Fear by Tetine

The statistics on prison rape are shocking.  According to the 2007 Department of Justice study, 4.5% of all state and federal inmates experienced at least one incident of sexual victimization. That is nearly 1 in 20 inmates. My first reaction to the information was to assume this was inmate on inmate victimization, but this is only part of it. More assault is reported involving facility staff (2.9%) than inmate perpetrators (2.1%).

The Prison Rape Elimination Act (PREA) was passed by the US Congress in 2003 and legislates actions to be taken by corrections personnel to prevent and respond to sexual assaults. PREA also established a Commission to monitor the process of preventing rape in the country’s jails and prisons. How can correctional nurses respond?

 What is Considered Prison Rape?

Any unwanted sexual contact between inmates is considered prison rape. This can include fondling of genitalia or even instilling fear of rape. It does not necessarily have to be full penetration and does not require force to be defined as prison rape.

There is an even higher standard for staff on inmate sexual contact. ANY sexual contact between a staff and inmate – even if consensual – is considered prison rape and can be prosecuted. Be clear for yourself and your work-mates – there is NO permissible level of sexual contact with an inmate. Staff members have been prosecuted and sentenced for writing sexually explicit letters to inmates. A recent example of progression into illegal sexual contact is described in this article.

Who is a Likely Rape Candidate?

As you might expect, studies confirm that the likely inmate sexual assault victim is young, a first time offender, and of small build. In fact, juveniles in adult prisons have a 5 times higher chance of being a rape victim. If you have juveniles in your facility, keep this in mind when you are providing care. Be on the look-out for indications of having been assaulted. Some prisons automatically take protective actions for any juveniles who have received adult sentencing. This is also true for transgender, mentally ill, or developmentally disabled inmates. Be alert when assessing and evaluating any of these categories of inmates.

Impacting Healthcare

Every one of our inmate-patients is at risk for sexual assault or rape and may seek medical treatment for it. We need to be alert to the possibility and ready to respond.  Here are a few clinical situations to consider

• An inmate arrives in sick call with a vague complaint – she is depressed, nauseous, agitated, or exhibit other traumatic stress responses
• While working in the segregation unit, you see a generally compliant inmate break rules toward the end of his seg stay, seemingly intent on extending his time
• A young inmate begins covering himself with feces. After mental health evaluation it is discovered that he uses this as a protective mechanism against repeated rapes by his cell mate

 Action You Can Take

Be familiar with your DOC procedures before you are confronted with a sexual assault situation. That way you will know what mechanisms to put into action. For example, you may need to inform the shift commander. Many places have a sexual assault response team consisting of a mental health provider, law enforcement professional and medical provider.

Document clearly the statements made by the individual.  Allow them to vent without moving into investigative mode and asking questions. Asking questions too early may cause a victim to retreat and close down.

Arrange for a sexual assault evaluation, including a rape kit if the report is within 96 hours of the assault. A specially trained individual should perform this function as forensic evidence will be obtained. In some facilities arrangements must be made to send the inmate-patient out to a hospital emergency room for this procedure.

Arrange frequent mental health follow-up for post traumatic stress responses.

Unfortunately, not all healthcare staff, correctional officers or administrative staff consider sexual assault an important issue. You may encounter conflict in your attempts to advocate for the victim. Be reminded, and remind your corrections colleagues, that being aware of the situation and not responding is both unconstitutional  (Eighth Amendment) and illegal (PREA). In addition, as nurses, we have a moral obligation to act in a rape situation. Sexual assault is not a part of the punishment. We need to respond compassionately as any prudent nurse would in a community situation.

Have you have an experience with a prison rape situation? Share your story in the comments section.

Meth Mouth

Unlike almost any other specialty area, correctional nurses get involved with dental issues. Whether during intake assessment or as a sick call request, we must initiate treatment and referral for a variety of oral conditions. It is important to determine which are emergencies requiring an immediate dental evaluation and which can await a standard dental visit.

Meth Mouth and other Drug Issues

Generally speaking any substance abuse is not good for mouth health. Drug abusers are not focused on dental care and often don’t even notice tooth pain until they are in jail and withdrawing. Mouth infections or abscesses can go on without notice while they have access to the drugs.

Meth mouth is a particularly unattractive mouth condition brought on by the common circumstances of methamphetamine use.  The drug decreases the production of saliva, a natural tooth enamel protector. Meth users crave sugary drinks and foods and the drug induces clenching and grinding of the teeth which leads to cracking and wear.

Oral Cancer

Heavy drinking and smoking, common behaviors for the inmate population, are significant contributors to oral cancers. Chewing tobacco and snuff increase the risk of oral cancer by 80% according to a World Health Organization report. These products are popular with inmates in some parts of the country.  Surprisingly, oral cancer is the sixth most common cancer in white males and the fourth most common in black males. Be alert for growths in the mouth when performing intake assessments and screenings. Common areas are under the tongue and the upper lip.

Oral Infections

Poor nutrition, substance abuse, and negligent dental hygiene leads to oral infections. Left unattended, a simple oral condition can turn into a systemic emergency. Oral infections can encompass the entire face and extend to sinuses or lead to airway obstruction.

When is Emergency Treatment Needed?

Emergency treatment is needed for a dental condition any time the patient is having difficulty breathing or swallowing. If the mouth cannot be opened or there is facial space involvement, immediate treatment is necessary. A ‘toxic’ appearance with a high fever would also be an indicator. In any of these situations immediate intervention should be sought.

Have you experienced dental emergencies in your practice? Share your story in the comments section below.

Correctional nurses can get jaded about treating inmate seizure disorders. After all, many perks can be claimed by those diagnosed with the condition including a coveted lower bunk and some real nifty medications. So, it would be easy to think that any inmate coming in with a history of seizures or appearing with seizure activity is merely faking it.

Inmates Have More Seizures

Around 1% of the US adult population will be diagnosed with a seizure disorder (1 in 100). In contrast, 4% of the US inmate population has a seizure disorder (1 in 25). That is a huge disparity and gives greater understanding to the frequency of seizure history or activity in our patient population. This patient community has several risk factors which increase the likelihood of seizure activities.

Head Trauma

The incarcerated have a background with greater violence and traumatic injury than the general population. In fact, recent studies indicate that 25-87% of inmates report having experienced a head injury or traumatic brain injury (TBI) as compared to 8.5% in a general population reporting a history of TBI. Head trauma increases the potential for seizure disorders.

Drug and Alcohol Withdrawal

Drug and especially alcohol withdrawal can lead to seizures. These seizures are not chronic in nature and require a specific treatment regimen. Seizure activity in withdrawal can be intensified if the inmate already has a background of epilepsy or TBI. Alcohol withdrawal can increase inmate seizure activity, especially in jails. The Federal Bureau of Prisons recently released revised Detoxification Guidelines.

Domestic, Child and Sexual Abuse

Past traumatic psychological stresses such as domestic, child or sexual abuse can produce a seizure disorder known as psychogenic seizures. These seizures have been described as a physical manifestation of a psychological disturbance and have received increased attention recently. Up to 1/3rd of patients sent for EEG-video diagnostics for seizures are diagnosed with the disorder. These seizures are of psychologic rather than physical origin; however, they are not being faked. Like other stress-induced conditions such as stuttering or fainting, psychogenic seizures are a physical response with only minor controllability from the individual. Psychogenic seizures do not respond well to epileptic medications, but rather to counseling and other psychotropics.

Treat all Seizures as Real

As healthcare professionals, correctional nurses must treat all seizures as valid until proven otherwise. If a witnessed event seems questionable, there are a few easy maneuvers to take in the post-seizure period including raising a arm over the chest and letting it drop (The non-seizing person will guard/the true seizing person will not) or using smelling salts (not effective for true seizing person). It is not recommended to do a sterna rub as this can cause unnecessary injury.

 What are your experiences with inmate seizures and how does your facility deal with them? Post a response in the comments section.

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?

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?

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.

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 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.