Abstract
The research aims were to (a) explore how correctional facility nurses in Montana perceived the balance between the autonomy required in their field and their scope of practice rights, and (b) contrast the correctional nursing specialty from the more traditional nurse setting. Twenty percent of Montana correctional nurses surveyed said there are times where they simply have to work beyond their state scope of practice boundaries. Respondents were most likely to report that the greatest differences in nursing process related to assessment and interventions. Nurses emphasized their feelings of safety, noting that in this practice setting safety takes the highest priority. Participants also said that correctional nursing had a stigma compared to other specialties.
Health care and nursing in correctional facilities differ in many aspects from the traditional nurse setting. Today’s inmates are older, sicker, remain in prison longer, and come from backgrounds of high risk for poor health and little access to health care services or treatment (American Nurses Association [ANA], 2007). In addition, chronic illness and infectious disease rates are significantly higher in comparison with the nonincarcerated client (ANA, 2007). Therefore, this nursing practice specialty poses a challenge for any nurse who has worked only in a traditional setting prior to employment in corrections.
The correctional nursing specialty is experiencing important advancements, including in 2010 the launch of the Certified Correctional Health Professional certification for registered nurses (National Commission on Correctional Health Care, n.d.). The American Correctional Association (n.d.) also offers certification for corrections nurses and corrections nurse managers. Despite the evolution of the specialty to include opportunities for certification, a focus on accreditation standards, and research in specialty journals, a paucity of details on the practice specialty for nurses in the Intermountain West region were available. Information about the challenges corrections nurses face, maintaining autonomy, and staying within the scope of practice while often being the primary provider (Smith, 2005; Weiskopf, 2005) may be of interest to new nurses interested in this practice area.
As the inmate population has increased, so has the need for corrections nurses. The research and publication of studies on this specialty area need to keep pace with the progression of nursing science in more traditional practice settings. Research focused on nursing practice in the correctional environment will serve nursing students, nursing professionals, and the community as a whole by bringing attention to a significant specialty. The following research sheds light on the perceptions and experiences of correctional nurses in Montana.
Six themes were noted in a review of the correctional nursing literature from the United States: Numerous studies found that correctional nurses often find themselves in a conflict between custody and advocacy (Norman & Parrish, 1999; Parrish, 2003; Weiskopf, 2005). Nurses often find themselves in a position of struggling to work with either too much or too little autonomy, dependent on both the health care demands of the inmate and the prison system (Wade, 1999, p. 310). Nursing scope of practice issues related to the limited availability of on-site physicians or midlevel providers was identified in a few articles (Dumpel, 2006; Smith, 2005). Although some were tempted to overstep their scope (Smith, 2005), others noted that standard decision making can be overridden by safety restrictions (Dumpel, 2006). Barriers to care (e.g., social/political issues, patient privacy, behavior, safety, security) made it difficult to provide a caring environment, although providing patient advocacy was not. This theme was found in nearly every article. Findings from the literature suggested that correctional nursing is an isolated specialty. While other fields of nursing have become well represented and respected, correctional nursing has been stigmatized and suffered from little recognition (Dumpel, 2006; Smith, 2005; Weiskopf, 2005). Available literature regarding correctional nursing is minimal. There is considerable room for research to establish the evidence base driving this specialty (Dumpel, 2006; Smith, 2005; Weiskopf, 2005).
The aim of this study was to gain insight on how correctional facility nurses in Montana perceive the balance between the autonomy required in their specific field and their scope of practice rights. The second objective was to compare and contrast the correctional nursing specialty from the more traditional nurse setting and explore Montana nurses' perceptions on the prevalent themes from the literature.
Method
The first step of the research was to develop a survey questionnaire. Both quantitative and qualitative questions were included in the questionnaire based on relevant information and the six themes noted in the literature review. The survey consisted of 16 items that inquired about sociodemographic data, job description and salary, and perceptions of the job of a correctional nurse. A 7-point Likert-type scale was used to assess how the specialty is different from other nursing specialties. Risk of physical and emotional harm was assessed using a 5-point agreement scale. The final item was an open-ended invitation to record additional comments. Written comments were analyzed using descriptive analysis.
The surveys were mailed to the five Montana prisons, located in Shelby, Deer Lodge, Glendive, Great Falls, and Billings. Responses were invited from licensed nurses employed by these facilities. Sixty surveys were mailed based on employment estimates from the director of nursing at each facility.
Results
In all, 30 completed surveys were returned yielding a 50% response rate. Respondents were mostly female (90%); 1 (3.3%) was a nurse practitioner, 6 (20%) held a bachelor of science in nursing degree, 12 (40%) were registered nurses, and 11 (36.7%) were licensed practical or vocational nurses. The average participant had been in corrections nursing for 5.1 years (range 1 to 16 years, SD 3.9 years) and had been a nurse an average of 6 to 10 years (range of 1 to 21+ years). Nurses worked in diverse settings serving populations ranging from 190 to 1,500 inmates and as members of nursing teams numbering from 2 to 26 members. The average full-time salary for correctional nurses was between $45,000 and $49,999 per year, with a range of less than $25,000 to greater than $55,000 for the 83% of participants who elected to answer the question.
In response to the question, “Do you feel that correctional nursing has a stigma in comparison with other nursing specialties,” 73.3% responded yes, 20% responded no, and 6.7% responded uncertain. Participants marked their level of agreement that the nursing process for correctional nursing differed from other nursing specialties on a Likert-type scale ranging from 1 = strongly disagree to 7 = strongly agree. Nurses on average strongly agreed that the assessment differed ( = 3, SD 2.24), but they neither agreed nor disagreed that the diagnosis differed ( = 3.63, SD 2.11). Nurses somewhat agreed that the nursing process differed in care planning ( = 2.73, SD 2.05), and they agreed that the process differed for interventions ( = 2.47, SD 1.96). Finally, the average participant somewhat agreed that the evaluation piece differed from other nursing specialties ( = 3.37, SD 2.05).
The correctional nurses also rated their level of agreement about how their specialty differed from other nursing specialties. On average, correctional nurses were neutral that their specialty differed from other specialties in prescribing medicine more often ( = 3.76, SD 2.05), somewhat disagreed that they were primarily responsible for adjusting the pharmaceutical regimen compared with other specialties ( = 4.80, SD 2.16), were neutral on the inability to advocate for clients ( = 4.40, SD 2.06), and somewhat agreed that their specialty gave them more access to members of the multidisciplinary team ( = 3.43, SD 1.76). The average correctional nurse also referred clients to other resources less often ( = 3.37, SD 1.96) and acted as the primary health care provider for their clients ( = 3.27, SD 2.13).
In response to the question, “I feel at risk of (a) physical harm and (b) psychological harm from my clients in the correctional setting more than in other practice settings,” 50% reported rarely to “physical harm,” 23.3% never, 16.7% sometimes, and 10% often. In response to “psychological harm,” 36.7% reported rarely, 33.3% reported never, 23.3% reported sometimes, and 6.7% responded often.
In answer to the question, “Are there times in your setting where you simply have to work beyond your state scope-of-practice boundaries,” 80% replied no. Of the 6 participants who responded yes, 5 said it was related to a “shortage of health care personnel,” 2 related it to working in a “rural setting,” 3 related it to “lack of a primary health care provider/physician,” and 3 said “the state rules don’t apply.”
The final item of the survey was an open-ended invitation for additional comments. The following five themes were derived from the written responses (n = 30): security takes priority, setting boundaries, assessments, public stigma, and scope of practice.
Security Takes Priority
Over half of the respondents noted that health care is subordinate to security. One nurse wrote, “Working within this environment is unique. Safety is the number one priority. The type of care given can be contradicting to what one learns in nursing school. Compassion and caring personalities take a ‘back seat’ to safety.” Another nurse wrote of the difficulties of remembering that “you are a nurse, not a correctional officer.” Another noted the loss of therapeutic touch in the correctional setting.
Setting Boundaries
Participants reported that there is a strict line between nurse and inmate. One nurse said that it was “difficult at times to balance caring with ‘firm, fair, and consistent’ and not become used by the inmates.” Another wrote that the care “must be employed at all times—no wavering” and “It is difficult to remain objective and empathetic when a large majority of our patients are exaggerating symptoms for secondary gain.”
Assessments
Correctional nurses noted that the assessment aspect of the nursing process differed in comparison to other nursing specialties. One nurse wrote, “Correctional nursing can be challenging. Your assessments center on finding the truth—not necessarily what the offender tells you.” Another suggested, “Correctional nursing is an excellent setting to improve your assessment skills. In addition to patient care, you become aware of your positioning with patients, security, and your surroundings. You learn to do excellent patient care while keeping yourself safe.”
Public Stigma
Participants responded in some way that correctional nursing had a stigma compared to other specialties. One wrote, “Publicly, there is a negative stigma on working in a jail or prison setting. Most people think it is very unsafe. There have been very few times that I have felt like I could have been in danger.” Another noted that she feels “safer in prison than in med-surg. If a patient misbehaves in the hospital you are obligated to keep working. If a patient misbehaves [in prison], the officers attend to the issue.” Furthermore, one nurse reminded the public that “often the only difference between the incarcerated and [the] community is that we know what they have done.”
Scope of Practice
Comments were split among those who felt they stepped out of their scope of practice and those who stayed within it. One nurse mentioned, “We are able to do more things on our own; we assess without [a medical doctor] present and are able to make decisions in patient care; more autonomy.” Another wrote, “Many times we practice outside our scope and then speak with a provider after the fact.” When justifying practice beyond their scope, these respondents cited the shortage of health care personnel (both nurses and providers), working in a rural setting, and that the state rules did not fit the setting. In sharp contrast, another participant wrote, “My scope is absolutely dictated by the Montana Nurse Practice Act. I do not give care outside my scope as an RN.”
Discussion
The primary objective of this research was to gain insight on how correctional facility nurses in Montana perceived the balance between the autonomy required in their field and their scope of practice rights. Participants mostly responded that they stayed within their scope of practice (80%). The 20% who responded that they operate outside their scope of practice commented that they later notify the physician. It is noteworthy that the latter group were all from the same facility and therefore the tendency to work with more autonomy may have been a reflection of geographic isolation in the rural practice setting, a shortage of health care personnel, or lack of a primary care provider. Smith (2005) supported this explanation, noting that the temptation may exist for nurses to make clinical decisions that are beyond their scope due to constrained access to primary care. Whether scope of practice violations are a function of workplace culture or being located in a workforce shortage area, correctional nurses must pay attention to the legal implications of operating outside their scope as well as the risk of censure from the state board of nursing. Correctional nurses must find the balance between using their expert knowledge to best treat the client and overstepping their scope of practice rights.
The second research objective was to compare and contrast the correctional nursing specialty from the more traditional nurse setting. Study results indicated a wide salary disparity but that may have been due in part to the nature of the facilities. One facility was a state-run prison, two were county jails that housed state inmates, one contracted its health care, another hired its own staff, one contracted with the local community health center, and the last was a private prison. It is also important to note that the credentials of the nurses surveyed ranged from licensed practical nurses to nurse practitioners. Benefit packages are an important aspect of compensation that was not assessed or analyzed.
Correctional nurses were also asked to describe their use of the nursing process. Respondents reported that the nursing process was most different from the traditional nurse setting on assessment and, secondarily, interventions and care planning. Nurses repeatedly noted that their assessment skills were exemplary because of the specialty, and that they must be much more objective as the inmates often report symptoms for secondary gain (i.e., to manipulate the health care system for reasons other than illness). This finding could not be compared with findings from other studies because past researchers who attempted to see how correctional nursing differs from other specialties have not compared them on the application of the nursing process. Because the nursing process embodies the foundation of the profession, this is an important finding.
Continuing with the comparison of the correctional setting to the more traditional setting, respondents reported that correctional nursing differed most on access to a multidisciplinary team, being the primary care provider, and referral of clients to other resources. Change in access to the multidisciplinary team and nurses' feeling that they are the primary care provider for their clients may be due to the unique prison setting where the nurse may have limited access to midlevel practitioners with prescriptive authority and where the nurse-to-inmate ratio may vary dramatically. The referral of clients to other resources was also noted as a significant difference. Lack of referrals may be intertwined with the lack of a multidisciplinary team. In the traditional setting, collaboration with other members of the health care team is essential. In acute care hospitals, for example, referrals to speech, physical, and occupational therapy as well as rehabilitation, spiritual, and nutrition services are readily available. It may not be feasible or cost-effective to have access to such referrals in a prison environment.
In accordance with Dumpel (2006), Smith (2005), and Weiskopf (2005), nearly every participant responded that correctional nursing had a stigma when compared to other specialties. The implications of a stigma may be detrimental to hiring correctional health care workers in the already established nursing shortage. This stigma may make it more difficult to convey the benefits of the specialty, such as improved assessment skills and increased autonomy, to potential applicants.
The final comparison was about the perception of safety. Respondents did not report feeling at significant physical or psychological risk in the correctional practice setting and, to the contrary, noted the emphasis on safety because of the constant presence of security personnel. This finding is in agreement with other studies (ANA, 2007; Dumpel, 2006; Parrish, 2003; Smith, 2005; Weiskopf, 2005) where the priority on security was also emphasized. While this is beneficial to the safety of the nurse, it can also be a noteworthy barrier to the care that nurses can give. Prison systems set strict boundaries, and nurses who care for clients in these systems must negotiate those boundaries between two distinctly different cultures: custody and care (Weiskopf, 2005).
Limitations to this research study included the small sample size and nonprobabilistic design. It is also important to note that almost all of the nurses were working with convicted, state inmates, with a small number working with county inmates. A sample that included nurses working with more county inmates or local or federal inmates would have been more representative of the variety of work environments possible for correctional nurses.
Conclusion
The first aim of this study was to learn whether correctional nurses in Montana operated outside of their state scope of practice rights. Overwhelmingly, nurses reported practicing within their rights. Nurses who reported operating outside of their scope of practice may face obstacles in their practice environment, such as being in a geographically isolated area with workforce personnel shortages. Future study should investigate the structure of the prison health care team to describe nurse-to-inmate ratios as well as in-house provider availability. Issues of standing orders and other mechanisms used to cover gaps in care should also be explored.
The second aim of this study was to compare the correctional setting to the traditional setting. As in any professional field, it is important for nurses to be informed in their particular specialties. The correctional nursing specialty differed most on the assessment piece of the five-step nursing process and the ability to use a primary care provider and make referrals to members of the multidisciplinary team. In future study, correctional nurses' access to referrals for spiritual support, behavioral counseling, dietary consultation, and occupational and physical therapy should be explored. While the feasibility of these resources in the prison setting may be debatable, their availability to the correctional nurse should be documented for those interested in the specialty.
Perhaps the most notable difference between the practice of nursing in the traditional setting and the correctional setting is providing care within a culture of custody. The fact that care is subordinate to safety is unlikely to change due to the parameters and environment of the workplace. There is a reason that security measures are set in place, and the nurses will continue to be challenged to find ways to provide a caring environment when safety precautions must outweigh client advocacy.
Correctional nursing is an important specialty and has drawbacks and benefits just as all nursing specialties do. The specialty has suffered from the stigma of being a high-risk workplace despite evidence to the contrary. An education campaign aimed at negating the public stigma may be beneficial for marketing future correctional nursing job vacancies. Correctional nursing provides a challenging experience while allowing nurses to remain within their scope of practice boundaries and work in a safe environment. The findings of this study suggest that a nurse who enjoys working in an autonomous environment and who has finely tuned assessment skills may be a solid fit for corrections.
Footnotes
Acknowledgment
The authors wish to acknowledge Cynthia Sparing, RN, BA, CCHP, for her help in refining the questionnaire and introducing us to the appropriate contacts in the Montana correctional system to conduct this research.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. For information about JCHC’s disclosure policy, please see the Self-Study Exam.
Funding
The authors disclosed receipt of the following financial support for the research in this article from Montana State University Undergraduate Scholars Program and Montana State University College of Nursing.
References
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