To the extent possible, nurse educators have a responsibility to prepare nursing students for situations they will face in their future clinical practice. As nurses, students will care for people who are different from themselves—individuals who are homeless, morbidly obese, transgender, or who have engaged in criminal activity. When nursing students care for people who are in situations unfamiliar to them, some nursing students' responses may be grounded in conscious or unconscious bias. They may not know how to approach patients with different life experiences. Nurse educators should introduce students to the reality that nurses care for all people, in all situations. Doing so provides nurse educators with an opportunity to guide nursing students' “moral formation” (Benner, Sutphen, Leonard-Khan, & Day, 2008, p. 473) and helps them learn “who they need to become” (Valiga, 2014, p. 247). If this is not addressed by nurse educators, nursing students may find it challenging to treat all people with “compassion and respect for the inherent dignity,” as directed by the Code of Ethics for Nurses (American Nurses Association [ANA], 2015, p. v).
The purpose of this article is to provide nurse educators with information as a basis for teaching nursing students to care for one of these patient populations: inmates or prisoners who are under the custody of law enforcement officials. It is likely that at some point in their career, nursing students will care for inmates, as inmates receive health care in places other than the correctional facility. Pregnant female inmates often deliver their babies in hospitals. Inmates have surgical procedures in acute care facilities and may receive follow-up care in clinics. Local law enforcement officials may bring individuals under their custody to the hospital for emergency care. There are some important points that make caring for inmates as patients in the acute care setting different from caring for other patients.
A person who is under the “jurisdiction of the criminal justice system” is referred to as an inmate (ANA, 2016, p. 1). The ANA uses the term patient to refer to an inmate who receives health care in the correctional facility (ANA, 2016). In this article, the term inmate-patient will be used to refer to a patient in the acute care setting who is also under the custody of law enforcement officials. Several other terms have been used to describe inmate-patients, such as prisoners-patients (Crampton & Turner, 2014) or forensic patients. The discussion of inmate-patients in this article is reserved for those individuals under the custody of local law enforcement officials or those who are inmates in state or federal correctional facilities. The nursing care of prisoners who are political detainees is beyond the scope of this article.
Although there is a growing body of literature focused on the health care needs of inmates within the setting of the correctional facility, much less is written about inmates who receive health care services outside the correctional facility. Information is limited on teaching nursing students about this difficult but important topic. What is known through researchers' and others' work is that caring for inmate-patients is difficult for nurses. On a practical level, nurses are “unfamiliar with custody requirements or how to safely care for” inmates (Smith, 2016, p. 282). Other challenges exist as well. Nurses may fear that an inmate-patient will seek out and harm them or their family (Smith, 2016). Although some nurses find caring for inmate-patients to be rewarding (Zust, Busiahn, & Janisch, 2013), other nurses report the experience as “emotionally draining” (Crampton & Turner, 2014, p. 114). The use of physical restraints, especially when female inmates are in labor, is troubling for some nurses (Zust et al., 2013).
In addition to the effects on nurses, researchers also have documented that nurses frequently treat inmate-patients differently than they do other patients—differences that reflected the nurse's personal views about someone who has committed a crime (Zust et al., 2013). Some nurses “judge” inmates (Crampton & Turner, 2014, p. 111). This judgmental attitude influences the care nurses deliver in that they do not empathize with patients who are inmates (Zust et al., 2013). Crampton and Turner (2014) also reported that inmate-patients receive “perfunctory” care described as “mechanical” and “without affection or genuine feeling” (p. 113).
Nursing Students' Educational Needs When Caring for Inmate-Patients
Researchers and scholars from many disciplines, including nursing, are concerned with the welfare of inmates and those who work with inmate populations, highlighting the importance of this topic and relevance in nursing education. Nursing students need practical information about caring for inmate-patients, such as the concern for safety and security and strategies that institutions use to maintain a safe environment. Nursing students also need to know general information about the health status of prisoners and their legal right to health care. Finally, they need to learn about the nurses' ethical mandate to treat all people with “compassion and respect for the inherent dignity…of every person” (ANA, 2015, p. v) because compassion and respect may be conveyed in a different manner when the patient is an inmate.
Environmental Safety and Security: Inmate-Patients in the Acute Care Setting
Whenever an inmate is moved beyond the correctional facility, there is heightened concern that the inmate will attempt to escape or harm others (Junewicz, 2014; Smith, 2016). To reduce these risks, inmates' movements are restricted with the use of hand or ankle cuffs (Junewicz, 2014). These also can be called forensic restraints. These physical restraints are under the control of the accompanying corrections officers (COs) but may compromise patient safety, especially during surgery; thus, they require nurses' attention (Smith, 2016). The transfer of an inmate to an acute care setting is coordinated between officials in the correctional facility and the hospital's police department or security personnel (Smith, 2016).
One of the first observations nursing students may make when an inmate is being cared for in an acute care setting is that law enforcement officials or COs are always positioned near the patient. Commonly, two COs accompany the patient; each CO has specific duties and responsibilities (Smith, 2016). COs carry weapons when they guard inmate-patients (Smith, 2016).
Nursing students should be taught that institutional policies are important sources of information about the care of inmate-patients. These documents provide information about the practical aspects of caring for inmate-patients. Institutional policies may describe the role and responsibilities of the accompanying COs in great detail, even specifying where they will be physically located, depending on where the patient is being cared for (e.g., operating department versus critical care area). These institution-specific policies also should clarify the inmate-patients' status with regard to visitors and telephone calls. Nursing students may be surprised to learn that inmate-patients usually are not allowed visitors or telephone calls.
In the corrections facilities, nurses care for inmates “without regard for their criminal allegations, convictions, or histories” (ANA, 2016, p. 15). In the acute care setting, nurses should not inquire about the inmate-patients' convictions, sentences, or feelings about incarceration. Nurse educators can emphasize to nursing students that when they are nurses, they are responsible to know and abide by institutional policies.
Inmates' Health Status and Right to Health Care
Population Health Concerns of Inmates
It is important for nursing students to understand that as a population, people who are incarcerated have myriad health concerns. Inmates in correction facilities have higher rates of diabetes, hypertension, asthma, and HIV than the general population of the United States (Wilper et al., 2009). Communicable diseases, such as hepatitis C, community-acquired methicillin-resistant Staphylococcus aureus, and tuberculosis are prevalent in the close quarters shared by many inmates in a correctional facility (ANA, 2016). Inmates aging in correctional facilities live in conditions not equipped to support people who develop mobility problems, worsening vision and hearing, and declining cognitive abilities (ANA, 2016). Incarcerated women have higher rates of diabetes, mental illness, drug abuse, sexually transmitted illnesses, and depression compared with incarcerated men (ANA, 2016). Wilper et al. (2009) reported that many inmates were not receiving treatment for a mental illness at the time of their arrest. Regarding mental illness, Wilper et al. (2009) described the problem as “ubiquitous” (p. 669).
Many inmates in correction facilities come from backgrounds of poverty and prior inadequate access to health care (ANA, 2016). Christensen (2014) stated that most of the women who are inmates in corrections facilities have had “adverse life experiences” (p. 223), including unhealthy relationships, and many had witnessed violence. Many incarcerated women experienced physical neglect and emotional or sexual abuse when they were young (Messina & Grella, 2006).
In 2003, Harlow reported that more than half of inmates in state correctional facilities lacked a high school diploma. More recent data about inmates' educational status is not readily available; however, the ANA (2016) reported that many incarcerated women are undereducated. Many women also were unemployed before being incarcerated (ANA, 2016). For many inmates, life before incarceration was difficult. There can be no doubt that dwelling in a correctional facility is stressful. This information is not meant as a defense or excuse for crime, but it is germane to the discussion with students about inmate-patients' health and the prevalence of some of the social determinants of health.
Inmates Have a Right to Health Care
Many nursing students may not be aware that in the United States, “prison inmates have a legally guaranteed right to health care” based on a 1976 Supreme Court ruling (Lyckholm & Glancey, 2016, p. 8). To deny inmates health care was viewed as a violation of the Eighth Amendment's protection against “cruel and unusual punishment” (Lyckholm & Glancey, 2016, p. 8). Nursing students need to know that inmate-patients have the right to make decisions about their own health care, including signing consents for procedures (Lyckholm & Glancey, 2016; Smith, 2016). Those decisions are not subrogated to prison officials (Lyckholm & Glancey, 2016). Consequently, inmate-patients need information before signing consents for procedures.
Because inmates are not in a position to “obtain care independently,” the cost of inmates' health care falls to the government (Lyckholm & Glancey, 2016, p. 8). Despite having a legal right to health care, many inmates do not receive the care they need (Lyckholm & Glancey, 2016). They are a “vulnerable” and “marginalized” population (Melillo, 2009, p. 3).
The ANA Code of Ethics for Nurses: “Compassion and Respect for Inherent Dignity and Worth of Every Person”
It is important for nursing students to recognize that the same Code of Ethics for Nurses applies to all nurses and all patients, including inmate-patients. Therefore, nurse educators should discuss the Code of Ethics for Nurses with nursing students. In their publication about Correctional Nursing, the ANA (2016) states clearly and frequently that nurses in correctional facilities are to treat inmates under their care with “dignity and respect,” “compassion, care, and concern…in every patient encounter” because “regardless of their circumstances,” they “possess intrinsic value” (p. 17).
However, within correctional facilities, common expressions of concern are prohibited. Touch, hugging, and sharing of personal information are not allowed (Christensen, 2014). When an inmate is a patient in an acute care setting, this is an important consideration. Of course, nurses touch patients; this cannot and should not be eliminated. Touching a patient during an assessment, bath, or treatment is always conducted in a professional manner, and the same professionalism exists when assessing, bathing, or otherwise treating an inmate-patient. Nursing students should be cautioned about using touch, such as holding a patient's hand, when caring for inmate-patients. They should not share personal information, such as their address, age, or family status with inmate-patients. These points may be hard for some nursing students to understand. However, nursing students can still convey compassion and respect while they establish a therapeutic relationship with inmate-patients. Weiskopf (2005) found that nurses who worked in correctional facilities could establish therapeutic relationships with inmates by communicating in an unhurried and “nonjudgmental manner” (p. 340). Smith (2016) advised that respect can be conveyed to inmates by addressing them by their name. A nurse's tone of voice can express respect. Nursing students also can demonstrate care and concern for inmate-patients by advocating for their needs and ensuring they are included in decision making about their health and treatment options. Teaching inmate-patients about their illness and treatments is another way to show respect and care. Honoring inmate-patients' cultural or spiritual practices demonstrates respect, care, and concern. Nursing students may not be able to convey compassion and respect with common gestures such as physical touch, but they can convey compassion and respect in their demeanor and communication with inmate-patients.
The Nursing Care of Inmate-Patients: Teaching Strategies
Nurse educators can introduce students to the care of inmate-patients in a case study. Case studies with inmates as patients are easily adaptable to many different courses, including maternity, adult medical–surgical, or psychiatric–mental health nursing. As the ANA (2016) noted, “juveniles” are “confined to detention facilities” (p. 7), and they too have various physical, cognitive, and emotional health problems. A case study about an inmate-patient also would be relevant in a pediatric nursing course. An example of case study for use in a medical–surgical nursing course and related questions for discussion are provided (Table).
Case Study of an Inmate-Patient Awaiting Surgery in an Acute Care Setting for an Orthopedic Injury, With Questions for Nursing Students
Case studies allow nurse educators to incorporate new content about caring for inmate-patients into a clinical topic. As students are introduced to the patient in the case study, educators can ask students about questions they may have. Depending on students' responses, educators can guide the discussion to several important points, asking students to identify the priorities of care for the patient in the case study. Educators also will want to point out similarities and differences in caring for inmate-patients and others. This can be accomplished by asking students to consider how caring for this patient is the same as or different from caring for other patients. It will be important for nurse educators to teach the clinical content to reinforce nurses' attention to inmate-patients' clinical needs in the same way they address all patients' clinical needs. For example, in this case study, nurses will assess Mr. Franklin's pain and neurovascular status, just as they would for any patient in this situation. However, other aspects of Mr. Franklin's care are different.
The example of the case study presented in the Table contains several points that could be used to discuss aspects of caring for inmate-patients. Questions that highlight some important points for nursing students' learning are provided. In this case study, the surgical consent is not signed. The unsigned consent provides nurse educators with an opportunity to discuss inmates' legal right to health care. The patient in the case study is a 32-year-old man with a history of hypertension. Nurse educators might use this point to introduce students to what is known about the health status of people who are incarcerated. Nurse educators also might want to use what is known about inmates' health status to introduce or reinforce students' understanding of the social determinants of health. In the case study, the patient's prior criminal history is intentionally not provided. Nurse educators can use this point to teach students that nurses should not inquire about the inmate-patients' convictions or sentencings.
The case study also references the position of hand and ankle cuffs and COs attending to the patient. Nurse educators should expect questions about the use of forensic restraints or caring for patients when COs must remain near the inmate-patient.
A case study also can be used to teach nursing students about the Code of Ethics for Nurses and how to treat inmate-patients with respect. Although this article provides nurse educators with examples of how nurses can convey respect for inmate-patients, this may be difficult for some students who may need time to reflect on their personal values and beliefs. Not all nursing students will agree that inmate-patients should be treated with respect, compassion, care, or concern. Christensen (2014) noted, “nurses themselves are faced with the challenge of looking past the crime and seeing the inmate as a human being” (p. 224).
Anticipating Differences of Opinion in the Classroom
Nurse educators may be anxious about creating a situation that results in tension in the classroom if students verbalize strongly held, opposing opinions on a topic like this. Nurse educators may seek guidance from ethicists or experts in group dynamics about maintaining a safe environment for discussion when there may be potentially conflicting personal viewpoints expressed. It may be helpful to begin this discussion with ground rules or norms that state expectations for respectful communication and a civil discussion.
Nurse educators may need to give students reasons to consider why inmate-patients should be treated with respect or compassion. It may be beneficial to share Christensen's (2014) comment that nurses can find it difficult to see a human being rather than a criminal. The ANA (2015) Code of Ethics for Nurses has no provisions that are reserved for some people and withheld from others, so the nursing response is and should be different than social opinion on this topic. Loeb (2009) commented that nurses should care about inmates' health because of “humanitarian” reasons (p. 5). These responses may seem insufficient to overcome strongly held opinions to the contrary. However, nurse educators may not know their full impact when they challenge students' opinions and offer new perspectives for them to consider.
There is a risk that some nursing students may misinterpret a discussion about inmate-patients as an excuse for crime and potentially dismissive of victims' suffering. However, that is not the intent, and nurse educators should clarify that point and repeat it as needed. The point of teaching nursing students about caring for inmate-patients is to teach students about professional nurses' responsibility to treat all people with respect. This respect is provided based on a person's humanity and is not withdrawn because of his or her status or the opinion of others.
As nurses, students will very likely care for inmate-patients who receive health care outside of the correctional facility. Some nursing students will have had little to no prior experience with inmates and may be unsure how to proceed. Other students may have strong opinions about how people who have been convicted of criminal activity should be treated. Nurse educators should anticipate that situations such as caring for inmate-patients can be troubling to students. To the best of their ability, nurse educators should teach students how professional nurses approach these situations because the nursing response is and should be different than the prevailing social thought.
Nurse educators can teach students about the practical issues of caring for inmate-patients when they receive care in places other than the correctional facility, especially the concern for a safe and secure environment. Nurse educators also should teach students about the health status of inmates and the influence of some of the social determinants of health on this patient population. As future nurses, students should know about inmates' legal right to health care. Nurse educators should teach students about appropriate behaviors that demonstrate respect and compassion for inmate-patients. In doing so, nurse educators can facilitate students' moral development and help them learn to uphold the dignity of every person.
- American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. Retrieved from http://nursingworld.org/DocumentVault/Ethics-1/Code-of-Ethics-for-Nurses.html
- American Nurses Association. (2016). Correctional nursing: Scope and standards of practice (2nd ed.). Silver Spring, MD: Author.
- Benner, P., Sutphen, M., Leonard-Kahn, V. & Day, L. (2008). Formation and everyday ethical comportment. American Journal of Critical Care, 17, 473–476.
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Case Study of an Inmate-Patient Awaiting Surgery in an Acute Care Setting for an Orthopedic Injury, With Questions for Nursing Students
|Tom Franklin is a 32-year-old man with an acute fracture of the right tibia and fibula. The injury occurred 18 hours prior, during a basketball game. He was transferred from the state correctional facility via ambulance and was evaluated in the emergency department before being admitted as an inpatient at 3:00 a.m. Other injuries were ruled out, and Mr. Franklin was scheduled for an open reduction and internal fixation of the fractures as an add-on case to the surgical schedule. The anesthesia consent was signed, but the surgical consent still needs to be signed and the surgical site needs to be marked. Mr. Franklin's right leg was immobilized and elevated on two pillows, and the neurovascular assessment of the right lower extremity is within normal limits.
Currently, Mr. Franklin is NPO pending surgery. He stated that his only allergy to medications is penicillin, which causes “a rash.” Mr. Franklin has a past medical history of hypertension, which appears to be well controlled with a daily oral dose of hydrochlorothiazide 25 mg. Mr. Franklin's vital signs are stable. His right lower extremity pain is being managed with hydromorphone 0.5 mg intravenously every 4 hours as needed for pain of at least a 6 on a scale of 0 to 10. He has an 18-gauge peripheral intravenous catheter in his left forearm with maintenance intravenous fluids infusing at 100 mL per hour. He has a left ankle cuff and a right arm hand cuff in place, and two corrections officers are in attendance.|
|Who should sign the consent for Mr. Franklin's surgery?|
|Why does Mr. Franklin require an ankle cuff and a hand cuff?|
|What factors might have led to Mr. Franklin's diagnosis of hypertension by the age of 32?|
|Can Mr. Franklin's family visit him before or after surgery?|
|The reason(s) for Mr. Franklin's incarceration are not mentioned from this case study. Is that important information nurses must have to care for Mr. Franklin?|
|How should the nurse treat Mr. Franklin?|