Correctional Facility Nurses: Spirits in the Dark

They may have been convicted of burglary, drug trafficking, kidnapping or even murder. But to nurses who work in the specialty of correctional nursing, prison inmates are simply patients who need compassionate, expert care. “The correctional environment is really just a microcosm of society in a controlled setting,” says CAPT. Beverly Dandridge, RN, MSN, a nurse recruiter for the Federal Bureau of Prisons (BOP), Health Services Division, based in Washington, D.C.

There are emergencies, chronic diseases and even mental health issues that occur within the prison environment–just like those found in the traditional hospital setting–and they all require medical attention. The difference is that these patients are cared for behind well-guarded prison walls. But it’s this combination of unusual work surroundings and a unique patient population that makes correctional nursing an interesting and rewarding career, especially for nurses who specialize in mental health care.

It’s also a career that’s in high demand. During the past 30 years, the prison population has grown exponentially. At federal prisons alone, the inmate population has increased from approximately 20,000 in 1970 to more than 170,000 in 2003, according to the BOP. When state prison statistics are factored in, that figure jumps to more than 1 million inmates nationwide. This rapid expansion not only represents a rise in convictions but also an increased need for health care professionals who are willing to take their expertise behind bars. Despite Hollywood-driven stereotypes of jailhouse nurses mundanely handing out medications with little else to do, correctional clinicians carry out many of the same job responsibilities as their counterparts in more conventional health care settings.

“My professors tried to discourage me from working in a prison by telling me that all I’d be doing is giving out meds,” recalls Myra Zapata, RN, BSN, who works at the Northern State Prison in Newark, N.J. “But that scenario is absolutely false, especially in the mental health specialty. This job involves the whole spectrum of nursing. We’re providing mental and physical health care to a population that normally wouldn’t have received the same services on their own or on the outside.”

“We deal with disease prevention, treat acute conditions and monitor behavioral changes,” adds Dandridge. “Nurses are also responsible for the educational, medication administration and other administrative tasks for each patient.”

A Statistically Documented Need

In 2000, then-U.S. Surgeon General Dr. David Satcher released a landmark report card on the mental health status of Americans. It stated that there was a far higher rate of incidence of mental illness than most health care professionals and laymen previously acknowledged. Specifically, “Mental Health: A Report of the Surgeon General” revealed that one in five Americans suffered from some form of mental illness, but that the majority of cases were treatable.

That same year, the American Correctional Association (ACA), an organization representing corrections professionals, released its study of the mental health status of prisoners. The findings mirrored those of the Surgeon General’s report: More than 17,000 state inmates were under 24-hour mental health care and another 137,492 were in therapy or counseling. Additionally, 105,403 prisoners were prescribed psychotropic medications, including antidepressants, stimulants, sedatives and tranquilizers.

In still another study, the Department of Justice (DOJ) examined the mental health differences between male and female inmates. Its research exposed the fact that a higher percentage of women prisoners (one in four) were in therapy or counseling and were prescribed medications more often than their male counterparts.

Over the years, departments of corrections have publicly acknowledged the need for standardized mental health care. As a result, the amount of psychological and psychiatric services available to inmates has multiplied right along with the explosion of the prison population. “There has definitely been an increase in the presence, recognition and diagnosis of mental illness in the correctional setting,” Dandridge agrees.

Indeed, according to the DOJ, there are currently 12 state facilities specifically designated for mental health or psychiatric confinement, and more than half of all state prisons provide 24-hour mental health care. Furthermore, three-fourths of all state prisons offer counseling and distribute medications, and another two-thirds help connect released inmates with community-based mental health services. This abundance of resources also means a plethora of opportunities for nurses specializing in the psychiatric field. Says Dandridge, “There’s more of a need for mental health nurses in the [correctional] system now than ever before.”

Making Cultural Connections

As with many other nursing specialties, there is also a greater need for more minority nurses in correctional nursing than ever before. It’s no secret that persons of color are disproportionately overrepresented in the nation’s prisons. The most recent U.S. Census revealed that 12% of the country’s population is African American and 13% is Hispanic. But according to the BOP, 40% of federal inmates are African American and 32% are Hispanic. Therefore, a racially and culturally diverse health care workforce is a necessity when it comes to establishing a cooperative relationship between providers and inmates.

“Nurses of color bring not only competency as clinicians but also a broader understanding of the cultural and social challenges that sometimes impact these patients–such as lack of family structure, unemployment and lack of educational opportunities,” says Mary Muse, RN, MS, CCHP, director of nursing services at Cermak Health Services in Chicago, an affiliate of the Cook County Bureau of Health Services and the largest single-site correctional health facility in the country. “[We] also tend to be more sensitive to the impact that constant exposure to violence and drugs has on a patient’s life, and to how the stress of incarceration and the environment impact mental health.”

This shared cultural understanding helps minority correctional nurses engage with patients of color and establish a sense of comfort and trust that will aid in the patients’ healing, adds Muse, who is African American. “For some people of color, there remains a stigma associated with mental illness,” she points out. “[With a minority nurse], patients may be less silent about conflicts they are experiencing and more open to sharing their struggles as well as accepting behavioral limitations and participating in the development of appropriate treatment plans. This enhanced communication ultimately results in an ongoing therapeutic relationship that will hopefully transfer into continued health care follow-up once an incarcerated patient is released.”

Having a culturally diverse nursing staff in the correctional setting has other benefits as well. For example, gang culture permeates prison walls and affects which clinicians patients will and will not respond to. Zapata says inmates seem to accept her easily because she’s Filipino.

“They think I’m Spanish, Hawaiian or Chinese,” she explains. “Because some of the gang members don’t want to talk to white or black nurses, they see me as a neutral nurse.”

Both the BOP and private correctional staffing recruiters are actively seeking out a diversified health care workforce, including racial, ethnic and gender minority nurses. In fact, it could be argued that the correctional environment seems to be well suited for male nurses. “We do focus on recruiting a diverse staff, but we don’t target male nurses specifically. However, there is a significant presence of them here, which is a good thing for us,” says Dandridge, who is African American.

Not Your Typical Nursing Career

Comparatively speaking, clinicians who have considered correctional health care as a viable career path are still a fairly small group. After all, working with people who have been convicted of a crime may not be as high-profile as working in a prestigious teaching facility or traveling the country accepting nursing assignments. But for a growing number of nurses, it’s a path that tests their clinical and managerial skills.

“I’m not surprised that people don’t know much about correctional nursing,” says Dandridge, “but the learning curve is getting smaller and with that there is definitely more interest in the specialty.”

“The type of patient population we treat makes the work interesting, but it is a totally different approach to patient care because these are inmates and you have to keep that in mind,” adds Rosario Buscar, RN, BSN, mental health supervisor of nursing at Northern State Prison.

Generally speaking, the first contact nurses have with patients is when inmates first arrive at the facility. The majority of state and federal prisons mandate that all incoming prisoners undergo a psychiatric and physical evaluation, often with nurses leading the procedures. “I check to see if they have any suicide risks, along with any history of hospitalization or mental health problems,” explains Zapata.

It’s from these assessments that the staff determines whether the new resident is suited for general housing or requires additional psychological monitoring and treatment. Not surprisingly, the latter is frequently recommended.

Although health services departments vary from prison to prison, they typically have a tiered structure, based on the extent of care required. After the incoming evaluation, the first encounter practitioners have with inmates is often in an acute-care unit. Here, guards might bring in someone demonstrating a threat to himself or others. “It’s a crisis unit, so we do get inmates who are combative and violent,” notes Zapata.

The health care team’s initial responsibility is to calm down the inmates and develop a treatment plan. Usually, the care is double-pronged, necessitating both psychological and physical attention. In fact, sometimes it’s a physical condition that brings an inmate to the unit, but the clinicians discover an underlying psychological issue that needs addressing. Whatever the reason initiating the patients’ arrival, nurses need to be skilled in both psychological and physical assessments when working in the correctional setting.

After their initial health conditions are stabilized, patients begin therapy or counseling. For many inmates, this may be the first time a name or diagnosis has been attached to their problems. For others, it’s a revamping of previous treatments. While medication usually plays a role in the program, there’s also an in-depth educational process, often led by nurses.

“The education is delivered according to the inmate’s level of understanding,” says Dandridge. “For higher-functioning patients, nurses will discuss topics like current events to get them involved. Lower- functioning patients are taught about body grooming and how to take care of themselves. During this time, the nurses are also doing behavioral observation and documenting their behavior assessments, which then get reviewed by the medical staff.”

As the patients progress, they’re usually transitioned to a residential unit before being released back into the general prison population. There, nurses continue to work as part of an interdisciplinary team that determines the focus of a prisoner’s care. “We have psychologists, social workers and occupational therapists working with the patients,” notes Buscar.

“They plan and develop programming for the patients to keep them busy and to help them develop social skills,” adds Dandridge.

Additionally, nurses facilitate group therapy sessions along with continuing the health education process. “We teach about hygiene, medication side effects and self-medication administration, because sometimes the patients are released from prison and they need to learn how to do their meds by themselves,” says Buscar.

In fact, of the average 600,000 inmates released each year from both federal and state prisons, approximately 14% have been diagnosed with a mental illness, according to the Justice Department and the ACA. Still, it’s the challenge of pushing the boundaries of their clinical, communication and psychological nursing skills that makes the job intriguing, say correctional clinicians. As Dandridge puts it, “The blending of the corrections, medical and mental health care settings is what makes this work so interesting.”

Safety First

Of course, the correctional environment does pose some risks, especially when dealing with patients suffering from mental illnesses and possible psychotic episodes. Obviously, security is a top priority and facilities provide numerous precautions, most notably an armed officer overseeing interactions between health care staff and inmates. “Safety is always a concern in the prison setting, and on the mental health unit that is heightened even more,” Dandridge stresses.

For some correctional nurses, this added security is one of the benefits of the environment. After all, even in conventional hospital emergency departments or psychiatric units, there can be an element of risk. For example, a patient under the influence of narcotics or alcohol can turn violent, as can someone suffering from hallucinations. At least in a correctional facility, there’s a trained, armed guard present at all times to intervene in case an incident occurs.

“They’re there to protect me and make sure everything’s okay,” says Buscar. “I like the fact that someone’s watching.”

Additionally, newly hired correctional nurses are usually required to attend an in-depth training session specifically designed to educate them about what to do in case a potentially dangerous situation develops. “Nurses need to be astute to changes in patients’ behaviors,” adds Dandridge.

But however beneficial constant security can be to a nurse’s comfort, it also has its drawbacks. Because prison officers witness every interaction with patients, open communication between inmate and nurse may be limited, which in turn can limit the extent of help inmates receive.

“You have to know where you are at all times and the fact that there are a lot of ears. The officers hear everything the inmates say to us and that’s a problem because they won’t be as truthful with us,” explains Zapata.

“Confidentiality is very important,” Buscar agrees. “I limit myself as to what to ask [patients] because I don’t want to disclose to the officers anything more than what’s necessary. Inmates think everyone’s against them, that society is against them, but they do seem to trust nurses for some reason.”

Room at the Top

When it comes to hiring correctional mental health nurses, diversity isn’t the only thing that recruiters are looking for. First, most prisons require nurses to be U.S. citizens, but even more importantly, officials want practitioners with previous experience in mental health care, preferably in a correctional setting. Still, given today’s nursing shortage, it’s not a deal-breaker. For instance, neither Zapata nor Buscar had worked in a prison before signing up with Correctional Medical Services, a private staffing organization that contracts with correctional institutions. Zapata, however, had been practicing in a long-term care facility on a mental health unit.

Once they have gotten their foot in the door, nurses have plenty of opportunities to advance their careers. Against all stereotypes, correctional nursing is not a dead-end job. Buscar, who is Filipino, is a good example: She started off as a staff nurse on night shifts in 1999 and within four years she’s been promoted to both a supervisor and recruiter. “Working in a prison has always intrigued me and it gives me so many different types of challenges and opportunities,” she says.

At the BOP, nurses can pursue careers as public health officers, which offers its own set of promotion opportunities and benefits. But for many correctional nurses, the true job satisfaction comes from the impact they have on their patients. “You get to observe their behavior when they first come in and then you get to watch their responses to medication and therapy,” says Dandridge. “That is very rewarding.”

Buscar has similar feelings. “I had one inmate tell me, ‘If it wasn’t for you, I wouldn’t have left that unit,’” she reports. “I saw that I really did help someone and that makes me want to go and do more for these people.”

While working in a prison may not be the career that most nursing students envision, Muse recommends her chosen specialty to other minority nurses without hesitation. “Correctional health care offers a unique opportunity for service,” she explains. “This population is hidden from society, and society has formed certain attitudes about them. Caring for this population allows nurses to demonstrate an increased level of compassion and advocacy. Correctional nurses must move out of their personal experiences and prejudices to serve without judgment of a person’s life choices.”

This career is also a unique opportunity to provide health education and care to persons who otherwise would not receive it, Muse continues. “If you make an incarcerated person healthier, you impact their community by making it healthier,” she says. “If a nurse is truly passionate about nursing, this is a place to live out that passion.”

For More Information

Federal Bureau of Prisons
www.bop.gov

American Correctional Health Services Association

National Commission on Correctional Health Care
www.ncchc.org

National Institute of Corrections
(see section on “Mentally Ill Persons in Corrections Settings” under “Correctional Research Topics”)
www.nicic.org

Corrections.com, Health Care Section
www.corrections.com

Correctional Health Resources
www.corrections.com/chr

Correctional Medical Services
www.cmsstl.com