage other nurses into the prison system. As one participant

explained:

5

A casual nurse is one called in to work in the prison that is not a regular member of the nursing staff.

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There is not enough education for correctional health nurses, we need up-to-date practices with emergency dressings and in-services concerning current trends. I also think it would be a good idea to send someone to work in the major teaching hospitals to learn and spread the word of what prison nursing is like…4: 84.

The lack of nursing staff caused many problems for the participants and this was illustrated well by the comment:

The numbers of correctional health nurses is deteriorating and this is due to increased workload leading to increased pressure, lack of job satisfaction, lack of appreciation for doing the job as best you can and all of this increasing the stress levels of my fellow workers….1:4

The same participant said that to increase nursing numbers there was a need to ‘grab hold of any one you can’ …1:5. This was claimed to have happened but it led to problems in health care delivery as another respondent explained:

All the casual nurses coming into the prison tended to give the prisoners what they wanted and this caused problems when the regular staff then said to the prisoners that they could not have what they wanted. There was no consistency and these new nurses were not meeting the standards of the prison….2:36

Another participant suggested that the answer to recruiting better trained nursing staff in prisons was the implementation of a University course that would educate nurses wanting to come into the corrections environment and for those already in the job:

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The subjects in the course would include, assessment and diagnosing skills, legal implications of working in a jail, signs and symptoms of suicide/self-harm, caring and counselling skills for people at risk…2:39

The lack of quality-trained staff impinged on the regular staff who worked fulltime at the prison. This sub-theme is perfectly summarized by one of the participants who explained:

The regular staff need to be given more chances to expand their training and knowledge and they are not and that is the reason a lot of people are leaving. This means that we have to rely on casual staff and that takes away from what the regular staff does. The lack of consistency is a major problem….3:69

4.2.3

Sub
Theme: Prejudice amongst others

The participants talked about the ethical and moral dilemmas that they faced in treating prisoners. Every prisoner that the participants encountered in their everyday workplace had committed a crime and these crimes were committed against fellow human beings. The need to treat every prisoner as equal is one of the hallmarks of a correctional health nurse (Doyle, 1998). The participants found this situation difficult to manage at times. As one participant stated:

The problem is basic human nature and to want to judge somebody. You are supposed to leave your prejudices, personal and religious beliefs at the door. I don’t think all nurses are able to do this. It is a human condition and all nurses do this and being in a prison exacerbates it. Years of experience have taught me the ability to overcome this and not

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oppress the oppressed. I treat them all like a human being and try not to make myself aware of the crime....1:15

Participants said that it was difficult at times not to be aware of the nature of certain prisoner’s crimes. With television, the newspapers and general conversation it was at times impossible not to be aware of a prisoner’s crime. Participants were asked how they dealt with this. One respondent explained:

Sometimes you know what a certain person has done in regard to their crime and they are whinging about something stupid. It upsets me because what kind of world are we living in when someone who has committed this horrendous crime is complaining that his Playstation (computer game) does not work?…5:99

This participant clarified the comment saying it was unusual for her because “when you are there it is irrelevant why the person is in jail”….5:105

Participants were asked how different attitudes towards prisoners from some nursing staff affected the level of nursing care and the attitude of the prisoners towards other nursing staff. One participant said:

I treat them all the same. Some nurses treat inmates differently depending on the crime. For example non-payment of fines as compared to rapists. I treat them all them the same. Some nurses think the crime determines the level of health care….3:71

Concern was expressed by participants that some nurses treated prisoners based upon their crime and others treated everybody similarly regardless of the crime. One participant explained:

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If nurses are abrupt towards prisoners then they are (prisoners) going to be abrupt back towards you. A lot of nurses suffer as a consequence. Prejudging them is not good for your ability to interact with them and establish rapport….3:74

This same respondent explained further:

Nurses can suffer from harassment from inmates when some nursing staff pre-judge inmates and this inmate takes it out on others…3:76

One participant highlighted another of the difficulties of working in a prison alongside COs who had different agendas. This participant explained:

Custodial staff were too rigorous in the time that they allowed me to talk to the inmates. The custodial staff assume I am unaware of the constraints of the jail, they assumed I was an idiot and that I did not know how to maintain professional boundaries….3:56.

This lack of awareness of the role of the nurses in the prison setting caused much stress amongst the experienced nurses with one of the participants explaining:

Custodial staff thought I was getting too friendly with the inmates, when all I was trying to do was to establish a therapeutic relationship….3:59

The participants talked about the delivery of health care in a prison and the associated level of bias and prejudice that is shown towards the prisoners. As one participant said:

Most of the nurses, we don’t even know what the inmate is in for, I like it that way as you can’t form any prejudices….4:90

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All of the participants were asked if they determined the level of care by the crime. One response illustrated a personal creed:

There are no differences between any patients. The crime does not influence me, the crime does not bother me, and the crime does not influence the way in which I deliver my care….2:33

One of the participants summed up this sub-theme with the comment:

CHNs can get very custodial in their view and you need to get rid of that to regain the therapeutic touch with the patients….3:67

All three sub-themes compromised elements of the theme ‘barriers to caring’. It was not possible to group all of the data surrounding ‘barriers to caring’ into one theme and consequently the presentation of the data was broken up into three subthemes. This allows for a greater analysis of all three components of the theme ‘barriers to caring’.

4.3

Theme Two: Striving to Care

4.3.1

Sub Theme: Against the Odds

The level of prisoners with mental illnesses and the number of prisoners developing mental illnesses whilst in custody was a major concern to all

participants. One of the participants described the prisons as:

The jails are becoming the psychiatric hospitals of the future….1:10

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The participants expressed the opinion that nurses that already work in the prisons need to be adequately supported and encouraged in their task of caring for those who were mentally ill because not all nursing staff had completed a formalized training program in mental health nursing and some of the nursing staff had limited contact with people with a mental illness. One of the participants stated:

Nurses working in the prisons need to make decisions that you would not make in hospitals. If they are not properly trained to make psychiatric assessments then mistakes can be made. Unfortunately there is not enough mentally trained staff to go around in the hospitals so what do you expect in the jails….1:17

It was the cause of distress to all participants as to what was happening to a group of vulnerable people inside a prison and how stronger prisoners ‘picked upon’ these people.

One of the participants explained:

There has been an increase in the number of people with mental illnesses and yet there is a lack of knowledge of mental illness demonstrated by the nurses. There is not a high proportion of psychiatric nurses at … (name of prison deleted) and there is not enough trained staff Queensland. …1:8

The lack of available care for the mentally ill prisoner in prison was particularly upsetting for another of the participants:

The mentally ill are picked on and targeted inside jail. One fellow was being set upon for sex and the bullies in a particular Unit were starving another fellow. The mentally ill are

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discharged into the community and very soon end up back in jail. It is a cheaper option for the Government….1:11

Another reiterated the theme:

The prison population is getting larger because they are shutting down a lot of mental health institutions and there is nowhere for them to go, so we need more jails and more nurses to look after them….3:78

All of the participants were asked how they could best care for the prisoner who suffered from a mental illness, preventing any further exacerbation of their mental illness and hurting themselves or others. One participant responded:

I have to identify what the problem is. I get them up from the Unit and talk to them. If I think that they are going to hurt themselves I put them on Observations6 and have them monitored. I then clearly document what has happened so all staff are aware of the problem….2:32

One of the participants gave an example on how she was able to prevent a situation in one of the working areas of the prison in the hope of averting a prisoner suffering from a mental illness:

An inmate said ‘I need to speak to you Miss’, when he came up to the Health Centre he explained how he was being stood over in the workshop and after listening to him I talked to the workshop supervisor and we solved the problem. Here was someone of the brink of a nervous breakdown”. ….2:38

6

A CO visually checks the prisoner every 15 minutes. This is done to prevent any incidence of suicide or self-harm.

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Finally one of the participants gave an example of how she portrayed her role of caring for prisoners not only with a mental illness but those who are just lonely and isolated from their friends and family:

Prisoners are just like normal people. I will talk to the inmate like you talk to an everyday person. It is not my job to make it harder for them in jail; we are there to help when we can….4:87

4.3.2

Sub Theme: Who cares about us

The participants were asked what they believed the public thought of the role of nurse in prisons and also what the public perceived to be the health care needs of prisoners. From the responses of the participants their opinion, was that the public perception was poor and the acknowledgement of the role of the nurse in prisons was still very limited or uninformed. The following extracts illustrate typical responses:

The general public isn’t even aware of the existence of the nurse in the prisons. They do not care about what the prisoners receive in regards to health care. They expect the prisoners to do their time and that is all they want to know about, they don’t what to know so they don’t have to care….1:3 If the public hear about the health care that prisoners receive then sometimes they are resentful (the public). Why should the prisoners receive that care when we the public have to pay for it…3:73

The participants felt the lack of recognition from the public was also apparent in the in the philosophy of the prison administration. One participant explained:

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The focus of the jail is security and not the level of care needed for the inmate. Somewhere amongst all that the nurse has to find time to do the job. The health centre isn’t a priority in the jail. All the other staff get time off to attend in-services, all except the nursing staff. They close the jail down but they can’t close the health centre down, we are needed 24 hours but are not important enough to keep up our skills….1:9

Along with the lack of recognition for caring for a group of people in a hostile environment the participants also commented on the potential for violence in a dangerous workplace. One participant explained:

Working in a prison, which is a violent place is fraught with its dangers. You have the prospect to be more at-risk in a prison than in a public hospital…. 3:61

This fear of the dangers that could present themselves at any time led the participants to engage in the formation of strong bonds amongst themselves. A sense of teamwork developed and friendships were quickly established. As one participant explained:

We need to stick together, we need to look out for one another. We are always alert for danger….5:106

Participants were the asked if this need to be aware of danger at all times and to keep an ‘eye out’ for one and another helped build camaraderie and establish

teamwork amongst the nursing staff. All of the participants agreed. The following extracts illustrate this point:

There is a great sense of teamwork we are all friends….4:81

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We would do anything for each other….4:83 There is a level of respect and appreciation that everybody demonstrates towards each other….1:16

The sub-theme of ‘who care about us’ was summed up by one of the participants who expressed the opinion that as nobody knows or cared about nurses that care for prisoners, a sense of professional isolation lead to greater bonding between the nursing staff. She explained:

You are in an environment that nobody knows about, it is completely different to any other place were you work as a nurse. Until you have worked in a prison you do not know what it is like to work in a prison. Once you are a CHN you are always a CHN and this builds a great sense of community. You feel like you are part of a family….5:112

Once again the presentation of this theme, ‘striving to care’ was presented in two sub-themes to allow greater analysis of the data surrounding the particular theme ‘striving to care’.

4.4

Summary

The two significant themes that evolved from the data section compromised ‘barriers to caring’ and ‘striving to care’ and described the lived in experience of nurses’ caring within a prison. Both themes presented were read back to each participant after data analysis and all of the participants concurred with the findings.

The lived experience of delivering nursing care to prisoners has been shown to be unique because of the restrictions placed upon the nurse. All of the participants agreed that their

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role was made harder due to the presence of the Custodial Officer and the rules that exist within the prison setting. The nurse in the prison must continually negotiate the boundaries between two vastly different cultures, the culture of custody and the culture of care. One the participants described her role as, “walking a tightrope between providing therapeutic treatment and maintaining a secure environment”…..3:42. Regardless of all these restrictions nurses continue to strive to care for the prisoners and display the utmost professionalism in the delivery of health care to a disadvantaged group of people.

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5.

CHAPTER FIVE: DISCUSSION

5.1

Introduction

The difficulty of delivering health care to prisoners in a hostile, closed environment is not well documented in the literature. There are many frustrations encountered by the nursing staff in prisons worldwide due to the nature of the environment that they work in and with whom they have to work with to deliver this care. The previous chapter demonstrated that two themes described the lived experience of nurses caring for prisoner-patients for one group of participants. The significance of these themes will be explored in relation to existing knowledge.

5.2

Barriers to Caring

5.2.1

Obstructive Practices

The subtheme of ‘obstructive practices’ is evident current in all of the literature examined for this study. Doyle (1998) found in one of his studies that the theme of “feelings of entrapment and intrusion on professional values” was evident to describe correctional health nursing (Doyle, 1998). Nurses in Doyle’s (1998)

study also felt trapped and professionally intruded upon by the omnipresent custodial staff, the CO’s derogatory commentaries as well as the presence of the COs during interviews or counselling (Doyle, 1998). He also found that the agenda of the prison with its predetermined administration and policies contributed to nurses feeling their role was compromised and a degree of

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humiliation was attached to the role when permission was needed to carry out duties that are taken for granted in other circumstances (Doyle, 1998).

Establishing a relationship with a client is seen as the cornerstone of caring in nursing (Leininger, 1984; Watson, 1985; Forrest, 1989; Bush & Barr, 1998). The opportunities to establish a relationship have been reported to be limited in the prison setting (Mercer et al. 2001). All of the participants in this study agreed that the establishment of the therapeutic relationship was vital no matter what the setting and was seen as one of the most important factors in nursing and very important within the forensic setting, a finding supported by Encinares and Lorbergs (2001) and Yurkovich and Smyer (2000). The participants in this study expressed dissatisfaction with the CO’s in not allowing them to initiate and maintain therapeutic relationships with the prisoners. Norman and Parrish (1999a) stress that one of the challenges for the nurse in the prison is to create the therapeutic environment that allows the establishment of the nursing role within the prison. The participants in this study felt the importance of their role was often neglected, a finding that Rask and Hallberg (2000) also found to be true in their study and they commented that the importance of the nurse-patient relationship was often underestimated yet nurses regarded this to be a considerable part of their work. With the omnipresence of the Custodial Officer who determines the opportunity and length of prisoner contact, the correctional nurse has limited opportunity space to implement one of the key facets of caring. This caused undue stress amongst the participants in this study.

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All of the participants said that they were not given the respect they felt they were due in dealing with the prisoners. They felt the Custodial Officers hampered the health care of the prisoners by not allowing the nurse-prisoner relationship to develop. Their feelings have been validated and confirmed by one international colleague in similar situations (Maeve, 1998).

The prison setting is one of a few health care settings that necessitates security and vigilance as nursing staff has to be aware of the physical danger that they could be in at any time including being in locked wards in psychiatric wards or forensic wards. This need for extra caution in their workplace sets apart the correctional nurse from other streams of nursing (Mercer, 1998). To complete their job, nurses must use the Custodial Officers as a security device to protect themselves. This was acknowledged by the respondents. However all participants felt that the lack of autonomy and the lack of ability to initiate prisoner contact restricted the full range of caring that they could perform. This is a consistent finding in other research studies (Doyle, 1998; Doyle 1999; Hammer, 2000; Maeve & Vaughn 2001).

None of the participants talked about the role of the Custodial Officer positively. They all expressed feelings of restraint by the presence of the Custodial Officer and offered no solutions to this problem. However prisons do not exist to provide health care. They provide custody, therefore nurses need to work with the COs to provide a transparent system where both parties can perform the roles they are employed to do (Norman & Parrish, 2001). Peternelj-Taylor and Johnson (1995) assert that the philosophies of caring and custody can coexist and the ability to

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establish the therapeutic relationship is one of the most important forensic nursing competencies (Peternelj-Taylor, 1995).

Maeve and Vaughn (2001) describe how COs are paid to watch every activity that occurs within the prison and nurses also come into this role. COs are observing all people in the prison and as they are paid to be suspicious, it is up to the nursing staff to maintain a team friendly approach with the COs because of the possibility of violence and the need to be safe at all times. However this can cause distress amongst nurses and the pressure on nurses to conform to custodial subculture is intense and from a historical perspective, correctional health care practitioners who “pushed too aggressively for improvements in health care for prisoners did not last long at the prison” (Maeve & Vaughn, 2001).

5.2.2

Standards of Practice

This was the second sub-theme contributing to the theme: ‘barriers to caring’. It was shown in this study that this factor was a specific concern within the prison. There were examples presented by the respondents suggesting that the health care delivered to the prison population was compromised when the staff employed to work with the prisoners were inexperienced. This study found that the permanent nursing staff felt inadequate when inexperienced staff delivered health care and frustrated by the inability of the prison to recruit qualified and experienced staff. Maeve and Vaughn (2001) also highlighted in their study on prison nursing many factors that lead to prisons having problems recruiting experienced nursing staff. Some of these factors included geographical isolation, nurses’ wages in

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comparison to public hospitals and the lack of education opportunities (Maeve & Vaughn, 2001). These were also the factors experienced by the participants of this study.

All of the participants agreed that they continually need up dating their medical/nursing skills to enable them to deliver high quality first class nursing care. The participants felt that their needs were not being met in this regard and other staff members always came before them Saunders (2000, p 50) stated: when it came to education.

Before the doors are likely to be opened wider to forensic nurses in Australia, further work needs to be done to establish educational programs that will contribute to role clarification, develop practice standards and educate major stakeholders in the health and justice systems of the scope of this specialized practice.

The participants mentioned in this study that educational opportunities did not exist for them. All emphasized that a university course would empower existing staff with status, increase the knowledge of the prison health care system and lead to better qualified nursing staff. This theme is relevant within the findings of Norman and Parrish (2001,p 30) who stated that:

The professional development of prison nurses needs clearer definition within the postgraduate registration framework, and standards for practice with programmes of education developed with recognized institutions required to meet this specialist group of nurses’ needs.

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Many of then studies examined for this dissertation listed geographical isolation as one of the factors that led to lack of experienced staff recruited to the particular prison (Wilton, 1992; Carmody, 1992; Paskalis, 1993). The increased numbers of casual nursing staff was mentioned by all of the respondents who gave examples of how this directly impacted upon the level and standard of care that is delivered within the confines of the prison. All of the participants felt disheartened that experienced nurses had left the prison and that experience could not be replaced. This lack of experienced staff is also found in the study by Polczyk-Przybyla and Gournay (1999) who examined psychiatric nursing in English prisons and detailed that out of a population of 1456 health officers only 21 % were registered nurses and approximately 25 % held no nursing qualification at all (Polczyk-Przybyla & Gournay, 1999).

The lack of consistent nursing practices mentioned by the respondents in this study meant that the full-time nursing staff felt that they were placed under extra pressure. The respondents sensed that the casual nurses were inconsistent with their care standards and all the responsibility fell back onto the full-time staff. Increasing educational opportunities was seen as one method to recruit and

develop better-qualified staff. Norman and Parrish (1999d) highlighted that by increasing educational opportunities and valuing the staff improvements in the morale of full-time nursing staff in prisons can be expected.

The respondents talked about teamwork and related how they were happy to work in that team and develop friendships. Therefore the situation of working in the

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prison as a nurse was not all negative. This is reiterated by Norman and Parrish (1999a, p 1032) who stated that:

….delivering a high standard of nursing care to prisoners is possible, but the right nurses need to be attracted with the right skills, qualities and attitudes.

Maeve and Vaughn (2001, p51) called it an ethical dilemma for nursing staff who worked full-time in the prisons and had to rely on “under qualified staff for providing care outside of their scope of practice” to fill the gap between when permanent staff were not available.

5.2.3

Prejudice amongst others

The ability of the correctional nurse to be nonjudgmental and deliver health care to a wide range of people, some of whom have committed crimes against children and older people is an essential component that all nurses need if they are going to perform their work properly within the prison (Norman & Parrish, 1999a; Mercer et al. 2001). Peplau (1986) maintained that the nurse, the patient and what happens between them are the crucial elements of nursing no matter the setting. From the participants’ responses it appeared that not all nurses had the courage and skills to treat all prisoners without prejudice. This lack of consistency was evident in the responses of the participants and led to friction being amongst the nursing staff. According to Gannon (2000:61), “Nurses in the prison setting must work together to bring complementary skills to their fellow workers”.

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All of the respondents talked about refraining from finding out what crimes the prisoners had committed. Comments were made that it did not matter what the crime committed was, it would not alter the care delivered. One author believes that some nurses may despise patients for whom they are and question the patients’ ability to benefit from treatment, others will believe that every possible resource should be committed to reconciling the patient and society (Burrow, 1993). It appeared through the interviews that the participants took pride in not allowing the knowledge of the crime to influence nursing care. This is supported by Norman and Parrish (1990d, p655) who state:

Nurses must have the ability and be educated to see a prisoner as an individual whose punishment starts and finished with the serving of his/her sentence.

The level of professional respect amongst the participants is consistent with not judging the person and an awareness that there are people placed in jail who are wrongly accused. To refrain from judging clients whilst delivering care is the hallmark of the correctional nurse according to Hammer (2000) and Maeve and Vaughn (2001). This finding is consistent with the findings of Mercer (1998) who found that in the care of prisoners, strong negative feelings could prevent nurses from completing their roles properly and these feelings need to be suppressed. Mason (2002) suggests that some nurses may find they despise their patients for the crimes, however, it is the hallmark of the nurse working in the prison to remove her/himself from these feelings (Mason, 2002).

Staff must come to terms with the feelings of revulsion and horror about some of the crimes that these offenders have committed, staff have to face the fact that they carry a

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great responsibility for the welfare of the offender and the community and staff must be willing to ask unthinkable, unaskable and even unimaginable questions if they are to engage effectively (Martin, 2001, p 30).

With all these barriers against the nurse that works in the prison delivering care to prisoner-patients is it any wonder that anybody would want to work in this hostile, dangerous environment. The participants in this study demonstrated that they perform their role with the utmost professionalism and uphold the sanctity that is nursing.

5.3

Striving to Care

5.3.1

Against the odds

The increasing numbers of prisoners with mental illnesses coming to prison was of a major concern to the nurses. Studies have demonstrated that the numbers of mentally ill people that had been incarcerated in prisons was on the increase (Peternelj-Taylor & Johnson, 1995; Lego,1995; Dunn, Selzer, & Tomcho, 1996; Morrison, 1996). With the advent of deinstitutionalization7 and the lack of community care options for the mentally ill; there appears nowhere else for this section of disadvantaged people to go (Conklin et al. 2000). All of the participants felt undermanned and under educated to care for the mentally ill prisoners, the participants felt that more in-service, research and training were required to empower them with the required skills to care for the mentally ill in prison (Doyle, 1998). Doyle (1998, p22) states:
In the 1970s the government of the day shut down many of the large psychiatric institutions forcing a lot of the mentally ill on to the streets.
7

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The mental health nurse who delivers care in the prison context appears to face unique professional challenges associated with their distinctive client population and close coexistence with custodial staff. Additional research is needed to further identify and clarify the problematic aspects of prison-based nursing.

The participants highlighted the problems that they had with delivering nursing care to the mentally ill. A lack of resources, lack of opportunity to acknowledge and detect mental illness in the prison population and growing numbers of mentally ill people in prison saw nurses faced with the extremely difficult task of detecting and maintaining the large numbers of mentally ill prisoners in the prisons. This theme is reinforced by Doyle (1999, p29) who stated, “many offenders experience their first mental illness in prison”.

All of the participants felt that they were not supported in their delivery of quality nursing care to the mentally ill person in the prison. This study found that the participants felt they needed to be given more respect in their role as a registered nurse with multi-dimensional skills, and if this was acknowledged then they were better able to facilitate the delivery of nursing care to the mentally ill prisoner.
Other authors have identified that the delivery of health care to the mentally ill can be diverse, complex and demanding (Metzner, 1997; Doyle, 1999; Conklin et al. 2000). Doyle (1999) in his study of nurses working in Australian prisons described how there is little research surrounding the topic of how nurses care for the mentally ill in prisons and with the increase in the population of mentally ill prisoners (Doyle, 1999) the provisions and potential for nurses to care for these people has not fully explored.

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Along with the increasing numbers of mentally ill prisoners coming to the prisons, there also existed problems associated with this disadvantaged group. The participants in this study talked about the same being ‘set upon’ by stronger prisoners and the participants felt powerless to prevent this harassment. This caused concern amongst the participants and they expressed the opinion that there needed to be more trained nurses to help deal with this problem. A study of American prisons by Harding (1997:26) found that the increasing numbers of mentally ill in prisons led to consequences:

Quietly but steadily the jails and prisons are replacing public mental hospitals as the primarily purveyors of public psychiatric services for individuals with serious mental illness

5.3.2

Who cares about us?

The participants all described how they felt about themselves as part of the prison environment. The participants expressed the opinion that the COs did not give them the respect they felt they deserved and the COs deemed that the delivery of health care was not important. Norman and Parrish (1999a) found a similar theme in their study on nurses working in jails in the United Kingdom. They commented that nursing staff working in the prison system need to be valued and their knowledge and feelings respected for optimal performance (Norman & Parrish, 1999a).

One of the participants said that no one cared about prisoners, therefore who would care about the caregivers of prisoners. This participant felt that this view

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severely undermined the role of the nurse and would not lead to job satisfaction. The difficultly recruiting qualified, experienced staff against this professional stigma has also been noted in the studies by Doyle (1998) and Doyle (1999), Maeve and Vaughn (2001).

Along with the professional stigma associated with caring for people that society does not want to know about, the participants talked about the lack of opportunities to talk about their job to other nurses with resulting professional isolation. This is supported by the article by Evans (2000) who examined professional attitudes surrounding nurses working in the prisons in the United Kingdom and came to the conclusion that through a lack of awareness amongst fellow nurses which impinged upon recruitment problems. Evans (2000:15):

The absence of recent relevant clinical experience and specific knowledge of forensic issues in the current educational staff of universities is a serious deficit when attempting to prepare pre and post registered nurses for working within these specialized field.

The participants in this study expressed the opinion that social and professional isolation was evident, as they believed society did not want to know what health care prisoners received and therefore cared little about the people who delivered this care. In support of this subtheme Doyle (1999) highlighted in his study on Australian prison nurses, that prison nurses did not inform their nursing colleagues about their workplace for fear of social stigma associated with caring for society’s failures (Doyle, 1999). This sub-theme is evident in Doyle (1999, p16) who stated that:

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Society only wants those who are paid to deal with its problematic elements to develop further techniques to euphemize them.

The participants told of how they cared for people that society did not want to know about and this at times upset the participants. However they acknowledged that this was one of the downfalls of the job and they continued to do their job and not worry about public opinion. This was consistent with Mason (2002) who described the need for positive views to maintain professional that is caring for prisoners.

The participants felt that nobody knew exactly what the work of a nurse entailed in the prison system. They commented that once the prisoner was put in prison and in many cases the crimes committed were repugnant, therefore society thought no more and were largely ignorant of who worked in the prison setting. To people foreign to the forensic milieu, working with prisoners is a great mystery (Doyle, 1998; Peternelj-Taylor, 1999). Mercer et al. (2001) in their study on nursing in the forensic setting commented that society has distaste for the particular types of offences and therefore negative views are made towards people that care for these prisoners. Frank (1999) also described how nurses who work

in prisons and receive no recognition for this from either their colleagues within the prison or from nurses in general. Despite this nurses continue to provide compassionate care (Frank, 1999).

The lived experience of the participants in this study who cared for prisoners demonstrated that the work is both demanding and rewarding. The data extracted

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from the interviews showed that this type of nursing is different from other aspects of environments of nursing. The most significant factor influencing the delivery of care was the restrictive setting in which these nurses work (Doyle, 1998; Doyle, 1999; Norman & Parrish 1999a; Norman & Parrish, 1999c; Hammer, 2000; Maeve & Vaughn, 2001; Mercer et al, 2001). The nurse that chooses to work in the prison environment then has to juggle both components of the job; maintaining a secure environment and providing nursing care to prisonerpatients.

5.4

Limitations

This research was conducted by a single researcher and the data was analyzed by this one researcher not referring the findings to another for analytical validation. This risks introducing bias and misrepresentation of the data. However this potential has been acknowledged in the study and the researcher took this into account when analysing the data. Davies and Dodd (2002, p280) suggest: “an implicit part of ethical practice

involves acknowledgement and location of the researcher within the research process”.

This comment implies that the details of the research and the place of the researcher are made known to the reader.

Another potential bias occurred with

the

second validating interview with the for a short time with each

participants. This interview was conducted by phone

participant. A personal interview may have led to better clarification and validation of the themes.

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A problem that could have arisen from the data collection method was the Hawthorne Effect. This is also called reactivity, the reactivity of the participants to the researcher (LoBiondo-Wood & Haber, 1994, p206). As the researcher knew all the participants and had worked with them in the prison setting, a potential consequence was that their responses to the questions may have been biased towards pleasing the researcher. This form of bias was taken into account by the formalization of the introduction. However as interviewing is social interaction and is a shared communication process it is not always possible to avoid this bias but to ensure that it is acknowledged (Davies & Dodd, 2002).

It is not possible to form generalizations from this study because of the small sample size and the nature of qualitative research design. Despite this, it cannot be denied that the depth of the information given by the participants in the study gives valuable insights into the lived experience of these participants caring for prisoner-patients.

5.5

Implications

5.5.1

Collaboration

All the participants in this study revealed that much work needs to be done to increase custody and health care communication, cooperation and collaboration. The findings demonstrated that it is important that the nursing staff work collaboratively with the custodial staff to allow this delivery of quality health care. There is a need to ameliorate the friction that exists between nursing staff and custodial officers to allow both parties working as a team to aid in health care delivery and a secure prison. The respondents demonstrated their frustrations with

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the custodial staff in attempting to establish relationships with the prisoners. The identification of these issues associated with health care delivery in prisons will hopefully result in a more transparent environment where the health care decisions are identified quickly by nursing staff and the ability to implement these decisions are not hampered but enhanced by custodial staff (Evans, 2000). For example, custodial staff should be incorporated in the decision making process and allowed to have feedback on the health care delivery. This empowerment for the custodial staff would enable both parties to work more closely within the prison system.

In discussing the sub-themes that were presented, it was demonstrated that the participants in this study were concerned with the increasing numbers of mentally ill prisoners arriving in the prison system and that the treatment for these people once incarcerated needs improving. Also the training of qualified nursing staff to care for the mentally ill was not evident in the literature or from conversations with the respondents. Both these areas need to be addressed by employer groups.

5.5.2

Future Research Needs

The studies that were critically analyzed for this study demonstrated that nursing research on caring for prisoner-patients in prisons are limited. The dearth of research covering this topic has meant that little is known about this specialty of nursing and consequently little is known about caring for prisons from the nurses’ perspective. Further research in this specialized area is needed.

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This study examined the experience of nurses’ caring for prisoner-patients in the Southeast of Queensland, Australia, therefore it is important to look at nurses’ experiences in other geographical areas. In addition, study participants included Caucasian, English speaking females and were not representative of other cultures.

Another of the sub-themes highlighted the tenuous relationship that exists at the moment between nurses and custodial officers within the Southeast Queensland prison system. It was shown in this study that this relationship directly effects the delivery of health care in the prison and therefore research could aid in the improvement in health care delivery.

‘Inexperienced nurses’ was also one of the issues raised. Further research needs to be undertaken to determine what educational deficiencies exist in the prison system from the perspective of nursing staff. How to establish a better trained, more experienced group of people working as qualified correctional nurses should be the object of future research.

5.6

Conclusion

This study examined the lived experience of one small group of nurses caring for prisoners in prisons in one geographical area; Queensland. As the prison population continues to expand, the need for nurses to care for this population’s complex health needs will also expand. The dearth of research surrounding this topic does not give justice to the significance to the role of the correctional health nurse and the dangers they face in

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delivering health care to a select population. The discovery of the nurses’ experience can only enable this undervalued branch of nursing to flourish and has the potential to improve the development of health care delivery to prisoners.

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