Women’s Health in Prison

Girl in Prison By Alice Cope

The number of women in prison is much less than men, however, the rate of growth of female prisoners is nearly double that of males in the US. From 1995 to 2002 the female inmate population grew by 42% and is the fastest growing prison population. Currently 7% of the US prison population and 12% of the jail population is female. Gender issues must be considered in correctional healthcare. Women inmates have increase need for healthcare.

Trauma Informed Care

As many as 57% of women inmates have been physically or sexually abused at some point in their lives.  This trauma contributes to increase in depression, stress & anxiety disorders, learning problems, behavioral disorders, and substance abuse according to NCCHC. The trauma-informed approach recognizes trauma as a central issue in the health of the majority of women inmates.  Sensitivity and acknowledgement of a traumatic history can lead to interventions promoting recovery.

Mental Health

Trauma and abuse coupled with drug and alcohol abuse lead to increase mental illness. 36% of women inmates are treated for some form of mental illness compared to 24% of men. Correctional nurse working in women’s prisons  experience first-hand the increased medication administration, esp. psychotropics, for female inmates.  Women inmates are more willing to seek out counseling and psychiatric services, although many facilities are under staffed in these area.

Pregnancy and Reproductive Health

Incarcerated women tend to have complicated and high risk pregnancies due to their past medical histories, lack of prenatal care, and drug/alcohol use.  Reproductive health is jeopardized by increased sexually transmitted diseases, pelvic inflammatory disease, and poor hygiene. Inadequate attention to female-specific screenings such as breast exams and Pap smears can lead to undetected cancers. 

Impact of Prison on Health

A study in the UK found that imprisonment was largely detrimental to women’s health for a number of reasons. The shock of imprisonment coupled with separation from family and children affected health, as did poor health habits such as lack of exercise, poor dietary choices and close proximity to smokers.

What other female-specific health conditions have you seen in corrections?

Bridging Meds

September2008© by HiLaRioN_

Bridging meds is a process in correctional healthcare of covering the medication gap between what the inmate was taking in the community and what is provided behind bars. Recent reports of inmate death or violence related to not providing prescribed medications in a timely fashion can easily lead to the question – “How hard can it be to get them the right medications?” Indeed, it can be more challenging than it first appears.

The guiding principle is for the facility medical unit to validate any prescribed medications and provide to the inmate necessary medications from stock until an individual prescription can be started for the duration of their stay.

Inmates come in with unknown medications

Many arrestees come in to the jail from the street with their own personal medications. However, they have often been removed from the original containers with the prescription label. The best situation is when the medications are in the original bottles and can easily be validated by the facility healthcare providers. Unfortunately, more often than not, the person arrives with a mixture of unidentifiable pills in a personal container or pocket. Since many inmates are detained for drug charges, it is unacceptable to allow the inmate to self-medicate using unknown and unvalidated medications.

 Knowledge of medications and providers

Many people are unable to articulate the medications they take and the primary reason for the medication. This is intensified in the corrections setting. Misinformation abounds and must be sorted out to deliver care behind bars. If the individual is not carrying the medication with them and can not identify their prescribing physician, medication can not be provided until a full evaluation and treatment plan is determined by a prescribing provider (NP, PA, MD).

Connecting with the community provider

The greatest number of arrests do not take place during normal business hours. Delays in medication delivery can take place during weekends and off hours while awaiting communication with the primary provider.

Medication not on formulary or in stock

Occasionally a medication is needed that is not on formulary or not in stock at the facility. This can also lead to a delay while the medication is located. Well-managed correctional healthcare units will have a local back-up pharmacy which can handle emergency need for unusual medications until scripts can be filled through the standard pharmacy channels.

Inmate can’t be found

Seems odd that an inmate can’t be found when behind bars, but it happens. The transient nature of the jail situation, in particular, can lead to missed medication. The inmate may have been released, had a court date, or been transferred. If communication between custody and the healthcare unit is spotty, these gaps in medication delivery can happen.

Summary

For all these reasons, every correctional facility needs a solid system for bridging medications including tracking, good community and intrafacility connections, and extreme diligence to follow-through on medication delivery. Each healthcare staff member must understand the importance of their actions in the information and treatment chain. If there is a breakdown in any of these areas, disaster can strike.

Ethical Dilemmas in Correctional Nursing

I recently had the opportunity to be interviewed for the KindEthics Radio Program. We had an interesting discussion about ethical dilemmas unique to nurses (and doctors) working in corrections.

Basis of Ethical Care

Two basic principles of ethical care are beneficence (acting only for the benefit of the patient) and nonmalfeasance (do no harm to the patient). In the course of working in a security environment, an ethical dilemma can arise when the  goals of custody administration seem to conflict with these principles. A code of ethics specific to correctional healthcare was created by the American Correctional Health Services Association (ACHSA). Lets look at just a few examples of ethical dilemmas that may be encountered.

Body Cavity Searches

 Healthcare staff may be asked to perform searches of rectal or genital areas for contraband items such as drugs or weapons. This action would not be of benefit to the patient and has no health purpose. Professionals may have concerns that these searches done by custody might injure or harm the patient. However, there is general agreement that body cavity searches should not be performed by healthcare staff that have a patient-provider relationship with the inmate.

Collecting Forensic Information

 Along the same lines, requests can be made to assist with collecting forensic evidence to be used against the inmate, such as blood tests, DNA analysis or psychological evaluations. Providing such services would constitute a conflict of interest for the care providers working in the facility. Resources outside the facility medical unit should be accessed to provide these services.

 Executions

 Fortunately most states executing the death penalty have moved to the use of outside providers for monitoring and initiating lethal injection. All authorities agree that participation in executions is inappropriate for healthcare staff with a patient-provider relationship to the inmate population.

Hunger Strikes

 Ethical conflict can develop regarding treatment choices during hunger strikes. Most certainly, monitoring the health status of a striking inmate would be beneficent and nonmalfesent care. The dilemma begins if healthcare staff are asked to force feed (tube feed) the starving inmate. Practitioners are mixed on a response to this request. Although there is no clear consensus, the ACHSA has adopted a position statement advocating force feeding in some situations. The Federal Bureau of Prisons has a program statement on hunger strikes indicating force-feeding is a medical decision based on emergent life threatening criteria.

Inmate Discipline

 Involvement in inmate discipline can also result in an ethical dilemma. For the most part, healthcare staff should not be involved in disciplinary action or disciplinary committees determining actions in the facility in which they work. However, involvement becomes necessary when a staff member has witnessed or is the receiver of wrongful action. It is appropriate to provide factual objective testimony in order to maintain security in the facility and the safety of other inmates and staff members.

Patient Confidentiality

Healthcare providers often get queries from custody staff about the health condition of particular inmates usually related to infectious diseases or mental health. Information can also be spread through knowledge of the type of services provided to specific inmates or special needs issues (bottom bunk, food privileges, etc). In these situations it is important to carefully share needed information which will minimally jeopardize patient confidentiality. The specific need can be shared (bottom bunk) without sharing the diagnosis (epilepsy).

What other ethical dilemmas might be experienced in correctional practice?

Save Healthcare $$$ – Deliver Care Behind the Walls

Prison Tower, Joliet, IL

A West Virginia jail is discovering what many county and state governments have confirmed – inmate healthcare is less expensive when delivered onsite rather than in the community. Why is that? Lets discuss the factors that make onsite healthcare efficient and effective for the corrections community.

Officer Manpower

The greatest savings, by far, in delivering care, treatment and diagnostics behind the security wall of the prison or jail is sheer manhours. Every time an inmate must leave the facility, officers need to attend them, often putting the facility into overtime mode. More than one officer may be needed to deal with transportation, shackles, and continuous observation. Consider the round-the-clock needs while caring for an inmate in a hospital setting. Some states reduce costs by having a locked unit within the hospital which can decrease manpower needs. A few states have an entire prison hospital and/or long-term care facility within a security perimeter.

Telemedicine Behind Bars

A popular way to increase the specialty care delivered behind bars is the use of telemedicine. Televideo equipment beam the specialty practitioner into the facility to dialog with the inmate-patient and the facility medical staff. This operation is most effective for specialty areas like infectious diseases (ongoing management of HIV/HCV) and psychiatry. More sophisticated equipment has been developed to allow accurate assessment of heart and lungs, but they can be ost-prohibitive.

Mobile Diagnostic Units

Another way care is coming to the inmates rather than transporting the inmates to the care is through mobile units. X-rays, Mammography, MRI, and CT Scan Units are now available to come to the facility. Secure outlets from the facility to the mobile unit are arranged and staffed during special periods of operation.

Healthcare is a major component of any Department of Corrections budget. The recent Pew Report on America’s prisons cites an average of 6.8% of state budgets goes toward corrections. Investigating methods to deliver effective and efficient healthcare within the walls is a priority.

HIV & Inmates

New York State is considering increased oversight of HIV inmate care. This article had me considering the many issues and barriers to providing care for inmates with HIV. To be sure, healthcare providers have education, drug protocols and clinical practice guidelines specific for the correctional environment. Many of the medication regimens have been standardized and commonly available through prison pharmacy distributors. However, several elements of the operation of correctional facilities and the patients themselves mitigate against consistent care.

HIV is Now a Chronic Condition

Due to advances in treatment and pharmacologics, HIV is now considered a chronic condition. This can result in less attention to the details – not good for long-term outcomes. Many prison medical units now place HIV inmates into an Infectious Diseases Chronic Care Clinic. This is a good practice, as is regularly scheduled visits with ID specialists. The advent of televideo medicine allows for this specialty care practice without the burden of specialist access beyond the security perimeter.

HIV Treatment Requires a Well Educated Patient

The complexities of the treatment plan and medication regimen can overwhelm the most educated of individuals. The average inmate is undereducated and undermotivated toward long-term health, although there are always exceptions to this generality. Information about their condition and directions for any actions on their part need to be clear, simple and repeated often. This information can be mixed with social myths and misconceptions. An open and honest communication channel allows these myths to emerge and be dispelled.

DOT or KOP Medications – Decisions, Decisions

The two options for medication administration in corrections are DOT (Direct Observation Therapy) which requires the inmate to come to a pill line and receive a single dose of medication where it can be observed to be taken, or KOP (Keep on Person) which allows the inmate to self-medicate, having been given a 30 day supply of the prescribed medication.

DOT is inconvenient for the inmate but assures more consistent treatment. KOP allows inmate independence and self-care but requires a highly motivated and diligent patient. Both are used for HIV management depending on the philosophy of medical and correctional leadership.

Inmates Don’t Stay in One Place

I know this may seem hard to believe – it was for me – but inmates are not always that easy to find. Just when they are settled into a routine at one of the state prisons, there is a reason for transfer. Security may need to transfer an inmate related to classification, time remaining in the sentence or due to altercations, gang activity, or attempted collusion. In any case, the inmate is moved to another facility. Communication of medical condition or treatment plan can be missed since a medical condition is not a primary consideration, but secondary to the security issue warranting the move.

For all these reasons, and some I probably missed, HIV inmate care will remain a challenge. It requires a well-running system to overcome the inherent barriers to care in a security environment. Many medical units find success through the designation of a nurse who provides case management for the HIV inmates in the facility. However, all staff members, from those working sick call to those working the med pass line, must understand their role in the HIV treatment plan.

What are your thoughts on HIV inmate care? I look forward to your comments.

Shackling Inmates in Labor? What’s Up with That?

Shackling laboring inmates has been an issue for some time in corrections and is getting press due to coverage in New York. Last week they became the sixth state to ban the use of shackles during labor except is special situations. The ACLU and other prison watch groups have been actively pursuing a change in this corrections practice. It is one of many ethical dilemmas correctional nurses become involved with. Unlike in hospitals, healthcare is secondary to security and safety in the running of the correctional facility. The Department of Corrections and custody officers can have a very different perspective on any given situation from the healthcare providers. A ‘Command and Control’ attitude can be quite challenging to deal with.

Shackles are for Outside the Walls

Some clarification is necessary to the uninitiated. The news articles make it appear that the women are INSIDE the prison giving birth and being shackled. Unless referring to the few prison hospitals around the country, what is really happening is that the women have been transported to the hospital to give birth. They are therefore outside the security perimeter of the prison and there are standard precautions in place to decrease the chance of escape and to reduce the need for a large number of officers to attend them. Those standard precautions include handcuffs and shackles.

Standard Security Procedure

Now those of us who have given birth know that it is highly unlikely that a women in true labor is going to have the wherewithal to evade an officer in the L&D Unit and escape into the community. However, inmates have been known to be very creative in their escape plans. No corrections officer wants to be the one on duty when an escape takes place. Therefore,the custody officer is going to use standard procedures (IE shackles) unless special directives are issued – thus the need for specific policy to be in place regarding the laboring inmate in the community.

Advocating for Change

I’m not really an advocate for legislation for everything so the idea of getting legislation about this in all 50 states seems a bit much to me. However, the Federal Bureau of Prisons and 5 other states so far have specific policy or legislation allowing the laboring inmate to be free of shackles. The visibility of the New York situation may speed the adoption throughout the country – that is a good thing. The Rebecca Project for Human Rights has also taken up the call and been instrumental in facilitating the New York State legislation. A listing of specific state by state information was recently posted by the Crime Reporter.

Correctional Nurses Keep Infection Under Control

Recent news that there are big issues with MRSA(methicillin-resistant Staphylococcus aureus) in some Illinois Prisons got me thinking about how observant correctional nurses can have a great impact on reducing the incidence and spread of this deadly infection in inmate community, thereby protecting custody staff, as well. I am not familiar with the healthcare staffing patterns in IL Prisons, however, many facilities have a designated infection control (IC) nurse who focuses on prevention, containment and treatment of infections in the inmate community. Here are some of the key activities of an infection control nurse in corrections.

Education to Prevent Outbreaks

One of the main ways infection outbreaks are prevented is through continuous education of the inmates and custody staff about methods to decrease the spread of infection (Frequent Handwashing!!!). Inmate workers such as porters, kitchen help, and laundry workers need special education in methods to decrease infection spread. The generally low literacy levels of the inmate population require simple and practical instruction methods.

Environmental Scanning

IC nurses regularly round throughout the facility specifically checking for any conditions that might indicate an infection issue. From the temperature of the water in the laundry area to the location of raw foods in the kitchen, the nurse is looking for opportunities to prevent disease spread. Shower stall mold, empty soap dispensers and even leaks resulting in stagnant water are areas of concern. Custody staff are less likely to be attuned to the health implications of these issues. An alert nurse, working in conjunction with custody peers, can improve health conditions.

Inmate Assessment and Early Treatment

IC nurses focus on intake assessments which determine any potential infections which might be brought into the inmate community by new arrivals. Evaluations for TB, skin infections, and H1N1 or other flu symptoms take place at intake. Those with high potential for these conditions are isolated from the general population until definitive diagnosis can take place. These nurses are also often involved in the ongoing treatment of chronic infections such as HIV and hepatitis, by managing the Infectious Diseases clinics with the ID physician specialist.

Reporting and Responding

Most states have health departments which manage the public health and require reporting of any potential outbreak or pandemic situations. An IC nurse can be the key point person with the health department and initiate immediate action in the event of a potential outbreak. It appears that there was lack of communication with the health department in the IL situation cited above. Immediate response to a potential outbreak through containment and treatment can prevent further spread.

A more thorough review of the IC nurse role in corrections can be found in my article for an issue of CorrectCare – an NCCHC publication.

Nursing Care During a Prison Riot

The recent prison riot in Chino, CA brings to mind the need for a well prepared nursing staff to handle mass casualties. According to reliable reports, 250 inmates were injured, 55 seriously. 

What is the role of the correctional nurse in a riot?

Correctional healthcare staff prepare regularly for a mass casualty situation. In an accredited facility, a prison-wide disaster drill is enacted annually to review the processes and skills necessary to deal with a large influx of injuries. An area of the prison (possibly a rec area or exercise yard) would be designated to triage the victims. Once this area has been secured, correctional nurses provide immediate emergency evaluation and treatment to the inmates brought there by custody staff. They make determinations about the need to transport to a hospital based on degree of injury.

What other challenges for care delivery exist due to a riot?

 A common practice during periods of unrest in a correctional facility is the practice of lockdown. Facility lockdown severly restricts inmate movement and communication. This standard procedure for containment reduces the chances for further violence but is a severe stress on manpower and normal processes. Increased security services are required and often increased healthcare staff are needed, as well. Since inmate movement is limited, normal healthcare processes like sick call and medication administration must take place cell-to-cell rather than having inmates travel to the medical unit. Facilities may not be set up to accommodate medication carts in the housing units and pills may have to be ‘pre-poured’ which increases the potential for errors. Diabetic’s insulin injections are now given on the cell block requiring transport of needles and vials. Privacy becomes an issue for various treatments and assessments.

What protection do healthcare staff have during a riot situation?

Prisons and jails are arranged to contain or separate various areas within the security parimeter, usually using a sally port system. Sally ports, strictly monitored and operating by custody staff, greatly increasing protection in an emergency situation. Inmate and staff movement is totally curtailed during the immediate danger. Once the violence is subdued and contained, staff members would be escorted in and out of the building. 

In addition, once it is determined which inmates were the leaders of the riot, they will likely be transferred to different facilities to reduce communication, collusion, and/or retaliation.

A prison riot is an emergency situation requiring the skilled intervention of correctional nurses to assess and manage trauma victims. Custody officers and healthcare staff work together to deal with the emergency.

Correctional Nurse Interview Prep Guide

So you are thinking about correctional nursing and even have an interview set up at a local facility. How should you prepare for your interview and what questions should you ask? Of course, all the standard principles for successful interviewing apply here. Good tools for general interview preparation such as interview tips and career guides are available online.

In the specialty of corrections, however, several other things that you should keep in mind in order to prepare yourself for a productive interview.

Dress

Most correctional facilities require modest dress. Dress conservatively for your first experience inside. This means no visible cleavage, no strappy high-heeled sandals, no sleeveless tops or dresses. It is best to leave cellphones and wallets locked in your car. Bring your drivers license, keys, and any paperwork with you. You will likely go through a security process similar to airport security which may include wanding and possibly a pat down. Pat downs should only be done by a same-sex custody officer.

Facility Tour

Be sure to get a full tour of the facility including every location in which you may be working as a staff nurse. Pay attention to the number and location  of custody staff at each location. There should be an officer available at all times for security purposes. Check your own emotional response to being behind bars. It is not for everyone. Find out during your interview process if this environment will be a difficulty for you.

Correctional Officers (COs)

COs are also referred to as Custody Officers or Security Officers. Try not to refer to them as guards. This is considered a derogatory term. During your security entry take note of the diligence with which the officers perform their duties. You want to know that they follow procedure and are not lax in their position. If their focus is on chatting or other non-work activities they may be distracted from their primary role.

Questions to Ask

During the interview you will be asked for any questions you might have. Take this opportunity to find out the following:

• Does nurse orientation include orientation to security procedures and dealing with inmates? A good orientation in corrections includes more than policy and procedure. You will want to hear that you would receive information about security procedures, how to remain safe in the facility, safety codes and rules, as well as how to deal with the inmate population.
• Are nurses given safety alarm mechanisms? What is used in this facility? There should be a mechanism for nurses to sound an alarm if they feel they are in an unsafe situation. Generally, staff will not be out of sight and/or sound of a custody officer at any time. However, even with mirrors for ‘blind spots’ there is a small opportunity for loss of contact. A well-run facility will have a mechanism in place to alert security of an unsafe situation.
• Is the facility accredited by NCCHC or ACA? Current accreditation with either of these independent bodies indicates that the facility meets nationally recognized quality standards. Their seal of approval is similar to a Joint Commission accreditation for hospitals. An accredited facility is more likely to have well running clinical processes and established practices.

Armed with this information you can make an informed decision about the healthcare at the facility and launching your career in correctional nursing.

Do you have other interview questions or tips for someone entering the correctional nursing field? Enter a comment below.

Can Correctional Nurses Care? – Part II

Caring for and about the inmate population has a variety of challenges to overcome. Besides the dilemma of caring for a criminal, there is the issue of showing care and concern to this population.

‘Warm and Fuzzy’ is Not the Way to Care for Inmates

 Many healthcare environments allow, and even encourage, physical expressions of caring such as touching the arm, patting the shoulder, or holding a hand during a painful procedure. These are not appropriate caring behaviours in the corrections setting. These actions in the correctional setting can frequently be sexualized and misinterpreted as making advances.  Touching the patient is limited to necessary procedures and treatments.

Firm, Fair and Consistent

Verbal interactions with inmate patients require similar boundaries. Idle chat or asking personal questions which may come naturally in other care settings are inappropriate in corrections. Being firm, fair and consistent in all communication with the patient reduces misinterpretation.  A goodly amount of inmates have socially deviant or manipulative behavior patterns. This group of inmates will prey on staff members with insecurities or poor self-esteem. Being ever vigilant to deflect these behaviors can establish the necessary boundaries for good nursing care.

Caring by Protecting from Themselves

Another avenue of caring in correctional nursing is though protecting the inmate from breaking custody rules. Establishing and maintaining barriers in the care environment prevents access to contraband or opportunity for theft. Keeping narcotics, sharps, syringes, and dental equipment under constant observation or locked away prevents the inmate from taking a foolish action that could cause harm to themselves or others.

Caring by Advocating within the Custody Environment

My final thought is that correctional nurses care through advocacy for inmate healthcare needs within the custody environment. I have great respect for my custody colleagues – they provide protection and safety 24/7 in very challenging situations. Sometimes the goals of security and healthcare conflict. Depending on the situation, advocating for a patient’s health need can be percieved as counter to the immediate security needs or the general goals of the facility. Challenging the status quo in these circumstances is an act of caring.

What other ways do you think correctional nurses care for their patients? Leave a comment