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Caring: The Essence of Correctional Nursing By: Jamie S. Brodie, MSN, RN, CS, ANP Correctional settings pose unique dilemmas for professional nurses accustomed to working in traditional healthcare settings where the purpose and mission is care. Nurses working in correctional facilities must accept that the fundamental mission of a correctional facility is first and foremost public safety and security. While the delivery of healthcare is an important component of the institutional program, it is not the primary reason that the facility exists. This mission incongruency may have profound impact on nursing practice, and can create role strain as nurses strive to provide professional care within the boundaries of the security environment. Nurses adapt to the correctional setting by modifying their behavior, values and beliefs in ways that reduce this role strain. Correctional facilities can be disorienting for nurses, who may feel like “fish out of water” when the setting lacks appropriate professional leadership, structure, and support of values essential to professional nursing practice. There is danger of being co-opted by the security system, especially when orientation and training focuses too much on security issues and not enough on professional practice. Professional isolation and the need to maintain boundaries while accommodating facility needs can erode the essential nurse-patient relationship that is the core of nursing practice. Correctional facilities present ethical and professional dilemmas for nurses educated to value caring as essential to nursing practice. Nurses who choose to work in a correctional setting must reconcile their role as a “helping professional” with the prevailing societal stigma associated with prisons and jails. The very act of locking up another human being is generally repugnant, and nurses may question whether or not they want to be a part of a correctional system. In society, patients go to hospitals or clinics solely for care. Inmates come to prison or jail for detention or punishment, and not as a vehicle for having their health care needs met. Correctional nurses often debate whether their role in the delivery of care is valued by the organization, or considered a necessary evil because of the legal requirement to deliver care. Whereas medical care focuses on diagnosis and cure, the central and fundamental characteristic of nursing practice remains that of care and health promotion. Nurses experience professional conflict when practicing in an anti-therapeutic environment (Start, March, 2000). According to Michael Puisis, DO, “The development of correctional medicine can be understood as a series of evolving perceptions of acceptable conditions.” Correctional settings are inherently unhealthy environments, when measured by most parameters of health. The environment limits autonomy and choices patients have about their care, contributes to stress, anger, hostility and depression; isolates individuals from family and society; promotes the transmission of communicable diseases; and rarely promotes behaviors having a positive effect on health. Diet and exercise may be limited and boredom prevails. There is risk of violence and physical harm and few opportunities for personal growth. Ethical conflicts are experienced by nurses working in an environment where opportunities for health promotion are limited. Yet many correctional nurses report a high level of job satisfaction related to the degree of professional autonomy and ability to make independent patient assessments. Nurses readily acknowledge the importance of caring to nursing practice, however they may differ in how care is defined. Some nurses view care as only direct intervention, focusing effort on procedures, administration of medications and technical aspects of care. They may view their role as a “job” having limited responsibilities. The hallmark of professional nursing encompasses a broader definition of care, embracing the concept of wholism — caring for the whole person including their physical, psychological, social and spiritual dimensions, respecting the patient’s beliefs, values and membership in family and social groups. Professional nurses acknowledge an obligation to the patient and society to promote health and wellbeing. Madeline Leininger, a pioneer in the field of transcultural nursing, describes care as being the central unifying and dominant domain of nursing. She notes that care is essential for human growth, well-being, survival, and facing death or disability (Leininger, 1988). Care is described by J. Watson as “the moral ideal of nursing;” believing that nursing has a moral commitment towards protection, enhancement and preservation of human dignity (Watson, 1985). Central to the concept of caring is the nurse-patient relationship, a relationship based on mutual trust and respect. Empathy and compassion, normal emotions and caring behaviors, may be viewed with suspicion in correctional settings. Even the words “nurse-inmate relationship” denote an imbalance in power and trust and may be viewed as suspicious or inappropriate closeness. Nurse-patient relationships require undistorted honesty and a level of self-disclosure that may be inappropriate in this setting. Correctional settings pose significant safety and security issues that cannot be ignored. Nursing professionals must continually support and maintain appropriate professional boundaries. In fact, newly hired nurses may be at risk if they aren’t properly oriented, and experienced nurses may require periodic reinforcement of boundaries to ensure that nurse-patient relationships remain therapeutic and appropriate to the setting. Correctional nurses must understand the importance of working within the security policies of the institution. I marvel at the enormous changes and improvement in correctional healthcare during the last twenty-five years. The development of national standards, recognition by the courts of the legal rights of the incarcerated to care, licensure standards, and certification programs have all contributed to improved care for adults and youth in correctional facilities. Correctional nursing is increasingly recognized as an important and legitimate public health specialty that attracts caring, committed and competent nurses. I am concerned however when I see the emergence of attitudes and beliefs that are contrary to quality care, particularly in the absence of adequate nursing leadership. Why do “good” nurses change when they walk through the gate of a correctional facility? Is it professionalism left at the door, “fish out of water syndrome,” role strain between the expectations of the correctional system and those of the nursing profession, or inadequate professional orientation and support of nursing values in a closed system? I believe that there are reasons for the emergence of these attitudes, which must be acknowledged, studied and addressed. Does practice in a correctional setting alter the attitudes and beliefs of nurses? Why do some nurses hold punitive attitudes towards inmates that interfere with the delivery of non-judgmental care? Why do some correctional nurses abandon professional modes of dress, professional modes of communication and professional ways of caring? Here are some statements by nurses I have heard in the last few years:
Peters and Austin, (A Passion for Excellence, Peters T., Austin N., 1985), used the term “thinly disguised contempt” to describe behaviors which reflect a lack of concern for people. Such behaviors include social or technical arrogance, discounting the importance of respect and courtesy, depersonalizing of the patient (he’s only an inmate), basing care on rigid rules rather than needs of the patient and failing to communicate the rationale for care decisions. Staff who view inmates as less worthy or as lesser beings exhibit “thinly disguised contempt” which damages the quality and outcome of care. Some nurses may feel justified in their beliefs because of the crime that the individual has committed. Do we expect inmates to be grateful for our care, and become upset when they don’t express gratitude? Do we perform examinations without adequate privacy or subject inmates to indignities that we would find unacceptable in any other context? When we substitute the word “inmate” for patient, does it affect the quality of the caring we communicate? Some nurses may feel justified in their belief because of the crime that the individual has committed. Do we expect inmates to be grateful for our care, and become upset when they don’t express gratitude? Do we perform examinations without adequate privacy or subject inmates to indignities that we would find unacceptable in any other context? When we substitute the word “inmate” for patient, does it affect the quality of caring we communicate? The value differences and conflicting ideals of healthcare and criminal justice professionals must be acknowledged as a source of role strain. Rachel Stevens, EdD, RN, (Stevens, December, 1993) has identified a number of values that differ between health care and criminal justice. Nurses are educated to individualize care according to the needs of the patient. Security personnel are educated to treat everyone equally according to the institutional procedure. – Rachel Stevens, EdD, RN Nurses value health care as the priority. Correctional professionals value enforcement of security procedures as the priority. Nurses may believe in the basic goodness and potential of the individual, whereas correctional professionals may view the individual with distrust and suspicion. Nurses are educated that hostility and anger may be normal during illness and that our role is to assist the individual with resolving this anger. Correctional personnel may view such behavior as unacceptable and requiring a higher level of security. Nurse-patient relationships are based on trust, and the inmates must trust that the nurse will act in their best interest. The relationship of correctional professionals to inmates can be described as a “keeper/kept” rapport. Nurses value confidentiality of information, whereas correctional professionals may view the flow of information as necessary to good security. Nurses value kindness, which correctional professionals may interpret as “softness” and potentially dangerous. Correctional staff may view appropriate behavior as being rugged, firm and tough, believing that kindness will cause an inmate to take advantage of you. Many correctional nurses begin employment with naive ideas about caring for inmates, which are then modified based on their experiences and interactions with inmates, nursing peers and security personnel. Some nurses may depersonalize inmates as a coping mechanism, particularly in stressful conditions, however this very process increases the likelihood of superficial interactions and facilitates the process of stigmatization. Nursing leaders need to understand the dynamics when nurses enter an environment where the predominant values and beliefs differ significantly from those of the nursing profession. There are a number of behavioral theories that suggest that professionals feel uncomfortable when their outward behavior is inconsistent with their internal values and beliefs. In general, we like to feel a level of conformity and consistency with the group in which we work. Closed systems such as prisons tend to support uniform attitudes among co-workers, resulting in “group think.” When entering the correctional setting, nurses seek to be included in the group, and may verbalize values that are thought to fit into the tone of the group. Even excellent nurses, when isolated from peers and role models which promote values of caring may develop a support system in co-workers to justify attitudes as being “right.” We tend to form in groups to consolidate and support the prevailing attitudes. Effective nursing leadership promotes caring values within the boundaries of the correctional setting, inspiring the development of a shared vision of quality nursing care. In the words of Mahatma Gandhi, “Be the change you want to see in the world.” And, from Carolyn Myss, “What you give your energy to each day becomes an investment in the process of life.” Correctional nurses deliver care to a population in great human need. That population may come from a background of poverty, have enormous health needs, appear tormented, confused, depressed, angry, and yes, sometimes evil. Correctional nurses are pioneers in the delivery of care to one of the most underserved populations in America, working diligently each day to care, the essence of nursing. Dr. Albert Schweitzer, a medical pioneer once said, “I cannot but have reverence for all that is called life. I cannot avoid compassion for everything that is called life. That is the beginning and foundation of morality.” Jamie Brodie directs the Correctional Health Nursing Program at Vanderbilt University, Nashville, TN. He is the author and grant director of a recent federal grant to prepare graduates to meet the needs of correctional populations. His correctional background includes practice as a Nurse Practitioner with the Tennessee Department of Corrections, where he became the first non-physician Director of Health Services for the State. He continues to be an advocate for care of the incarcerated.
References: Brown-Stewart, Pamela, RN, BSN, CCRN (1985). Thinly Disguised Contempt: A Barrier to Excellence. JONA Vol. 17 No. 4. April 1987. Carlson, Carolyn E. Behavioral Concepts and Nursing Intervention. (1970) J.B. Lippincott Co., Philadelphia, Pa. Leininger, M. (1988). Caring: An Essential Human Need. Thorofare, NJ: Slack. Leinginger, M. (1988) Leininger’s Theory of Nursing: Cultural Care Diversity and Universality. Nursing Science Quarterly, I. 152-160. Peters T., Austin N. A Passion for Excellence. (1985) New York: Random House. Start, Armand, M.D. Keynote address: NCCHC Clinical Conference. New Orleans, LA. March 2000. Stevens, Rachel. Values, Beliefs and Norms in Health Care and Criminal Justice. Nursing Forum. Vol. 28, No.4. December 1993. Watson, J. (1985). Nursing: Human Science and Human Care. A Theory of Nursing. Norwalk, CT: Appleton-Century-Crofts.
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