Unsafe and Unsettling: An Integrative Review on Correctional Nursing Work Environments and Stressors

Abstract

Background:

Stress remains a major occupational hazard among nurses. As the U.S. maintains the largest correctional system in the world, little is understood regarding the occupational stress of correctional nurses and how that stress impacts their overall health and wellbeing.

Question Addressed:

What are the occupational/environmental stressors and professional burnout factors of correctional nurses?

Review Methods:

Guided by Whittemore and Knafl’s methodology, an integrative review was conducted using online databases of Scopus, CINAHL, NIOSH-tic and PubMed in July of 2021 for peer reviewed articles ever published internationally. Key concepts of ‘correctional health nursing’ and ‘occupational stress’ were used in our search.

Review Results:

A total of 152 articles were identified. Eleven articles met eligibility criteria and were included in this review. Three key themes emerged as conflict, fear, and demands.

Discussion:

Conflict arose from ethical and relational issues among co-workers, management, and incarcerated patients. Fear stemmed from physical safety concerns and workplace violence, while demands involved high workloads paired with a lack of organizational support. Findings revealed evidence on the unique occupational environment of correctional nursing professionals that impacted levels of stress and burnout across all types of correctional settings (e.g., jails and prisons).

Implications:

Better assessment and consistent evaluation of the health and wellbeing of correctional nurses and their correctional nursing environments are needed. Additional resources to reduce stress, along with ensuring policies that mitigate ethical challenges, workplace violence, and bullying, may promote professional and safe workspaces.

Problem Identification

There is a global prison crisis with over 11 million people incarcerated worldwide, living in institutions designed to be punitive (Penal Reform International, 2020). Keeping in mind this global perspective, we focus our interest on the U.S. with over 2 million adults confined in more than 7,000 correctional-based facilities (The Sentencing Project, 2021; Sawyer & Wagner, 2020). There is also incredible churn of the U.S. correctional system as roughly 10 million persons cycle through local jails and state and federal prisons on any given year (Assistant Secretary for Planning and Evaluation [ASPE], n.d.). U.S. facilities differ in length of stay for incarcerated persons, and vary in management at the local, state, federal, private, and international levels (Binswanger & Elmore, 2021; Brooks, 2019). Persons who are or have been incarcerated in these environments are substantially more likely to suffer from higher rates of infectious disease, chronic health conditions, and serious mental illness compared to those who have not been detained (Binswanger & Elmore, 2021; Davis et al., 2018; Penal Reform International, 2020). With such high churn of medically complex individuals in settings not designed to promote wellbeing and good health, it is no surprise that correctional facilities have been identified as extreme and stressful environments to work in (let alone live in) (Penal Reform International, 2020; Castle & Martin, 2006).

Correctional staff often work in low-resourced settings and witness overcrowding, violence, and inhumane treatment of incarcerated persons (Penal Reform International, 2020; Almost et al., 2020; Wright, 2020). The stress from working in corrections remains a significant occupational safety hazard putting employees at risk for emotional or physical harm (The National Institute for Occupational Safety and Health [NIOSH], 2014). The consequences of stress on health and wellbeing are widely recognized, including poor sleep quality and duration, burnout, anxiety, depression, and the negative impact on job satisfaction, job performance, and the ability to do one’s job safely and effectively (Fortes et al., 2020; Zhang et al., 2019).

With numerous safety and health risks of correctional environments, most occupational research has focused on correctional officers (El Ghaziri et al., 2020). Current research has uncovered an increased risk for suicide and early death related to chronic conditions including hypertension, depression, and obesity in correctional officers (Violanti, 2017; Obidoa et al., 2011; Buden et al., 2016). The psychological toll and hypervigilance related to correctional officer work has also been linked to stress and burnout, increased divorce rates, and substance use issues (Ferdik & Smith, 2017; El Ghaziri et al., 2020). However, little is known about the experiences of correctional nurses and how this environment impacts their overall health and wellbeing.

Correctional nurses are often the largest group of health professionals in any given correctional environment and include advanced practice nurses, registered nurses, licensed practical or vocational-type nurses (Almost et al., 2020; Blair et al., 2014). The role of correctional nurses encompasses a broad range of care responsibilities to effectively manage the complex needs of all patients detained in just one correctional setting. These responsibilities range from administration, primary care, acute/emergent care, behavioral health management, and other community/population health care duties (such as infectious disease control and prevention) (American Nurses Association, 2018; Almost et al., 2013; Almost et al., 2020). Because of their unique work environment and the persistent retention issues globally (Almost et al., 2020; Goddard et al., 2019; Wright, 2020; Chafin & Biddle, 2013), it is necessary to consider the impact of the work stressors on correctional nurses specifically.

Further exploration of contributors to occupational stress in this population may highlight where changes to the occupational environment can be made to enhance the health of correctional nurses and ensure high quality care delivered to incarcerated persons. Therefore, the purpose of this integrative review was to uncover what is known about the correctional nurse working environment and what factors contribute to stress. This review was guided by Whittemore and Knafl’s (2005) five stage methodology: problem identification, literature search, data evaluation, data analysis, and data presentation. The guiding research question was: What are the occupational/environmental stressors and professional burnout factors of correctional nurses?

Review Methods

Literature Search

The online databases Scopus, CINAHL, NIOSH-tic and PubMed were reviewed for articles to answer the research question in July 2021. Key words used for this search included ‘correctional nurses’, and ‘occupational stress’ or ‘burnout’ (see Figure 1 for database variations). No limitations on years, countries, or correctional settings, were used. The inclusion criteria were: English written articles, study sample including correctional nurses or other healthcare personnel, peer reviewed journal articles, primary sources, and psychological stress, physical stress, or burnout as the focus. The exclusion criteria included: main study population of general staff at correctional facilities (i.e., correctional officers), a study population of prisoners, the sole focus on nursing interventions in prisons or jails, literature reviews, periodicals, or personal experience narratives.

The search returned a total of 152 articles: 148 from databases and four additional resources identified from ancestry searching. There were 18 duplicates, leaving 134 articles whose titles and abstracts were screened for eligibility. Twenty-seven full text articles were read, excluding those that included correctional officers without clearly distinguishing results among the occupational groups. Figure 2 displays a PRISMA flowchart that provides an overview of the inclusion process for narrowing the articles (Moher et al., 2009).

Articles were critiqued using the Johns Hopkins’ Evidence Level and Quality Guide to evaluate rigor and quality (Johns Hopkins Nursing Evidence-Based Practice, 2021). This critique method involved assigning a level to each study design from I to V, where level I refers to experimental studies, level II includes quasi-experimental studies, level III involves only nonexperimental studies, level IV are opinion pieces, and level V is research based on experiential or non-research evidence. Researchers using this method also assign a measurement of quality from A (high quality), B (good quality), to C (low quality or major flaws).

Review Results

Data Evaluation

Eleven published studies met review criteria. Characteristics revealed five studies were conducted only in prisons, one study was conducted in the jail setting, and five did not limit sampling from any specific type of correctional facility. We included studies conducted in Canada (2), United Kingdom (2), United States (5), Italy (1), and Australia (1). Of the eleven studies, six focused solely on staff correctional nurses, another article included nurse managers, and the remaining four articles included other healthcare staff. All the articles were rated per the Johns Hopkins’ Evidence Level and Quality Guide as level III studies due to the nonexperimental designs. Three studies were determined as high-quality articles (A), seven studies were adequate (B), and one was of lower quality (C). Table 1 explains the detailed characteristics for all articles included in this review.

Of the articles, four had quantitative designs, two had mixed-method designs, and five had qualitative designs. The majority of studies that listed response rates ranged from 26%-71% with participants conveniently and purposively sampled. Sample sizes ranged from 95- 677 survey respondents, and 8- 13 participants in qualitative data collection. Most of the researchers included a description of instrument validity and reliability, although all studies used varying measurements to evaluate stress and only some reported Cronbach alpha information. Furthermore, ten of the 11 articles had explicitly mentioned IRB approval.

Data Analysis & Presentation

The data were ordered, coded, and categorized by making iterative constant comparisons between articles, discerning patterns and themes (Whittemore & Knafl, 2005). The key influences of stressors emerged as: conflict, fear, and demands. A subgroup of ‘setting’ was created to manage the data and facilitate the analysis. Penal institutions are generally referred to as either ‘jails’ or ‘prisons’ across the globe, but prisons are differentiated from jails in the U.S., and thus institutions are referred to broadly in this paper as correctional facilities unless otherwise specified. This subgroup revealed that nurses experienced similar stressors across the different institutions in this review. The coded patterns and themes were compiled into a matrix in Table 2 for the presentation of the data. This matrix summarizes the evidence and provides information regarding the experience of job stress across this occupational environment.

Conflict

Studies have highlighted multiple sources of conflict for nurses in the correctional setting as ethical and relational. Ethical dilemmas arise when one’s personal and professional morals are conflicted as correctional security is prioritized over quality health care delivered to incarcerated persons (Flanagan & Flanagan, 2002; Ghaziri et al., 2019; Kalra et al., 2016). Unlike other nursing environments, being ‘too caring’ is often seen to make correctional nurses more vulnerable and open to manipulation (Walsh, 2009). Instead, descion-making for correctional nurses can be influenced by their need to follow safety protocols and be accompanied by correctional officers who may dictate what care is allowed to be completed and for how long (Weiskopf, 2005). Care can also be canceled if incarcerated persons are moved within the system for custodial or judicial reasons (White et al., 2014).

Studies highlighted how security needs ultimately affect patient interactions and what care is provided to patients, creating ethical concerns for the nurses. Healthcare personnel reflected that their professional duties often conflict with security duties, and they had to morally decide when security concerns could override professional obligations and vice versa (White et al., 2014). One study revealed that 24% (n=118) of respondents viewed their ethics to be regularly compromised by their work in jails related to patient treatment and inadequate monitoring for quality care (Kalra et al., 2016). In fact, 91.1% (n=217) of nurses in another study reported complying with regulations and rules that they believed were contrary to their personal ethics (Lazzari et al., 2020). One example includes healthcare personnel reporting the ethical dilemma of being unable to maintain patient confidentiality when correctional officers must remain present during the assessment of patients (Weiskopf, 2005; White et al., 2014).

Complex and challenging relationships can also lead to stress among correctional nurses. Various relationships include those with patients, correctional officers, and supervisors. The desire to facilitate rehabilitation and care for patients paired with a hypervigilance for the risk for abuse or violence conflicts with nurses’ traditionally caring role and their professional code of ethics (Kalra et al., 2016; Walsh, 2009).

While correctional officers help to keep the nurses safe, differing professional roles exist between the care nurses want to provide and safety protocols of correctional officers (Almost et al., 2013; Walsh, 2009). Participants in one study reported a “clash of culture” with correctional officers over a lack of communication and understanding for each other’s working roles (Walsh, 2009, pg. 146). This conflict is further complicated by the nurses’ hesitancy to speak out against the status quo, as they are appreciative of the protection offered by correctional officers, wanting to maintain their help if situations abruptly change (Weiskopf, 2005; Walsh, 2009).

Some studies highlighted a lack of support from other correctional professionals (i.e., non-clinical staff) and organizational leadership (i.e., supervisors, administrators). For instance, correctional healthcare staff have reported not feeling valued, understood, or respected at work (Hunsted & Dalton, 2021). This was echoed in another study where a nurse reported, “[m]anagement misunderstands the real needs of my department” (Flanagan & Flanagan, 2002, pg. 291), suggestive of their dissatisfaction. Inadequate staffing and resources for healthcare personnel to perform their jobs safely, further fosters dissatisfaction among nurses and the organization as a whole (Flanagan, 2006; Flanagan & Flanagan, 2002; Ghaziri et al., 2019; Walsh, 2009).

Fear

Seven of the 11 articles in this review discussed fear stemming from bullying, personal security, physical safety, and violence. Almost et al. (2013) reported sources of bullying for nurses from correctional officers (31%), nursing colleagues (30%), inmates (20%), health care managers (11%), and physicians (5%) . Gender differences also influenced the experience of bullying with female nurses reporting higher prevalence of regular co-worker bullying (El Ghaziri et al., 2019).

Correctional nursing risks for injury at work includes sharps and bodily fluid exposure, along with physical abuse, verbal assaults, and workplace violence (El Ghaziri et al., 2019). Working with aggressive people or difficult patients was reported as a major source of stress for these nurses (Flanagan, 2006). It was found that 96.5% (n=83) of participants reported workplace violence exposure, including being yelled or sworn at, threatened, sexually harassed, or physically hurt by an inmate in the past 12 months (El Ghaziri et al., 2019). Healthcare personnel in another study reported a daily occurrence of receiving or witnessing threats from patients (Husted & Dalton, 2021). To further underscore this experience, one nurse reported “when I have been in the clinic with more than one inmate or I’ve had to walk from one place to another without an officer and there are inmates around, I don’t like that, ‘cause you never know who they are, what they’ve done, what crimes they’ve committed, you don’t know if they could just snap, and I just feel unsafe” (White et al., 2014, pg. 337). A general concern for the unknown was perpetuated by the chance of rapidly changing situations where fights could break out or violence could be directed at healthcare personnel from incarcerated persons (Almost et al., 2013).

Healthcare personnel tended to cope with the threats by either ignoring them or appearing calm (Husted & Dalton, 2021). This can be considered emotional dissonance, or ‘labor’, involving the need to regulate and display certain emotions expected for one’s job, and may include suppressing or hiding gut reactions (Hochschild, 2012; Suh & Punnett, 2020). The emotional labor of maintaining professional standards while caring for vulnerable patients is paired with an increased alertness and paranoia associated with security concerns of the correctional environment, increasing stress, and impacting wellbeing (Walsh, 2009; Weiskopf, 2005).

Demands

Demands specific to correctional nurses include high perceived workloads with little support from management, leading to job dissatisfaction. One study reported that "one nurse may be responsible for administering medications to over 300 inmates" (Almost, et al., 2013, pg. 7). Another study found that when correctional clinics were understaffed, strategies of withholding medications or requiring patients to make an appointment were used (White et al., 2014). Time pressures and heavy workloads create stressful work environments, which are exacerbated by mandatory overtime requirements and a lack of appropriate staffing or resources (Almost et al., 2013; Flanagan, 2006; Flanagan & Flanagan, 2002; Ghaziri et al., 2019).

Cumbersome task demands and inadequate pay were found to be negatively associated with job satisfaction across studies. Both nurses and nurse managers were most dissatisfied with salary and benefits, followed by limited time to do their work (Almost et al., 2013). Frustration from practice restrictions preventing them from providing high quality care and feeling like they could not make positive changes also created job dissatisfaction (Walsh, 2009; Stephenson & Bell, 2019). Flanagan & Flanagan (2002) reported that the Nurse Stress Index (NSI) score was the strongest explanatory variable, accounting for 30.3% of the variance in job satisfaction. An inverse relationship was further supported between job stress and job satisfaction (Flanagan, 2006). Conversely, it was found that correctional nurses were satisfied with levels of enjoyment and quality of care given to patients, along with pay, interaction, professional status, autonomy, purposeful and meaningful work, stability, variety, and ‘making a difference’ (Almost et al., 2013; Flanagan & Flanagan, 2002; Flanagan, 2006; Stephenson & Bell, 2019; Husted & Dalton, 2021).

Discussion

Very few studies have been conducted on the occupational environment, experiences, and stress of correctional nursing professionals. Of the 11 studies meeting review criteria, environmental stressors stemmed from three primary themes: conflict, fear, and demands. Results from this review found correctional nurses are working in demanding and threatening environments with inadequate resources and staffing, along with low perceived support from management (Almost et al., 2013).

In line with our results, other reports have noted that security protocols in the correctional environment often override the quality or frequency of nursing healthcare priorities for incarcerated persons (Dhaliwal & Hirst, 2016), contributing to moral distress (Kalra et al., 2016). Moral distress is described as the negative experiences resulting from when a nurse knows what the right action is and is unable to act on it based on certain obstacles like institutional pressures or policies (Jameton, 1984; Smith et al., 2021). The phenomenon of moral distress could be investigated more within the correctional nurse environment in future studies.

Additional evidence reiterates that certain stressors of correctional nurses may stem from repeated exposure to violent behavior and verbal assaults, manipulation, and frequent exposure to infectious diseases (Almost et al., 2020; Bell et al., 2019; Hancock, 2020). These unique experiences increase the risk for compassion fatigue, vicarious or secondary trauma, and burnout among correctional nurses (Flanagan & Flanagan, 2002; Hancock, 2020; Wright, 2020). In one study of 270 nurses and 27 nurse managers, approximately 19% of each group did not intend to stay at their current job over the next year for reasons including dissatisfaction and work being too stressful (Almost, et al., 2013). Another study indicated that 30% (n=114) of the respondents reported an overall dissatisfaction with their job and 33% (n=179) experienced burnout by their work (Kalra et al., 2016), highlighting the need for strategies to mitigate stress in this occupational group. Current literature similarly supports that improving the working environment and nurse morale is necessary to increase correctional nurse satisfaction and decrease rates of stress and burnout (Merrifield, 2018).

Efforts to build evidence, support worker wellbeing, and create a safer and healthier correctional workplace climate is already underway. One study has used a qualitative content review to collaboratively and comprehensively examine the impact of correctional environments on health among correctional officers (El Ghaziri et al., 2020). As new ways to create healthier correctional workforces begin, it is imperative to include correctional nurses in the conversation and examine the ways to alleviate the stressors specific to them.

Implications for Nursing Practice

Results from this study suggest numerous considerations to improve safety and reduce the stress of correctional nurses. The first consideration involves the evaluation of workplace adherence to policies centered on safe nurse/patient ratios and the reduction of workplace violence and bullying. However, these policies and standards vary by each state within the U.S., as well as globally, depending on the correctional facility, their size, and needs. The National Commission on Correctional Heath Care (NCCHC, n. d.) provides a set of standards recommended for U.S. facilities, offering accreditation to those that adhere to best practices. These standards are explained in separate manuals for prisons, jails, and juvenile correctional facilities, and while they discuss the training for healthcare personnel, the manuals mainly focus on the treatment and health outcomes of the patients instead of the workforce caring for them (NCCHC, n. d.). The designated Responsible Health Authority person ultimately determines the policies and procedures in each health facility in alignment with state laws and practice regulations, covering resource allocation and staffing ratios (Blair et al., 2014).

Nurses may also benefit from receiving resources such as linkages to up-to-date safe patient care guidelines and stress management strategies to reduce burnout. Employee assistance programs that ensure adequate access to frequent counselling, debriefing activities, and supportive services, could help to mitigate emotional labor and encourage positive coping (Walsh, 2009). Educational courses that combine topics of emotional intelligence, health promotion, and wellbeing could aid in stress management for nurses as well. Cross-sector collaboration between security staff and nursing staff could be another way to reduce role confusion, promote collegiality, and possibly improve patient care. An example to improve communication and teamwork would be simulation-based training for different correctional environment scenarios (Diaz et al., 2019).

Making changes towards a safer workplace environment may be seen as a positive effort from management to understand staff’s needs and may improve the relationship between healthcare personnel and the organization. Additional support from supervisors could help correctional nurses to better maintain their sense of professional identify and uphold their code of ethics to practice with compassion and respect, promote health, and advocate for the rights of their patients (American Nurses Association, 2015; Smith et al., 2021).

Limitations

The review was limited to those published online and accessible through databases with certain key terms, increasing the risk that some studies may have been left out of this review. The small number of qualifying studies led to the inclusion of older articles, and lower quality evidence to inform this review, with no randomized controlled trials included. The analysis was also complicated by the differing countries, correctional setting contexts, and the lack of clarification between the roles of licensed practice nurses, registered nurses, and nurse practitioners. Despite these limitations, a rigorous process was used to collect and screen articles. Evidence quality was evaluated using a systematic method from Johns Hopkins Nursing Evidence-Based Practice (2021) and the review was guided by Whittemore & Knafl’s (2005) methodology.

Conclusion

Correctional nursing is a highly specialized area that requires adequate supports and resources in order to carry out tasks effectively (American Nurses Association, 2018). Better high-quality investigation with an array of mixed-method and longitudinal designs is needed to determine how the unique stressors of the correctional working environment impact the wellbeing of correctional nurses, their families, and the care of incarcerated patients. Doing so, can lead to intervention development designed to holistically support the safety, health, and wellbeing of correctional nurses.

Appendices

Figure 1.

Database Variations

Figure 2.

PRISMA Flowchart

Table 1.

Article Characteristics

Author & Date	Purpose & Design	Sample, Setting and Theoretical Framework	Measures/Study Concepts and Results	Limitations	Evidence Level, Quality
Almost et al., 2013	To explore the work environment of nurses working in provincial correctional facilities Mixed methods: cross-sectional survey and semi-structured interviews	N= 11 (8 correctional nurses (RNs/ RPNs) and 3 healthcare managers) completed interviews; N= 297 (270 correctional nurses and 27 healthcare managers) completed survey responses. Convenience sampling 5 correctional facilities in Ontario, Canada Aiken’s Magnet Status 56.1% survey response rate	Survey collected data on role overload, autonomy, control over practice, nurse-physician collaboration, adequacy in staffing, intragroup conflict, bullying at work, respect, burnout, job satisfaction, intent to leave, and role overload to evaluate the relationship of variables with workplace stress Key stressors included limited resources, challenging work relationships regarding conflicting values, inadequate staffing and demanding workloads Other stressors included limited control over practice and scope of practice as a result of security concerns Reasons for those who intended to leave their job in the next year included: demanding workload, low support, low pay, long hours, no full-time positions, no advancement opportunities, and dissatisfied or too stressful Majority of participants reported emotional abuse (from patients and others), and bullying in the past year Little educational advancement opportunities	Large sample size of nurses was reported as representative of correctional nurses in Ontario. However, the healthcare manager sample remained small in both qualitative and quantitative parts of the study Numerous instruments were used to evaluate concepts of interest in the survey and components were described. However, validity and reliability were not reported for every measurement The face-to-face interview process and questions were not described so the qualitative design quality and procedures cannot be assessed thoroughly The article did not discuss the researchers' steps to reduce bias in qualitative interviews or how they were trained for data collection	Level III B
Kalra et al., 2016	To assess satisfaction, attitudes, and beliefs in relation to ethics and burnout of health care employees in NYC jails. Mixed methods: cross-sectional survey and 5 follow up focus group sessions	N= 677 correctional healthcare employees completed the survey Non-probability purposive sampling 12 jail facilities in New York City, U.S. 49.5% survey response rate	Main sources of stress that lead to burnout among the sample included: strained relationship of provider and patient, stemming from dual loyalty conflicts, multiple security points, and smaller workspaces Most commonly reported ethical challenges were violations of patient confidentiality, a focus on quantity of care over quality, and poor treatment of patients by carceral staff Results revealed a strong association (p < .01) between the measures of job satisfaction and ethical compromises 499 participants reported ‘ever been physically assaulted’, which is significantly correlated to ‘feel your ethics as a healthcare provider regularly compromised by work environment’ (p = 0.001) 25% of respondents frequently or occasionally felt physically afraid or intimidated in the workplace (p < 0.000) 91% felt unable to maintain patient confidentiality	The study design was not clear, and the sample was not well defined IRB approval was not mentioned The specific survey questions were included in a table without explanation or rationale for use. The source and quality of the survey cannot be assessed with the provided information Reliability and validity of measurement tools were not provided Despite major limitations statistical analysis was well described, and a table was included which comprised specific survey question variables, their corresponding correlation coefficients and p-values, adding understanding of results	Level III C
Flanagan & Flanagan, 2002	To measure the job stress and job satisfaction of correctional nurses and determine the correlates of job satisfaction and job stress. Nonexperimental correlational/cross-sectional: mailed survey delivered by nurse managers	N= 287 registered prison nurses Convenience sampling 56 correctional facility units in state prison systems in the southwestern U.S. Stamps and Piedmonte Job Satisfaction 58% survey response rate	Measures of Index of Work Satisfaction (IWS) and Nurse Stress Index (NSI) were used to evaluate the relationship between work stress and job satisfaction Sources of stress included time pressures, little organizational support and involvement Stress, age, and years of experience produced a multiple correlation coefficient of .60 [F (3, 188) = 35.18; p < .001] explaining 35.3% of the variance in job satisfaction	The research aims were clearly identified The instruments were explained with supported reliability (IWS: Cronbach’s alpha .92; NSI: Cronbach’s alpha .92) The IWS had reported content validity. However, validity within this context was not addressed for the NSI measure Nurse managers distributed surveys and may have influenced the response rate and responses to the questions	Level III B
Flanagan, 2006	To replicate a previous survey of job satisfaction and stress applying the anticipated turnover model. Nonexperimental correlational/cross-sectional: mailed survey to the home address	N= 454 unionized prison nurses Convenience sampling State prison systems in the northeastern USA. Anticipated turnover model 46% survey response rate	The relationship between work satisfaction and stress were evaluated with the Nurse Stress Index (NSI) and Index of Work Satisfaction (IWS) Correctional nurses rated workload and organizational support as the highest source of stress The variables of sex, supervisory status, race, unit specialty, and years in correctional nursing, explained 7% of the variance in stress and produced a multiple correlation coefficient of .28 [F (6,447) = 6.25; p < .000] Nurse stress index scores were higher for males, supervisors, White nurses, nurses working in units with specialties or inpatient beds, and more experienced correctional nurses	A theoretical basis for the study was described Surveys were mailed directly to employee’s homes to decrease the influence on responses and maintain participant confidentiality The included tools were explained and had supported reliability (IWS: Cronbach’s alpha .92; NSI: Cronbach’s alpha .90) The validity of tools within this context was not described for the Nurse Stress Index (NSI) Only one author completed this study increasing the risk for bias	Level III B
Ghaziri et al., 2019	To describe and compare sex and gender role differences in occupational exposures and work outcomes among correctional registered nurses Non-experimental correlational/cross-sectional: web-based survey	N= 95 registered nurses Non-probability purposive sampling Northeastern U.S. correctional healthcare system (which employs nurses working in 16 Department of Corrections (DOC) facilities and 31 DOC-contracted halfway houses (HWH) The Organization of Work conceptual framework 71% survey response rate	Survey contained 71 items to measure concepts of well-being, safety, health, job exposure, justice, stress, conflict, burnout, intent to leave, and job satisfaction The high work stress level among the correctional nurses was indicated by low decision-making authority, low supervisor support, high physical demands, and high psychological demands Male nurses reported a higher risk for exposure to blood-borne pathogens and body fluids (p < 0.05) Male nurses reported a higher sharps-related injury risk (p = 0.06) More than 95% of participants reported having been victims of workplace violence perpetrated by an inmate	High response rate achieved by using a multi-tiered approach where participants received a pre-survey, followed by an invitation, a follow-up email, and a final email reminder Manuscript provided an organized and well-structured summary of the study Sample of male nurses was reported as adequate, supporting the study goal to assess sex and gender role differences Cross-sectional design limited the ability to support causality Although there was a rigorous design for the survey, there remains the risk for bias due to the nature of the self-reported survey Reliability was reported for the instruments (Bullying Negative Act Questionnaire-Revised α alpha = 0.90; burnout α = .731; CPH-NEW adapted Job Content Questionnaire: justice α = 0.648; civility norms α = 0.597; masculine culture α = 0.93; BSRI-SF: Femininity scale α = 0.89, Masculinity scale α = 0.82)	Level III A
Lazzari et al., 2020	To investigate the moral distress of nurses who work in Italian correctional settings and validate the Moral Distress Scale for Correctional Nurses (MDS-CN) Non-experimental cross-sectional: survey emailed via Survey Monkey	N= 238 correctional nurses, including those with a bachelor’s degree, nursing diploma, educated provided by a hospitable, or those with post-bachelor education Convenience sampling of nurses working in multiple Italian correctional facilities, affiliated with the Society of Medicine and Penitentiary Health 51.6 % response rate	The MDS-CN included 20 items, measured with a Likert-type scale from 0 (minimal distress) to 5 (maximum distress) Nurses working in correctional facilities indicated overall moderate moral distress (median score= 46.5) Distress was affected by years of work experience in a correctional facility 108 participants (45.38 % of the sample) reported an intent to leave correctional nursing The MDS-CN was supported as a valid and reliable tool	The MDS-CN had reported content validity (Content Validity Index-Scale (CVI)= 0.99), internal consistency reliability (α = 0.91) and test–retest reliability (Spearman’s Rho = 0.99; p < 0.001) The sample was reported as adequate for factor analysis (Barlett’s sphericity (p = 0.001) and KMO = 0.74) Authors acknowledged their study limitations as not knowing the characteristics of those who did not participate in the research	Level III A
Stephenson & Bell, 2019	To discover the positive job attributes and challenges of working in a prison environment Qualitative: emailed survey requiring written responses to open-ended questions	N= 269 prison healthcare workers, such as physicians, physician assistants, nurses, nurse practitioners, dentists, as well as alcohol and drug counselors. Conveniently sampled from one state Department of Corrections in the Mid-Atlantic region of the U.S. 26% response rate	Open-ended questions were: What is your favorite part of your job? If you were given the opportunity to change one thing about your job, what would it be? Is there anything else that you would like to share about your role as a health professional in the DOC delivery system? Themes for positive job attributes emerged as meaningful work, stability, variety, and feelings of support Themes for challenges emerged as: ineffective leadership, job constraints, perceived inequity, and culture	Coding procedures were clearly explained Sample size was large for a qualitative study Triangulation and maintaining an audit trail were reported, adding to author credibility and trustworthiness No theoretical basis reported to inform the survey questions	Level III B
Walsh, 2009	To examine the emotional labor of nurses working in prisons Qualitative: reflexive methodology with semi-structured interviews, clinical supervision, and documentary evidence	N= 9 registered nurses working in prisons completed the interviews; 2 nurses met monthly with the researcher as a clinical supervisor over a 6-month period Sampling method not included 3 adult prisons in England and Wales	4 key questions guided the interviews: How do you see your role as a prison nurse? What is it like to be a nurse in this environment? Is nursing in prison much different to that outside? Can you describe to me, without naming names, an example of caring for a prisoner who you found difficult, and another who you found rewarding? A challenge of working in prison environments is the experience of emotional labor as a result of care vs. custody conflict Emotional labor included managing their emotions appropriately to meet the expectations of their discipline Care towards patients was negatively impacted by a lack of time and constraints on practice related to security Clinical supervision could improve nurse confidence	Sample included registered nurses only in prisons Although reflective journaling was mentioned to decrease author bias, only one researcher completed the analysis A theoretical basis was not reported to inform the interview questions Saturation was not addressed	Level III B
Weiskopf, 2005	To examine the experiences of nurses delivering care to incarcerated persons in a correctional setting Qualitative: phenomenology with a face-to-face interview	N= 9 full-time registered nurses Purposive sampling through computer list serv Jails or prisons in the Northeastern U.S. and Canada Husserl’s (1931) phenomenology	5 themes were discussed: negotiating the boundaries between custody and caring, struggling to create a caring environment, striving to turn a life around, a risky situation, and staying vigilant Working in the correctional environment was reported as complex and conflicting	Saturation of participants was not mentioned A guiding framework to develop interview questions was not described Authors modeled their approach based on credibility, fittingness, and auditability from Guba & Lincoln (1981)	Level III B
White et al., 2014	To examine the impact of the prison context on the health professionals working within it Qualitative: field observation and semi-structured interviews that happened at or away from work (depending on participant preference)	N=13 healthcare employees: 6 medical doctors and 7 registered nurses 2 women’s prisons in New South Wales, Australia	In the interviews, participants were asked to reflect on when they learned about ethical practice and what principles arose in their work. Then they were asked to reflect on situations of ethical significance in their work where one was resolved, and one was not Healthcare staff were challenged by the ethical and professional obligations they have to their patients Interviews provided a nuanced view of the dual loyalty complex of correctional work. Themes were found as physical context, security, discipline and order, access, equivalence of care: inside and outside, and divided loyalties	Thematic saturation was noted Interview questions were not reported to be informed by a specific theory Lack of tables and explicit mention of themes hindered clarity of results	Level III B
Husted & Dalton, 2021	To explore frontline healthcare worker's experience in and perceptions of providing care within a low-to-medium security hospital Qualitative: semi-structured one-to-one interview	N= 8 participants (6 healthcare assistants and 2 registered mental health nurses) Purposive sampling from gatekeeper access to the hospital floor, distribution of recruitment flyers, and emails A medium secure hospital in the United Kingdom	Participants explored the question of what motivated them to do their job Three themes emerged as: living with threat, need for support, and unique environment The theme of living with threat involved two subthemes of ‘acceptability of threat’ and ‘daily threat’ The theme of need for support included two subthemes of ‘importance of talking’ and ‘organization vs. the individuals’ The theme of unique environment involved two subthemes of ‘environmental challenges’ and ‘making a difference’	Reflexivity was addressed and anonymity of participants was discussed, adding trustworthiness to the authors The thematic map facilitated understanding of themes The specific correctional setting was not described in detail Saturation was not specifically mentioned, although authors reported the sample size as appropriate Interview questions were not informed by a theory but were based on literature according to the authors	Level III A

Table 2.

Themes

Setting	Author & Year	Themes
		Conflict	Fear	Demands
Unspecified Correctional Facilities	Almost et al., 2013	Sources of conflict were reported as correctional officers (28%), nursing colleagues (27%) inmates (24%), managers (17%), and physicians (2%) Correctional officers had different values and expectations, placing safety over healthcare Participants viewed conflict among other staff members as negatively impacting the environment	Over 63% of nurses and 44% of healthcare managers (HCMs) experienced emotional abuse from inmates Over 55% of nurses and 66% of HCMs experienced emotional abuse from someone other than an incarcerated person during the past year Sources of bullying were reported as correctional officers (31%), nursing colleagues (30%), inmates (20%), HCMs (11%), and physicians (5%) During the past year, 25% of nurses and 30% of the HCMs reported frequently observing bulling During the past year, 53% of nurses and 67% of HCMs reported being the subject of bullying	Limited time to provide care paired with inadequate staffing contribute to a demanding workload 66.7% of HCMs and 39.3% of nurses had high levels of emotional exhaustion as a subscale of burnout Lack of time and heavy workload decreased the chances for nurses to achieve continual education needed to improve competencies and practice to the full extent of their scope Overtime hours contributed to the increased role overload and burnout found among the participants
	El Ghaziri et al., 2019	There was significant difference in civility norms experienced by female nurses vs. male nurses	50% of the nurses reported their workplace as unsafe 37% of participants reported a sharps-related injury or exposure to blood-borne pathogens and body fluids within the previous 2–5 years, presenting safety concerns The majority of the participants (99%) reported being at risk for workplace violence and having been victims of workplace violence from an incarcerated person in the past 12 months (96%) Male nurses faced more assault threats and female nurses received more verbal abuse from incarcerated persons Low decision-making authority contributed to stress	Stress is created from the high psychological and physical demands of the work Low supervisor support contributed to the stressful work environment Nurses and healthcare managers slightly disagreed that they felt respect from supervisors
	Husted & Dalton, 2021	Peer support was perceived as beneficial and positive, allowing participants the opportunity to cope with their stress There were conflicting results regarding the perception of organizational support, yet most were negative	Participants experienced daily occurrences of threats yet used coping strategies and personal resilience to mitigate stress Ignoring the threat or remaining calm were common strategies, but staff also reported becoming desensitized to threats, which may potentially impact their long-term mental health	Demanding and stressful aspects of the job involved environmental challenges of workload, staffing, shift length, role conflict, security levels, and other unknown aspects of their role Participants described heavy workload as adding to their daunting work experiences
	Weiskopf, 2005	Ethical dilemmas surrounded: following the rules, not being able to touch patients, and being mandated to disclose otherwise protected patient information There was a conflict of not being able to show the compassion that nurses usually professionally maintain If correctional officers “…did not value health care, particularly related to mental health, [the nurses] did not feel supported or autonomous in their practice” (pg. 339) Participant accounts highlighted the struggle between trying to maintain positive workplace relations while also being caring towards patients	Participants reported corrections as a “difficult environment to work in” (pg. 340) Non-caring thoughts and attitudes towards patients from other nurses and staff members created a negative work environment Hostile and manipulative behavior of incarcerated persons added to the negative environment where nurses felt they couldn’t show their caring emotions Nurses remained vigilant with the premise that security is a vital part of one’s practice	Participants reported difficulty in maintaining the patience and perseverance to try and turn an incarcerated person’s life around Limited opportunities to provide patients with appropriate treatments created unattainable treatment goals Participants reported frustration with feeling as though they were not meeting patient’s basic needs
	Lazzari et al., 2020	91.1% (n=217) of the nurses reported complying with regulations and rules that they believe are contrary to their personal ethics 92.4% (n=220) of the nurses reported working with a doctor or nurse who was incompetent	Among the sample of nurses, 92.4% (N=220) reported not always feeling secure about their personal safety in caring for their patients 99.1% (N=236) reported carrying out activities outside of their nursing role	Incompetent colleagues and short staffing were related to higher levels of moral distress Years of experience in correctional nursing was significantly and positively associated with moral distress (p < 0.001) Among the sample of nurses, 98.3% (n=234) reported working without resources and/or tools to ensure quality care
Prisons	Flanagan & Flanagan, 2002	Difficult patients were rated highly as sources of stress among the nurses	The environment was described as a coercive and threatening setting The experiences of low autonomy in practice were influenced by confidence and competence in their role	Time pressures, competing priorities, and deadlines for trivial tasks were found as sources of stress among nurses A lack of organizational support and understanding were sources of stress. Nurses reported: “I only get feedback when my performance is unsatisfactory” (pg. 291)
	Flanagan, 2006	Difficulty dealing with difficult patients and aggressive people were rated highly as sources of stress among the nurses (M = 3.5, SD = 1.2 and M = 3.4, SD = 1.3, respectively)	One of the highest mean scores on the stress index was that “decisions or changes which affect me are made above without my knowledge or involvement” (M = 3.5, SD = 1.3) (pg. 320)	Nurses experienced difficulties in managing the workload priorities and time effectively, adding to their stress Autonomy was among the top sources of job satisfaction along with pay Lack of organization support and involvement were noted as contributors of stress
	Walsh, 2009	Nurses were impacted by the conflict in relationships with their officer colleagues, the institution, their patients, and themselves. Nurses may suppress their emotional actions in order practice safely in this environment, contrasting their core aspects as a nurse Seeing peers practice below a high standard created anxiety for participants Compromising ethics led to frustration	Safety was influenced by the ethical perspective of self-governance, and the need to adhere to protocols Nurses were reported to be obsessive about record-keeping and overly cautious in case of incidents that could lead to legal repercussions Concerns were expressed for supervision as nurses felt unsure about the best course of action without adequate guidance Some nurses were uncomfortable in making decisions where security was valued over healthcare, provoking anxiety and concerns of punishment Feelings of disempowerment lead to low morale, along with thoughts of low self-importance and the inability to make positive changes	Managing personal and profession conflicts along with the psychological effects of the work added to emotional labor One nurse remarked, “…you need to be strong, other than being professional, you need to be strong and able to detach yourself from situations…” (pg. 146)
	Stephenson & Bell, 2019	A lack of respect and deficient communication from leadership caused participants to view them as ineffective One nurse explained their frustration with leadership, “the proven and accepted best policies in dealing with healthcare workers and structuring a rewarding and progressive work environment are completely lost upon a management that lacks the experience, the training, and the motivation to improve” (pg. 32) Negative coworkers were described to impact the environment (i.e., “So many employees have such a negative outlook on things at work…” (pg. 32)	One participant reported “staff safety is not at its highest” (pg. 32) Main issues of concern for participants included safety Lack of opportunity for continued education and appropriate training was also noted among participants	One nurse participant reported, “We are constantly understaffed, mandated, or work long stretches without days off. . .” (pg. 72) Lack of resources also hindered the quality of care able to be provided Inconsistent standards and expectations for their role was reported, with inconsistencies of workloads
	White et al., 2014	Security and tightly supervised movements of the patients added limitations for providing care Custodial and judicial requirements can often override healthcare A conflict of morality was described where participants needed to choose when to follow their professional obligation and override security protocols, or when to follow security protocols instead of their professional obligation Limiting the healthcare of the incarcerated persons was often viewed as a denial of human rights by participants Certain reporting policies conflict with the professional duty of doctors and nurses to maintain confidentiality	Personal security was raised by participants as an issue One doctor remarked, “there have been, for instance, threats like “I’m going to get [the doctor] next time” … In those situations, you take that seriously and you just alert the guard that this has occurred” (pg. 340) Participants described specific procedures in place including when and how the incarcerated person can enter the clinic/hospital Sight and sound policies allow correctional officers to be within sight and/or sound of the assessment of the incarcerated person Staff regularly take security awareness courses Participants reported there was a sense of doctors and nurses protecting one another	Overcrowding raised concerns for the participants Healthcare personnel have a duty to protect their patients, while also protecting incarcerated persons from each other, and from themselves. This duty requires the staff to be vigilant and report assaults and self-harm instances The environment was described as “…too many patients and not enough health care and other staff” (pg. 340), alluding to understaffing issues Participants reported that roadblocks of policy and security make accessing outside health care facilities or scheduling specialist procedures more difficult Participants described a lack of resources, such as clean needles to give to patients
Jails	Kalra et al., 2016	Stress arose from the conflict in patient/provider relationships, caused by the dual loyalty among nurses to meet the security measures of the jails and provide ethical care to patients The inability to maintain patient confidentiality in their roles was among the most prominent factors affecting ethical compromises and burnout (p < .01) A quarter of survey respondents felt that their ethics as health care providers were regularly compromised by their work environment, creating internal conflict	23.5% of participants frequently or occasionally felt physically afraid or intimidated in their workplace Results found that there were no significant associations between physical assault and burnout directly, potentially related to inadequate measurements	A challenging work environment was described involving draining and negative experiences with patients Multiple security points and small workspaces were reported as a cause of burnout