With more than two million men and women in custody in American jails and prisons, there's a great need for nurses to care for the correctional population. Nurses who can cast off their biases and follow strict security rules while helping inmates restore and maintain health could find an ideal career in correctional nursing, says Mary Muse, Director of Nursing for the Wisconsin Department of Corrections. "Correctional nursing allows you to really focus on what nursing is: caring for people," she says. "If nurses want to be autonomous in their position, there's probably no better setting than correctional nursing."
Muse, a nurse for three decades, faced common misconceptions and stereotypes early in her career. Many perceive that correctional nurses aren't held to the same standards as nurses in other health care settings, such as hospitals and doctors' offices. "It was a job you took when you didn't necessarily have something else," Muse says. "This was a nontraditional health care setting." Vowing to ignore the stigma, Muse made it her mission to enhance correctional health delivery and help eliminate disparities, while making the fi eld more visible. "Nurses who practice in correctional settings have really been absent from the larger landscape of nursing," she says.
Of the many ways correctional nursing differs from nursing in a health care setting, the most obvious might be the "challenge of caring versus custody," says Ginette Ferszt, associate professor of nursing at the University of Rhode Island. While nurses come to their work from a caring science perspective, she says, the primary goal in U.S. prisons is custody and safety.
That disconnect makes the role of a correctional nurse even more important, says Pat Voermans, a correctional nurse consultant and nurse practitioner with the Wisconsin Department of Corrections. "What's so striking to me is the need of the people in these systems," she says. Inmates can't choose their providers, and correctional nurses are the gatekeepers to getting prisoners the health care they need. And, she adds, "We can't choose who we get. Sometimes we get patients who don't have the best handle on their decision making and how they interact with others. They're angry and you have to try to work with them. Trust is a really hard thing to establish with an inmate because they often see us as part of security."
Every day is different for a correctional nurse, but many of the nurse's duties are the same at jails and prisons across the country. In Connecticut, where the Department of Corrections oversees jails and prisons, intake screening is a major responsibility for nurses, says Dr. Connie Weiskopf, Director of Nursing and Patient Care Services for Correctional Managed Health Care at the University of Connecticut Health Center. Correctional nurses in the state perform about 35,000 intake screenings every year, she says, filling out a four-page document on each inmate's physical and mental health status.
In addition, correctional nurses in Connecticut administer more than one million doses of medication each year, Weiskopf says. "Many of the inmates in the system are on medication. The nurses administer medication to all the patients." Inmates who were recently released from the hospital are cared for by nurses in the prison infirmary. Other nursing duties include coordinating outside services for inmates and overseeing care management for HIV-positive patients.
When it's time for an inmate to leave prison, Weiskopf says nurses coordinate with the correctional department to facilitate the patient's discharge and arrange for continued care and medications on the outside. Nurses also run hospice units within some correctional facilities, and they can play a role in decisions on early release for ailing inmates. "Sometimes there's a great deal of effort put into compassionate releases," she adds.
Voermans, who has spent 25 years working in correctional facilities, deals with programs and policies and provides chronic disease management care to male inmates in minimum security settings. The population, often disproportionately minorities, faces chronic conditions such as obesity, diabetes, and liver disease. Lab work is done on-site, and medications are provided by the state pharmacy. With several inmates sometimes crowded into the same cell, infection control is key, Voermans says. "If you get a transmissible disease like H1N1, you've got a crisis on your hands."
Ferszt says some correctional nurses also try to help patients with mental health issues. "They also do a lot of psychosocial support," she says. Many of the women prisoners Ferszt works with in Rhode Island put in requests to get medical treatment for reasons other than physical concerns, such as anxiety related to the death of a family member.
Nurses accustomed to working in hospitals or doctors' offices might fi nd a correctional setting takes some acclimation. Correctional nurses work closely with security officers, Muse says, in an environment much more regimented than the outside. Sometimes, nurses are prohibited from even bringing a cell phone into the prison clinic. "One of the primary differences is the work environment," she adds. "It's not necessarily a warm, bright environment. It tends to be dark.
" Even the equipment available to correctional nurses might be different than in a hospital, Voermans says. While nurses in health care settings can often access state-of-the-art tools and the skills and input of other providers, that's not always the case in a correctional facility. And, in some ways, the extent of care provided might be different in a prison. "The care you give here is medically necessary care," she adds. "It's not elective care."
Weiskopf says interactions between correctional nurses and patients can take on a new quality within prison walls. While a hospital nurse wouldn't hesitate to tell a patient with a broken leg about her own similar experience, discussing such details is inappropriate in a correctional facility. "You really do not divulge anything personal to prisoners at all," she says. And while a hospital nurse might hug a patient with dementia, Weiskopf says, a correctional nurse wouldn't hug an inmate. "You really need to just focus on the care."
Correctional nurses need to maintain boundaries because of the potential for an inmate to take advantage of a health care provider, Muse says. "You have to be aware that someone might say, 'I'm really concerned about my mom. I haven't heard from my mom in a while,'" she says. While a hospital nurse might help the patient reach out to a relative, correctional nurses would be ill advised to accept a request that could lead to more demands from the inmate. Even when it comes to discussing an inmate's upcoming surgery, correctional nurses should only give family members vague details, since the inmate could be planning an escape attempt. "You have to clearly present yourself as a professional nurse," she says.
The differences between correctional nursing and nursing in health care settings can lead to challenges. When nurses can't hug or touch patients, it might be difficult to show empathy, says Arleen Lewis, a nurse consultant for infection control at the University of Connecticut Health Center Correctional Managed Health Care. Instead, correctional nurses can verbally empathize with patients grieving the loss of a loved one or reeling from a disease diagnosis. "We'll bring that patient to an area where we can maintain confidentiality," Lewis says, "and we'll allow that inmate to verbalize his or her feelings." Patients are encouraged to discuss their fears while nurses express their support and, if needed, bring in mental health clinicians.
Even routine patient interaction can prove challenging in a correctional setting, Ferszt says. When prison nurses perform tuberculosis or fl u clinics, inmates are lined up for vaccinations. But if a patient wants to speak to the provider, there's not always time for counseling. While the nurse can request for the inmate to be brought back to the clinic for a later discussion, everything moves more slowly due to facility rules and inmates' tight schedules. "You just can't be as spontaneous in your teaching," Ferszt says, "and in communicating with a woman or man when you're providing health care."
Patient privacy is another potential hurdle for correctional nurses. In private practice, Ferszt says, a quiet, calm setting is the most amenable to counseling a patient. But in a correctional facility, it can be tough to find a private room. Even then, other staff members sometimes walk in and out during a session. "You don't have the same total privacy you would in another setting," Ferszt says. The same goes for physical assessments, Voermans adds, which sometimes take place in noisy cells as patients wears chains or shackles.
Because correctional nurses work in a security setting, rather than a health care environment, they follow a different set of rules. "You're basically in the house of the department of corrections," Weiskopf says. "That means we need to obey their rules around safety." For instance, while nurses in health care settings might leave needles on the counter in a patient room, she says, correctional nurses are "constantly counting sharps."
Muse, who hasn't experienced any safety issues on the job, says it's important to be mindful of what nurses leave unattended in exam rooms. Even a seemingly innocuous roll of tape, she says, could be used as a weapon. "It doesn't mean that weapon is to be used on you. For many people, it's so they have something to protect themselves should they get in trouble."
As for Muse, she didn't consider the potential safety hazards of correctional nursing before she started the job. Walking through the correctional facility during her fi rst week, a supervisor mentioned gang activity there, surprising Muse that such affiliations existed behind bars. The supervisor also noted that nurses should greet passing inmates. "They remember the people who were kind and respectful of them," Muse says. "If you treat people with respect, generally you get that back."
Despite the challenges of correctional nursing, the compliance rate, at least anecdotally, is sometimes better among the prison population, says Michael Ajayi, a prison administrator and regional nurse manager, and clinical faculty member at the University of Medicine and Dentistry of New Jersey. "I'm sure many of them know they get good care," he says. "They respond better to therapy than patients who are on the outside."
It's estimated that African American and Hispanic prisoners account for more than 60% of the inmates in jails and prisons, according to the Bureau of Justice Statistics. Although the prison population is quite diverse, that isn't always the case with the staff of correctional nurses. "You see more minority inmates," Ajayi says, "but almost all the nurses working with them are Caucasian."
Correctional nurses should be conscious of this diversity and treat all inmates with respect. "With people from so many different places immigrating to our country," Ferszt says, "we really need to work on becoming culturally aware." Patients with certain cultural backgrounds might resist taking medication due to their beliefs, while others turn to herbs for healing. Just as in a traditional health care facility, nurses working in corrections should make an effort to understand those beliefs and find ways to work with patients. "It requires a nurse to be proactive and comfortable seeking out individuals from different backgrounds."
Because correctional nurses work with a disproportionate number of incarcerated minorities, Voermans says health issues particular to the groups might be more likely inside prisons than on the outside. The correctional population sometimes faces higher rates of HIV/AIDS, hepatitis C, MRSA, and even infectious diseases. Working with minorities means correctional nurses can serve as advocates, shining a light on health issues that afflict certain populations more frequently. One example she mentions is sickle cell disease in black patients. Muse also encourages correctional health care providers to consider the unique needs of female prisoners who are sometimes forgotten in the male-focused field. "For a patient to see a minority nurse they can connect to that might advocate for their health is helpful," she says.
Since language is sometimes a barrier, Weiskopf says health education materials are often available in English and Spanish. Many correctional nurses have access to a language translation line and chaplains of various religions. Her unit has mandatory diversity training for staff. "We try to be culturally sensitive," she adds.
Not everyone is cut out for correctional nursing. "It's important to be someone who wants to serve that population," Ferszt says. "Nurses need to, like anyone, examine their own potential biases toward that population." Voermans adds that patients can experience bad medical outcomes when their complaints aren't taken seriously by medical personnel. And as for the nurses, "If they don't like the disadvantaged and the poorest, they shouldn't be there," Ferszt says.
Correctional nurses should be generalists, Muse says, but also ready to cross over into specialty areas. "In correctional nursing, you never know how your patient is going to present." Correctional nurses should be poised to leap from oncology to mental health at a moment's notice, Muse adds. Critical-thinking skills and a strong background in nursing assessment are also key. Ferszt says there are other important traits for correctional nurses, including flexibility and the ability to maintain good working relationships with correctional officers and administrators. "The system can be very frustrating because of its structure. You need someone who can be really flexible."
It's sometimes tough to recruit new nurses to corrections. But despite the challenge, Muse says, it's just as important to recruit the right type of nurse, especially to correctional leadership positions. "There is a need to have minorities in more leadership roles," she adds. Opportunities within the correctional nursing field include positions for advanced practice providers, nurse practitioners, managers, quality assurance personnel, juvenile nurses, and more. For nurses who feel ready for the challenge of practicing in a correctional facility, Ferszt says there's an unending opportunity to do good for patients. "By realizing the issues they deal with, we can become better advocates for them in the community and change health care," she says. "There's an opportunity to make a real, significant impact."