The health of inmates impacts the community around them because approximately 98% of individuals incarcerated eventually return to the community (Ruddell & Tomita, 2008). Inmate health extends beyond criminal justice systems and becomes a public health matter (Kuhlmann & Ruddell, 2005); attempts to tend to inmates’ health needs become a public health necessity (Williams, 2007). In addition, 25% of inmates experience high rates of mental health problems (Wilber et al., 2009). In 2007, it was estimated that more than 2 million individuals with severe mental illness were incarcerated in the United States (Steadman, Osher, Robbins, Case, & Samuels, 2009). According to the Bureau of Justice Statistics (Maruschak, 2006), 64% of local jail inmates had a mental health problem and, based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) criteria, 60% had symptoms of a mental health problem. Of the local jail inmates with a mental health problem, 76% depended on or abused drugs or alcohol. The purpose of the current article is to describe the methodology used for conducting research in a jail setting.
Individuals with mental illness are over-represented in the jail population and examining the extent of these higher rates is the first step to developing policy and interventions to provide appropriate and effective treatment. Previous research has found increased levels of problem and pathological gambling in incarcerated individuals (Binswanger, Krueger, & Steiner, 2009; Williams, Royston, & Hagen, 2005). A review of the literature revealed increased rates of problem gambling and decreased levels of perceived health in incarcerated populations (Binswanger et al., 2009; Williams et al., 2005). Although some research was found regarding prison populations, there was a dearth of literature examining gambling and health in jail populations.
Williams et al. (2005) reported that an average of 33% (range = 26% to 100%) of individuals in custody met the criteria for problem or pathological gambling. However, Turner, Preston, Saunders, McAvoy, and Jain (2009) studied Canadian male federal prisoners and found a lower prevalence (13%) of disordered gambling. In the current authors’ original study (Hickey, Kerber, Astroth, Kim, & Schlenker, 2014), 184 inmates were surveyed regarding gambling behavior and perceived health using the South Oaks Gambling Screen (Lesieur & Blume, 1987) and Short Form 36v2 Health Survey (Ware, Kosinski, & Gandek, 2005). The prevalence of problem and pathological gambling was 35%; among individuals who scored in the problem and pathological range, only 23% specified they had a gambling problem (Hickey et al., 2014). Although perceived health scores showed no significant differences between recreational gamblers and problem and pathological gambler groups, scores were significantly lower compared to U.S. norms (Hickey et al., 2014). In addition, although it is evident inmates experience higher rates of problem or pathological gambling, rates of other behavioral addictions in jails are unknown. Statistics related to incarcerated individuals with mental illness are generally reported from the correctional system’s perspective.
To provide effective care, mental health nurses must understand and respect the needs, attitudes, and concerns of their clients (Lakeman, 2012). The first step to providing effective care for inmates could be to ask about their experiences with mental illness and addictions. However, conducting research in a prison may be challenging. Although it may be difficult or unpopular to conduct research with the jail population (Williams, 2013), it is important to understand the needs of this vulnerable group and create effective interventions to promote their mental and physical health.
In the current article, learned information and strategies to promote successful research projects with county jails in the future are described. To accomplish this, the context of the original study is provided, followed by a presentation of learned strategies in conducting secure, respectful, and beneficent research in a jail environment.
Research in a County Jail
Establishing Relationships and Environmental Assessment
The primary investigator (PI) of the original study (K.L.H.) became familiar with the field of corrections nursing when she used a jail site to expose undergraduate community health nursing students to diverse areas of nursing practice. While scheduling tours, the PI discussed with the jail captain and clinic site manager the possibilities of conducting research in this setting. Several informal meetings were held over 2 years, which established a relationship of trust and reliability prior to beginning research. When the current authors formally met to discuss details of methodology and access to the population, there was a shared goal of helping these vulnerable individuals. The PI obtained university institutional review board (IRB) approval and the jail captain and jail clinic site manager assisted in planning how data from inmates would be collected safely and securely.
Prior to beginning research, the PI familiarized herself with the jail environment through discussions with jail staff and reading articles from corrections journals as well as articles discussing previous research experiences in locked environments. The PI visited the jail seven times over 2 years while taking undergraduate community health nursing students on tours. During the tours, the PI and students asked questions regarding the jail’s daily operations, safety of staff, and how health care was delivered in this environment. They were shown most areas of the jail, including the booking area, medical unit, kitchen, classrooms, and an empty housing unit.
Entry into the jail was granted by the jail captain, who obtained permission for the conduct of research from the county sheriff’s office. The current authors agreed on a day and time that was most convenient for the jail staff. The PI entered the jail through metal detectors and several locked doors, then signed in at the visitation desk, leaving her driver’s license as identification. Admittedly, the PI had reservations about safety the night prior to visiting. When the PI arrived at the jail on research day, these concerns were discussed with the jail captain. Safety was assured and an officer accompanied the PI at all times throughout the day.
Throughout the data collection process, the jail captain and a female corrections worker accompanied the PI. It was stressful when initially entering the first housing unit and introducing the research to approximately 200 male inmates. However, having the IRB informed consent script to read helped and most inmates were responsive to the information. Some inmates asked questions about why the PI was conducting the research and wished the PI luck with studies, whereas others never looked up from their card games. On one housing unit, which had been on lockdown for an extended period of time, most inmates appeared drowsy and uninterested; few inmates participated from this unit.
Initial Contact With Inmates. On the day of the visit for data collection, the total jail census was 1,111; however, 363 inmates were away in court or housed in high security areas (i.e., maximum security, segregation, and mental health units) and did not have the opportunity to participate (jail captain, personal communication, July 2012). The PI worked with the jail captain to choose a date and time for data collection when most inmates would be available. Meal times and dates when largely attended classes or meetings were offered (i.e., General Education Development classes, Alcoholics Anonymous®, or religious courses) were avoided. The PI had the opportunity to introduce the research study to 748 inmates on the day of data collection. After introducing the study and reading the informed consent document aloud, 323 inmates accepted surveys and took a packet containing all of the surveys and a sealable return envelope. Participants had 1 hour to complete the surveys. The PI was available to answer questions or provide assistance with surveys. No participants requested additional time and most completed the surveys within 40 minutes.
Safety Precautions. Metal objects are prohibited in jail, so survey packets did not include staples and envelopes were self-sealing. Survey pages were kept together with a no-staple stapler purchased from an office supply store. Pens acceptable for use in housing units were provided by jail administration. The jail captain warned the PI that all surveys might not be returned, as the inmates would want to keep the paper and envelopes as commodities. Eighty envelopes were not returned and 22 were returned empty, perhaps due to the value of stationary as a commissary item.
Limited subject selection due to the secure environment was a concern as internal validity was threatened. Internal validity refers to the extent to which it is possible to determine if the independent variable is influencing the dependent variable (Polit & Beck, 2012). Although the current study was non-experimental, threats to internal validity, such as selection and history, were possible (Polit & Beck, 2012). Data collection was only allowed in the general housing units and kitchen. History threats to validity may include extraneous events, such as any events that occur in jail life; health changes (positive or negative) that may be due to imprisonment; or the jail environment, which may increase or decrease exposure to gambling.
Upon entering every housing unit (except for the one on lockdown), inmates were in groups playing card games. After the PI announced gambling as a research topic, many inmates laughed and smiled; the PI interpreted this response to indicate that gambling is a prevalent activity in jail. One survey was returned stating that there is nothing else to do but gamble while in jail. Inmates approached the PI to voice concerns about lack of health care services, whereas others said they were receiving health care and staying clean while in jail. It was noted that each housing unit had a culture of its own, which the jail captain said is often dictated by the housing units’ officers, and this may have affected if and how inmates responded to the surveys.
The PI found that maintaining a neutral position toward the inmates and correctional staff was difficult. The PI could not be perceived as favoring the inmates or correctional staff and it was easy to unintentionally do both. Preparation work completed with the jail captain in terms of schedule and procedure assisted in keeping a neutral position with the staff, who had been informed of the PI’s arrival and reasons for being in the jail ahead of time. As for the inmates, it was important to keep to the script when addressing the groups and introducing the study. Questions arose regarding inmate health care and information was reiterated that surveys were not being used to report on quality of health care services.
Reflections on the Day
Upon leaving, the PI had mixed emotions. She felt a sense of satisfaction in the work and personal enrichment from the experience, and that there were so many more possibilities for nurse researchers with this population. The PI wondered what effect input from the inmates who did not participate, such as those in maximum and segregation housing, psychiatric and medical housing, and those in court, would have had on results. What future research studies could promote and protect the health of inmates? The PI was also happy to leave the jail and was appreciative of her freedom even more; the experience provided a new perspective on life inside a locked environment. Although exhilarated, the PI was also emotionally exhausted from a long day of collecting data and listening to inmate stories about health care and gambling experiences. The PI called her dissertation chair after data collection to debrief on the day’s experiences.
The current research project was a rewarding experience. The jail staff were supportive and accommodating even though the study added work to an already busy day. For the most part, inmates were receptive to participating and polite; at no time did the PI feel her safety was threatened. Although the research is complete, the PI continues to maintain contact with the jail captain to let him know progress on articles resulting from this research and to offer to attend correctional conferences to present the research.
Implications for Nursing Research
There are several key components to successfully conducting research in a jail environment to be gleaned from the current research. First, good interpersonal skills are important to build and maintain relationships with jail administration and health care providers. Second, knowledge of daily jail operations, such as meal schedules, court times, inmate movement, and access to health care resources, prior to beginning jail research demonstrates respect for the environment and the need to maintain safety measures. Researchers are a source of extra work for jail personnel; knowing what is not acceptable, such as staples or gifts, alleviates additional work for jail personnel so they can focus on security. Third, flexibility and having a grateful attitude toward inmates and corrections staff is appreciated by forensic personnel. Collaborative, trusting, and reliable relationships were important to the success of the research. Research in a secure environment (e.g., a county jail) has unique challenges, such as gaining access, maintaining security, ensuring research rigor, and weathering unpredictable events. However, the current authors hope that the information provided will encourage and assist nurse researchers to conduct studies in this environment to gain a wider understanding of mental health issues affecting this vulnerable population.
Further behavioral addictions research with inmates will add to nursing knowledge and assist creating effective interventions for incarcerated individuals, thereby improving the potential for releasing inmates back into society healthier than when they arrived. Ideas for further behavioral addictions research in the incarcerated population include: determining the extent to which disordered gambling is under-diagnosed and untreated and if it is correlated with substance addictions.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
- Binswanger, A., Krueger, P.M. & Steiner, J.F. (2009). Prevalence of chronic medical conditions among jail and prison inmates in the USA compared with the general population. Journal of Epidemiology and Community Health, 63, 912–919. doi:10.1136/jech.2009.090662 [CrossRef]
- Hickey, K., Kerber, C., Astroth, K., Kim, M. & Schlenker, E. (2014). Gambling and perceived health among adult inmates. Journal of Forensic Nursing, 10, 36–43. doi:10.1097/JFN.0000000000000019 [CrossRef]
- Kuhlmann, R. & Ruddell, R. (2005). Elderly jail inmates: Problems, prevalence, and public health. California Journal of Health Promotion, 3, 49–60.
- Lakeman, R. (2012). What is good mental health nursing? A survey of Irish nurses. Archives of Psychiatric Nursing, 26, 225–231. doi:10.1016/j.apnu.2011.10.005 [CrossRef]
- Lesieur, H.R. & Blume, S.G. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gambling. American Journal of Psychiatry, 144, 1184–1188. doi:10.1176/ajp.144.9.1184 [CrossRef]
- Maruschak, L.M. (2006). Medical problems of jail inmates. Retrieved from http://www.bjs.gov/content/pub/pdf/mpji.pdf
- Polit, D.F. & Beck, C.T. (2012). Nursing research: Generating and assessing evidence for nursing practice. Philadelphia, PA: Lippincott Williams & Wilkins.
- Ruddell, R. & Tomita, M. (Eds.). (2008). Issues in correctional health. Richmond, KY: New-gate Press.
- Steadman, H.J., Osher, F.C., Robbins, P.C., Case, B. & Samuels, S. (2009). Prevalence of serious mental illness among jail inmates. Psychiatric Services, 60, 761–765. doi:10.1176/ps.2009.60.6.761 [CrossRef]
- Turner, N.E., Preston, D.L., Saunders, D., McAvoy, S. & Jain, U. (2009). The relationship of problem gambling to criminal behavior in a sample of Canadian male federal offenders. Journal of Gambling Studies, 25, 153–169. doi:10.1007/s10899-009-9124-1 [CrossRef]
- Ware, J.I. Jr.. , Kosinski, M. & Gandek, B. (2005). SF-36 health survey: Manual and interpretation guide. Lincoln, RI: Quality Metric.
- Wilber, A.P., Woolhandler, S., Boyd, J.W., Lasser, K.E., McCormick, D., Bor, D.H. & Himmelstein, D.U. (2009). The health and health care of US prisoners: Results of a nationwide survey. American Journal of Public Health, 99, 666–672. doi:10.2105/AJPH.2008.144279 [CrossRef]
- Williams, D.J. (2013). Gambling in jails and prisons: Abstinence or management?Journal of Gambling Issues, 28, 1–4. doi:10.4309/jgi.2013.28.12 [CrossRef]
- Williams, N. (2007). Prison health and health of the public: Ties that bind. Journal of Correctional Health Care, 13, 80–92. doi:10.1177/1078345807301143 [CrossRef]
- Williams, R.J., Royston, J. & Hagen, B.F. (2005). Gambling and problem gambling within forensic populations: A review of the literature. Criminal Justice and Behavior, 32, 665–689. doi:10.1177/0093854805279947 [CrossRef]