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Scope and Standards: Trends and Issues in Correctional Nursing

The Correctional Nursing Scope and Standards is a document that defines and guides the specialty practice of nursing in the criminal justice system. A key section of the scope of practice is dedicated to identifying trends and issues that affect our particular specialty. Here is a synopsis of the issues and trends facing correctional nurses today.

Key Issues of Correctional Nursing Practice

Poor health status of patient population: Incarcerated patients are less likely to be effectively managing chronic illness and more likely to have an infectious condition than the general population.
Volume of healthcare services utilized: The poor health status of the patient population combined with high rates of mental illness contribute to high use of health care services while incarcerated.
Conflicts with security: A correctional facility is arranged and managed to maximize safety for the public, staff, and other inmates. Health care goals can conflict with security goals, requiring superior advocacy skills.
Correctional environments: Many correctional facilities are older and in need of significant upgrading. This living environment can be unhealthy and contribute to worsening health conditions.

Response to Key Issues

The following actions are suggested to deal with these issues.

Partner with health providers from the community: Collaboration across the health care continuum is necessary to improve the poor health status of the patient population.
Build partnerships: A team approach is needed to overcome environmental and security barriers to health care delivery.
Commit to caring for patients with mental illness: Government entities must come to terms with the mental health needs of the incarcerated. Resources must be invested in behavioral health and substance abuse programming both in-custody and at re-entry.
Screen, test and treat for infectious disease: Screening tests and treatment of infectious diseases is needed in every U.S. prison and jail, in collaboration with the public health departments.

Future Trends

New Technology: Technological advances such as telehealth and electronic medical records can assist in managing health care in a secure setting. Telehealth for specialist appointments increases patient access while decreasing public safety issues in moving patients outside the correctional setting. Electronic medical records, especially when connected to the local health system, can improve continuity of care when incarcerated patients are released or when patients enter the correctional system.
Administrative Segregation: While separating dangerous or vulnerable inmates from the general population in a correctional facility is part of safe correctional practice, a growing body of evidence indicates the far-reaching dangers of this practice to the health and well-being of the patient population. The National Commission on Correctional Health Care recently published a position paper on the need to reduce the use of segregation and isolation due to the negative health effects of the practice.
Collaboration and Entrepreneurship: Correctional health care systems are challenged to collaborate both within and without the criminal justice system to provide the continuum of care necessary for today’s incarcerated patients.

Do you agree with these trends and issues for our specialty? Share your thoughts in the comments section of this post.

This post is part of an ongoing series discussing key components of the Correctional Nursing Scope and Standard of Practice, 2^nd Ed. Review prior posts in this series here. Purchase your own copy of this highly recommended book through Amazon.

Scope and Standards: Principles to Guide Correctional Nursing Practice

By Lorry Schoenly

It has been a while since my last post on the Correctional Nursing Scope and Standards. Time to think again about the foundations of our professional practice in the criminal justice system. The scope of our correctional practice is guided by principles of our profession that transcend location or patient population. These 11 principles of correctional nursing practice remind us of just how values-driven our practice must be.

1-Primary Duty to the Patient: We have a therapeutic duty to our patient at all times. This duty is to restore and maintain health, prevent illness, and promote health and wellness through education. Our duty is not to become part of security or to deliver punishment.

2-Interprofessional Collaboration: Not only must we collaborate among other health professions to fulfill our primary duty, but we must strive to include our officer colleagues in our health mission.

3-Encouraging Health Care Responsibility: Our patients will not always have us around to keep them healthy. More than 95% of them will leave the correctional facility. We have a duty to encourage responsibility for health maintenance.

4-Professional Patient Encounters: As correctional nurses we struggle to maintain the balance of care and compassion while being mindful of professional boundaries with a risky patient population.

5-Treating Patients with Dignity and Respect: The general population (and sometimes our officer colleagues) does not think very highly of our patients. It can be easy to absorb this perspective. Yet, our calling is to treat all patients with dignity and respect.

6-Patient Confidentiality: Preserving patient confidentiality can be a challenge when nursing care must be delivered cell-side or with an officer present.

7-Cost-Effective Quality Care: Keeping up with the latest evidence-based practice concepts is important for correctional nursing practice; as is keeping costs down and creatively using available resources.

8-Including Family and Significant Others in Care: While family and significant others may be absent from the correctional practice setting, they are still an important part of nursing practice. Engaging family to encourage health promotion and keeping them informed of health status is a priority.

9-Collaboration with Correctional Staff: Like principle two, this principle emphasizes the contribution of security administration and staff to the health of our patient population. Good working relationships among officer and health care staff improve the delivery of health care in any correctional facility.

10-Encouraging Life-long Learning: There is always something new to be learned in correctional nursing. However, there is always a time crunch, as well! Encouraging life-long learning needs to be a part of our personal practice and, hopefully, supported by our leaders.

11-Contributing to New Knowledge: Research into improved correctional nursing practices is needed to continually grow as a specialty.

As you can see, these principles would be helpful to guide any professional nursing practice. They are, however, vital for practicing professionally in the criminal justice system. When faced with a decision about how to respond in a risky situation in the correctional setting, these 11 principles can shine a light on the best path to take.

What is the most challenging principle of correctional nursing for you? Share your thoughts in the comments section of this post.

Scope and Standards: Five Tenets of Correctional Nursing

By Lorry Schoenly

Correctional nurses practice in a unique setting with a unique patient population, however, the way we practice is based on tenets common to nursing across all settings. These five tenets of nursing practice are identified in all nursing specialties and here applied to our practice in the criminal justice system.

NURSING PRACTICE IS INDIVIDUALIZED

In the end, correctional nursing is providing care to one patient at a time. Yet, we are careful to understand the demographics of our particular patient population when providing that care. For example, when working in a maximum security setting every patient is considered a high safety concern. However, correctional nurses constantly struggle with the challenge of balancing objectivity with cynicism due to the potential for manipulation of some in the patient population. Actively focusing on the individual needs of the current patient while keeping in mind the patient population characteristics can help maintain individualized care.

NURSES COORDINATE CARE BY ESTABLISHING PARTNERSHIPS

Nursing care in all settings requires collaboration with other disciplines, the patient, and family members to reach health goals. In the correctional setting, nurses also coordinate and negotiate with officers and non-healthcare administrative leadership to reach these goals. Correctional nurses, in particular, need skill in communication, collaboration, and persuasion to be successful.

CARING IS CENTRAL TO THE PRACTICE OF THE REGISTERED NURSE

Correctional nurses struggle with the definition and application of caring in a secure setting. Professional boundaries, safety issues, and security rules are ever-present concerns that alter caring practices from those of a traditional care setting. Defining caring in our practice is an important professional goal.

REGISTERED NURSES USE THE NURSING PROCESS TO PLAN AND PROVIDE INDIVIDUALIZED CARE TO THEIR PATIENTS

The nursing process is foundational to nursing practice. Correctional nurses use the nursing process to plan, deliver, and evaluate care in such activities as nursing sick call, emergency treatment, and infirmary care. The autonomous nature of nursing practice in jails and prisons requires excellent assessment and critical thinking skills.

A STRONG LINK EXISTS BETWEEN THE PROFESSIONAL WORK ENVIRONMENT AND THE REGISTERED NURSE’S ABILITY TO PROVIDE QUALITY HEALTH CARE AND ACHIEVE OPTIMAL OUTCOMES

Our practice environment affects our practice, no way around it. Although many correctional nurses work in positive environments, the nature of the corrections culture is punishment and control. These twin goals can facilitate an oppressive work environment where care and caring are difficult. Correctional nurses must strive to overcome a negative work culture that can discourage and demoralize our practice.

Do you have a favorite tenet of correctional nursing? Share your thoughts in the comments section of this post.

If you like this post, you might like:
Scope and Standards: Trends and Issues in Correctional Nursing
Scope and Standards: Principles to Guide Correctional Nursing Practice
Scope and Standards: Five Correctional Nurse Roles
Scope and Standards: Care Settings
Scope and Standards: Population Served

Scope and Standards: Five Correctional Nurse Roles

By Lorry Schoenly

I love helping nurses discover the invisible specialty that is correctional nursing. In fact, that was my original purpose in starting this blog over 5 years ago. I was sure that if more nurses knew about our specialty then more would join our ranks. From my own experience I know that few nurses get exposure to incarcerated patients during their education. There are practical reason why student nurses don’t have clinical rotations in the local jail, but it hampers the ability for new nurses to consider entering our challenging specialty. Regularly I am asked by new nurses if they should apply for a correctional nursing position. Although I enthusiastically encourage these individuals; I also caution them to be careful in selecting their first correctional nursing position if they are a new graduate. Here is why: Correctional nurses have so many roles and must often do them with little support and resources. This can be overwhelming for a new nurse; who may need a good bit more structure to get a solid foundation for their nursing career.

Based on the Correctional Nursing Scope and Standards of Practice, here are the five leading roles of a correctional nurse.

Primary Care

Correctional nurses are most often the first point of contact for incarcerated patients with healthcare needs. They manage access to all other aspects of healthcare and make determinations of appropriate level and type of care needed. In this way they coordinate ambulatory care provision to the patient population.

Emergency Care

Correctional nurses also provide immediate treatment of injury and acute illness while determining if a life-threatening injury exists that would warrant emergency transport to an emergency room. Patients are stabilized for transport with the provision of first aid and basic life support.

Health Promotion

The inmate patient population is often underserved with limited healthcare access in the community. They enter the correctional system having made poor lifestyle choices and often have little knowledge of how to manage chronic conditions. Therefore, correctional nurses have a major role in promoting heathy lifestyle choices while educating the patient population at every encounter.

Patient Advocacy

Healthcare is not the primary mission of correctional institutions. Security concerns and community safety may vie with an individual patient’s healthcare needs. Correctional nurses negotiate the security system and collaborate with officer peers to meet patient health needs within system constraints. They act as patient advocates through these efforts.

Care Coordination

Correctional nurses coordinate patient care within a system arranged for other purposes. Barriers to care must often be overcome. Standard security constraints such as restricted movement or limited personal items can inhibit continuity of care. Correctional nurses must creatively navigate the system to coordinate appropriate care.

Along with the above roles, correctional nursing practice is a merger of multiple nursing specialties: Occupational health, emergency nursing, acute care, community health, psychiatric care, geriatrics, women’s health, adolescent health, palliative and end-of-life care. A correctional nurse must be prepared to deliver a full menu of assessment and interventions within the security perimeter; knowing when a patient needs to be transported to an advanced level of care or specialty. This can be a daunting task for even the experienced professional.

Although I caution new nurse graduates to pick their first correctional nursing position with care; it can be done. With an extended orientation and good management support, many new nurses have made correctional nursing their first specialty.

Do you have a story about the various roles of correctional nursing? Share your thoughts in the comments section of this post.

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Scope and Standards: Care Settings

By Lorry Schoenly

The other day I was trying to explain correctional healthcare to an attorney who was considering taking on a case involving care in a county prison. I was familiar with the facility and told her that although the facility’s name used the word prison, it was really a jail. Thus began an extended conversation about the differences between a prison and a jail and why that might matter to the case and the clinical experts she would want to engage. One of the challenges of correctional nursing advancement is the great diversity of practice settings in which we work.

In an earlier post I discussed the definition of correction nursing, which encompasses the ANA definition of professional nursing tempered by the particular location of the criminal justice system. This location defines our practice being framed by our patient population (discussed here) and our care setting. The care setting is a unique component of correctional nursing and part of our scope of practice.

Where in the Pipeline

Our care location is first defined by where our patients are in the criminal justice process. The two primary areas are jails and prisons but I have also been involved in nursing care consultations that involved courtroom detainment and half-way houses after release. Our correctional patients can also be found in locked hospital units and addiction treatment centers.

Jail – The majority of arrested individuals are brought to a jail. Jail detainees may be awaiting a court hearing, trial, or sentencing. Many jails also hold those sentenced to a term less than one year as transfer into the prison system would not be cost effective and 12 month or less sentences are rarely high security issues. Jail health care, especially in urban areas, involves high concern for drug and alcohol withdrawal. Jails also have higher suicide rates than prisons so this is also a top-of-mind issue in this setting. Jails have a high rate of turnover, with people coming in for short stays before being released or bonded out to await trial. Therefore, it can be difficult to keep track of your patients and manage chronic care issues or diagnostic follow-through.

Prison – Once convicted of a crime and sentenced to longer than 12 months, an inmate is transferred to prison. Depending on the type of crime, this could be a state or federal prison. Each prison system designates intake facilities that evaluate and classify inmates as to security level and, possibly, healthcare requirements. Security classification is primarily determined by violence potential and escape risk, although some systems also house sex offenders or gang members in separate locations. Health requirements can affect classification if the system has a central hospital facility or a working prison such as a farm or industrial site. Prison health care is generally more stable than jail health care as the patient population is less transient.

Mixture – Smaller states combined the jail and prison system. Delaware, Rhode Island and Massachusetts have combined jail and prison systems where both detainees and sentenced inmates reside.

Who is in Charge?

The government entity in charge of the criminal justice setting also changes based on location within the system. For example, most jails are managed the county government, although some large urban jails are managed by city officials. Prisons are managed by the state or federal government. The chief executive of a jail may be a sheriff or a jail administrator who reports to the sheriff while the chief executive for a prison most often holds the title of warden. A jail may have deputies as officers while a prison may use the term custody officer or correctional officer (CO).

Age Matters

Offenders under the age of 18 are usually held in juvenile or youth facilities. Some youth are also held in adult facilities if they have been sentenced for an adult crime.

Picture This

Here is a graphic representation I like to use to help visually describe the primary components of the criminal justice system.

This is a fairly simple explanation of the criminal justice system – the setting of correctional nursing practice. After talking with the attorney, she decided she needed a jail nurse expert for her case. Have you ever tried to describe the criminal justice system to another nurse or care provider? How do you do it? Share your tips in the comments section of this post.

Photo Credit: © viperagp – Fotolia.com

Scope and Standards: Population Served

By Lorry Schoenly

This post is part of an ongoing series discussing key components of the Correctional Nursing Scope and Standard of Practice, 2^nd Ed. Review prior posts in this series here. Purchase your own copy of this highly recommended book through Amazon.

Many of us entered the nursing profession to help those in need. I can’t think of a needier patient population than those in correctional facilities. The demographic make-up and specific health needs of our patient population contribute to what makes correctional nursing a specialty. Because our patient population is defined by location and jurisdiction, rather than disease or health need (as in most traditional settings), correctional nurses must be proficient in a broad array of conditions and, often, a variety of ages and genders. For example, a small jail may house detained men, women, and juveniles. While, larger systems such as a state or federal prison system have the volume and support necessary to separate populations by gender and age.

Although the majority of prisoners in the US criminal justice system are white, there is a disproportionate number of minorities behind bars. Therefore, conditions found more frequently in black and Hispanic populations are prevalent in the inmate patient population. According to the CDC, blacks are three times more likely to have diabetes and strokes and have a higher death rate from HIV disease. Likewise, the CDC reports Hispanics having higher rates of death from these conditions along with higher rates of chronic liver disease. Therefore correctional nurses must be proficient in assessing for and treating these conditions.

Coming from disadvantaged backgrounds, with less access to regular healthcare services, the incarcerated patient population has many untreated conditions and a high burden of chronic disease. A study of jail and prison inmates found higher rates of diabetes, hypertension, asthma, and prior MI than the general population. The correctional nurse may be a first contact with the healthcare system. Therefore, correctional nurses must be proficient in evaluating symptoms that might indicate an undiagnosed chronic condition. For example, I have seen newly diagnosed diabetes and asthma in the correctional setting.

Our patients are also prone to infectious disease with high rates of sexually transmitted infections, tuberculosis, and blood-borne infections such as HIV, HCV, and HBV. Many have poor hygiene practices and a cramped correctional environment can contribute to the spread of infection, like norovirus, throughout a facility. Correctional nurses often become infection control specialists; containing a varicella outbreak, reporting food poisoning to the health department, and educating patients to reduce transmission.

The inmate patient population has high rates of mental illness. Every correctional nurse is a mental health nurse! Among the mental conditions over-represented in the incarcerated are mania, major depression, psychotic disorders, and borderline personality disorder. Not only must correctional nurses understand the assessment and treatment of these conditions but must be aware of the implications of personality disorder, sociopathic, and psychopathic tendencies on the nurse-patient relationship.

The often violent and abusive backgrounds of the correctional patient population means higher rates of traumatic brain injury, post-traumatic stress disorder, and suicidality. Correctional nurses must be astute in detecting the potential for self-harm and seeking to prevent it. Histories of abuse require sensitivity in nurse-patient interactions to avoid triggering panic, anxiety, or suspicion. An understanding of the effects of traumatic brain injury is needed when providing patient instruction.

Finally, our patient population is highly substance involved. Drugs and alcohol are a way of life for so many under our care. An extensive study found nearly 85% of all U.S. inmates involved with alcohol or illegal drugs. You can bet that means withdrawal concerns when they enter the criminal justice system. Our patients are also willing to coerce others (including you!) to obtain drugs for them while they are ‘inside’. Their desire for alcohol can lead to hooch-making from spoiled fruit and potato peels – that can be deadly. Amazingly, alcohol –based hand sanitizer has also been ingested in the correctional setting.

In summary, it is clear that correctional nurses work with a unique patient population that requires specialized knowledge, skills, and attitudes. Did you see your patient population in this description? Share your thoughts in the comments section of this post.

Scope and Standards: Prevalence of Correctional Nurses

By Lorry Schoenly

Before I accidentally became a correctional nurse, I didn’t even know the specialty existed. However, I soon learned that, although we work in a hidden practice setting, there are many correctional nurses. Unfortunately, we are almost invisible to the larger profession. Take any nursing survey that asks for your specialty area and you will see what I mean. I have never seen a place to check for correctional nursing. Most often we are filling in the open space next to ‘other’.

The task force revising the Correctional Nursing Scope and Standards of Practice had quite a time searching for verifiable information on the number of correctional nurses working in American jails and prisons. We finally settled on reporting numbers from the Health Resources and Services Administration (HRSA) data from the National Sample Survey of Registered Nurses. This survey estimated a total of 20,772 registered nurses working in correctional settings. That is almost 1% of all nurses working in the US (0.08%).

To those of us active in the profession, however, this seems a low number. Could it be that more nurses work in criminal justice? The way nurses are employed to work in a correctional setting may skew survey findings. For example, correctional nurses may be employed by a university medical system (like those working in Connecticut and New Jersey prison systems. Many jails are staffed by nurses working for the public health department. Nurses may provide care to inmates but work for private companies such as those who manage dialysis units within prison systems.

Maddie LaMarre, in a chapter on nursing practice for Clinical Practice in Correctional Medicine (2006), cited an estimated 2-3% of US nurses work in corrections. With Bureau of Labor Statistics of over 2.6 million employed registered nurses in 2008, this would suggest between 52,374 and 78,561 correctional nurses. The figure does not include the many LPN/LVN nurses practicing in the specialty.

Also not reflected in the National Sample Survey are nurses who work in correctional settings in a part time or per diem capacity. Some prison settings in remote areas must rely on traveling nurses to meet healthcare needs. Many settings regularly employ agency nurses to fill gaps in the schedule.

Without a professional association specifically dedicated to correctional nursing practice, there is no reliable collection on information on the number and characteristics of correctional nurses. More the pity. Correctional nursing might be more visible with an accurate idea of the number and strength of the specialty.

How many correctional nurses do you think there are in the country? Share your thoughts in the comments section of this post.

The full Correctional Nursing Scope and Standards of Practice, 2^nd Ed. Is available through Amazon.

Scope and Standards: New Definition of Correctional Nursing

By Lorry Schoenly

How has professional nursing practice in the correctional setting changed and evolved over the last decade? When discussing any concept, the first place to start is with a definition. How has the definition of correctional nursing changed over the years?

To start with, the very name of our specialty has moved from corrections nursing to correctional nursing. This name change indicates a movement away from purely defining nursing practice based on location. Similar evolutions have taken place in such specialties as emergency nursing (no longer Emergency Room Nursing) and Perioperative Nursing (no longer Operating Room Nursing).

Definition of Corrections Nursing in 2007

Corrections nursing is the practice of nursing and the delivery of patient care within the unique and distinct environment of the criminal justice system.

As the general definition of nursing has progressed, so has the definition of correctional nursing. This edition of the Correctional Nursing Scope and Standards of Correctional Nursing unveils an expanded definition of correctional nursing which mirrors the 2010 ANA definition of nursing.

Definition of Correctional Nursing in 2013

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, and delivery of health care to individuals, families, communities, and populations under the jurisdiction of the criminal justice system.

Nurses practice professionally in every setting. Therefore, the core components of correctional nursing include protecting, promoting, and optimizing the health and abilities of patients. Nurses in all practice settings, including corrections, prevent illness and injury while alleviating suffering. Correctional nurses, as those in other settings, diagnose and treat the human response to illness and injury. They advocate for their patient’s health and deliver health care to individuals, families, communities, and populations.

The location of care – under the jurisdiction of the criminal justice system – does give context to the practice of nursing. The criminal justice system presents the unique environmental constraints and ethical dilemmas of our specialty. In addition, the criminal justice system creates a unique patient population for nursing care. This patient population has demographic characteristics and illness patterns that require specialized nursing knowledge. The combination of environment and patient can lead to specific patient advocacy situations for correctional nurses.

What do you think of the new definition of correctional nursing? Share your thoughts in the comment section of this post.

The full Correctional Nursing Scope and Standards of Practice, 2^nd Ed. Is available through amazon.com.

New ANA Scope and Standards of Correctional Nursing

By Lorry Schoenly

Correctional nursing has been recognized by the American Nurses Association (ANA) as a specialty area of practice since 1985. A new edition of Correctional Nursing: Scope and Standards of Practice was recently published by the ANA and highlights advances in the specialty practice. How has professional nursing practice in the correctional setting changed and evolved over the last decade?

Using professional experiences and standard professional documents like the Code of Ethics for Nurses, the Nursing Social Policy Statement, and the Nursing Scope and Standards of Practice, a taskforce of 17 correctional nursing experts from various settings across the country created this document over the course of 18 months through a series of monthly meetings. This revision of the standards builds on the prior four versions and expands the definition of the specialty, unique nursing roles, and principles of practice.

The Correctional Nursing: Scope and Standards of Practice book is meant to be a guide to practicing this nursing specialty. Therefore, it needs to be read and used by both front-line correctional nurses and nurse leaders in the field. Here are a few ways to consider using the standards:

A self-evaluation of competency
Orienting new staff
Job description creation
Policies and procedures
Performance reviews
Professional development

Information Outline

Here is a basic outline of the information found in this book:

Definition of Correctional Nursing Specialty

Scope of Correctional Nursing

Prevalence
Population Served
Care Settings
Roles
Tenets of Correctional Nursing
Guiding Principles
Trends and Issues

Standards of Correctional Nursing

Standards of Practice

Assessment
Diagnosis
Outcomes Identification
Planning
Implementation
Evaluation

Standards of Professional Performance

Ethics
Education
Evidence-Based Practice and Research
Quality of Practice
Communication
Leadership
Collaboration
Professional Practice Evaluation
Resource Utilization
Environmental Health

It was my pleasure to serve as a member of the ANA Taskforce that created this version of the Scope and Standards. Future posts will dig in to the various scope elements and specific practice and performance standards with an emphasis on practical application.

Have you used the ANA Correctional Nursing Standards in your practice? Share your thoughts in the comments section of this post.

The full Correctional Nursing Scope and Standards of Practice, 2^nd Ed. Is available through amazon.com.