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Population Health for Nurses

29.3 Correctional Nursing

Population Health for Nurses29.3 Correctional Nursing

Learning Outcomes

By the end of this section, you should be able to:

  • 29.3.1 Discuss the history of correctional nursing.
  • 29.3.2 Explain the scope and standards of practice of the correctional nurse.
  • 29.3.3 Describe the role of the correctional nurse.
  • 29.3.4 Examine settings for correctional nursing.
  • 29.3.5 Identify common health problems of individuals who are incarcerated.
  • 29.3.6 Explain the nurse’s role in planning, implementing, and evaluating interventions (primary, secondary, and tertiary) to improve outcomes and safety for incarcerated individuals.

Correctional nursing is defined as providing nursing care to clients within the criminal justice system. Settings where correctional nurses may work include (Schoenly & Knox, 2012):

  • Locked correctional settings: local jails, state prisons, federal prisons
  • Local police departments
  • Immigration detention centers
  • Forensic hospital units
  • Department of Corrections (DOC) hospitals
  • DOC-managed nursing homes
  • Mental health institutions
  • In the general hospital caring for patients transferred from correctional settings

In the nursing and health literature, these individuals are often referred to as justice-involved (ANA, 2021; CDC, 2023b). The incarcerated population is very different from the general population regarding gender, race, education, and age because most people incarcerated in the United States are men, although the number of women in prison has increased dramatically (CDC, 2023d; National Commission on Correctional Health Care [NCCHC], 2020).

  • Incarcerated females have reproductive health needs and are more likely to have custody of their children and to have been a victim of sexual abuse or domestic violence (American Academy of Family Physicians [AAFP], 2021; American College of Obstetricians and Gynecologists [ACOG], 2021).
  • Incarcerated Black and Hispanic people are disproportionately represented in the incarcerated population (CDC, 2023d; Pew Charitable Trusts, 2023).
  • White men have a rate of one out of 106 men imprisoned, whereas one out of 15 Black men are imprisoned and one out of 36 Hispanic men are incarcerated (Nellis, 2021).
  • Education levels of the inmate population are lower than the general population: some sources report that less than half of the incarcerated population have a high school diploma, which is well under 20 percent for the general U.S. population (Center for American Progress, 2018; CDC, 2023d).
  • At midyear 2020, inmates ages 18 to 34 accounted for 53 percent of the jail population, although inmates aged 55 or older comprised 7 percent (Minton & Zeng, 2021).

Given the unique client population of inmates and detainees, the nurse must defer to correctional officers and safety protocols before embracing the health-promoter and care-provider role. Many layers of ethical issues are at play in correctional nursing. Correctional nurses need to develop a therapeutic relationship with individuals convicted of crimes, some of them violent and disturbing. Nurses must be able to critically evaluate and make treatment decisions for clients who may be seeking secondary gain (seeking a privileged status, a more comfortable cell or situation, or special creams or lotions) from their medical visit. This can further cloud the nurse’s view of these encounters. Other ethical issues may relate to the very real limitations of being in a locked facility. For example, education plans for clients with diabetes often require fresh fruits and vegetables and cardiovascular exercise routines, but this may not be feasible in a prison setting. Other ethical issues may arise when correctional nurses are evaluating clients who are in solitary confinement where the incarcerated individual lacks meaningful contact with other individuals. The boundaries set by the corrections system can prove to be an ethical issue for nurses desiring to show compassion for clients. Another common ethical issue is the lack of privacy as corrections officers oversee all aspects of correctional centers’ health care delivery system. Balancing the conflicting roles of public safety and security by the corrections department and the professional nursing mission to promote the well-being of all clients is at the heart of corrections nursing (Schoenly & Knox, 2012).

History of Correctional Nursing

The correctional setting for professional nursing practice emerged in the 1970s as prison riots and the civil rights movement shed light on barely existent prison health care services. The 1976 Supreme Court Case of Estelle v. Gamble established the constitutional obligation to provide health care to any individual in the government’s custody, guaranteeing health care for incarcerated individuals. Before this ruling, no organized or regulated health care was provided to inmates (ANA, 2021). However, currently there are no mandatory health care standards or required health care accreditations within correctional health facilities, resulting in minimal oversight and substantial variability in access to and quality of care (ACOG, 2021). In 1985, the ANA recognized correctional nursing as a specialty and published the first Standards of Nursing Practice in Correctional Facilities. Currently two groups offer certification in correctional nursing, the American Corrections Association (ACA) and the NCCHC. In 2017, an estimated nearly 30,000 registered nurses and 20,000 licensed practical nurses worked in correctional facilities in the United States (ANA, 2021). These two organizations have published health care standards and offer accreditation of correctional health care systems, but accreditation is entirely voluntary (ACOG, 2021).

Scope and Standards of Practice of Correctional Nursing

Correctional nursing requires devotion and advocacy to care for an underserved, disenfranchised, and often-forgotten population (ANA, 2021). The scope and standard of practice for correctional nursing follows the nursing process with the addition of 11 standards reflecting culturally and ethically appropriate care that is evidence based. The 11 standards are ethics, culturally and congruent practice, communication, collaboration, leadership, education, evidence-based practice and research, quality of practice, professional practice evaluation, resource utilization, and environmental health (ANA, 2021). Within each standard, there are several competencies that can be used to demonstrate evidence of compliance with the standard (ANA, 2021).

Introduction to Forensic Nursing

Forensic nursing is a specialty of nursing providing focused care for clients who are experiencing or have experienced victimization and violence. These nurses practice with a trauma-informed approach when caring for the acute and long-term health consequences associated with victimization (International Association of Forensic Nurses, 2023).

Watch the video, and then respond to the following questions.

  1. What are your impressions of forensic nursing?
  2. What is the relationship between forensic nursing and caring for underserved populations?
  3. What additional competencies do you think a forensic nurse needs to have to address the needs of victims of violence and abuse?

Role of the Nurse in the Correctional Nursing

Correctional nurses use a broad range of nursing skills caring for individuals across the justice system, including incarceration, probation, parole, treatment programs, individuals housed in immigration and customs facilities, and those transitioning between settings. At the end of 2018, an estimated 6.7 million individuals were under correctional supervision, including 2.2 million individuals detained in jails and prisons and approximately 4.5 million individuals supervised under probation and parole, known as community corrections (ANA, 2021). Probation is community supervision in place of incarceration, whereas parole is a form of conditional supervised release allowing individuals to complete prison sentences in the community (ANA, 2021). Counties or cities often manage local jails and are responsible for holding individuals awaiting court hearings, trials, or sentencing, but they may also house individuals who have been sentenced to less than 12 months of detention. Prison often houses individuals convicted of a crime with sentences longer than a year. The Federal Bureau of Prisons (FBOP) manages a prison system of 130 facilities housing people whose sentences are related to federal crimes (n.d.). These facilities are dispersed throughout the United States but have consistent standards of practice and centralized management. State prison systems are under the authority of the state’s government, and each state may have different practice standards. Both the FBOP and 27 state prison systems use private prisons as contractors to house some of the incarcerated population. In 2021, almost 100,000 incarcerated individuals were being detained in private prisons, representing 8 percent of the total state and federal prison population (Budd & Monazzam, 2023). States’ use of private prisons varies. For example, Montana incarcerates close to half of its prison population in privately-run facilities, whereas in 23 states, private prisons are not used at all (Budd & Monazzam, 2023).

Since correctional nurses care for a broad spectrum of clients across the justice system, they need to possess strong assessment and clinical decision-making skills. This role requires flexibility, attention to detail, a solid understanding of the standards of professional nursing practice, and strong advocacy skills to be champions for access to quality health care. Correctional nurses occupy a multitude of roles while providing care and often find themselves practicing in a variety of settings with justice-involved clients, such as caring for justice-involved individuals in restricted housing, primary care clinics, urgent care clinics, inpatient infirmaries, community-based facilities, and palliative and hospice care. In addition to these practice settings, the correctional nurse provides care related to substance misuse, sexual abuse, mental health, and transitional care along with providing services like medication management, health promotion screening, and teaching. The practice of correctional nursing is more than bedside care; it is community and public health care, addressing the needs of an underserved population.

Restricted Housing

Restricted housing is a type of detention that includes voluntary or involuntary removal from the general incarcerated population with placement into a locked cell or room for most of the day (ANA, 2021). This is known as segregation, solitary confinement, special housing, enhanced security units, or isolation units, among other names. Since correctional agencies are tasked with housing justice-involved individuals in safe facilities, they need to maintain safety of the incarcerated individuals and the staff. At times, it is deemed necessary to place certain individuals who may be a threat to others, a target of violence from the general incarcerated population, or a danger to themselves into restricted housing. Correctional nurses must ensure that these special housing arrangements do not adversely impact a client’s health. Numerous studies have demonstrated the higher rate of psychiatric illnesses among these individuals, ranging from anxiety and depression to hallucinations, psychosis, and suicidal ideation (ANA, 2021). Pregnant individuals, older individuals, transgender people, and adolescents are considered more vulnerable than the general incarcerated population; it can be difficult to house these individuals safely, requiring the correctional nurse to assess and advocate as necessary (ANA, 2021).

Correctional nurses are often the primary advocates for clients and need to assess and evaluate these individuals in restrictive housing and be part of the interprofessional care team to ensure their physical and psychological wellness. The NCCHC’s position statement on solitary confinement is that “correctional health professionals’ duty is to the clinical care, physical safety and psychological wellness of their patient and should not condone or participate in cruel, inhumane, or degrading treatment of patients” (NCCHC, 2016, p. 4). The NCCHC defines prolonged, greater than 15 days, solitary confinement as cruel and inhumane treatment and further states that adolescents, pregnant individuals, and individuals with mental illness should never be in solitary confinement.

Primary Care

Primary care in the corrections setting occurs during nursing encounters for intake screenings and assessments, sick call visits, chronic care clinic visits, medication administration, and in response to emergencies (Figure 29.5). The corrections nurse is involved in health promotion screening and education, falling under the realm of primary care. To meet public health and safety principles, infectious disease screening is imperative in a confined population. With each encounter, the nurse can educate the client on issues related to specific health needs. Correctional nurses also coordinate care between providers, arrange for ordered testing, and ensure follow-up visits with various health entities as ordered.

A nurse in navy fatigues stands across from a seated client in a room with a scale that measures height and weight.
Figure 29.5 One role of nurses working in corrections settings is to provide health education to clients. (credit: “Navy Lt. j.g. Tiffany Rozas, a nurse with Joint Task Force Guantanamo’s Joint Medical Group, discusses dietary nutrition with a detainee, July 9, 2010” by Joshua R. Nistas/U.S. Navy/Wikimedia Commons, Public Domain)

Acute Care

Some large correctional facilities have health facilities capable of providing acute care services, similar to those available in community hospitals. Care provided in an acute care setting is used to treat unexpected, urgent, or emergent episodes of injury and illness that could result in disability or death without intervention. The correctional nurse’s role is to triage these clients and ensure the appropriate care is provided to minimize potential disability and suffering. If a facility cannot meet its client’s needs, the nurse is involved in stabilizing the client and arranging for transfer to the appropriate facility.

Urgent or Emergent Care

The corrections nurse is often the first responder when there is a health care issue with a client, a visitor, or a staff member with a sudden complaint of illness, trauma, or another emergency. The nurse is responsible for responding to the location with appropriate emergency equipment and providing emergency care as needed. Depending on the assessment, the nature and severity of the injury or illness, and applicable policies, protocols, and procedures, the nurse will initiate an emergency plan of care that might include the activation of local emergency medical services (EMS). Throughout the entire process, from activating EMS, to the transition of care for the client across settings, to receiving the client back in the correctional facility, the nurse is responsible for effective communication and continuation of necessary care.

Palliative Care

Palliative care incorporates four attributes: individualized client care, support for the family, an interprofessional team approach, and effective communication (ANA, 2021). The correctional nurse may be the first health professional to recognize that a client will benefit from palliative care and needs to advocate for access to this specialty level of care. With the palliative care team, the correctional nurse develops a plan to ensure client-centered care and may need to advocate for a release from a facility, for a nursing or home placement, or for family involvement. Correctional nurses provide palliative care by providing relief from distressing symptoms, coordinating treatments for the underlying disease or condition, integrating psychological and spiritual considerations into the care plan, offering support to assist clients to live as actively as possible, and helping clients understand their choices for treatment.

Hospice Care

Hospice care is palliative care provided to clients with less than six months to live if their disease were to follow its normal trajectory (ANA, 2021). The goal is to ensure the client’s remaining time is as comfortable as possible. Correctional nurses provide this care to respect and carry out the end-of-life wishes of the client. This may involve advocating for the release from a facility, or it may mean advocating for appropriate lodging within a facility to allow for the provision of maximum comfort measures.

Transitional Care

Transitional care is moving from one facility to another or transitioning back into the community upon release from corrections. Correctional nurses are involved in assessing how well clients are adjusting to new a new facility or into the community. These nurses can act as care coordinators, making appointments, educating, and facilitating a discharge plan to continue medications, treatments, and services such as medical, dental, and psychiatric care when released from corrections (Schoenly & Knox, 2012). Just as discharge planning begins as soon as a client is admitted to a hospital, planning for reintegration back into society begins as soon as the client enters the correctional system (U.S. Department of Justice, n.d.).

Care Coordination

Correctional nurses provide care coordination services throughout a client’s time in corrections through reintegration into the community. Nurses partner with the client to identify health issues, make appropriate referrals, track pending appointments and treatments, and ensure necessary care is completed. The nurse educates the client appropriately so that they can make informed decisions regarding their care. The corrections nurse is the liaison between the correctional health team, the client, and the community health team.

Medication Management

Correctional nurses administer medications that are ordered for clients and must be knowledgeable on appropriate dosing, side effects, contraindications, route of administration, and any food or drug interactions. In addition to administering the medications appropriately in compliance with state laws, the nurse needs to ensure the client is taking the medication and not “cheeking” it to divert it. Nurses are responsible for ensuring clients are properly educated about their medications and their role in managing their disease.

Health Promotion and Education

Health promotion, maintenance, and education are extremely important, given the health disparities in this justice-involved population. Often, clients have a history of a lack of access to care, to insurance, and to healthy lifestyle choices. Correctional nurses provide health education and health promotion activities for healthy lifestyles by encouraging preventive health practices and addressing health issues. By building skills for healthy living in this population, these individuals can transfer knowledge and skills when released back into communities. Correctional nurses can also educate the corrections staff on wellness issues that affect the clients such as infectious disease, first aid, responding to mental health crises, and suicide prevention. A large part of health promotion is client education. Client education helps to ensure clients are informed about their own health so that they can make informed decisions and take care of their health needs when they transition back into the community. An example of client education is the newly diagnosed client with diabetes who needs information on medication, monitoring blood glucose levels, diet, and exercise. An example of a community-level program would be educating communities on naloxone administration for opioid overdose.

Advocacy

The role of client advocate only intensifies when caring for a population that is incarcerated. Correctional nurses must work with correctional staff to limit barriers that may affect the delivery of timely health care interventions and treatments. Advocacy also includes ensuring follow-up appointments, appropriately triaging and attending to requests for health care visits, collaborating with correctional staff and court officials to guarantee clients receive needed health services, ensuring clients have access to proper hygiene and clean housing units, and discussing with correctional staff regarding the transfer of clients for specialized health care needs such as dialysis.

Correctional nurses serve a socially marginalized population: these justice-involved individuals have lower educational attainment, lower pre-incarceration incomes, and numerous health disparities (ANA, 2021). Mental health disparities are evident in justice-involved individuals. Lifetime trauma exposure is higher for incarcerated women and men than for individuals without a history of incarceration, and these individuals are more likely to be diagnosed with a serious mental illness or SUD (ANA, 2021). Correctional nurses can improve this population’s health through treatment and education of these long-term conditions during incarceration.

Common Health Problems of Incarcerated Individuals

Given the variety of settings where correctional nursing occurs, all nurses should understand the role of the corrections nurse and be familiar with common health problems of justice-involved individuals. Members of this population who are housed in prisons have much higher rates of disease than the general population; being incarcerated is associated with early mortality (AAFP, 2021; ANA, 2021). This population experiences many common health problems due to a multitude of factors, including pre-incarceration social conditions, lack of autonomy within the system, violence within the system, overcrowding, and overall congregate living situation (AAFP, 2021; ANA, 2021; Schoenly & Knox, 2012). Common health problems among members of this population include long-term diseases, infectious diseases, reproductive concerns, mental health and SUDs, violence, and self-harm. Additionally, certain populations, such as older adults, may have age-related functional limitations like mobility or sensory impairments, making the provision of appropriate care more challenging (Table 29.3) (ANA, 2021). Some prisons and jails require copays from the detainees to access health care services, serving as a potential barrier to care, adding an additional undue burden on this vulnerable population (ACOG, 2021).

Health Condition Percent Reporting
Cancer 12 percent
Kidney problems 12 percent
Heart disease 23 percent
Diabetes 23 percent
Arthritis 45 percent
Hypertension 62 percent
Table 29.3 Percentage of People in State Prison Age 55 and Older Who Report Ever Having Specific Health Conditions (See Wang, 2022.)

Long-Term Diseases

The most common long-term conditions in justice system-involved persons are hypertension, arthritis, asthma, and hepatitis (Maruschak et al., 2021), some of which are seen at much higher levels in the justice system-involved population than the overall U.S. population due to persistent health disparities.

  • Almost 17 percent of justice-involved individuals aged 55 and above in state prisons have asthma, whereas the general population of adults with asthma is 8 percent (Wang, 2022).
  • About 10 percent of justice-involved individuals aged 55 and above in state prisons have hepatitis C, whereas the general population is under 2 percent. Hepatitis C is a curable disease; however, 80 percent of justice-involved individuals in state prison who have ever had a diagnosis of hepatitis C still have it (Wang, 2022).
  • An estimated 65 percent of the U.S. prison population has a substance use disorder compared with 16.5 percent of the general population (National Institute on Drug Abuse [NIDA], 2020; U.S. Department of Health and Human Services, 2023).

Correctional nurses need to be well versed in the care of these long-term conditions, including screening intervals, follow-up intervals after medication adjustments, and ensuring the appropriate referrals to specialty care in the monitoring for potential complications. Asthma poses challenges for clients in correctional settings due to the nature of the disease process that results in intermittent asthmatic flare-ups. Justice-involved clients need to request care through the correctional officers, which may result in a delay from when a client feels a flare-up is imminent and actual care. Some asthmatic medications are meant to be used as a “rescue” when the client is having trouble breathing. This extra layer between a client and their medications can adversely impact their overall health and disease severity. Correctional nurses must advocate for these clients appropriately and educate correctional officers on bringing them to the nurse as soon as feasible. By being a health advocate and champion, correctional nurses can improve these individuals’ health through health promotion and disease prevention activities so that when the justice-involved clients reenter society, they are in better health and know how to manage their long-term diseases.

Infectious Diseases

Infectious diseases are a major concern in correctional facilities where environmental conditions make the spread of infectious disease more likely (ANA, 2021). Nurses are on the front line in preventing infectious disease spread through screening, client education and counseling, immunizations, handwashing, isolation procedures as necessary, and monitoring treatment compliance (CDC, 2023d; Schoenly & Knox, 2012). Individuals who are justice-involved often experience numerous risk factors for HIV, hepatitis, STIs, and tuberculosis (TB) (CDC, 2023d). Like long-term diseases, the incidence of these infections and diseases is higher in the justice-involved population and are often related to pre-incarceration SDOH, such as homelessness, poor nutrition, lack of medical care, substance use, and risky sexual behaviors (AAFP, 2021; CDC, 2023d; Schoenly & Knox, 2012). The corrections nurse will likely identify, treat, and manage these conditions and help limit their spread through client education and reinforcement of risk-reduction practices (CDC, 2023d; Schoenly & Knox, 2012). Justice-involved individuals incarcerated in state or federal prisons had the following rates of infection in 2021 (CDC, 2023d):

  • 3 times higher rate of HIV
  • 10 times higher rate of hepatitis C virus and between 3 to 38 times higher rate of hepatitis B virus
  • Higher rates of chlamydia and gonorrhea
  • 6 times higher rate of TB
  • Rate of COVID-19 infection estimated to be 5.5 times higher among individuals who are incarcerated (LeMasters et al., 2022)

The CDC (2023k) recommends screening all individuals at intake for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), TB, gonorrhea, chlamydia, and syphilis. As of 2021, 16 states conducted mandatory HIV testing under state law, and 23 states and the FBOP offer opt-out HIV testing where individuals are informed that they will be tested for HIV unless they decline the screening (CDC, 2023d).

The CDC also recommends the following primary prevention measures (2023k):

  • Beginning the hepatitis A vaccine series for all previously unvaccinated juveniles under 18 and all adults at increased risk for hepatitis A infection, such as men who have sex with men, those who use IV drugs, and individuals experiencing homelessness
  • Beginning the hepatitis B vaccine series for juveniles and adults not previously vaccinated

Correctional nurses are also a part of the care team during transitions when the justice-involved client will be leaving the correctional facility. The nurse must ensure the client is linked with a community-based provider for continued care, especially with HIV, hepatitis, and TB as a public health prevention measure (CDC, 2023c).

At the height of the COVID-19 pandemic, justice-involved clients living in correctional facilities were at increased risk for COVID-19 for the same reasons they are at increased risk for other infectious diseases; congregate living arrangements and higher prevalence of comorbid medical conditions placed them at higher risk for infection (CDC, 2023f; LeMasters et al., 2022). The CDC (2023f) continues to recommend intake testing for COVID-19 as an enhanced prevention strategy. The CDC has released updated guidance on assessing a facility’s risk for COVID-19 and enhanced prevention strategies for everyday operations. For more information on COVID-19, see Pandemics and Infectious Disease Outbreaks.

Case Reflection

Correctional Nursing Intake Interview

Read the scenario, and then respond to the questions that follow.

Jason, a correctional nurse employed in a state prison, is completing the initial intake for a client who is new to the prison system. The client, Rory, is a 23-year-old woman with a past medical history of asthma, bipolar disorder, substance use disorder, and a prior suicide attempt. She reports she was in an abusive relationship that ended about 9 months ago and resulted in her experiencing homelessness. She has been sleeping outside as she had a negative encounter at the shelter on her first night there 9 months ago. She does not wish to go into further detail but reports she started using IV heroin while on the streets about 6 months ago.

  1. What screenings should Jason recommend for this client?
  2. Given Rory’s social and medical background, what health issues is she at risk for?
  3. What are Jason’s priority actions at this time?
  4. How can Jason build rapport and a therapeutic relationship with this client?

Reproductive Health Care

Women are the fastest-growing segment of the incarcerated population, comprising 10 percent of those incarcerated in 2019 (ACOG, 2021). The majority of justice-involved women are parents and of reproductive age. According to the ACOG (2021), reproductive health care for justice-involved individuals should be provided with the same guidelines and recommendations as for the general population, paying particular attention to the increased risk of infectious diseases and mental health conditions. The corrections nurse is an advocate, educator, and leader when advising detention facilities on guidelines and protocols to address comprehensive reproductive health and pregnancy needs. This includes contraception management, cervical and breast cancer screening, and holistic maternity care with the promotion and support of breastfeeding (ACOG, 2021).

Additionally, the corrections nurse needs to advocate at the organizational, local, state, and federal levels to support and push for the elimination of copays to access health care while in custody; to restrict shackling during pregnancy, labor, and the postpartum period; and to ensure adequate menstrual products are available at no cost (ACOG, 2021). The nurse should foster an appropriate birthing environment for justice-involved individuals who give birth while in custody and allow them to have the same opportunity to bond with their newborns. ACOG strongly urges all health professionals within corrections to advocate fiercely against placing pregnant clients in restrictive housing and for community-based alternatives to incarceration in this population, as incarcerated pregnant individuals have higher risks of adverse perinatal outcomes (ACOG, 2021; ANA, 2021).

Women who are incarcerated have higher rates of previous sexual and physical abuse than the general population. Therefore, the nurse must be trained to provide trauma-informed care (TIC) for these clients (ANA, 2021). When assisting health care providers with pelvic examinations, acknowledging that this procedure may be re-traumatizing to some clients and, as such, unnecessary. Nurses can be a chaperone to the health care provider performing the pelvic examination. They should also advocate that correctional officers not be present for these sensitive exams (ACOG, 2021). Research has demonstrated that justice-involved women have higher rates of gynecological conditions, such as irregular menstrual bleeding and vaginal discharge, than the general population of women. Long-term stressors related to poor social conditions in their pre-incarceration lives, such as unstable housing and exposure to trauma and violence, may influence abnormal menstrual bleeding, affecting up to 40 percent of these women (NCCHC, 2020). For transgender individuals, continuing hormone therapy and enabling access to gender-affirming care is key to providing comprehensive health care (ACOG, 2021).

Rates of breast and cervical cancers are higher among justice-involved women than among the general population, likely related to a lack of screening before and during custody (NCCHC, 2020). Many cervical cancers are preventable with appropriate screening, such as Pap smears and human papillomavirus (HPV) testing. National guidelines recommend females ages 21 to 29 get screened every 3 years, and those ages 30 to 65 get screened every 3 to 5 years. HPV vaccination is recommended through age 26, and this can be started while in custody (NCCHC, 2020). Guidelines for screening mammograms should follow appropriate national guidelines. The correctional nurse needs to be able to follow up on any abnormal Pap or mammogram results, which can be difficult during times of transition. Therefore, ensuring clients are connected with community health providers upon release is a key component of correctional nursing (NCCHC, 2020).

Among justice-involved women, rates of SUD, prior trauma and abuse, mental illness, and STIs are higher than the general population and higher than justice-involved men. The disproportionate rate of these conditions in women results from their intersection with the SDOH and, in BIPOC justice-involved women, structural racism as well (AAFP, 2021; ACOG, 2021; NCCHC, 2020). Additionally, the prevalence of trauma and sexual, physical, or emotional abuse in justice-involved women was as high as 90 percent in one study, indicating just how commonplace trauma and violence are among these women (NCCHC, 2020). Correctional nurses should be trained in trauma-informed care and should screen all women for trauma history to identify those needing resources and treatment (NCCHC, 2020). Caring for Vulnerable Populations and Communities discusses TIC in more detail.

Mental Health

According to the NAMI (2021), two out of every five individuals who are incarcerated have a history of mental illness, twice the number in the overall U.S. population. The origins of this disproportionate burden date to the mid-1950s when mass deinstitutionalization from mental institutions occurred (Roth, 2021). At the height of mass institutionalization in 1955, half a million people lived in state-run psychiatric facilities (Roth, 2021). In 1963, President Kennedy signed the Community Mental Health Act (CMHA) into law; the goal was to decrease the number of institutionalized individuals by supporting and nurturing self-sufficient local mental health care centers within communities (Erikson, 2021). This made federal grants available to states to establish these community mental health centers to care for clients released from state hospitals. During this time, Medicaid was introduced, shifting funding for individuals with severe mental illness from state-funded and run hospitals to a shared partnership with the federal government (Yohanna, 2013). This incentivized states to close facilities and move these clients with severe mental illness into community-based centers, hospitals, and nursing homes partially funded by Medicaid and the federal government (Yohanna, 2013). Few community mental health centers were built, resulting in a shortage of mental health care (Roth, 2021). Mass deinstitutionalization and the unmet needs of individuals with mental illness often resulted in initial criminal justice issues and subsequent recidivism (ANA, 2021; Roth, 2021).

NAMI Policy Priorities: Mental Health Treatment While Incarcerated

This video highlights the intersection between individuals with mental illness and incarceration. Mental illness is often not treated while individuals are incarcerated, resulting in unnecessary suffering and higher rates of suicide while incarcerated. NAMI supports public policies and laws to expand and improve access to metal health care within prison and jail settings.

Watch the video, and then respond to the following questions.

  1. What is the relationship between mental illness and incarceration?
  2. What are some alternatives to jail for individuals who have severe mental illness?

The correctional health system consistently underperforms in providing mental health care to individuals who are incarcerated (Roth, 2021). As law enforcement and courts treat mental illness like a crime, prisons and jails have more and more individuals with severe mental illness who are not being treated appropriately (Figure 29.6) (Wang, 2022). In a report from 2016, despite 56 percent of the state prison population having a mental health problem, only one-quarter of these individuals received professional mental help (Wang, 2022). The most common disorders are post-traumatic stress disorder, depression, bipolar disorder, and psychotic disorders such as schizophrenia (Aufderheide, 2014). The rates of most of these disorders are almost 3 times as high in women as in men (NCCHC, 2020; Wang, 2022). In prisons and jails, two-thirds of women had a history of a mental health diagnosis compared with 35–40 percent of men. There is a higher risk for attempted and completed suicide in the incarcerated population than in the general population (Hahn, 2022). In adolescents, suicide attempts are four times higher in justice-involved adolescents than in the general population (ANA, 2021). Correctional nurses must consider suicide potential during the intake of new justice-involved individuals into a facility and in all incarcerated persons, especially when there are threats of violence while incarcerated (Schoenly & Knox, 2012.)

A bar graph shows the indicators of mental health problems of people in state prisons and the treatment received in state prisons. 56% have recent or prior history of mental health problems; 43% have ever received a diagnosis of a mental disorder; and 14% have had serious psychological distress in the past 30 days. Meanwhile, only 26% have received professional help for mental health since admission and only 6% are currently receiving counseling or therapy from a professional.
Figure 29.6 The extent of mental health problems in justice-involved individuals does not match the mental health help provided to these individuals. Over half of people in state prisons have reported a mental health issue, but only one in four has received professional help while incarcerated. (See Wang, 2022; data source: Maruschak et al., 2021; attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Mental illness is common among justice-involved individuals, so correctional nurses need to be able to identify and care for clients with mental health problems. Understanding the implications of mental illness and comorbidity with other conditions, monitoring for drug interactions, and managing side effects are key aspects of correctional nursing care. A 2016 survey found that approximately 50 percent of individuals incarcerated in state prisons with a history of a substance use disorder also had a history of one or more mental health conditions, compared with only 38 percent of the general U.S. population with a history of a substance use disorder (Wang, 2022).

Substance Use

According to the NIDA (2020), an estimated 65 percent of the incarcerated population has an active SUD; an additional 20 percent was under the influence of drugs or alcohol at the time of their crime. Alcohol and drug withdrawal is a major concern for correctional nursing, along with health promotion activities designed to assist justice-involved clients in developing alternative coping mechanisms to reduce recidivism (Schoenly & Knox, 2012).

Although the incidence of opioid use disorder (OUD) in criminal justice settings is high and treatment of SUDs within the criminal justice system has been shown to make a difference in outcomes for affected individuals, most correctional facilities do not offer any medication to treat individuals with OUD (NASEM, 2019; NIDA, 2020). Appropriate treatment and counseling can change attitudes, beliefs, and behaviors toward drug use, decreasing opioid use and criminal activity once a person is released from prison (NIDA, 2020). Overdose deaths post-incarceration are lower when justice-involved individuals receive treatment and medications for addiction while incarcerated (NIDA, 2020). According to the National Academies of Sciences, Engineering, and Medicine (NASEM, 2019), medication-based treatment for SUD is effective across all settings and withholding approved medications—methadone, buprenorphine, and naltrexone—for the treatment of OUD in criminal justice settings amounts to blocking medical treatment.

The lack of medication-based treatment for these individuals results in a greater risk of returning to use and overdose post-incarceration, with a high risk of mortality following release (NASEM, 2019). Justice-involved individuals were more likely to engage in treatment post-incarceration and less likely to use illicit drugs 6 months out when they initiated medication-based treatment within the prison system (NASEM, 2019). There are ethical implications because withholding medications to treat OUD is associated with adverse outcomes for the individual and the community (NASEM, 2019). Another consideration with this population is the care transitions that occur upon release. Many justice-involved individuals are not adequately transitioned or even referred to outpatient medication-based treatment upon release (NASEM, 2019).

Correctional Health Care

In this video, nurses describe the role of the correctional nurse and explain why they consider it to be the hidden gem of health care.

Watch the video, and then respond to the following questions.

  1. What did you think of correctional health nursing before you read this chapter and watched this video? What do you think of it now? How has your perspective on corrections nursing changed, if at all?
  2. What, if anything, about the role of correctional nurse surprised you?

Case Reflection

Correctional Nursing

Read the scenario, and then respond to the questions that follow.

As introduced previously, Rory is a 23-year-old woman who completed her initial health intake with nurse Jason two months ago when she first arrived in state prison. At that initial intake, Rory underwent many screening tests, including STI testing and pregnancy testing. Rory tested positive for chlamydia, hepatitis C, and pregnancy. She was treated with antibiotics for chlamydia and started on a prenatal vitamin for her pregnancy. The medical facility also ordered asthma medications, a steroid inhaler, and a rescue inhaler for Rory. Rory went through active detox after admission because the state facility does not offer medication-based treatment for her opioid use disorder. She has yet to have her bipolar disorder evaluated or treated by the health care team but is scheduled to see the nurse midwife for her first obstetric visit next week. Rory’s scheduled release date is in 11 months.

  1. What is the role of the correctional nurse in caring for this client?
  2. Given this client is pregnant, how should the correctional nurse approach the upcoming nurse midwife visit? What can the nurse do to help the client prepare for it?
  3. How can the nurse assist this client with receiving treatment for her mental health diagnosis?
  4. What is this client at risk for upon discharge? How can the correctional nurse assist Rory as she plans for discharge in less than a year?
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