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NURSES BEHIND BARS
Sadly, correctional healthcare is a growth industry, one that is continuously seeking qualified professionals to join its ranks. According to the Bureau of Justice Statistics of the US Department of Justice, the state and federal prison population reached a record high census of 1.1 million as of
Correctional Nursing is a unique practice setting. It is a blend of public health, acute and chronic care, and mental health nursing. The basis of correctional healthcare is to provide primary care for an inmate population from the time of entry into the system, through transfers to other institutions, to final release from custody. Primary health services include all aspects of the nursing process.
One of the basics for a correctional care nurse is solid assessment skill. The nurse must hold sick call and screen out those inmates who do not need to see the physician. The nurse may prescribe medication through protocols developed by the physician, coordinate trips to the emergency room, and schedule appointments with specialists and the dentist. The care provided is primarily ambulatory.
The most commonly cited medical conditions as seen in correctional settings were asthma, TB, infectious diseases, hypertension, diabetes, and seizure disorders. Some correctional facilities have infirmaries, so there may be some post-op patients or those who need skilled nursing care. A few larger facilities have cardiac monitors. But any inmate who cannot be effectively treated in the jail is sent to a local charity hospital. With very few exceptions this is the policy nationwide.
Ken Faiver was Director of Health Care for the Michigan Department of Corrections for 16 years. Currently he is President and CEO of Correctional Health Resources in
Faiver says that there are not too many correctional facilities that will hire a graduate nurse. "Most prisons that I am aware of would say wait until you get your RN." He adds that while he likes to see nurses with a little bit of experience, it is not essential.
He's looking for people who are comfortable working in an outpatient clinic. "Mostly, it's basic primary care nursing. There are not very many sophisticated inpatient settings where very sick people are kept," says Faiver. "You want somebody who's sharp, with good judgement and good maturity."
Betty Hron, a certified correctional health professional, advanced status since 1994, is the Health Services Administrator at the
"Working in a medical unit in a jail or prison is very similar to working in any medical clinic. Distributing medication, and evaluating inmate complaints, screening, and treatments. But with a very intense security component."
"We see everything from the very mundane dermatological conditions such as athlete's foot and acne to individuals on hemodialysis, cardiac cases and manic depressives. We've had individuals who have had quadruple by-pass surgery and been back to us within three days of surgery."
Quality pre-natal care is a significant issue and a correctional nurse should expect to encounter a large number of high-risk pregnancies. "There are lots of women who are pregnant when they come in and most of them probably never had any pre-natal care on the outside. A lot of them are better off in jail because they are off the drugs, their diet is probably better and they get some help," says Faiver.
Dr. Jacqueline Zalumas, PhD, FNP-C heads up the Southeast Aids Training and
"One of the exciting opportunities in prison health care is that you are dealing with a very high risk population. You may get to people who have never had the opportunity to think about their own health care," says Zalumas.
Jackie Moore has a Ph.D. in nursing and has been in correctional health care for about 30 years. She is now an independent nurse consultant for Jacqueline Moore & Associates out of
"There is lots of room for nursing judgement in this. People who want the challenge have the opportunity to do so. There is a lot of autonomy and independence in this system for nursing staff. We tell anyone who talks to us that this is a nurse driven system we're in. The nursing staff is first line and knows what works and what goes on in the facilities," says John R. Brown, Director of Nursing for the Division of Prisons in
Faiver agrees. "There is nothing ever boring about working in a correctional setting. It is interesting. You have a lot of pathology that you probably never see in an office practice, and people tend to like it".
Jackie Moore doesn't feel that correctional care is any more hazardous than working in an inner city ER or in a psychiatric hospital. "For the most part, you know what your patients are there for, and the security is a lot tighter in a correctional institution."
"I have never been in an altercation with an inmate; I have never been threatened by an inmate in 30 years. I don't think that nurses who work in psychiatric hospitals can always say that," she adds.
In her 20 years at the jail, Hron has never seen any incident with medical personnel and inmates. But fights routinely break out with inmates and correctional officers so that the potential for danger is there. "But if you work in a nursing home, some of the elderly kick you and bite you and slap you, so it's relative," says Hron.
Says Faiver, "I tell people and I really believe it that you are safer in working in a prison than you are in most emergency rooms around the country. In an emergency room you don't know whose going to come in, what drugs they're on and whom they are mad at. In a prison you know who's there and the officers know. And if a person is dangerous, they take extra precautions. And if you treat an inmate with respect and carry yourself professionally, that prisoner is going to be the same way back to you.
Brown holds a similar opinion. "The inmates will test you and push your boundaries as far as you will let them. What I advise people to do is be fair, firm and objective with the inmates. Treat them like you would anybody else. Build rapport and a sense of professionalism with them. Once people can learn that, they can get over that period of being afraid of the inmates."
Correctional nursing is not for everybody.
For Hron, some of the stress is caused by the sound of the door closing behind her. "Not everybody can work in this type of environment because you are locked in with the inmate and you can't move about as freely as would in a hospital or clinic."
"With just the idea that you are going into a confined setting behind locked doors and working with people who have been convicted for criminal acts out on the street, there is a certain amount of apprehension that goes through people's minds. Some people cannot adjust to that," says Brown.
"Also in this type of setting, inmates are notorious for suing you for just about anything. If they feel that you done anything that they don't approve of, they can sue you. It goes from the very ridiculous to very serious charges," says Hron.
"We work for a very litigious set of clients. Inmates have access to the federal courts. I think that the fear that someone may sue helps to keep people stressed out," says Brown. "But clinical healthcare should never be based on whether you're going to get sued or not. People can sue you for anything."
Injection drug use, other illicit drug use, unprotected sex, and tattooing are all risk behaviors for HIV. Drug offenses account for the single largest number of federal crimes for which people are incarcerated. In 1991, 79% of state prison inmates reported using illicit drugs at some time. Injection drug users (IDUs) are at special risk, as clean needles are almost impossible to find both in and out of the prison system.
Michael Haggerty of the Correctional HIV consortium has a Masters in Public Health. He says that the rise of HIV has put a strain on the correctional health care system. Prior to this, the system was geared to respond to critical injuries to inmates. The budget was very small. But now, with the number of dual diagnoses including HIV, and the amount of money spent on staff and HIV testing, correctional medicine has been thrust into the public spotlight.
Brown says that very few people actually realize that there is such a thing as correctional healthcare. It has not been highly publicized before and Faiver agrees. "People who choose the health profession rarely consider correctional medicine as a career. It doesn't even cross their minds."
"But what they are going to encounter when they get out there is quite different from what many of them imagine. If your image of what a prison is like is what you saw in a James Cagney movie, it's really quite different."
But does ethnicity really have an impact on being a good nurse? A large percentage of inmates are ethnic minorities. "I think being a minority helps you to cross the cultural boundaries a lot easier. "When I first started we had a lot of foreign medical graduates that would come in and there were language barriers," says
Many of the diseases that are seen are more prevalent among certain populations. For example, with the Hispanic population there's a higher level of hypertension and diabetes. In the juvenile population it's a high incidence of sickle cell. A nurse dealing with people who are from the same population is going to know these things.
"I think that good nurses from different racial and ethnic backgrounds who are astute in their culture relate well to some of the inmates and the inmates can relate better to that person," says Brown.
According to Haggerty the availability of minority nurses would make a difference to the institutions themselves because of artificially imposed quotas.
"Facilities have to hire a certain number of minorities or explain why," says Haggerty. "Healthcare has a lot of minority employees anyway. Nursing is an area that is thrilled to get a hold of minorities."
Hron says that she doesn't see where being a minority would make any difference. "When I came to work at the jail 20 years ago, I was the only female. It's only been within the last seven or eight years that our staffing has been more diverse. Right now probably 50 - 60 percent of our staff is black, about 35 percent are white, and the remainder Hispanic and Asian."
Nursing opportunities are available in juvenile facilities, detention centers such as a jail, plus state and federal prisons. Salaries tend to be competitive with what's being offered in outside facilities.
There are three ways primarily that health care is provided within the county or state correctional system: by the state itself; through the public health department; and through the services of a private company. There are approximately 13 such companies that provide health care services to prisons and jails. Nurses in detention centers and juvenile facilities may be county employees. Federal prisons are run by federal agencies such as Immigration and Naturalization Services.
According to Hron correctional facilities are looking for nurses like crazy. "There are many, many facilities that do not have any medical staff on board, or if they do, it may only be an EMT."
Over the past 25 years there has been an immense improvement in the quality of health care delivered in prisons and jails. It's a far cry from what it once was. Says Faiver, "What a nurse will find going into most prisons and jails is a pretty decent system."
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