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Caring for Inmate-Patients: A Review of the Literature

Caring for Inmate-Patients
In 2010, approximately one in every 27 adults (2.8 million) in the United States was behind bars according to a report from the National Commission on Correctional Health Care (NCCHC), 2012. Maintaining a safe and secure environment is the most important mission of correctional facilities - not healthcare. Correctional nurses are challenged to provide inmate healthcare services in a caring relationship that promotes wellness, restores health, and facilitates healing. A great deal has been written by nursing theorists regarding a caring attitude, and that it is fundamental to the nurse’s role. No other health care setting presents such limitations to nurses’ free expression of caring. The purpose of this paper is to conduct a review of the literature on how nurses balance the culture of security and the culture of care while delivering health care to inmate-patients in a correctional setting.
Analysis
It is well documented in the nursing literature that nursing care for prisoners is both complicated and conflicting. These findings clearly stated that the experiences of caring for inmate-patients vary greatly from that of any other health care setting. Both the infrastructure of a prison coupled with its restrictive security element, directly affects how the health care of inmate-patients is delivered. This is in direct correlation with the findings of Mathis & Schoenly, 2008; Muse, 2009; and Weiskopf, 2006. These identified restrictions presented a conflict, as to how nurses had to walk a fine line between providing therapeutic care while maintaining a safe environment.
According to Stern, Greifinger, and Mellow (2010), when employed in correctional facilities, nurses are instructed to refrain from having extended conversations with prisoners and warns new employees that prisoner to nurse politeness should be deemed as a mode of manipulation. Thus, in the orientation period, it is recommended nurses are not to care for them the same as inpatients (Stern et al. 2010). Nelson 2012 further suggests that because of the rigid demands from the security staff, many nurses lose sight of their healing and caring mission. Nevertheless, Nelson highlights the importance that nurses should never confuse the roles of nursing and security (2012).
One of the most noticeable distinctions between the caring research (Mathis & Schoenly, 2008; Muse, 2009; Stern et al., 2010; Trossman, 2011; Weiskopf, 2006), and these findings were nothing like a hospital setting. Custody boundaries in the correctional setting restrict nurses’ free expression of caring. This led nurses to feel discouraged as they tried to foster a caring and therapeutic environment, and connect with their inmate-patients inside the constricted boundaries of custody. Additional issues, for example: manipulative patients, uncaring co-workers, as well as feelings of helplessness and strain at not meeting basic patient needs can dramatically increase perceptions of this as a disconcerting experience Powell, Harris, Condon, and Kemple, (2010).
The literature is clear that these nurses placed the greatest importance on the interpersonal therapeutic aspects of care. Caring and nursing has always been seen as synonymous. Caring is the fundamental principle in the discipline of nursing which has led to the development of numerous caring theories Cara, (2003). Jean Watson (1979), an American nursing scholar has published numerous works describing her philosophy and theory of human caring. Watson acknowledges caring as the “essence” of nursing. A critical and essential characteristic of caring is the establishment of a relationship between the patient and the nurse. She also adds that (as cited in Cara, 2003) “caring can be viewed as the nurse’s moral ideal of preserving human dignity by assisting a person to find meaning in illness and suffering in order to restore or promote the person’s harmony” (p. 58, para 2). The nurses professed caring as a moral necessity, feeling an obligation to respect and uphold patients’ dignity, comparable to other reports (Mathis & Schoenly, 2008; Powell et al., 2010; Stern et al., 2010; Weiskopf, 2006).
Different from those in non-correctional settings, these nurses faced profound limitations. Many healthcare environments permit, and even promote, physical expressions of caring such as touching or holding a hand during an unpleasant procedure. These actions are neither safe nor appropriate in a correctional setting; however, they are recognized in the caring literature as an important quality that can offer comfort, improve communication, and connection with patients (Charles, 2010; Powell et al., 2010; Weinstein, 2010). The constraint on touching inmate-patients generated frustration and conflict, and was problematic because, like the report of Trossman (2011), these nurses were positively influenced by this caring interaction.
A common theme of the published literature is the loss of control of their practice by correctional nurses. Powell et al. (2010) views nurses constantly having to tolerate the philosophical culture of corrections and criminal justice upon their professional values. For Weinstein (2010), “prison nursing is at best a continuously negotiated compromise in order to mitigate or accommodate the priorities of correctional services: security, discipline, segregation, regulation, and order” (p. 628). For instance, Nelson (2012) found correctional officers being able to pick and chose inmates requests for health care treatment, and nurses compromising their practice routines by having no other option except to dispense medication through a trapdoor without being allowed to see the patient. Furthermore, any physical contact with patients occurs solely at the discretion of the security staff (p. 20).
Establishing a relationship with an inmate-patient depended upon a nurse’s relationship with correctional officers. Cashin, Chiarella, Waters, and Potter (2008) revealed that when correctional officers valued health care, a nurse’s judgment was then valued thus allowing them the authority for establishing health care priorities. Autonomous decision-making was sometimes accompanied by risk for the nurses. In need of effective resolutions, they sometimes showed their caring by advocating for inmate-patients through individual risk-taking (Cashin et al., 2008).
Nurses’ also expressed feelings of disappointment because of the actions and behaviors of uncaring nurse colleagues. Consistent with the findings by Muse (2009), uncaring colleagues were a source of pressure, displeasure and resentment. However, several of the testimonials in this review also referred to the pleasure nurses found in their work, and admitted to several positive changes in the delivery of health care to prisoners that have transpired over the years (Muse, 2009).
Correctional nurses must respect the worth, dignity, and rights of all inmate-patients, regardless of the individual’s lifestyle, values, or state of health. The ability of the nurse to be nonjudgmental and deliver health care to a wide range of individuals, some of whom have committed crimes against children and older people is essential if they are to perform their work properly (Stern, 2002; Trossman, 2011). Consistent with other nursing scholars, theorist Hildegard E. Peplau (1952) identifies the therapeutic nurse-client relationship as the “heart” of nursing. Peplau (1986) maintains that “the nurse, patient, and what happens between them are the crucial elements of nursing no matter the setting” (p. 12, par 3). From the review, it appeared that not all nurses had the courage and ability to treat all prisoners without prejudice.
The research findings reveal that most nurses talked about abstaining from finding out what crimes the prisoners had committed. Statements were made that it did not matter what the crime was, it would not alter the care rendered. To refrain from judging patients whilst delivering care is the hallmark of the correctional nurse according to Mathis & Schoenly (2008), and Nelson (2012). This finding is consistent with that of Weiskopf (2006) who found that when caring for prisoners, strong negative feelings could prevent nurses from completing their jobs properly and these feelings need to be concealed. Muse (2009) suggests that some nurses may find they detest their patients for the crimes they have committed; however, it is the hallmark of the nurse in the prison setting to remove him/herself from these feelings (Muse, 2009).
Conclusion/Recommendations
The nursing literature gives insight into what is known of “caring” in the prison system. Prisons do not solely exist to provide health care. They provide custody; therefore, nurses must work with the security staff in order to provide a transparent system where both parties can carry out the roles they are employed to do. Challenges exist on how nurses balance the culture of security and the culture of care while delivering health care to inmate-patients. One of these challenges is the inability for nurses to form therapeutic relationships with prisoners. A persistent theme in the literature found that knowing and forming a relationship with the inmate-patient were vital to allow the nurse to deliver adequate care. The lack of ability to initiate prisoner contact restricted the full range of caring that they could perform. A therapeutic relationship allows the nurse to create the bond that compels nursing care.
The nursing literature uncovers very little regarding the positive aspects of prison culture and the advantages of having prisoners as patients. It is worth remembering that those imprisoned are typically from marginalized at risk groups who are poor, subject to prejudice, and are labeled socially undesirable. When providing health care to those who have committed crimes against society’s norms and rules, society in general, is viewed as unsympathetic. It is a convoluted picture yet this is not completely understood by most members of society. If we vow that nursing is more than the act of caring, further research needs to be made into those qualities of caring that are especially challenging. The need of research surrounding the significance to the role of the correctional nurse and the dangers they face would seem to suggest many remarkable opportunities for future nursing research.

References
Cara, C. (2003). A pragmatic view of Jean Watson’s caring theory. International Journal for Human Caring, 7(3), 51-61. Retrieved from www.cinahl.com
Charles, C. E. (2010). Providing culturally competent care for the criminally insane inmate. Mental Health Nursing, 31(8), 432–434. doi: 10.3109/01612840903434597
Cashin, A., Chiarella, M., Waters, D., & Potter, E. (2008). Assessing nursing competency in the correctional environment: The creation of a self-reflection learning and development tool. Journal for Nurses in Staff Development, 24(6), 267–273. Retrieved from www.cinahl.com
Mathis, H., & Schoenly, L. (2008). What you need to know in correctional health care. The Nurse Practitioner, 33(5), 34-39. Retrieved from www.cinahl.com
Muse, M. V. (2009). Correctional nursing: The evolution of a specialty. Journal of Correctional Health Care. Retrieved from http://www.ncchc.org/pubs/CC/nursing_specialty.html
National Commission on Correctional Health Care. (2012). Correctional populations in the United States. Retrieved from http://www.ncchc.org/about/index.html
Nelson, R. (2012). Challenges to health care delivery in U.S. prisons. American Journal of Nursing, 112(1), 19-20. doi: 10.1097/01.NAJ.0000410351.11158.85
Peplau, H. E. (1986). The nurse as counsellor. Journal of American College Health, 35(11), 10-14. Retrieved from www.cinahl.com
Powell, J., Harris, F., Condon. L., & Kemple, T. (2010). Nursing care of prisoners: Staff views and experiences. Journal of Advanced Nursing, 66(6), 1257-1265. doi: 10.1111/j.1365-2648.2010.05296.x
Stern, M. F., Greifinger, R., & Mellow, J. (2010). Patient safety: Moving the bar in prison health care standards. American Journal of Public Health, 100(11), 2103–2110. doi: 10.2105/AJPH.2009.184242
Trossman, S. (2011). Ensuring standards are standard behind bars: Nurses work to review ANA document, promote corrections nursing practice. American Nurses Association. Retrieved from www.cinahl.com
Weinstein, C. (2010). The United States needs a WHO health in prisons project. Public Health, 124(11), 626-628. Retrieved from http://www.sciencedirect.com.ezproxy.lib.umb.edu/ science/ article/pii/S0033350610002702
Weiskopf, C. S. (2006). Issues and innovations in nursing practice: Nurses experience of caring for inmate patients. Journal of Advanced Nursing, 49(4), 336–343. Retrieved from www.cinahl.com

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