Supporting Older, Frail, and Vulnerable Adult Prisoners Through Peer Care: Observations, Reflections, and Recommendations Based on a UK/U.S. Researcher Exchange Visit

Abstract

This article describes key findings from a UK/U.S. prison health researcher exchange in September 2023. The aims were to increase familiarity with the research context and to observe the roles of peer caregivers in U.S. prison settings. The researchers identified several differences and similarities in peer caregiving between UK and U.S. sites and detail six recommendations related to policy and practice concerning both sides of the Atlantic. It is believed that the adoption of such recommendations will contribute to improved care and, thereby, the health and well-being of vulnerable people incarcerated in prison.

Introduction

In Fall 2023, the host institution hosted the first author and employer for an exchange visit, sponsored by the University of Brighton’s International Collaboration Fund. Two primary aims of the visit were for W.S. to increase his familiarity with the research context and to observe the roles of peer caregivers (PCs) in U.S. prison settings.

Peer caregiving has been defined as social, emotional, and practical peer-to-peer support, such as befriending and assisting with activities of daily living (ADLs) (Stewart, 2011). In this Viewpoint article, we describe several observations made during the visit, offer several comparisons between UK and U.S. peer caregiver policies and practices, and conclude by detailing six recommendations related to policy and practice concerning both sides of the Atlantic. It is believed that adoption of such recommendations will contribute to increased health and well-being of older or frail people incarcerated in prison through improved peer caregiving.

An Overview of the Exchange

Four correctional institutions in Kentucky were observed: the Louisville Metropolitan Department of Corrections (LMDC), Kentucky Correctional Institution for Women (KCIW), Kentucky State Reformatory (KSR), and Roederer Correctional Complex (RCC). The facilities were selected by S.G.P. to provide an overview of the pathway through the Kentucky criminal legal system. Broadly, numerous similarities exist between UK and U.S. institutions. These included approaches to commissioning, sociomaterial characteristics, workforce structures, and several other practices and processes. We also observed numerous rehabilitation programs and unique prison industries, including horticulture, braille production, and the training of canines for use in the community.

A primary difference between UK and U.S. facilities, however, relates to population management issues such as the assessment, categorization, and allocation process of people throughout state institutions. Prison leaders described a perennial “balancing act” of numerous critical considerations, including the number of prison spaces, programming across institutions, and associated costs by location throughout Kentucky.

Peer Care Observations

Both researchers have experience investigating and evaluating peer caregiver programs in prisons, and we were thus most intensely interested in the various health and social care facilities within these spaces and, specifically, the use of peer care. The terms “peer care” and “peer support” can translate to differing roles and responsibilities depending on the type and function of the carceral setting; for example, activities can range from assistance with mobilization to one-to-one assistance within residential social care units.

During the visits, we observed multiple models and methods of incarcerated people supporting other, more vulnerable incarcerated people. PCs may aid older people/younger people with chronic health needs; those living with frailty, physical disabilities, and cognitive disabilities; or those approaching the end of life. We were able to speak with a wide range of professionals and small groups of PCs in two prisons. At KCIW, the PCs were based in the mental health day unit, and at KSR, the PCs worked in a dedicated dementia unit.

At KCIW we visited the primary care and mental health centers, which include a chemotherapy unit and other allied health facilities, such as dentistry. On balance, the facilities were well equipped and the buildings appeared modern, indicating a good level of funding. We had the opportunity to speak with two PCs (there were eight in total), and they were paid $2.70 per day (a rate lower than earnings in the various industries highlighted previously). Significantly, both had worked as care assistants in the community before being sentenced.

The residents appeared to be generally self-caring; therefore, the role appeared to relate to mentoring and supporting social activity, rather than hands-on, practical care work. The manager suggested a regular turnover of PCs, describing challenges with retention due, in part, to working with people with cognitive impairment. Likewise, the PCs suggested that training on dementia would be useful, and we discussed the possibility of trainings related to other topics such as skilled interpersonal communication, resilience, loss, safeguarding, and learning from practice.

KSR had a very large health care unit, including mental health and physical health spaces, and the segregation area was upstairs within the complex. We were shown the “challenges” unit, where incarcerated people undertook courses such as psychological skills training. We also visited the dedicated regional dementia unit where older adults with neurocognitive needs could receive specialist support. The unit was well-staffed, overseen by a generic manager and a clinically oriented social worker on a day-to-day basis, and further supported and supervised by a neurocognitive psychologist. Five other psychologists affiliated with the prison had different responsibilities, such as mental health assessment or dual diagnosis.

Five PCs were on duty during our visit, with three PCs employed at night. This is a comparatively well-paid position with pay ranging from $4.40 to $6.60 per day. We observed PCs cleaning and helping older and disabled adults with occupational tasks, such as assisting with an art-based activity. We were shown a de-escalation room and three documents to be completed by the PCs, covering the nutritional intake, sleeping patterns, hygiene, and behavior issues. Critically, these documents formed the basis of a basic daily care record. The ratio of PCs to older adults was around 1 to 5. While we did not hear about a formal evaluation of the role of PCs, the staff did mention that PCs could not perform their regular activities during the lockdown and shelter-in-place period of the COVID-19 pandemic. The staff offered how much they appreciated the PCs’ support.

Comparing UK and U.S. Peer Caregiver Policies and Practices

Based on our visits, several areas of PC policy and practice were identified for targeted comparison: PC tasks, touch in the context of care, and training.

Peer caregiving tasks

In the United States, PC practice has been driven in large part by the extremely high number of deaths by natural causes per year (Carson, 2021). During our visits, we were informed that PCs may sometimes assist with ADLs, including eating, changing incontinence pads, bathing, and dressing. Yet, existing policies may impede completion of such tasks. In those prison health care units that are accredited by the National Commission on Correctional Health Care (NCCHC, 2018), standard P-C-06 Inmate Workers provides guidance regarding PC tasks. It begins as “inmates do not make treatment decisions or provide patient care.”

Although the units we toured may not be accredited by the NCCHC, it is unclear if “provide patient care” relates to tasks such as assisting with eating or more advanced skills such as changing dressings. It is further unclear if patient care refers to medical and social care as no definitions are provided. From a policy perspective, the term “inmate worker” or “buddy system” is preferred to “carer” or “peer caregiver”; however, the latter terms are freely used in practice.

There is also agency-based policy governing PCs that focus more specifically on vulnerability. Adding to the complexity, privately commissioned care providers may also have their own guidance and instructions (namely, Wellpath, Corizon), although these were not discussed during our visits.

Touch in the context of care

The Prison Rape Elimination Act (PREA; 2003) is federal U.S. legislation forbidding sexual contact between people who are incarcerated and between those incarcerated and staff under any circumstance. Closely parallel, the Kentucky Department of Corrections holds a “no touch” policy. These policies are designed to protect people; however, their application can create problems. For example, PCs may work with people with diminished cognitive capacity who seek physical affirmations such as hugs. Likewise, vulnerable people with limited vision or hearing may rely on the guidance of others to navigate the institutional space. An incarcerated person who could not see might need to place their hand on the shoulder of a PC who could see to lead them through the campus. These behaviors are regarded as infractions under federal and agency policy.

Although enlightened staff recognize the critical role of touch in practice and use their discretion in certain circumstances to ensure aid to vulnerable incarcerated people, PCs may be fearful of “catching a PREA” or similar disciplinary infractions and thus delay or decline from offering critical aid to older or frail people in prison.

In the UK, His Majesty’s Prison and Probation Service (HMPPS) policy Prison Service Instruction (PSI) “17/2015 Prisoners Assisting Other Prisoners” provides instruction on peer caregiving in prisons. Released after the Care Act (2014), PSI 17/2015 delineates between acceptable “personal care” and unacceptable “intimate care.” Personal care is somewhat parallel to “home help” and includes obtaining meals and tidying cells but very limited assistance with hygiene needs, whereas “intimate care” is off-limits to PCs and includes bathing and attending to toileting needs. Technically, external professional social carers would need to undertake the latter activities.

Similarly, in the U.S. institutions we visited, there are anecdotal narratives of a gray area between the personal and intimate care. In some cases, such guidance is not strictly enforced for pragmatic reasons or in the best interests of vulnerable incarcerated people (Stewart, 2018).

Training

In the UK, the number of PCs within an individual prison varies depending on the level of need of the population. According to Forsyth et al. (2020), 87% of UK prisons have PCs working in differing capacities. It is unclear how many PCs exist within U.S. prisons. Responsibilities are not standardized, and the frequency, intensity, and duration of training can vary between institutions and regions ranging from supervised, experiential learning to more didactic approaches. Some formal PC training interventions exist; for example, RECOOP, the national charity for older people in prisons, has an established network of trainers in two regions (Grainge et al., 2020). Furthermore, there is evidence of empirical evaluations of PC roles and training in the UK (Stewart, 2011, 2018), Israel (Einat, 2017), and Australia (Webber & Evans, 2020).

Some evidence exists that PCs complete a variety of trainings in the United States, most especially those working in end-of-life care settings (Prost et al., 2020; Wion & Loeb, 2016). Although PCs in the United States likely complete standard precautions training and make use of protective materials, many arrangements involve no training for specific roles. For example, no requisite knowledge or skills were identified for wheelchair ambulation. However, local staff delivered some focused training for PCs with caregiver responsibilities (although there was not a set curriculum). While there is an acceptance that there will be learning on the job, this is not acknowledged in an official sense and staff supervise newcomers.

Conclusion

Both researchers acknowledge gaining many insights during the exchange, thus enhancing context for future, transnational efforts. For example, for the UK researcher, the sheer size and scale of institutions and numbers of incarcerated people were somewhat astounding. The U.S. based researcher was surprised that UK institutions rarely had ready access to multiple psychologists, although perhaps even several remain too few considering the average daily census of U.S. prisons. Likewise, although many U.S. prisons were constructed before the 1900s, the U.S. researcher was made aware that many more institutions stateside are considered modern by UK standards.

In conclusion, our observations and reflections on policies and practices on both sides of the Atlantic contribute to six specific recommendations to support older and disabled vulnerable people who are incarcerated.

1. Collectively, we recommend that greater recognition be given of the role of the PCs and, thereby, the provision of further resources and ongoing support.

2. In the UK, the HMPPS is encouraged to consider developing regionalized, dedicated dementia units for incarcerated older people with neurocognitive needs.

3. Acknowledging the need for careful screening, training, and supervision, we suggest that HMPPS consider reviewing the list of care actions permissible under PSI 17/2015, with a view to relaxing some of activities listed as intimate care. This could permit for greater flexibility within the role, reduce costs for the institution, and provide opportunities for personal development for the PCs (Webber & Evans, 2020).

4. We encourage efforts to conceptualize and operationalize peer care in the U.S. prison context. Establishing a common language is an essential first step in the building and refinement of related policies and practices and in the conduct of PC research. Although several bodies may be capable of this charge, NCCHC may be especially well-positioned to undertake this effort with the consult of PCs, their supervisors, and scholars in this area.

5. The United States also needs tailoring to legislation and agency policies regarding touch to account for practical demands in specific vulnerable prisoner units.

6. The United States should also consider implementing a PC training template. Several have been developed in other countries, and Loeb et al. (2021) have offered an important framework for supporting incarcerated older adults and those with terminal illness through Inmates Care. This computer-based training included three primary units (Standard Precautions, Loss and Grief, and Role of the Inmate Caregiver in the Final Hours), and initial evidence indicates that the training is both relevant and feasible. It is recommended that the training be deployed alongside formal nursing training and ongoing support and supervision. Trainings like Inmates Care or those in UK and Australian institutions may stave off frustration and burnout, thereby reducing attrition among PCs. Likewise, prison staff are anticipated to benefit from parallel trainings (see Myers et al., 2022); such an approach is further expected to reduce conflict and thereby injury, most especially among those with cognitive impairment (namely, “sundowners”).

Authors’ Note

The views expressed herein represent those of the authors, not His Majesty’s Prison and Probation Service, the Louisville Metropolitan Department of Corrections, or the Kentucky Department of Corrections.

Authors’ Contributions

Both researchers collaborated fully on the production of this article.

Author Disclosure Statement

The authors disclosed no conflicts of interest with respect to the research, authorship, or publication of this article.

Funding Information

The exchange was funded through the International Exchange Fund, University of Brighton.