Scope of Correctional Nursing Practice
“Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2010, p. 1). Nursing is both a science and an art, the essence of which is caring for and respecting human beings, including those in the correctional environment.
Correctional nursing is the protection, promotion, and optimization of health and abilities; prevention of illness and injury; alleviation of suffering through the diagnosis and treatment of human response; advocacy for and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system.
Although the primary mission in correctional settings is to ensure the security and safety of inmates, staff, and the public, the primary role of nurses in correctional environments is, and has always been, the delivery of nursing care to inmates who are or may become patients. Within this environment, correctional nurses provide safe and competent nursing care, provide health education, and respond to and advocate for the healthcare needs of patients. The term inmate is used throughout this specialty scope and standards document to identify the individual who is under the jurisdiction of the criminal justice system. The term patient identifies an inmate who is a consumer of healthcare services provided within the correctional system.
The History of Nurses within the Correctional Environment
The history of correctional nursing in America began as early as 1797 with the opening of New York City’s Newgate Prison. Its warden, Thomas Eddy,
believed that criminals could be rehabilitated, and he established a school for the inmates as well as the first prison hospital and pharmacy.
believed that criminals could be rehabilitated, and he established a school for the inmates as well as the first prison hospital and pharmacy.
During the 1800s, Dorothea Lynde Dix, a humanitarian, reformer, educator, crusader, and nurse best known for her strong advocacy for the mentally ill and prisoners, initiated reform in the prison setting (Reddi, 2005). She traveled throughout the country visiting prisons, meeting with wardens, and evaluating the various systems for effectiveness (Kokontis, 2007). Dorothea Dix described scenes of prisoners tied in chains, lying in their own filth with inadequate clothing, food, and light (Reddi, 2005). In 1845, Dix wrote “Remarks on Prisons and Prison Discipline in the United States” (Reddi, 2005). This work discussed the reforms she wanted the government to implement, including the education of prisoners and the separation of various types of offenders (Reddi, 2005). In spite of Dix’s work, nursing remained unavailable in correctional facilities for quite some time. Instead, matrons, inmates, and corrections officers doled out inexpert medical care in dingy, unsanitary, and in most cases deplorable conditions (Sloan & Johnson, 2012).
November 1976 could be deemed the official start of the profession of correctional nursing (Schoenly, 2011). This was the date of the famous Supreme Court case Estelle v. Gamble (429 U.S. 97), which established health care as a constitutional right for U.S. inmates based on the Eighth Amendment (forbidding cruel and unusual punishment) (Schoenly, 2011). Correctional nursing began to gain increased visibility toward the end of the 20th century.
Rena Murtha, a pioneer in correctional nursing, described entering a large correctional facility where the nurse was perceived as a “tool of the warden, a slave of the physician and unknown to the patient” (1975). Since that time, correctional nursing practice has evolved into a variety of essential roles ranging from primary health care, mental health services, hospice, telemedicine, geriatrics, discharge planning, and chronic care management to management and administration. Today’s correctional nurse is a valued and respected member of the correctional healthcare team.
Nursing in correctional settings is mentioned twice in the Institute of Medicine’s report titled The Future of Nursing: Leading Change, Advancing Health (IOM, 2011). Both references make the point that nursing is diverse and that nurses will be present anywhere there are people who have healthcare needs. Dorothea Dix, Rena Murtha, and the nurses in correctional facilities today demonstrate passion, devotion, and advocacy in caring for an underserved and disenfranchised population that is, more often than not, forgotten by the public.
Health Care in Correctional Settings: A Brief Historical/Legal Perspective
Through most of the country’s history, correctional settings in the United States provided little to no health care to inmates. As a result, inmate health outcomes were dismal. Courts rationalized the “hands-off” approach regarding correctional health care issues with (1) jurisdictional reasons and (2) respect for states’ sovereignty to administer and operate correctional facilities within their borders. Thus, administrators in correctional settings had enormous freedom, with little regulation of, accountability for, or judicial oversight of daily operations that had an impact on inmates’ health. The lack of self-regulation and judicial oversight spawned a rising number of prisoner petitions for relief from negative healthcare conditions of their confinement [Coppinger v. Townsend, 398 F.2d 392 (10th Cir. 1968); Holt v. Sarver, 442 F.2d 304 (8th Cir. 1971); Martinez v. Mancusi, 443 F.2d 921 (2d Cir. 1970); Nelson v. Heyne, 491 F.2d 352 (7th Cir. 1974); Newman v. Alabama, 349 F. Supp. 278 (M.D. Ala. 1972), aff’d, 503 F.2d 1320 (5th Cir. 1975)]; these forced courts to develop appropriate standards of judicial review for health care in correctional settings.
Finally, in 1976, the U.S. Supreme Court initiated development of the proper standards in the landmark case of Estelle v. Gamble (429 U.S. 97). Texas Department of Corrections inmate Gamble alleged that prison officials inflicted undue suffering on him when they failed to provide adequate health care for an injury he sustained in 1973 while incarcerated. The Supreme Court held that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ … proscribed by the Eighth Amendment” (Estelle, 429 U.S. at 104). Thus, the Estelle decision gave judicial recognition to inmates’ constitutional right to health care. Estelle also established a two-pronged national standard of judicial inquiry: (1) Did prison officials manifest “deliberate indifference” to offenders’ medical needs?, and (2) Were those medical needs “serious”? (Posner, 1992). This national correctional healthcare inquiry standard applies whether the deliberate indifference is manifested by correctional healthcare providers in their responses to inmates’ healthcare needs or by correctional officials who intentionally deny or delay access to health care or intentionally interfere with prescribed healthcare treatment (Blair, 2000).
The Estelle decision established the following Eighth Amendment constitutional rights for inmates related to health care:
The right to access care
The right to professional judgment
The right to prescribed healthcare treatment
Judicial inquiry utilizing the constitutional standard established in Estelle v. Gamble has led to positive restructuring of correctional healthcare systems throughout the United States. Development of case law and national standards on correctional health care have affirmed that prisoners are entitled to receive at least a minimally acceptable standard of health care (Blair, 2000). Nurses, the largest group of healthcare providers in the correctional setting, play a pivotal role in providing ethical care that meets acceptable minimum standards.
PREVALENCE OF CORRECTIONAL NURSES
The National Sample Survey of Registered Nurses, performed every four years by the Health Resources and Services Administration (HRSA), has reported on the number of nurses working in correctional settings since 2000. The most recent survey, completed in 2008, estimated that 20,772 registered nurses (0.8% of all registered nurses) reported that their primary employment setting was in a correctional facility (HRSA, 2010). The percentage of correctional nurses reported in 2008 remained unchanged from surveys completed in 2000 and 2004 (HRSA, 2000, 2004). The number of advanced practice registered nurses (APRNs) who provide clinical services within correctional settings remains unknown.
Correctional nurses, the American Nurses Association (ANA), and other stakeholders believe that the HRSA report underrepresents the number of nurses who work in correctional settings. First, the primary employer of a correctional nurse may be a university, county health department, private/for-profit ambulatory care agency, or home health organization that has been engaged to provide health care at a correctional facility. Second, the organizational unit may be a licensed hospital within a correctional system, or a hospital or clinic operated by the federal government that provides care for inmates or detainees. Third, many experienced correctional nurses have more than one employer, especially if they prefer a part-time or intermittent schedule.
No national organization regularly and reliably collects information on the number and characteristics of correctional nurses. Currently there is no accurate picture of the nursing workforce, despite a National Council of State
Boards of Nursing recommendation for standardizing the collection of these data. The National Forum of State Nursing Workforce Centers identifies correctional nursing in the National Nursing Workforce Minimum Datasets. If the recommended data sets are adopted by states, more data on correctional nursing will be available to describe the specialty.
Boards of Nursing recommendation for standardizing the collection of these data. The National Forum of State Nursing Workforce Centers identifies correctional nursing in the National Nursing Workforce Minimum Datasets. If the recommended data sets are adopted by states, more data on correctional nursing will be available to describe the specialty.
Some consider correctional health care to be the last frontier of modern medicine, as the level of care given to those imprisoned can reflect the success of medicine, the effectiveness of legislation, the progress of nursing practice, and the advancement of society itself (Sloan & Johnson, 2012). As the correctional system grows and continues to evolve, correctional nurses will remain advocates to ensure that the patient is in an optimal state of physical and mental health to become a productive citizen upon return to the community.
POPULATION SERVED BY CORRECTIONAL NURSES
After three decades of soaring growth, incarceration rates in the United States have decreased. However, the United States continues to lead the world in rates of incarceration. At the end of 2009, 7.2 million people were on probation, parole, or in correctional facilities (Pew Center on the States, 2008).
The dramatic increases in the inmate population stem from policies aimed at punishing violations of parole and extending sentences, and from legislation requiring longer sentences. The war on drugs added to this explosive growth, with 73-83% of inmates reporting past drug use and 13-20% reporting injection drug use (Pew Center on the States, 2008;).
A view of the persons affected by imprisonment is disconcerting. Ethnic minorities are greatly overrepresented in correctional populations. African American males are incarcerated at rates nearly six times that of whites, and Hispanic males are incarcerated at nearly twice the rates of white males (Mauer & King, 2007).
The health needs of both adult and juvenile inmates are greater than they were a decade ago. The majority of the correctional population comes from disadvantaged backgrounds and socioeconomic groups associated with poverty and lack of access to regular healthcare services. Histories of excessive risky behaviors, trauma, alcohol and drug abuse, cigarette smoking, and poor diets prevail (Centers for Disease Control and Prevention [CDC], 2011). Not surprisingly, chronic diseases are also prevalent among these groups, with hypertension, diabetes, cardiovascular disease, obesity, and viral infections reported to be more common among inmates than the general population [Wilper et al., 2009; National Commission on Correctional Health Care (NCCHC), 2002; Binswanger, Krueger, & Steiner, 2009]. Additional challenges
to healthcare delivery include lower literacy skills and educational attainment among inmates in correctional settings as compared to household populations (U.S. Department of Education, 1994).
to healthcare delivery include lower literacy skills and educational attainment among inmates in correctional settings as compared to household populations (U.S. Department of Education, 1994).
Communicable diseases are of great concern in this country’s often overcrowded and antiquated correctional facilities, because diseases are easily transmitted in these closed settings. The prevalence of human immunodeficiency virus (HIV), hepatitis C (HCV), hepatitis B (HBV), tuberculosis, and other infectious diseases is higher among inmates than in the general population (Hammett, 2006), a fact that presents challenges in the provision of care and discharge planning for the inmate who is a patient. Currently, it is estimated that approximately 150,000 HIV-positive persons are being released annually from U.S. correctional settings; these persons need reentry initiatives to prevent risky behaviors, obtain medications, and provide continuity of care (Rich et al., 2011).
Incarcerated persons represent the largest group to be infected with HCV in the United States, with an estimated prevalence of 12-35% as compared to 1-1.5% of the general population (CDC, 2012). It is becoming a leading cause of illness and death in some correctional settings (HCV Advocate, 2003).
Overcrowded and cramped quarters in correctional settings are also conducive to the rapid spread of other infectious diseases, such as influenza, scabies, and community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections. There have been a number of CA-MRSA outbreaks in correctional settings among inmates after incarceration; these occurrences have prompted improvement in infection control practices and the development of treatment guidelines specific to prisons and jails to prevent disease spread (CDC, 2003; Malcolm, 2011).
Tuberculosis (TB) is particularly problematic for correctional facilities. The CDC (2006) indicates that the incidence of new TB cases among the U.S. population has remained at less than 10 cases per 100,000 persons since 1993, compared to substantially higher case rates reported in correctional populations. Latent TB infection (LTBI) prevalence among inmates may be as high as 25%.
Specialized populations, such as older adults, women, and juveniles, represent a smaller portion of the incarcerated population, but have unique characteristics that pose significant challenges to appropriate care in correctional facilities. Nevertheless, for some incarceration provides a window of opportunity to address health needs and improve health conditions.
The older-adult inmate cohort is increasing due to longer sentencing requirements (Pew Center on the States, 2008). This group suffers from age-related conditions earlier in life. Personal histories of poor nutrition, lack of preventive care, and high-risk behavior such as smoking and drug and alcohol use make a 50-year-old inmate’s health status comparable to that of a 65-year-old living in the community (Smyer & Burbank, 2009). Related functional limitations, dementia, mobility deficits, incontinence, hearing and visual impairments, and chronic illnesses create special needs that are challenging for correctional settings to address, and often require nursing care and support that may not be necessary for other inmates. Frail elderly inmates may also be vulnerable to being preyed on by younger, stronger inmates (Loeb & AbuDagga, 2006).
Women are the fastest-growing segment of the correctional population. More than 200,000 women were in correctional settings, and more than 1 million were on parole in 2007, which represents an 800% increase over the past three decades (Pew Center on the States, 2008). Nearly two-thirds are incarcerated for nonviolent offenses, many of which are drug-related. The majority of incarcerated women are under the age of 35, with women of color being disproportionately represented. Histories of drug and alcohol abuse, sexual violence, trading sex for money or drugs, multiple sexual partners, sexually transmitted infections, and pregnancies in early adolescence put them at high risk for chronic and communicable diseases (Anno, 1997; Baral Abrams, Etkind, Burke, & Cram, 2008). Many are not married, do not have a high school education, and were unemployed before incarceration. Four percent are pregnant upon incarceration, and many of these pregnancies are classified as high risk [Women’s Prison Association (WPA), 2009]. Incarcerated women are reported to have higher rates of diabetes, HIV, and sexually transmitted diseases, as well as higher rates of serious mental illnesses, drug abuse, depression, and other emotional problems in comparison to the male population. This results in female offenders using healthcare services more frequently than their male counterparts (Goldkuhle, 1999).
Juveniles confined to detention facilities are considered to be a highrisk group with many unmet developmental, medical, and mental health needs. Despite their youth, these individuals may present with one or more chronic illnesses, such as diabetes, asthma, seizure disorders, and learning and developmental disabilities. Approximately 11 million juveniles (under the age of 18 years) were arrested in 2008. Of those, 10% were referred to adult courts. Females make up about one-third of the juvenile arrests. As in the adult population, racial differences are evident, with the majority coming from impoverished backgrounds and single-parent households, with low levels of
educational attainment, and histories of high risk-taking behaviors [Office of Juvenile Justice and Delinquency Programs (OJJDP), 2011]. Although their general health needs mirror those of their counterparts in the community, these youths have specific health problems resulting from their backgrounds and risky behaviors of violence, substance abuse, and sexual activity. Youths in confinement facilities have the highest rates of sexually transmitted infections (STIs) in the nation. Other health problems include traumatic injuries, significant dental needs, and higher pregnancy rates than their nonincarcerated peers (American Academy of Pediatrics, 2011). Suicide is a major public health concern among adolescents, in particular for those in confinement (American Academy of Pediatrics, 2011; Hayes, 2009).
educational attainment, and histories of high risk-taking behaviors [Office of Juvenile Justice and Delinquency Programs (OJJDP), 2011]. Although their general health needs mirror those of their counterparts in the community, these youths have specific health problems resulting from their backgrounds and risky behaviors of violence, substance abuse, and sexual activity. Youths in confinement facilities have the highest rates of sexually transmitted infections (STIs) in the nation. Other health problems include traumatic injuries, significant dental needs, and higher pregnancy rates than their nonincarcerated peers (American Academy of Pediatrics, 2011). Suicide is a major public health concern among adolescents, in particular for those in confinement (American Academy of Pediatrics, 2011; Hayes, 2009).
Many inmates, including juveniles, are parents. In 2007, 65,600 women in custody reported being mothers, and 77% of these reported being the primary caretakers of their children (WPA, 2009). Incarceration results in abrupt separation from family, which can have a traumatic impact on the inmate’s psychosocial and mental health during incarceration, and present challenges for the reestablishment of relationships when the inmate is released back to the community (Pew Center on the States, 2008).
Correctional settings have been dramatically affected by the deinstitutionalization of persons with mental illness in the community over the past decades; this trend has caused a tremendous increase in the numbers of inmates who have major psychiatric disorders. The new therapies, decreased insurance reimbursements, and tightened state and local healthcare budgets have resulted in decreased lengths of stay and a drastic reduction in the number of state and county mental hospitals and inpatient beds. Lack of available community financial and social system supports often results in persons with mental illness becoming nomads who eventually end up residing, in ever-increasing numbers, in America’s correctional settings. The percentage of inmates with serious mental illnesses has nearly tripled in the past three decades. Estimates indicate that 16-20% of correctional populations are suffering from major psychiatric disorders and require mental health services (Fuller, Kennard, Eslinger, Lamb, & Pavle, 2010). Although many correctional facilities employ mental health staff, such as psychiatrists, psychologists, and other mental health workers, it is important for correctional nurses to build knowledge and skills that support nursing care for this population.
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